NEW IBERIA MANOR NORTH
For profit - Corporation
101 Beds
NEXION HEALTH
Data: November 2025
Trust Grade
50/100
#145 of 264 in LA
Photo by New Iberia Manor North
Photo by New Iberia Manor North
Photo by New Iberia Manor North
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
New Iberia Manor North has a Trust Grade of C, which means it is average and ranks in the middle of the pack. In Louisiana, it ranks #145 out of 264 nursing homes, placing it in the bottom half, and #3 out of 5 in Iberia County, meaning only two local options are better. The facility is showing improvement, having reduced issues from 19 in 2024 to 7 in 2025. Staffing is rated at 2 out of 5 stars and has a turnover rate of 48%, which is around the state average, indicating some instability. While there are no fines reported, which is a positive sign, the facility has had concerning incidents, such as failing to have a plan for treatments after a nurse resigned, which could affect residents' care, and not properly labeling medications, risking medication errors. Overall, while there are strengths like no fines, the facility still has significant areas that need improvement.
- Trust Score
- C
- In Louisiana
- #145/264
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 9 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 46%
No red flags
19 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 48%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Chain: NEXION HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 49 deficiencies on record
May 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment was completed accurately for 1 (#40) of 1 resident investigated for hospice services out of a finalized sample of 33 residents.
Findings:
Review of Resident #40's electronic health record revealed the resident was admitted to the facility on [DATE].
Review of Resident #40's current May 2025 physician's orders revealed an order dated 04/04/2025 to admit to Hospice provider related to protein cal (calorie) malnutrition dx (diagnosis).
Review of the resident's significant change MDS assessment dated [DATE] revealed under Section J-Health Conditions, prognosis - Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months, was answered No.
On 05/14/2025 at 3:50 p.m., an interview was conducted with S6MDS (Minimum Data Set Nurse) who verified Resident #40 started hospice services on 04/04/2025 and should have been coded under Section J prognosis as yes, and was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan for 1 (#72) out of 1 (#72) sampled resident reviewed for respiratory care by:
1.
Failing to follow physician's orders for changing nebulizer treatment tubing every week; and
2.
Failing to follow physician's orders for respiratory prior and after orders when administering nebulizer treatments
Findings:
On 05/14/2025, a review of facility's policy, titled Administering Medications through a Small Volume (Handheld) Nebulizer, with a last revision date of October 2010, revealed in part .Documentation .The following information should be recorded in the resident's medical record .2. The date, time, and length of treatment .5. Pulse, respiratory rate and lung sounds before and after the treatment .8. The resident's tolerance of treatment .
Review of Resident #72's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath.
Review of Resident #72's May 2025 physician's order revealed the following orders dated 11/14/2024: Albuterol Sulfate Nebulization Solution 2.5 mg (milligram)/3 ml (milliliter) 0.083% 3 ml, inhale orally via nebulizer every 8 hours for shortness of breath related to COPD; Change nebulizer treatment tubing q (every) week every night shift every Sun (Sunday). Further review revealed the following orders dated 12/05/2024: Respiratory prior orders: Document number of respirations, pulse per minute, breath sounds prior to administering breathing/nebulizer treatment. Document breath sounds: (1) Normal (2) Abnormal; Respiratory after orders: Document how resident tolerated breathing/nebulizer treatment. G-Good, F-Fair, P-Poor; Document how many minutes it took to administer respiratory/nebulizer treatment after treatment has been administered. Document # (number) of min (minutes) it took to administer treatment; and Document pulse/heart rate, respiratory rate, lung sounds after treatment is completed. Document lung sounds (1) Normal (2) Abnormal.
Review of Resident #72's care plan read in part .The resident has altered respiratory status/difficulty breathing r/t (related to) SOB (shortness of breath). Interventions included: Change nebulizer treatment tubing q week .Document how many minutes it took to administer respiratory/nebulizer treatment after treatment has been administered .Document pulse/heart rate, respiratory rate, lung sounds after treatment is complete . Respiratory after orders: Document how resident tolerated breathing/nebulizer treatment. G-Good, F-Fair, P-Poor . Respiratory prior orders: Document number of respirations, pulse per minute, breath sounds prior to administering breathing/nebulizer treatment .
Review of Resident #72's May 2025 MAR (Medication Administration Record) revealed the following: Documentation indicated that Albuterol Sulfate nebulization solution was administered on the dates of 05/01/2025-05/13/2025 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. and on the date of 05/14/2025 at 6:00 a.m. and 2:00 p.m. Further review revealed no documentation on these dates that indicated the respiratory prior or after orders were completed.
Further review of Resident #72's May 2025 MAR revealed no documentation on 05/11/2025 that changing of the resident's nebulizer treatment tubing was changed.
On 05/14/2025 at 3:03 p.m., an interview and record review was conducted S2DON (Director of Nursing). She reviewed Resident #72 May 2025 MAR and confirmed the resident's nebulizer treatment tubing was not changed as ordered on 05/11/2025, and the orders prior and after nebulizer treatments were not completed as ordered in May 2025.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents unable to carry out activities of da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 1 (#44) out of 33 sampled residents. The facility had a census of 78.
Findings:
Review of the facility's policy with a revision date of February 2018 titled, Fingernails/Toenails, Care of read in part, Purpose: the purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines, 1. Nail care includes daily cleaning and regular trimming.
Review of Resident #44's clinical record revealed that she was admitted to the facility on [DATE]. Her diagnoses include, in part, Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, Diffuse traumatic brain injury with loss of consciousness of unspecified duration, Tracheostomy and gastrostomy status.
Review of Resident #44's annual MDS (Minimum Data Set) dated 04/16/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) of 99, indicating the resident was not able to complete the interview. She was dependent on staff for personal hygiene.
Review of Resident #44's plan of care revealed she was care planned for ADL (Activities of Daily Living) self-care performance deficit. Interventions included in part, nail care prn .
On 05/14/2025 at 10:50 a.m., an observation and interview was conducted with S7CNA (Certified Nursing Assistant). S7CNA removed the covering from Resident #44's hands. The resident's fingernails on both hands were long and untrimmed. A brown substance was observed under the right thumb nail. S7CNA confirmed that the resident's fingernails on both hands were long and untrimmed and there was a brown substance under the resident's right thumb nail. When asked who was responsible for cleaning and trimming the resident's nails, S7CNA stated the shower aid should have cleaned the resident's nails when she showered her this a.m. She also stated that she was unsure who was responsible for trimming the resident's nails.
On 05/14/2025 at 11:00 a.m., an observation and interview was conducted with S2DON (Director of Nursing) and S8CN (Corporate Nurse). They both confirmed that the Resident #44's fingernails needed to be trimmed and there was a brown substance under her right thumb nail.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a resident's (#34) indwelling urinary cathete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure a resident's (#34) indwelling urinary catheter drainage bag was positioned off the floor for 1 (#34) out of 2 (#34 and #48) residents investigated for urinary catheter. The total census was 78 residents.
Findings:
Review of the facility's policy with a review date of 01/01/2024 and a revised date of March 2024, titled, Catheter Care, Urinary read in part .Infection Control: .2. b. be sure the catheter tubing and drainage bag are kept off the floor.
Record review revealed Resident #34 was admitted to the facility on [DATE] with the following diagnoses in part, Encounter for palliative care, Encounter for prophylactic measures, unspecified, and Alzheimer's disease.
Review of Resident #34's care plan revealed she was care planned for indwelling catheter.
On 05/13/2025 at 11:00 a.m., Resident #34's urinary catheter drainage bag was observed out of the blue privacy bag on the floor under the resident's bed.
On 05/13/2025 at 11:05 a.m., an observation and interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed that Resident 34's urinary catheter bag was on the floor and out of the blue privacy bag. She stated it should have not been on the floor.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles as evidenced by having medication labels and physician orders that did not reflect the correct route of administration for 2 (#28, #54) out of 2 (#28, #54) residents whose physician orders and medication labels were reviewed.
Findings:
Resident #28
Review of resident #28's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dysphagia, Aphasia, and Gastrostomy Status.
Review of resident #28's medical record revealed a Quarterly MDS assessment with an ARD (Assessment Reference Date) of 01/29/2025, which read in part . Section K. Nutritional Approaches .Feeding Tube .was indicated.
Review of physician orders dated May 2025 for resident #28 revealed the following:
1. Atorvastatin Calcium Tablet 20 mg (milligrams), give 20 mg by mouth at bedtime
2. Metoprolol Tartrate Tablet 25 mg, give 1 tablet by mouth two times a day
3. Gabapentin Capsule 100 mg, give 1 capsule by mouth three times a day
On 05/13/2025 at 12:59 p.m., while observing S5LPN (Licensed Practical Nurse) during medication administration, an observation of the label on the blister pack of Resident #28's medications revealed the following:
1. Atorvastatin Calcium Tablet 20 mg, give 1 tablet per tube at bedtime
2. Metoprolol Tartrate Tablet 25 mg, give 1 tablet by mouth twice daily
3. Gabapentin Capsule 100 mg, give 1 capsule by mouth three times a day
Resident #54
Review of resident #54's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dysphagia, Aphasia, and Gastrostomy Status.
Review of resident #54's medical record revealed a Quarterly MDS assessment with an ARD (Assessment Reference Date) of 02/08/2025, which read in part . Section K. Nutritional Approaches .Feeding Tube .was indicated.
Review of physician orders dated May 2025 for resident #54 revealed the following: Ascorbic Acid (Vitamin C) Tablet 500 mg, give 1 tablet by mouth two times a day.
On 05/13/2025 at 1:29 p.m., while observing S5LPN during medication administration, an observation of the label on the OTC (over the counter) medication revealed the following: Vitamin C 500 mg tablet.
On 05/13/2025 at 2:29 p.m., an interview with S2DON (Director of Nursing) confirmed the labels on the blister packs of medications were labeled for administration by mouth for Metoprolol and Gabapentin, and by tube for Atorvastatin. S2DON also confirmed the label on the OTC was labeled for administration by mouth.
On 05/14/2025 at 2:35 p.m., an interview and record review was conducted with S2DON who confirmed Resident #28 and Resident #54 received all medications via peg (percutaneous endoscopic gastrostomy) and there was a discrepancy with medication labels, and physician orders and should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain a clean and sanitary kitchen, as evidenced by:
1. Equipment:
A. Build-up of debris and brown substance inside the conventional ov...
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Based on observations and interviews, the facility failed to maintain a clean and sanitary kitchen, as evidenced by:
1. Equipment:
A. Build-up of debris and brown substance inside the conventional oven and the inside of the oven doors.
2. Food storage:
A. Walk-in Refrigerator
1. A container of Roux (thickening agent for cooking) not labeled with the date it was opened.
2. A container of chopped garlic with an expiration date of 03/17/2025.
B. Walk-in Freezer
1. A bag of beef patties not labeled with the date it was opened.
C. Dry Storage
1. One dented canned good.
2. A bag of pasta not labeled with the date it was opened.
D. Main Kitchen:
1. Three bags of bread were not labeled with the date it was opened.
3. S4DC (Dietary Cook) without a hair restraint while in the kitchen.
This deficient practice had the potential to affect 75 residents who consumed food from the kitchen.
Findings:
A review of the facility's undated policy titled, Sanitization, with a last revision date of 01/2024, revealed, in part, the food service area shall be maintained in a clean and sanitary manner . 1. Fixed equipment will be routinely cleaned and maintained . 3. Food contact equipment will be cleaned and sanitized after every use.
A review of the facility's undated policy titled, Food Preparation and Service, with a last revision date of 10/2022, revealed, in part, food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.
A review of the facility's undated policy titled, Dry Storage, with a last review date of 01/2023, revealed, in part, all expired food items must be removed . All dented cans must be removed . If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened . Bags of bread products should be closed and dated with the date that it was opened.
On 05/12/2025 at 8:27 a.m., an initial tour was conducted with S1ADM (Administrator). She confirmed that all opened food items should have been labeled with the date it was opened, all expired items should be discarded, dented cans should not be in the dry storage room, and the conventional oven should have been cleaned.
On 05/12/2025 at 8:54 a.m., an observation of S4DC was conducted. S4DC was prepping lunch, and her hair was down and exposed. It was not completely in a hair restraint while in the kitchen.
On 05/12/2025 at 11:00 a.m., a second observation of S4DC was conducted. S4DC was checking food temperatures on the steam table with her hair down and exposed.
On 05/12/2025 at 1:07 p.m., an interview was conducted with S1ADM. She confirmed that kitchen staff's hair should be completely covered with hair restraints at all times while in the kitchen.
Apr 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure there was a sufficient number of Certified N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure there was a sufficient number of Certified Nurse Aides (CNAs) and Shower Aides to provide services in accordance with resident care plans for 1 (Resident #2) of 4 (Residents #1 - #3, and R1) sampled residents. The facility's census was 76.
Findings:
On 04/15/2025, a review of the facility's policy titled Activities of Daily Living (ADL), Supporting with a revision date of 03/2018 read in part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene. Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .
Resident #2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to metabolic encephalopathy and morbid obesity.
Review of Resident #2's quarterly (Minimum Data Set) MDS dated [DATE] revealed the client had a Brief Interview for mental Status of 15, which indicated her cognition was intact. Further review revealed in section GG that the resident required substantial/maximal assistance to shower/bathe self.
Review of Resident #2's care plan revised on 12/09/2024 revealed a focus area which stated The resident has an ADL self-care performance deficit, and interventions which included substantial maximal assistance to shower/bathe.
During an interview with Resident #2 on 04/14/2025 at 9:43 a.m., she stated her shower days were on Monday, Wednesday, and Friday at 9:30 a.m., or 10:30 a.m. The Resident stated it was short staffed every day. She stated that her last shower was on Wednesday of last week (04/09/2025). Resident #2 stated she didn't get a shower on Friday (04/11/2025) because her CNA said they were short staffed.
During a follow up interview with Resident #2 on 4/15/25 at 1:08 p.m., the resident stated she did not receive a shower on 03/21/2025 and 03/24/2025.
A review of the whirlpool schedule and electronic shower log revealed Resident #2 did not receive her showers as stated above.
On 04/14/25 at 12:15 p.m., an interview and review of CNA staffing for April 2025 was conducted with S2DON (Director of Nursing) and S1ADM (Administrator). S2DON confirmed there were only 3 CNAs listed on the schedule for the day shift (04/14/2025) to cover the facility. S2DON stated S3CNA (Certified Nursing assistant), who was scheduled for the shower room, was pulled to work on the floor. S4CNASup (Certified Nursing Assistant Supervisor), and S5RA (Restorative Aide) were assigned to work the floor. S2DON confirmed that if there was no shower aide, the CNAs were responsible for ensuring the residents receive a shower.
On 04/14/2025 at 12:20 p.m., an observation of the shower room was conducted with S1ADM and S2DON. S2DON opened the door revealing a dry and unused shower room with shower chairs stored in the shower area behind the curtain. S1ADM and S2DON both confirmed the shower room was not used on the day shift.
On 4/14/2025 at 12:26 p.m., an interview and observation of the shower room was conducted with S4CNASup. She stated the residents should have gotten a shower on Friday (04/11/2025) and today (04/14/2025). During the observation of shower room with S4CNASup, she confirmed the room was dry with shower chairs stored behind the shower curtain. S4CNASup confirmed the shower room was not used on the day shift.
On 04/14/2025 at 12:34 p.m., an interview was conducted with S3CNA. S3CNA stated she was pulled from the shower room today to work as a CNA on the floor. S3CNA confirmed she did not shower any residents today and that included the ones she was pulled to provide care for. She stated she did not have the time.
On 04/14/2025 at 12:36 p.m., an interview was conducted with S6CNA and S4CNASup. S6CNA stated she worked the shower room on 04/11/2025 by herself. S6CNA stated there were 5 aides and herself working that day. She stated she did not shower Resident #2 or any resident who required 2 person assistance because the aides were supposed to bring them to the shower room and help her, but they did not. S4CNASup stated if there was only one shower aide the CNAs were supposed to take the residents who needed assistance to the shower room and assist the shower aide.
On 04/14/2025 at 3:18 p.m., an interview was conducted with S7CNA. She stated she worked in the shower room on 03/21/2025 and 03/24/2025. She confirmed Resident #2 had not received a shower on 03/21/2025 and on 03/24/2025. She stated Resident #2 was mad on 03/24/2025 but she could not bathe the resident by herself because she required 2 person assistance.
On 04/14/25 at 4:06 p.m., an interview was conducted with S8CNA. She stated that the facility doesn't provide enough help. She stated that today (04/14/2025) they pulled her from the shower room to work on the floor before she was able to shower any resident.
On 04/15/2025 at 12:48 p.m., an interview was conducted with S2DON and S1ADM. S1ADM confirmed that there were missed and undocumented scheduled showers identified.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were free from verbal abuse for 1 (Resident #1) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were free from verbal abuse for 1 (Resident #1) out of 5 (Resident #1, Resident #2, Resident #3, Resident #R1, and Resident #R2) sampled residents investigated for abuse.
Findings:
On 12/03/2024, a review of the facility's manual titled, Abuse Prohibition Policy with a last revision date of 05/17/2024, read in part: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. The policy also indicated verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Aphasia, and Dementia.
Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was incomplete indicating he was unable to participate in this portion of the MDS.
Review of a witness statement dated: 11/11/2024 by S3SSD (Social Service Director) read, Resident #2 informed S3SSD that his roommate was mistreated. Resident #2 stated that Resident #1 was making a grunting noise and the male CNA (Certified Nursing Assistant) told Resident #1 to shut up twice. The third time that Resident #1 made the noise, the male CNA said shut up and Resident #2 heard a slapping noise twice. Resident #2 said that this happened on Friday or Saturday night. Resident #2 stated that he was laying down in bed so he did not see where the CNA slapped Resident #1 but he heard the slapping noise twice .
Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating his cognition was intact.
Review of a witness statement dated: 11/12/2024 by S4CNA read, I, S4CNA, around last week (Thursday or Friday), Resident #1 was resistant to care. He is usually calm when he takes his medication but that day was fighting, hitting his hands and pushing his hands away. He stopped and waited until he calmed down. I did not notify the nurse because he calmed down eventually. On the allegation of telling him to shut up, I might have done that because it was out of reflex .
On 12/02/2024 at 12:59 p.m., an interview was conducted with Resident #2. Resident #2 stated the night of the incident was either on 11/07/2024 or 11/08/2024, he did not remember exactly what night. He stated his roommate (Resident #1) was nonverbal and only made grunting noises which made him vulnerable. He stated a male CNA entered their room and walked to Resident #1's side of the room. Resident #2 stated he was not able to see what was going on due to the privacy curtain drawn in between them, but he was able to hear the male CNA and Resident #1. Resident #1 made a grunting noise then he heard the male CNA say shut up. He stated Resident #1 made another grunting noise then he heard the male CNA say shut up. He stated the resident made a grunting noise for a third time and he heard the male CNA say shut up again then heard a slapping noise at the same time. Resident #2 stated the male CNA said shut up with an attitude and it sounded like the CNA was expressing frustration towards Resident #1 due to the CNA's harsh tone of voice. He stated he notified S3SSD of the incident a few days later.
On 12/02/2024 at 1:08 p.m., an observation was made of Resident #1. Resident #1 was awake and laying down in his bed. Attempted to interview Resident #1, but he was only able to respond by making grunting noises, and was therefore unable to be interviewed.
On 12/02/2024 at 1:17 p.m., an interview was conducted with S3SSD. She stated during her morning rounds on the residents Resident #2 (Resident #1's roommate) notified her that he was worried about his roommate. He stated a male CNA that worked either on Thursday 11/07/2024 or Friday 11/08/2024 night came into their room while he was awake. He stated to her the male CNA walked over to Resident #1's side of the room, Resident #1 made a loud grunting sound, and the male CNA said shut up. Resident #1 grunted a few more times and the CNA told Resident #1 to shut up. Resident #1 grunted again and the CNA told him to shut up then heard slapping noises. Resident #2 reported that he was unable to see the incident due to a privacy curtain between the two residents. S3SSD stated she reported this to S2DON (Director of Nursing) and S1ADM (Administrator). She stated S1ADM was able to determine the male CNA that Resident #2 was speaking of was S4CNA.
On 12/02/2024 at 2:45 p.m., an interview was conducted with S1ADM. She stated she was told by S3SSD that Resident #2 heard a male CNA tell Resident #1 to shut up and heard a slapping noise. She stated she was able to narrow it down to Friday 11/08/2024, and determined the male CNA was S4CNA. S1ADM interviewed S4CNA who stated he might have said shut up to Resident #1, but it was out of reflex. S1ADM confirmed saying shut up is against professionalism and company policy.
On 12/03/2024 at 8:44 a.m., a phone interview was conducted with S4CNA who confirmed he was a previous employee at the facility. Questions were asked regarding these incidents. The phone line was abruptly disconnected.
On 12/03/2024 at 11:10 a.m., an interview was conducted with S2DON. Resident #2 notified her of an incident while she was doing morning rounds. She interviewed Resident #2 with S3SSD present when he reported he overheard a male CNA giving care on the other side of the room telling Resident #1 to shut up, but could not see what was going on. She stated Resident #2 told her that the male CNA seemed short with Resident #1. She stated S4CNA saying shut up to the resident was inappropriate.
May 2024
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interview, the facility failed to ensure the resident was treated with respect and di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interview, the facility failed to ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep a resident's urine collection bag covered and private for 1 (Resident # 35) of 3 residents (# 35, # 52 and # 66) investigated for urinary catheter or urinary tract infection.
Findings:
Review of Resident # 35's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses, in part: Urinary Tract Infection, Other Retention of Urine, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms.
Review of Resident # 35's current physician orders for May 2024 revealed, in part:
03/19/2024- Foley Catheter Care Q (every) Shift and PRN (as needed); Privacy bag or covering over urine collection bag for dignity every evening and night shift.
Review of Resident # 35's care plan revealed the resident had an indwelling catheter with an intervention of privacy bag or covering over urine collection bag for dignity.
On 05/13/2024 at 6:50 a.m., an observation was made of Resident # 35 from the hallway as his room door was open resting in bed and his urine collection bag was observed hanging on the right side, at the foot of his bed without a privacy bag or covering. The urine collection bag was visible from the hallway.
On 05/14/2024 at 8:26 a.m., upon entering the resident's room, his door was opened and Resident # 35 was observed in bed. His urine collection bag was hanging on the right side, at the foot of his bed without a privacy bag or covering. The resident's door remained open and his urine collection bag was visible from the hallway.
On 05/14/2024 at 8:35 a.m., an interview and observation was conducted with S10LPN (Licensed Practical Nurse). She entered Resident # 35's room and confirmed the resident's urinary collection bag did not have a privacy bag or covering. S10LPN further confirmed there should have been a privacy bag or covering present over the urine collection bag to ensure the resident's dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#31) out of 35 sampled residents.
Findings:
Review of Resident #31's electronic clinical record revealed he was admitted to the facility on [DATE]. The resident's diagnoses included in part Hypertension, Angina Pectoris, Cerebral Infarction and Venous insufficiency (Chronic) (Peripheral).
Review of the resident's quarterly MDS (Minimum Data Set) dated 02/14/2024 revealed under Section N-Medications, the resident was coded for the use of an anticoagulant (blood thinner).
Review of the resident's active physician order as of 05/15/2024 revealed no order for an anticoagulant medication.
On 05/15/2024 at 2:53 p.m., a review of Resident # 31's MDS dated [DATE] and current physician orders was conducted with S9RMDS (Regional MDS). S9RMDS stated that according to the physician orders, Resident #31 was not ordered any anticoagulant medications. She confirmed that the resident's MDS assessment conducted on 02/14/2024 was not accurate for the use of an anticoagulant.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Resident #57
A review of Resident #57's record revealed an admission date of 03/23/2023. Further review revealed she was diagnosed with Unspecified Psychosis on 09/16/2023; Major Depressive Disorder ...
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Resident #57
A review of Resident #57's record revealed an admission date of 03/23/2023. Further review revealed she was diagnosed with Unspecified Psychosis on 09/16/2023; Major Depressive Disorder on 07/28/2023; and Generalized Anxiety Disorder on 7/28/2023; Adjustment Disorder with Mixed Disturbance of Emotions and Conduct on 7/28/2024; Unspecified Mood (Affective Disorder) on 7/28/2023; and Anxiety Disorder on 7/28/2023.
A record review of the Office of Behavioral Health- PASRR Level II Evaluation Summary and Determination Notice dated 07/10/2023 stated that a Level II decision is not required. There were no additional PASARR forms on or after the resident's diagnoses on 7/28/2023 in the resident's record.
On 05/15/2024 at 3:30 p.m., an interview was conducted with S1ADM and S11SSD. Both confirmed that Resident #57 received a qualifying diagnosis after her admission date. Both confirmed the facility had not resubmitted for a Level II PASARR and should have.
Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 (Resident #37 and #57) of 2 (#37 and #57) residents investigated for PASARR in a final sample of 35 residents.
Findings:
Resident #37
A review of Resident 37#'s medical record revealed an admission date of 03/01/2024. Further review revealed he was diagnosed with Unspecified Psychosis on 03/13/2024.
Further review of Resident #37's medical record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 03/01/2024. No PASARR Level II was noted in Resident #37's record.
On 05/15/2024 at 12:43 p.m., an interview was conducted with S11SSD (Social Service Director) and S1ADM (Administrator) regarding resubmission for a Level II PASARR after a diagnosis of Unspecified Psychosis. S1ADM stated she would look into the matter, and would update when available.
On 05/15/2024 at 3:45 p.m., an interview was conducted with S11SSD, she stated they would get back with an update shortly.
On 05/15/2024 at 6:45 p.m., at survey exit, the facility failed to provide any further information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that a resident with a qualifying mental disorder, was not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that a resident with a qualifying mental disorder, was not admitted to the facility before a preadmission screening by the State Office of Behavioral Health (OBH) was completed or obtained for 1 (#33) of 4 (#31, #33, #37, and #57) residents investigated for PASARR (Preadmission Screening and Resident Review) out of 34 sampled residents.
Findings:
Resident #33 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Major Depressive Disorder and Psychotic Disorder with Delusions Due to Known Physiological Condition.
A review of the resident's quarterly MDS (Minimun Data Set) with an ARD (Assessment Reference Date) of 03/18/2024 revealed under section I: Primary Medical Condition, that the resident had diagnoses which included Depression and Psychotic Disorder.
A review of the resident's current plan of care revealed:
1)The resident was physically aggressive. On 05/03/2023 the resident had a physical fight with another resident .Interventions included administering medications as ordered .intervene when resident becomes agitated .
2)The resident uses antidepressant medication .administer antidepressant medications as ordered by physician.
A review of the resident's medical records revealed a PASARR Level II dated 04/28/2020 with a response from the Office of Behavioral Health stating the resident did not meet federal criteria for serious mental illness. There was no documentation of a PASARR Level I in the record.
On 05/14/2024 at 4:25 p.m., an interview was conducted with S10LPN (Licensed practical Nurse). She stated that she had been working at the facility for two years and that Resident #33 had been at the facility well before her. S10LPN stated the resident did not like to get up in his chair and would scream when he was encouraged to do so.
On 05/15/2024 at 10:21 a.m., an interview was conducted with S11SSD (Social Services Director). She stated that the resident was transferred from another facility on 10/22/2020 and since his transfer he had not had a new diagnosis. A review of the resident's admission records from the previous facility with S11SSD revealed that the resident had diagnoses including Violent Behavior, Major Depressive Disorder, and Psychotic Disorder with Delusions due to known Physiological Condition. S11SSD stated that she did not have a PASARR Level I screening from the previous facility to see what diagnoses were submitted to OBH.
On 05/15/2024 at 1:00 p.m., S1ADM (Administrator) and S11SSD presented a copy of the Level I PASARR that was faxed from the resident's previous facility. A review of the Level I PASARR revealed a date of 01/28/2020 and under section 111: Mental Illness, the resident was suspected as having no mental illness. S11SSD confirmed that the facility did not request a Level I PASARR screening from the previous facility until it was requested by the survey team.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #66
Review of Resident #66's electronic record revealed an admission date of 01/09/2024 with diagnoses that included...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #66
Review of Resident #66's electronic record revealed an admission date of 01/09/2024 with diagnoses that included Major Depressive Disorde.r
Review of S15NP's Progress Note dated 03/26/2024 revealed that Resident # 66 was assessed for a chief complaint of urinary frequency with slight burning. S15NP ordered a UA (Urinalysis), C/S (Culture and Sensitivity) that was to be completed on the morning of 03/27/2024.
Review of a nurse's progress note created by S21LPN on 03/26/2024 read: UA with C&S (Culture and Sensitivity) in the a.m.
Review of the lab request form dated 03/26/2024 revealed a check in the box for Urinalysis w/ (with) reflex to culture.
On 05/14/2024 at 2:30 p.m., a phone interview was conducted with a phlebotomist at the outpatient lab used for the resident's UA. The phlebotomist reported that the lab request sent for Resident #66 on 03/26/2024 from the facility, indicated that a UA with reflex culture was ordered. She stated the request for a urine culture was not indicated on the lab request, so therefore a urine culture was not performed.
On 05/15/2024 at 1:12 p.m., a second phone interview was conducted with a Medical Technician from at the outpatient lab used for the resident's UA. The Medical Technician verified that if a provider orders a UA, C/S, the lab request should have a check mark placed for Urinalysis no reflex as well as a check mark for Culture, Urine. She confirmed that a Culture and Sensitivity should be requested and collected for an order for U/A, C/S.
Based on observations, record reviews, and interviews, the facility failed to develop and implement a person-centered care plan for 2 (#37 and #66) out of 2 residents investigated for care plans out of a total sample of 35 residents by:
1. failing to follow physician's orders for completing wound care for Resident #37,
2. failing to request a urine C/S (culture and sensitivity) from the laboratory after order was received for Resident #66
Findings:
1. Resident #37
Review of Resident #37's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: Cerebral Infarction, Hemiplegia and Hemiparesis, Nontraumatic Intracerebral Hemorrhage, Contracture of Left Hand, and History of Falling.
Review of Resident #37's nurse's notes revealed the resident had a fall on 04/21/2024 that resulted in a skin tear above his right eyebrow.
Review of Resident #37's April 2024 physician's orders revealed the following order dated 04/25/2024: Skin tear right eyebrow: Clean with normal saline, pat dry, apply TAO (Triple Antibiotic Ointment) q (every) day until healed.
Review of Resident #37's April 2024 TAR (Treatment Administration Record) revealed the following order dated 04/25/2024: Skin tear right eyebrow: Clean with normal saline, pat dry, apply TAO qday until healed. Treatment for the resident's skin tear was started on 04/25/2024.
On 05/15/2024 at 04:55 p.m., an interview and record review was conducted with S3DONIP (Director of Nursing/Infection Preventionist). She reviewed Resident #48's April 2024 physician orders and TAR and confirmed the resident's treatment for his right eyebrow skin tear was not started until 04/25/2024, and should have been started on 04/21/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to perform daily wound care as ordered by the physician and failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to perform daily wound care as ordered by the physician and failed to provide weekly wound assessments for 1 (#48) of 3 (#17, #35 and #48) residents investigated for pressure ulcers.
Findings:
Review of Resident #48's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Ischemia, End Stage Renal Disease, Arteriovenous Fistula, Atherosclertoic Heart Disease of Native Coronary Artery, Moderate Protein Malnutrition, and Muscle Wasting and Atrophy.
Review of Resident #48's May 2024 physician's orders revealed the following:
orders dated 04/13/2024: Right big top of toe, clean with normal saline, pat dry, apply betadine, leave open to air, every day until healed; Right foot inner heel, clean with normal saline, pat dry, apply betadine and cover with dressing, every day until healed.
Further review revealed the following orders dated 05/01/2024: DTI (deep tissue injury) of Left great toe: Clean with normal saline, pat dry, apply betadine, cover with gauze wrap with kerlix q (every) day and PRN (as needed); Unstageable Pressure Injury to Right great toe: Clean with normal saline, pat dry, apply betadine, wrap with kerlix q day and PRN every day shift; and Unstageable Pressure Ulcer to Right Heel: Clean with normal saline, pat dry, apply betadine, cover with with kerlix q day and PRN.
Review of Resident #48's May 2024 TAR (Treatment Administration Record) revealed the following orders dated 05/01/2024: DTI (deep tissue injury) to Left great toe: Clean with normal saline pat dry, apply betadine, cover with with kerlix q day and PRN; Unstageable Pressure Injury to Right great toe: Clean with normal saline, pat dry, apply betadine, wrap with kerlix q day and PRN every day shift; and Unstageable Pressure Ulcer to Right Heel: Clean with normal saline, pat dry, apply betadine, cover with with kerlix q day and PRN.
There was no documentation that treatment was done for the resident's wounds on the date of 05/07/2024.
Resident #48's April 2024 Weekly Wound Observation Tool failed to reveal an assessment of the resident's right great toe and right heel for the week of 04/30/2024.
On 05/14/2024 at 3:13 p.m., an interview and record review was conducted with S3DONIP (Director of Nursing/ Infection Preventionist). She reviewed Resident #48's TAR and confirmed the resident's treatment to her left great toe, right great toe and right heel were not completed as ordered on 05/07/2024. S3DONIP then reviewed Resident #48's Weekly Wound Observation Tool and confirmed there was no right great toe or right heel wound assessment or measurements documented for the week of 04/30/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that a resident (#62) with limited range of moti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that a resident (#62) with limited range of motion received the appropriate treatment and services by failing to implement recommendation by the physical therapy department for the restorative nursing program for 1 (#62) of 1 resident investigated for position/mobility in a total sample of 35 residents.
Findings:
Review of the resident's electronic record revealed she was admitted to the facility on [DATE]. Her admitting diagnoses in part: Cerebral Vascular Accident, Unspecified Myoneural Disorder, Muscle wasting and atrophy, right and left thigh and lower leg, and Lack of coordination.
On 05/13/2024 at 10:52 a.m., Resident #62 stated she received 3 to 4 days of therapy after she was admitted , but she was no longer receiving therapy because her insurance would not pay for the therapy. When asked if she was on a restorative program, she replied No.
Review of the resident's quarterly MDS (Minimum Data Set) dated 04/11/2024 revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating she was cognitively intact. She had functional limitation in range of motion to both lower extremities. She required substantial to maximal assistance with sitting to standing and chair/bed-to chair transfer. Toilet transfer and walking 10 feet or more was not attempted due to a medical condition or safety concerns. Further review under Section O-Special Treatments, Procedures and Programs revealed the resident was not receiving therapy or on the Restorative Nursing Program.
On 05/14/2024 at 11:10 p.m., S17TD (Therapy Director) stated Resident #62 had started therapy but went to a different payer source and that payer source denied payment for her to continue receiving physical and occupational therapy. She stated they recommended that the resident be placed in the restorative nursing program.
Review of the physical therapy Discharge summary dated [DATE] revealed the resident was seen for 4 days during the 10/26/2023 to 10/31/2023 progress period. Further review revealed that the resident was discharged due to a change in payer source. Discharge recommendations included in part, .Restorative program .
Review of the Occupational Therapy Discharge summary dated [DATE] revealed the resident was seen for 4 days during the 10/26/2023 to 10/31/2023 progress period. Further review revealed that the resident was discharged because she reached her highest practical level. Discharge recommendation included in part, .Restorative Program .
On 05/15/2024 at 9:35 a.m., S3DONIP (Director of Nursing/Infection Preventionist) stated that when therapy recommends a resident be placed on the restorative nursing program, a form is completed by the therapist and the Restorative aide. The form is then given to the Medical Records department and an order is generated for the resident to start receiving restorative care. The order is entered in the resident electronic record so that the restorative aides can document the restorative task.
On 05/15/24 at 10:40 a.m., a review of the resident's Ambulation, Transfer and Range of Motion (ROM) Competency and Discharge Planning Form dated 11/13/2023 was reviewed with S3DONIP. She confirmed that this was the form completed by the therapist and the restorative aide when a resident is placed on the restorative nursing program. She confirmed that Resident #62's form had not been given to the Medical Records personnel; therefore, no order was obtained for the resident to be placed in the Restorative Nursing Program.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident was free from accidents for 1 (#37) of 2 (#37 a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident was free from accidents for 1 (#37) of 2 (#37 and #61) residents investigated for accidents.
Findings:
Review of Resident #37's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Cerebral Infarction, Hemiplegia and Hemiparesis, Nontraumatic Intracerebral Hemorrhage, Contracture of Left Hand and History of Falling.
Review of Resident #37's significant change MDS (Minimum Data Set) dated 04/11/2024, revealed he had a BIMS (Brief Interview for Mental Status) score of 8, indicating the resident had moderate cognitive impairment.
A review of Resident #37's care plan revealed he was at risk for falls and for an actual fall. Further review of the plan of care revealed Resident #37 had actual falls on 03/02/2024, 03/05/2024, 03/09/2024 and 04/21/2024. Interventions included in part .staff assist back to bed when ready.
A review of the facility's investigative report by S1ADM (Administrator) on 04/21/2024 at 2:40 p.m., revealed Resident #37 would slide down in his wheelchair whenever he became tired. S19LPN instructed S22CNA (Certified Nursing Assistant) to put Resident #37 in his bed after lunchtime. Resident #37 fell and sustained a small laceration to his forehead right above the brow line as a result of S22CNA failing to put the resident in bed as instructed.
On 05/15/2024 at 03:05 p.m., an interview was conducted with S19LPN. She stated on 04/21/2024, she found Resident #37 on the floor soon after the resident returned from lunch. When the resident returned from lunch, he was seated at the nurses' station, and attempted to slide out of his wheelchair. S19LPN stated she asked S22CNA to assist the resident into his room and transfer the resident to his bed to rest. S19LPN stated S22CNA did not bring the resident to his room to put him in his bed as instructed. As a result, the resident and was left in his wheelchair in his room, unsupervised, and fell shortly after S22CNA left the room.
On 05/15/24 at 04:55 p.m., an interview was conducted with S3DONIP (Director of Nursing/Infection Preventionist). S3DONIP stated through the investigation conducted by the facility, it was determined the incident could have been prevented had Resident #37 been placed in bed as delegated per S19LPN.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview, the facility failed to ensure a resident received necessary respiratory car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview, the facility failed to ensure a resident received necessary respiratory care and services as evidenced by:
1. Failing to ensure the resident was assessed for respiratory therapy and
2. Failing to obtain a physician's order for respiratory therapy.
This deficient practice was evidenced for 1 (Resident # 35) of 3 residents (# 35, # 50 and # 71) investigated for respiratory care.
Findings:
On 05/14/2024 a review of the facility's Policy and procedure titled, Oxygen Administration, with a revision date of February 2023, revealed in part:
The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order .Review the resident's care plan to assess for any special needs of the resident .Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: .4. Vital Signs . Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record 1.The date and time the procedure was performed .4.The frequency and duration of the treatment. 5. The reason for p.r.n. (as needed) administration. 6. All assessment data obtained before, during and after the procedure.
Review of Resident # 35's electronic medical record revealed the resident was re-admitted to the facility on [DATE] with the following diagnoses, in part: Dysphagia Following Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Seizures and Tracheostomy Status.
Further review of Resident # 35's electronic medical record failed to reveal an assessment for respiratory therapy.
Review of Resident # 35's May 2024 physician's orders revealed:
03/06/2024 Tracheostomy suction prn (as needed) every 24 hours as needed related to Tracheostomy status.
Further review of Resident # 35's May 2024 physician's orders failed to reveal an order for additional respiratory therapy of oxygen administration via tracheostomy tube.
Review of nursing progress notes revealed an entry dated 05/07/2024 at 8:10 p.m. per S20LPN (Licensed Practical Nurse): Resident returned from hospital per stretcher per ambulance, alert, trach (tracheostomy) not capped at present, trach mask and oxygen applied, sat (saturation) 94% .
On 05/13/2024 at 6:50 a.m., an observation was made of Resident # 35 resting in bed with oxygen in place at 5 Liters via his tracheostomy.
On 05/14/2024 at 8:26 a.m., Resident # 35 was observed resting in bed with oxygen in place at 5 Liters via his tracheostomy.
On 05/14/2024 at 8:35 a.m., an interview and observation was conducted with S10LPN in Resident # 35's room. S10LPN confirmed Resident # 35 was receiving oxygen at 5 Liters via his tracheostomy.
On 05/15/2024 at 4:20 p.m., an interview was conducted with S3DONIP (Director of Nursing / Infection Preventionist) who confirmed the resident did not have a respiratory assessment nor an order to receive oxygen at 5 Liters via tracheostomy and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility as evidenced by failing to change the physician's order to reflect dialysis treatment days for 1 (#48) out 1 (#48) resident investigated for dialysis.
Findings:
Review of Resident #48's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: End Stage Renal Disease (ESRD), Arteriovenous Fistula, and Dependence on Renal Dialysis.
Review of Resident #48's care plan read in part . The resident needs hemodialysis r/t (related to) ESRD with Pulmonary Edema/Congestion .new order noted: Resident to receive dialysis 3 days a week on M, W, F (Monday, Wednesday, Friday) at dialysis center.
Review of the Resident #48's nurses notes dated 05/10/2024 at 2:35 p.m. revealed, pt (patient) will have a new day and time starting 5/13/2024. Chair time will be at 11:15 MWF notified van driver.
Review of Resident #48's May 2024 physician's orders revealed the following order dated 01/22/2024: Resident to receive dialysis 3 days a week on T, R, S (Tuesday, Thursday, Saturday) at the dialysis center under the care of Dr.___ (nephrologist)
On 05/14/2024 at 3:13 p.m., an interview and record review was conducted with S3DONIP (Director of Nursing/ Infection Preventionist). Resident #48's care plan, nurses notes, and May 2024 physician's orders were reviewed with S3DONIP. She confirmed Resident #48 attended dialysis on MWF and the current physician's order was not accurate and should have been revised.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week.
Findings:
Review of the facility's PBJ (P...
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Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week.
Findings:
Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1, 2024 (October1 - December 31), revealed a One Star Staffing Rating.
Review of Time Card Reports and RN (Registered Nurse) clock in hours for the months of October 2023 to December 2023 revealed an RN did not work a total of 8 hours for the following dates in October 2023: 10/13, 10/16, 10/17, 10/30, and 10/31. Further review revealed an RN did not work a total of 8 hours for the following dates in November 2023: 11/13, 11/14, 11/15, 11/20, and 11/22.
On 05/14/2024 at 2:50 p.m., a phone interview was conducted with S1PBJ (Payroll Based Journal) who confirmed that the facility did not have an RN for 8 hours per day for the dates mentioned from October and November of 2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the menu was followed for 2 (#27, #37) residents out of 3 (#27...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the menu was followed for 2 (#27, #37) residents out of 3 (#27, #30, #37) residents who received pureed diets.
Findings:
Resident #27 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Unspecified Dementia and Gastro-Esophageal Reflux Disease. Review of Resident #27's physician's orders revealed a diet order dated 08/04/2022 that read in part: Regular diet, pureed texture, thin consistency.
Resident #37 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Other Sequelae of Cerebral Infarction, Type 2 Diabetes Mellitus, and Gastro-Esophageal Reflux Disease. Review of Resident #37's physician's orders revealed an order dated 04/03/2024 that read in part: Reduced Concentrated Sweets diet, pureed texture, nectar thickened consistency.
Review of the facility's menu for 05/13/2024 revealed breakfast consisted of the following food items: Cereal Cream of Wheat, Scrambled Egg, Bacon Strip or Sausage Link, Biscuit.
On 05/13/2024 at 8:14 a.m., an observation was made in the facility's kitchen as nursing staff returned to the kitchen, stating Resident #37 did not have enough food on his plate and complained that his portions were small. The kitchen staff made a second plate for the resident, but did not put any pureed biscuit on the resident's plate.
On 05/13/2024 at 8:25 a.m., S14Dietary was asked where the pureed biscuit was on the food serving line. She proceeded to remove the lid from a steam pan that held the container of pureed biscuit. It was covered with saran wrap that had not been opened or removed. S14Dietary confirmed that Resident #27 and #37 did not receive their pureed biscuit on their breakfast tray as listed on the menu and ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure the resident received a mechanically soft chop...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure the resident received a mechanically soft chopped meats diet as ordered for 1 (# 61) of 3 (# 61, # 66, and # 71) residents investigated for food concerns in a final sample of 34 residents.
Findings:
Review of Resident # 61's record revealed he was admitted to the facility on [DATE] with diagnoses, in part . Sequelae Cerebral Infarction, Potential for Malnutrition, Other Speech and Language Deficits Following Cerebral Infarction.
Review of the resident's physician orders for May 2024 revealed an order dated 02/01/2024, Mechanical soft texture, thin consistency, chop meats, no grapefruit products
Review of the resident's care plan revealed Focus: Dietary Concern Speech Deficits, Protein Calorie Malnutrition Interventions included: Mechanical soft texture, thin consistency, chop meats, no grapefruit products.
On 05/13/2024 at 8:55 a.m., an observation was made of Resident # 61 sitting up on the side of his bed feeding himself breakfast. The resident's meal tray was observed with a whole slice of bacon and a biscuit. Review of the resident's meal ticket on his breakfast tray revealed Regular Diet, mechsoft (mechanical soft) with chopped meat and entree included bacon crumbles.
On 05/13/2024 at 9:00 a.m., an interview and observation was conducted with S10LPN (Licensed Practical Nurse) who confirmed the resident's breakfast meal was not his ordered diet. S10LPN further confirmed that the resident was supposed to have bacon crumbles instead of the whole slice of bacon that was present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing...
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Based on observation and interview the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to:
1.
Ensure cooked food items were not stored on the same shelf as raw food items;
2.
Remove expired food items from the kitchen's walk in cooler.
Findings:
A review of the facility's policy titled, Food Receiving and Storage with a last reviewed date of January 2023 read in part: 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetable and other ready-to-eat foods.
On 05/13/2024 at 6:30 a.m., an observation was made of the kitchen's walk in cooler with S5DM (Dietary Manager). Observation of the cooler revealed a bottom shelf to the right of the cooler. There were 2 rolls of uncooked ground beef defrosting in a pan on the bottom shelf, and uncooked sausage and raw chicken defrosting in a second pan. In between the two pans, was a large pan covered in foil labeled with a date of 5/11 and pinto beans. S5DM stated the beans had been cooked and confirmed cooked food items should not be on the same shelf as the raw meat. Further observation of the cooler revealed 2 containers of cottage cheese with expiration dates of 10/16/2023. S5DM confirmed they were expired and should have been removed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable...
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Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to ensure clean laundry and linen was not stored on the contaminated side of the laundry department.
Findings:
A review of the facility's environmental services policy with a last revised date of 10/2023, read in part: Laundry Flow .After washing, clean linens should be transported from the washing area to the drying area .Linen Storage .Clean linen must always be kept separate from contaminated linen through the use of separate rooms, closets, or other designated spaces with a closing door as the most secure methods for reducing the risk of accidental contamination.
On 05/13/2024 at 10:29 a.m., an observation was made of the laundry department. S12Laundry was observed on the contaminated side of the laundry department placing soiled linen into the washing machines. She stated that clean laundry could not be stored on the contaminated side and no soiled laundry could be on the clean side. Further observation of the contaminated side of the laundry department revealed a basket of dried mop heads, mop pads, and towels in a rolling basket. S12Laundry was asked if the mop heads, mop pads, and towels were dirty. She then stated they were clean, but that was where they kept them until the end of each day.
On 05/13/2024 at 10:31 a.m., an observation of the laundry department and interview was conducted with S13HSKSup (Housekeeping Supervisor). S13HSK confirmed the basket of mop heads, mop pads, and towels were clean and they always kept them on the contaminated side until they were distributed to the facility's housekeeping staff. Further observation was made of the contaminated side of the laundry department which revealed a covered cart with blankets and comforters. S13HSK stated the blankets and comforters were clean, and that was where they were stored. A gray bin was then observed against the wall next to the soiled laundry barrels. There were white folded blankets in the bin. S13HSKSup stated that they were clean blankets, and that was where the blankets were always stored.
On 05/13/2024 at 10:37 a.m., an interview was conducted with S3DONIP (Director of Nursing/Infection Preventionist). S3DONIP confirmed that clean laundry and linen should not be stored on the contaminated side of the laundry department.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to thoroughly investigate and adequately intervene when the resident reported his pain medication was not treating his pain effectively for 1 ...
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Based on interview and record review, the facility failed to thoroughly investigate and adequately intervene when the resident reported his pain medication was not treating his pain effectively for 1 resident (#326) out of 1 sampled resident (#326) for pain.
Findings:
Review of Resident #326's electronic record revealed an admission date of 05/07/2024 with diagnoses that included Pain Unspecified, Other Chronic Pain, and Chronic Venous Hypertension (Idiopathic) with Ulcer of Bilateral Lower Extremity.
Review of Resident #326's MAR (Medication Administration Record) for May 2024 revealed the resident was ordered and received:
Acetaminophen Tablet 650 mg (Milligrams). Give one tablet by mouth three times a day related to Other Chronic Pain, started on 05/07/2024.
Gabapentin Capsule 300 mg. Give 1 capsule by mouth three times a day related to Other Chronic Pain, started on 05/07/2024.
Oxycodone-Acetaminophen Tablet 7.5-325mg. Give 1 tablet by mouth every four hours as needed for pain, started on 05/07/2024.
Review of his MAR indicated the resident had been receiving Oxycodone-Acetaminophen as needed 4-5 times a day since his admission. An average pain rating of 8-10 (0 means no pain, and 10 means the worst possible pain) was recorded prior to Oxycodone-Acetaminophen administration. The resident received a dose on 05/14/24 at 07:41a.m., approximately two hours before being interviewed below.
On 05/14/2024 at 09:37 a.m., an interview was conducted with Resident (#326). He stated that his pain was at a level of 10 on the pain scale and was located in his lower extremities. He stated and he had received a dose of pain medication after 7:00 a.m., this morning but he remained in a great amount of pain. He stated that he received minimal relief from his pain medications. He stated he informed the nurses of this when they asked him about the effectiveness of pain medications.
On 05/15/2024 at 10:18 a.m., an interview was conducted with S16LPN (Licensed Practical Nurse). She stated that the resident asked for pain medications every hour and that his pain medications were not effective. She stated that she had informed S15NP (Nurse Practitioner) at least three times since Resident #326's admission. She stated S15NP reported to her that he could not change the pain medication.
On 05/14/2024 at 12:20 p.m., an interview was conducted with S15NP and S3DONNIP. S15NP stated the nurse had reported to him in the past that the resident's pain regimen was ineffective. He stated that he definitely found the pain regimen to be ineffective but wanted to wait for a period of time to make changes to Resident #326's pain medication. S3DONNIP verified that there was no progress note from the NP or nursing documentation since admit mentioning the ineffectiveness of Resident #326's pain regimen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure the Nurse Practitioner (NP):
1. Re-evaluated Resident # 66...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure the Nurse Practitioner (NP):
1. Re-evaluated Resident # 66's urinary tract infection symptoms after lab (laboratory) results were received for 1(#66) of 3 residents (#66, #35, #52) investigated for UTI (Urinary Tract Infection); and
2. Responded to staff reporting a change in medical status for 2 (#66, #326) of 2 residents (#66, #326) investigated for UTI and Pain.
This deficient practice had the potential to affect 73 residents that reside at the facility.
Findings:
1. Resident #66
Review of Resident #66's electronic record revealed an admission date of 01/09/2024 with diagnoses that included Major Depressive Disorder.
Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact.
Review of a S15NP's Progress Note dated 03/26/2024 revealed that Resident #66 was assessed for a chief complaint of frequency with urination with slight burning. S15NP ordered a Urinalysis (UA) C/S (Culture and Sensitivity) to be collected on the morning of 03/27/2024.
Review of nurse's note created by S21LPN on 03/26/2024 revealed new orders noted per S15NP UA with C/S in the A.M.
Review of UA results collected on 03/26/2024 revealed Trace Blood, Positive Nitrites, and Moderate Bacteria. No Culture and Sensitivity was initiated.
On 05/14/2024 at 3:00 p.m., an interview was conducted with Resident #66. The resident reported that she had been having burning with urination and frequency with urination for the last couple of days. She also stated months ago, she was having similar urinary symptoms. She stated she did not see the NP, but the nurse did collect her urine. She stated no one reported the results of her urine sample until she asked the nurse and who told her that she did not have an infection. Resident #66 stated no one, including the S15NP, asked her if her symptoms continued. She states she then treated the symptoms herself with a supply of AZO (medication for urinary pain relief) that she had in her purse. When she ran out of her AZO supply she reported her symptoms were better but returned again a couple of days ago.
On 05/15/2024 at 1:12 p.m., an interview was conducted with S15NP along with a review of his progress notes from 03/26/2024 to present date. He verified that he was aware of the UA results from 3/26/2024. He stated he could not recall relaying the results to her nor following up on her symptoms, but he should have. He also verified that there was no documentation from him regarding the UA results received on 03/26/2024 addressing her symptoms until 5/14/24.
2. Resident #66
Review of Section D of Resident #66's Quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed that the resident answered yes to feeling down, depressed or hopeless nearly every day. Section D also revealed that Resident #66 answered yes to trouble falling or staying asleep or sleeping too much.
Review of the Resident's PHQ-9 (Patient Health Questionnaire) dated 04/16/2024 completed by S11SSD revealed the resident answered yes to feeling down, depressed or hopeless nearly every day. The PHQ-9 also revealed that resident answered yes to trouble falling or staying asleep or sleeping too much. Interview Details read: Resident stated that she has been depressed on nearly every day in the last two weeks because of things in the past with her family. Resident stated that on several days in the last two weeks she had trouble sleeping because she was worried about things going on with her funds. Further review of the resident's electronic medical record revealed S11SSD placed the resident on the S15NP's list to be seen for depression and difficulty sleeping.
Review of S15NP's progress notes from 04/16/2024 to 05/15/2024 revealed no documentation regarding the resident's depression or trouble sleeping.
On 05/14/2024 at 03:00 p.m. an interview was conducted with Resident #66. She verified that she had reported feelings of depression and that she was having trouble sleeping to S11SSD. She stated that no one, including the NP, had asked her about these issues since she reported them. She stated that the NP had not come to visit her for these issues, and continued to feel this way.
On 05/14/2024 at 3:41 p.m., an interview was conducted with S11SSD. She stated she completed the PHQ-9 with the resident on 04/16/2024. She verified that the resident reported feeling down, depressed, or hopeless nearly every day and also had trouble with sleep. She stated that she placed the resident's name in the communication binder for the NP to address these problems, and she did specify on the communication form what symptoms the resident was experiencing.
On 05/15/2024 at 1:12 p.m., an interview was conducted with S15NP who verified that his progress note for a visit on 04/16/2024 had no indication of the resident being assessed for depression or trouble sleeping.
Resident #326
Review of Resident #326's electronic record revealed an admission date of 05/07/2024 with diagnoses that included Pain Unspecified, Other Chronic Pain, and Chronic Venous Hypertension (Idiopathic) with Ulcer of Bilateral Lower Extremity.
Review of Resident #326's MAR (Medication Administration Record) for May 2024 revealed the resident was ordered and received:
Acetaminophen Tablet 650 mg (Milligrams). Give one tablet by mouth three times a day related to Other Chronic Pain, started 05/07/2024.
Gabapentin Capsule 300 mg. Give 1 capsule by mouth three times a day related to Other Chronic Pain, started 05/07/2024.
Oxycodone-Acetaminophen Tablet 7.5-325mg. Give 1 tablet by mouth every four hours as needed for pain, started 05/07/2024.
Review of his MAR indicated the resident had been receiving Oxycodone-Acetaminophen as needed 4-5 times a day since his admission. An average pain rating of 8-10 (0 mean no pain, and 10 means the worst possible pain) was recorded prior to Oxycodone-Acetaminophen administration. The resident received a dose on 05/14/2024 at 07:41a.m., approximately two hours before being interviewed below.
On 05/14/2024 at 9:37 a.m., an interview was conducted with Resident (#326). He stated that his pain was at a level of 10 on the pain scale and was located in his lower extremities. He stated he had received a dose of pain medication after 7:00 a.m. this morning but he remained in a great amount of pain. He stated that received minimal relief from his pain medications. He stated he informed the nurses of this when they asked him about the effectiveness of pain medications.
An interview was conducted with S16LPN on 05/15/2024 at 10:18 a.m. She stated that the resident asked for pain medications every hour and that his pain medications were not effective. She stated that she had informed S15NP at least three times since Resident #326's admission. She stated S15NP reported to her that he could not change the pain medication.
On 05/14/2024 at 12:20 p.m., an interview was conducted with S15NP and S3DONNIP. S15NP stated the nurse had reported to him in the past that the resident's pain regimen was ineffective. He stated that he definitely found the pain regimen to be ineffective but wanted to wait for a period of time to make changes to Resident #326's pain medication. S3DONNIP verified that there was no progress note from the NP or nursing documentation since admit mentioning the ineffectiveness of Resident #326's pain regimen.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent, by failing to administer medications at the right time for 4 of 4 (#16, #41, #53, and #67) residents observed during morning medication pass. This deficient practice had the potential to affect a census of 74 residents.
Findings:
On 05/15/2024, a review of the facility's policy titled Administering Medications with a revision date of 04/05/2024, read in part: Policy heading: Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .
A review of the facility's medication pass schedule revealed Med Pass Times: Culture Times .BID (twice a day): 6 a.m. (before noon) - 11 a.m., 7 p.m. (after noon) - 10 p.m. TID (three time a day): 6 a.m. - 11 a.m., 12 p.m. - 1 p.m., 7 p.m. - 10 p.m .
On 05/13/2024 beginning at 11:07 a.m., an observation was made of S18LPN (Licensed Practical Nurse) during morning medication pass on Hall W. As she was preparing the resident's medications, the EMARs (Electronic Medical records) revealed the following residents' names highlighted in red which indicated the medications were being administered late:
Resident #16:
Resident #16 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Cardiomyopathy, Chronic Diastolic Heart Failure and Essential Primary Hypertension.
A review of current physician's orders revealed an order for Carvedilol tablet 3.125mg (milligrams) two times a day related to Essential Primary Hypertension.
A review of the medication audit report revealed on 05/13/2024, Carvedilol tablet 3.125 mg was scheduled to be given at 7:00 a.m., but was administered by S18LPN at 12:18 p.m.
Resident #41
Resident #41 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified Atrial Fibrillation, Unspecified Diastolic Congestive Heart Failure, and Anxiety Disorder.
A review of current physician's orders revealed an order for Xanax Tablet 0.5 mg. Give 1 tablet by mouth two times a day for anxiety related to Anxiety Disorder. Further review revealed an order for Buspirone HCL (Hydrochloride) tablet 10 mg. Give 1 tablet by mouth two times a day related to Anxiety Disorder.
A review of the medication audit report revealed that on 05/13/2024, Xanax Tablet 0.5 mg, and Buspirone HCL Tablet 10mg were scheduled to be given at 7:00 a.m., but were administered by S18LPN at 11:34 a.m.
Resident #53
Resident #53 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, Central Cord Syndrome at C2 Level of Cervical Spinal Cord, Central Cord Syndrome at C4 Level of cervical Spinal Cord, Neuralgia and Neuritis, Pain, and Legal Blindness.
A review of current physician's orders revealed orders for Gabapentin capsule 100 mg Give 1 capsule by mouth three times a day for nerve pain related to Neuralgia and Neuritis, Timolol Maleate Ophthalmic Solution 0.5% (percent) Instill 1 drop in left eye two times a day for Intraocular pressure, and Docusate sodium capsule 100 mg. Give 1 capsule by mouth two times a day related to constipation.
A review of the medication audit report revealed that on 05/13/2024, Gabapentin capsule 100 mg, Timolol Ophthalmic solution 0.5% and Docusate Sodium capsule 100mg were to be given between 6 a.m. to 11 a.m., and were administered by S18LPN at 12:56 p.m.
Resident #67
Resident #67 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus without Complications, Atherosclerosis of Coronary Artery Bypass Graft (s) without Angina Pectoris, Vitamin Deficiency, and Critical Illness Myopathy.
A review of current physician's orders revealed orders for Apixaban Oral Tablet 5 mg. Give 1 tablet by mouth two times a day related to Atherosclerosis of Coronary Artery Bypass Graft without Angina Pectoris, Jardiance Oral Tablet. Give 1 tablet by mouth one time a day related to Type 2 Diabetes Mellitus with Unspecified Complications, Magnesium Oxide Tablet 400 mg. Give 1 tablet by mouth two times a day related to Vitamin Deficiency, and Metformin HCL Oral Tablet 500 mg. Give 2 tablets by mouth two times a day related to Type 2 Diabetes Mellitus.
A review of the medication audit report revealed that on 05/13/2024, Apixaban Oral Tablet 5 mg, Magnesium Oxide Tablet 400 mg, Jardiance Oral Tablet 25 mg, and Metformin HCL oral Tablet 500 mg were scheduled to be given at 7:00 a.m., but were administered by S18LPN at 11:47 a.m.
On 05/13/2024 at 12:13 p.m., an interview was conducted with S18LPN. She stated that morning medication pass was between 6:00 a.m. and 11:00 a.m., but she was late for work this morning and reported it to the S3DONIP (Director of Nursing/Infection Control) and S4ADON (Assistant Director of Nursing). S18LPN confirmed all the medications listed above were administered late.
On 05/14/2024 at 7:59 a.m., an interview was conducted with S3DONIP and S4ADON. S4ADON stated she worked the night shift on 05/12/2024 and was also on call. She confirmed that S18LPN called to inform her that she was running late for work. S4ADON stated that when she was leaving on 05/13/2024 at 9:30 a.m., S18LPN was just doing her narcotic count. S3DONIP stated that she became aware on 05/13/2024 at 7:18 a.m. that S18LPN was running late for work. She further stated that she was informed by S18LPN on 05/13/2024 at 3:00 p.m. that the medications were late. S3DONIP stated S18LPN should have informed her that residents' medications were going to be late, but she did not.
Nov 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE] with diagnoses in part .Other Cord Compression, Myotonic Muscular...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE] with diagnoses in part .Other Cord Compression, Myotonic Muscular Dystrophy, Unspecified Severe Protein Calorie Malnutrition, Pressure Ulcer of Right Hip Stage 3, and Pressure Ulcer of Sacral Region Stage 3.
Review of Resident #3's November 2023 physician's orders revealed the following order dated 11/14/2023: Open area to sacrum-Cleanse with wound cleanser, apply Medihoney, and cover with optifore (Optifoam) every other day and PRN (as needed).
Review of Resident #3's Weekly-Wound Observation Tool revealed the following wound information in part .A. Wound Information .1. Site 23) Coccyx 1b. Date acquired: 11/14/2023 .3. Wound type .3c. Pressure Injury .Stage b. Stage II
Review of Resident #3's care plan dated 10/24/2023 revealed that the resident was care planned for Pressure Injury to Sacrum (Stage 3). Further review of the resident's care plan revealed no update or revision to the care plan to reflect the resident's new Stage 2 pressure injury to his sacrum acquired at the facility on 11/14/2023.
On 11/29/2023, at 4:25 p.m., an interview and record review was conducted with S6MDS (Minimum Data Set). Resident #3's care plan was reviewed with S6MDS. S6MDS confirmed that the resident's care plan should have been updated and/or revised to reflect his current wound status.
Based on record review and interview, the facility failed to ensure that a resident's care plan was accurately updated with the appropriately identified problem areas and interventions to reflect the resident's current wound status for 2 (#2, and #3) out of 8 (#1, #2, #3, R1, R2, R3, R4 and R5) sampled residents.
Findings:
Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, read in part .8. The comprehensive, person centered care plan will: .g. Incorporate identified problem areas .further review of facility policy .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.
Resident #2
Review of the Resident #2's electronic medical record revealed he was admitted to facility on 08/20/2021 with the following pertinent diagnoses: Spinal Stenosis-Lumbar Region with Neurogenic Claudication, Spinal Stenosis-Thoracic Region, Neuromuscular Dysfunction of Bladder, Peripheral Vascular Disease (PVD), Lymphedema and Chronic Viral Hepatitis C.
Review of Resident #2's current care plan revealed, in part, problem area of Stage 2 Pressure Injury to right buttock (superior) initiated on 10/13/2023 by S6MDS (Minimum Data Set Coordinator).
Review of weekly wound observation tool dated 11/07/2023 revealed Resident #2 right buttock wound was newly identified as an unstageable pressure injury.
On 11/29/2023 at 4:22 p.m., an interview was conducted with S6MDS. S6MDS reviewed Resident #2's care plan and confirmed the resident was care planned with a problem area of a Stage 2 Pressure Injury to his right buttock. S6MDS stated she was not aware that Resident #2 now had an unstageable pressure wound to his right buttock. S6MDS confirmed that the resident's care plan should have been updated and/or revised to reflect the resident's current wound status.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE] with diagnoses in part .Other Cord Compression, Myotonic Muscular...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE] with diagnoses in part .Other Cord Compression, Myotonic Muscular Dystrophy, Unspecified Severe Protein Calorie Malnutrition, Pressure Ulcer of Right Hip Stage 3, and Pressure Ulcer of Sacral Region Stage 3.
Review of Resident #3's November 2023 physician's orders revealed the following order dated 11/14/2023: Open area to sacrum-Cleanse with wound cleanser, apply Medihoney, and cover with optifore (Optifoam) every other day and PRN (as needed).
Review of Resident #3's November TAR (Treatment Administration Record) revealed the following: Open area to sacrum-Cleanse with wound cleanser, apply Medihoney, and cover with optifore (Optifoam) every other day. One time a day every other day. Order date 11/14/23. There were no documented treatments for the resident's sacral wounds on the following dates: 11/17/2023, 11/19/2023, 11/21/2023, 11/23/2023, 11/25/2023, and 11/27/2023.
Review of Resident #3's November Weekly Wound Observation Tool failed to reveal an assessment of the resident's sacral wound for the week of 11/21/2023.
On 11/28/2023 at 3:10 p.m., an interview and record review was conducted with S2DON (Director of Nursing). Resident #3's TAR and Weekly Wound Observation Tool was reviewed with S2DON. S2DON confirmed that the resident's treatment to his sacrum was not completed as ordered. S2DON's hand written wound observations and measurements were then reviewed. S2DON stated that she assessed the resident's wound on 11/22/2023. Further review of the hand written assessment failed to include measurements of the resident's sacral wound. S2DON further confirmed that there was not a sacral wound assessment or measurements documented for the week of 11/21/2023.
On 11/28/2023 at 4:15 p.m., an interview was conducted with S7LPN (License Practical Nurse). S7LPN stated she had not provided any type of wound care for Resident #3 for the month of November.
On 11/29/2023 at 9:02 a.m., an interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN stated she had not provided any type of wound care for Resident #3 for the month of November.
Based on record review, observation and interview, the facility failed to provide weekly wound assessments and failed to perform daily wound care as ordered for 2 (#2 and #3) out of 2 (#2 and #3) residents investigated for pressure ulcers out of a final sample of 8 residents (#1-#3 and R1-R5).
Findings:
Review of the facility's policy titled, Pressure Injury Prevention Program, revealed in part:
Standard: All residents will be assessed for risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. 6. Weekly Wound Assessment a. Each identified skin issue/area is assessed weekly in electronic medical record for:
Size
Stage (staged by RN (Registered Nurse) or PT (Physical Therapist))
Location
Drainage amount
If odor is present
Signs and symptoms of infection if present
Wound bed description
Wound edge and surrounding tissue description
How the resident tolerated the wound care .b. If treatment or interventions change or wound presentation is reclassified (ex. PrI to Arterial or Stage II to unstageable) update care plan .7. Wound Care .d. If a resident refuses dressing changes/treatments, administrative nursing is notified and intervenes with education. If refusals continue, a psych evaluation may be warranted and/or physician re- evaluation. Clinicians should document refusals, notification of administrative nursing, physician and RP (responsible party) Care Plan should be updated to reflect refusals and attempts to obtain compliance to care .
Resident #2
Review of the resident's electronic medical record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses: Protein Calorie Malnutrition, Spinal Stenosis-Lumbar Region with Neurogenic Claudication, Spinal Stenosis-Thoracic Region, Peripheral Vascular Disease (PVD), Lymphedema and Chronic Viral Hepatitis C.
Review of Resident #2's Annual Minimum Data Set (MDS) Assessment revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating he was cognitively intact.
Review of Resident #2's November 2023 physician's orders revealed an entry date of 11/08/2023 for wound to right buttock to Cleanse with wound cleanser, moistened gauze, apply into wound, cover with abd (abdominal) pad and tape in place once daily and prn (as needed).
Review of Resident #2's November 2023 TAR (Treatment Administration Record) revealed a treatment with an order date of 11/09/2023 for wound to right buttock to cleanse with wound cleanser, moistened gauze, apply into wound, cover with abd pad and tape in place once daily and prn. The treatment was last completed on 11/15/2023 by S5LPN (Licensed Practical Nurse).
Further review of Resident #2's November 2023 TAR revealed the resident refused treatment to wound to right buttock on 11/17/2023 and 11/20/2023. There were no documented treatments for the wound to the right buttock on the following dates: 11/16/2023, 11/18/2023, 11/19/2023 and 11/21/2023 through 11/27/2023.
Review of Resident #2's Weekly Wound Observation Tool revealed there was no documentation or wound assessment for the week of 11/21/2023.
On 11/28/2023 at 1:20 p.m., an interview was conducted with Resident #2. Resident stated the new treatment nurse S10LPN (Licensed Practical Nurse) had not performed any wound care to his right buttock since S5LPN resigned approximately two weeks ago.
On 11/28/2023 at 3:12 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S4CorpRN (Corporate Registered Nurse). S4CorpRN reviewed Resident #2's electronic medical record and confirmed there was no documentation indicating the resident refused treatment to the wound to his right buttock nor that treatment was completed for the following dates that were blank on his November2023 TAR: 11/16/2023, 11/18/2023, 11/19/2023 and 11/21/2023 through 11/30/2023.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a safe and sanitary, environment to help prev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a safe and sanitary, environment to help prevent the development and transmission of communicable diseases and infections by failing to remove contaminated gloves and perform hand hygiene during wound care for 1 (#3) resident out of 7 (#2, #3, R1, R2, R3, R4, R5) residents investigated for wound/skin treatments.
Findings:
Review of the facility's policy titled, Hand Washing and Hand Hygiene, read in part .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc .i. After contact with a resident's intact skin.
Resident #3 was admitted to the facility on [DATE] with diagnoses in part .Other Cord Compression, Myotonic Muscular Dystrophy, Unspecified Severe Protein Calorie Malnutrition, Pressure Ulcer of Right Hip Stage 3, and Pressure Ulcer of Sacral Region Stage 3.
Review of Resident #3's November 2023 physician's orders revealed the following order dated 11/14/2023: Open area to sacrum-Cleanse with wound cleanser, apply Medihoney, and cover with optifore (Optifoam) every other day and PRN (as needed).
On 11/29/2023 at 9:27 a.m., an observation was conducted of S3ADONIP (Assistant Director of Nursing/Infection Preventionist) as she provided Resident #3's wound care treatment. S3ADONIP put on a pair of gloves then cleaned the resident's wound. S3ADONIP retrieved Medihoney, applied it to the resident's wound, then covered the wound with a clean dressing wearing the same gloves used to clean the resident's wound. S3ADONIP did not change gloves or sanitize hands after cleaning Resident #3's wound or prior to applying the Medihoney or clean dressing.
On 11/29/2023 at 09:45 a.m., an interview was conducted with S3ADONIP. S3ADONIP confirmed she should have changed gloves and sanitized her hands after cleaning Resident #3's wound and prior to applying Medihoney and the clean dressing.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 6 (#1, and R1-R5) out of 8 (#1-#3, R1-R5) sampled residents as evidenced by:
1. Failing to ensure a floor mat was at the bedside for Resident #1 and;
2. Failing to ensure skin and wound treatments were completed as ordered for Residents R1, R2, R3, R4, and R5.
Findings:
Review of the facility's policy titled Care plans, Comprehensive Person-Centered read in part .A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.
Resident #1
Resident #1 was admitted to the facility on [DATE] with diagnoses in part: Flaccid Hemiplegia Affecting Right Dominant Side, Unspecified Non-displaced Fracture of Surgical Neck of Right Humerus, Repeated Falls, and Generalized Anxiety.
Review of Resident #1's November 2023 physician's orders revealed an order dated 04/10/2023 that read: Landing pad beside bed two times a day for safety.
Review of Resident #1's plan of care revealed in part: The resident had an actual fall, and an intervention for landing pad at bedside as ordered.
On 11/28/2023 at 12:15 p.m., an observation was made of Resident #1 in her room as she rested in bed. The resident's bed was flush against the wall. Further observation revealed the resident's landing pad propped against the dresser and not on the floor at the resident's bedside.
On 11/28/2023 at 1:00 p.m., a second observation was made of Resident #1 in her room in her bed. S7LPN (Licensed Practical Nurse) entered Resident #1's room at this time to administer medication to the resident's roommate. Resident #1's landing pad remained propped against the dresser and not on the floor at the resident's bedside. S7LPN confirmed the landing pad was propped against the dresser and should have been placed on the floor at Resident #1's bedside.
Residents R1, R2, R3, R4, R5
Resident R1 was admitted to the facility on [DATE] with diagnoses in part: Hemiplegia and Hemiparesis following cerebral infarction affecting left non dominant side, Unspecified Dementia, and Type 2 diabetes.
Review of Resident R1's November 2023 physician's orders revealed an ordered dated 09/29/2023 that read: Right great toe- Apply skin prep daily to DTI (Deep Tissue Injury) on outside of right great toe one time a day.
Review of Resident R1's plan of care revealed in part . The resident has a DTI to rt (right) great toe, with an intervention to apply skin prep daily to DTI on outside of right great toe.
Review of Resident R1's October 2023 TAR (Treatment Administration Record) revealed no documented treatments to the resident's right great toe on the following dates: 10/2/2023, 10/3/2023, 10/7/2023, 10/8/2023, 10/14/2023, 10/21/2023, 10/22/2023, 10/28/2023 and 10/29/2023.
Review of Resident R1's November 2023 TAR (Treatment Administration Record) revealed no documented treatments to the resident's right great toe on the following dates: 11/1/2023, 11/2/2023, 11/4/2023, 11/5/2023, 11/11/2023, 11/16/2023, 11/18/2023, 11/19/2023, 11/21/2023, 11/23/2023, 11/24/2023, 11/25/2023, and 11/27/2023.
Resident R2 was admitted to the facility on [DATE] with diagnoses in part: Extension of Lower End of Right Femur, Subsequent Encounter for Closed Fracture with Nonunion, and Disruption of External Operation (Surgical) Wound.
Review of Resident R2's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 15, indicating her cognition was intact.
Review of Resident R2's November 2023 physician's orders revealed an order dated 11/20/2023 with a discontinue date of 11/28/2023 that read: Cleanse with wound, apply abd (Abdominal) pad, and secure with meflex tape qd (Every Day) and prn (As Needed) every day shift.
Review of Resident R2's plan of care revealed in part . The resident has actual impairment to skin integrity of the RT (Right) Knee, with an intervention to cleanse with wound cleanser, apply abd pad, and secure with meflex tape qd and prn.
Review of Resident R2's November 2023 TAR (Treatment Administration Record) revealed no documented surgical wound treatments on the following dates: 11/21/2023, 11/23/2023 to 11/25/2023, and 11/27/2023.
On 11/29/2023 at 11:45 a.m., an interview was conducted with Resident R2. Resident R2 stated that she did not receive wound care to her surgical site daily. She further stated that the nurses completed her wound care mostly every other day but never on the weekend.
Resident R3 was admitted to the facility on [DATE] with diagnoses in part: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side and Type 2 diabetes.
Review of Resident R3's November 2023 physician's orders revealed the following orders:
1. Excoriation to groin area: apply skin paste q (every) day and prn until resolved ordered 10/30/2023;
2. Vashe Wound External Solution 0.033% (Wound Cleansers) Apply to left 3rd toe topically every day shift for wound, cleanse with vashe, apply calazime protectant paste to peri wound. Apply aquacel ag, cover with 4x4 then abd pad, secure with kerlix and tape ordered 11/21/2023;
3. Vashe Wound External Solution 0.033% (Wound Cleansers) Apply to right lateral foot topically every day shift for wound, cleanse with vashe, apply calazime protectant paste to peri wound. Apply aquacel ag, cover with 4x4 then abd pad, secure with kerlix and tape ordered 11/21/2023.
Review of Resident R3's November 2023 TAR revealed no documented wound treatments on the following dates: 11/24/2023, 11/25/2023, 11/26/2023, and 11/27/2023.
Resident R4 was admitted to the facility on [DATE] with diagnoses in part: Other Chronic Osteomyelitis, Right Ankle and Foot and Type 2 diabetes.
Review of Resident R4's November 2023 physician's orders revealed an order dated 10/11/2023 and discontinued 11/28/2023 that read: Cleanse with Vashe, apply calazime to periwound, pack with Aquacel AG Advantage Hydrofiber rope with silver, apply gauze and ABD, wrap with kerlix and secure with Mefix tape.
Review of Resident R4's plan of care revealed in part: Surgical wound to right foot plantar, with an intervention to cleanse with Vashe, apply calazime to periwound, pack with Aquacel AG Advantage Hydrofiber rope with silver, apply gauze and ABD, wrap with kerlix and secure with Mefix tape.
Review of Resident R4's November 2023 TAR revealed no documented surgical wound treatments on the following dates : 11/21/2023, 11/22/2023, 11/24/2023, 11/25/2023, 11/26/2023, and 11/27/2023.
Resident R5 was admitted to the facility on [DATE] with diagnoses in part: Type 2 diabetes and Peripheral Vascular Disease.
Review of Resident R5's November 2023 physician's orders revealed the following orders:
1. Right lower front shin: Clean with wound cleanser, pat dry, apply marathon, allow to dry, pad with 4x4 gauze, wrap with kerlix secure with tape q (every) 3 days or prn ordered 11/17/2023;
2. Right outer ankle: Clean with wound cleanser, pat dry, and paint with betadine open to air QD (Every Day) ordered 11/17/2023.
Review of Resident R5's plan of care revealed in part: The resident has diabetic wound to rt (right) ankle with an intervention for Right outer ankle- Clean with wound cleanser, pat dry, and paint with betadine open to air QD. Further review of the resident's plan of care revealed an intervention for right lower front shin to Clean with wound cleanser, pat dry, apply marathon, allow to dry, pad with 4x4 gauze, wrap with kerlix secure with tape q 3 days and every 24 hours as needed.
Review of Resident R5's November 2023 TAR revealed no documented wound treatments to the resident's right lower front shin on the following dates: 11/18/2023, 11/21/2023, 11/24/2023, and 11/27/2023. Further review of Resident R5's November 2023 TAR revealed no documented wound treatments to the resident's right outer ankle on the following dates: 11/18/2023, 11/19/2023, 11/21/2023, 11/23/2023, 11/24/2023, 11/25/2023, and 11/27/2023.
On 11/29/2023 at 4:30 p.m., an interview was conducted with S3ADONIP (Assistant Director of Nursing/Infection Preventionist). Resident R1's October and November 2023 TARs and Residents R2, R3, R4, and R5's November 2023 TARs were reviewed with S3ADONIP. S3ADONIP confirmed that there was no evidence the residents' treatments were completed as ordered and the nurses should have completed those treatments or documented refusals in the resident's medical record.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, the facility failed to have a plan in place to ensure how treatments were going to be ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, the facility failed to have a plan in place to ensure how treatments were going to be completed when the treatment nurse resigned. This deficient practice had the potential to affect the 75 residents who resided in the facility.
Findings:
Upon entry to the facility on [DATE] at 9:00 a.m., S10LPN (Licensed Practical Nurse) stated she was a prn (as needed) staff and helped the facility with completing treatments. She pulled up the facility's list of resident's with current wound and skin treatments, which failed to include Resident #2.
On 11/28/2023 at 9:30 a.m., S11LPN was asked to provide surveyor with names of current residents on her assigned hall who currently received wound and skin treatments. S11LPN stated Resident #2 had an unstageable pressure ulcer.
Record review of sampled residents' October 2023 and November 2023 electronic Treatment Administration Records (eTARs) revealed there was no documentation to indicate the treatments were completed as ordered.
Review of sampled residents' progress notes failed to include documentation that resident's had refused ordered treatments.
On 11/28/2023 at 3:12 p.m., an interview was conducted with S2DON (Director of Nursing) and S4CorpRN (Corporate Registered Nurse). They reviewed sampled residents #2 and #3 eTARs. S4CorpRN confirmed there were no documented treatments or documented refusals for Resident #2 on the following dates: 11/16/2023, 11/18/2023, 11/19/2023 and 11/21/2023 thru 11/27/2023. S2DON confirmed there were no documented treatments or documented refusals for Resident #3 on the following dates: 11/17/2023, 11/19/2023, 11/21/2023, 11/23/2023, 11/25/2023 and 11/27/2023.
On 11/29/2023 at 9:40 a.m., a phone interview was conducted with S5LPN who stated she had provided the facility with her two weeks notice and her last day worked was 11/15/2023. S5LPN further stated she was not instructed to nor did she train a replacement treatment nurse during her last two weeks.
On 11/29/2023 at 3:30 p.m., an interview was conducted with S9MD (Medical Director). S9MD stated he would expect the facility's administrative staff to notify him of any concerns regarding treatments not being carried out after S5LPN resigned. S9MD confirmed he was not notified by administrative staff, therefore he was not aware resident treatment's were not being completed as ordered.
On 11/29/2023 at 5:13 p.m., a group interview was conducted with S1ADM (Administrator), S3ADONIP (Assistant Director of Nursing and Infection Preventionist) and S4CorpRN. S1ADM and S3ADONIP explained that S10LPN was assigned responsibility of completing the residents' wound and skin treatments after S5LPN resigned. Both further stated S10LPN was a prn staff member and did not have a set schedule or hours. If S10LPN was unable to come in, S3ADONIP stated the floor nurses were responsible for completing the ordered treatments. S3ADONIP further stated there was no follow up to ensure treatments were being completed as ordered. S1ADM was unable to provide information that a process was implemented after S5LPN resigned to ensure treatments were being performed as ordered.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to maintain a clean and homelike environment by failin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to maintain a clean and homelike environment by failing to ensure a resident's urine was properly disposed of in order to prevent the overly pungent odor of urine for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents.
Findings:
Review of the facility's policy, Homelike Environment revealed, in part, the following: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment .pleasant, neutral scents .
Review of Resident #2's record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses= Intervertebral Disc Degeneration Lumbar Region, Major Depressive Disorder-Recurrent, Type 2 Diabetes Mellitus, Morbid (Severe) Obesity, Chronic Obstructive Pulmonary Disease, Repeated Falls, Orchitis (Testicular Swelling), Heart Failure, Neuromuscular Dysfunction of Bladder, Peripheral Vascular Disease and Hypertension.
Review of Resident #2's Annual 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating his cognition was intact.
Further review of Resident #2's Annual 5 day MDS assessment revealed he required one person physical assistance with toileting. Resident #2 was coded as not being steady, but able to stabilize without staff assistance when moving from seated to standing position.
On 08/14/2023 at 9:22 a.m., an initial walkthrough of Hall B revealed a strong presence of a urine odor. Upon entering Resident #2's room, the urine odor was at its strongest. Resident #2's roommate was observed resting in bed and Resident #2 stated his roommate had a stroke and was unable to talk or care for himself. A plastic urinal dated 07/24/23 was observed on top of Resident #2's bedside table with a yellow stain noted on the rim of the uncovered urinal.
On 08/14/2023 at 9:30 a.m., Resident #2's roommate had 2 visitors and the visitors made a comment about the strong urine smell in the room.
On 08/15/2023 at 10:09 a.m., upon entering Resident #2's room, a strong urine odor was noted.
On 08/15/2023 at 10:15 a.m., an interview was conducted with S5CNA (Certified Nursing Assistant) in the hallway directly outside of Resident #2's room. S5CNA confirmed Resident #2 used a urinal that he kept at his bedside and stated the resident urinated a lot pointed out the strong smell of urine that was present. S5CNA further stated that when she entered his room earlier, she had picked up his blankets from the floor that were wet with urine and she left his bed without linens to allow the bed to air out because the urine smell was so bad.
On 08/15/2023 at 10:18 a.m., S5CNA accompanied surveyor to Resident #2's room and confirmed the presence of a plastic uncovered urinal dated 07/24/23 that was located on the resident's bedside table with approximately 700 mls (milliliters) of dark yellow urine inside. S5CNA also confirmed the presence of a yellow stain noted on the rim of the uncovered urinal. S5CNA immediately disposed of the urine and urinal.
On 08/15/2023 at 3:17 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse) who stated that the CNAs were to change out the urinals on the day shift. S4LPN confirmed Resident #2 used a urinal in his room and sometimes his room had a strong urine smell. She stated Resident #2 sometimes spilled urine on his floor, on his bed and bedside table.
On 08/15/2023 at 4:13 p.m., an interview was conducted with S1ADM (Administrator) who confirmed Resident #2 used a urinal in his room and often did not allow staff to throw the urinal. S1ADM agreed that since Resident #2 has a roommate, staff should be making sure the room does not remain with a urine odor.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews the facility failed to ensure their grievance policy and procedure was fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records reviewed and interviews the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents.
Findings:
Record review of the policy titled, Filing Grievances/Complaints read in part, Our facility will assist residents, their representatives .in filing grievances .when such request are made .2. Grievances may be submitted orally or in writing .6. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer. 7. Upon receipt of a written grievance .the grievance officer will review and investigate the allegations and summit a written report of such findings to the administrator within 72 hours of receiving the grievance. 10. The Administrator will review the findings with the Grievance Officer to determine what corrective action .to be taken . 13. The results of all grievances filed, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.
Review of Resident #2's record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses= Intervertebral Disc Degeneration Lumbar Region, Major Depressive Disorder-Recurrent, Type 2 Diabetes Mellitus, Morbid (Severe) Obesity, Chronic Obstructive Pulmonary Disease, Repeated Falls, Orchitis (Testicular Swelling), Heart Failure, Neuromuscular Dysfunction of Bladder, Peripheral Vascular Disease and Hypertension.
Review of the facility's grievance log dated 05/2023 to 08/14/2023 failed to include Resident #2 concerning his scheduled shower in the whirlpool room.
On 08/14/2023 at 9:22 a.m., an interview was conducted with Resident #2 who stated he was supposed to receive his scheduled shower, in whirlpool, a couple of weeks ago but was unable to alleging that one of the shower CNAs (Certified Nursing Assistants) told him he had to wait. Resident #2 explained when staff informed him that it was his turn to shower, that it took him longer than normal, because his roommate was being assisted by staff. Resident #2 stated once staff were finished assisting his roommate, he used his walker and walked to the whirlpool room. When he reached the whirlpool room, one of the shower CNAs, S8CNA, told him that he had to wait. The resident stated S8CNA told him that he should have walked faster. Resident #2 admitted that he became frustrated because he was expected to stand and wait until the shower was available for him. Resident #2 and the S8CNA began arguing, then Resident #2 walked away to go to the gym for his therapy session. When Resident #2 was in the therapy gym, he stated that he was still upset about not being able to shower and began arguing with another resident in the gym. Resident #2 stated S3RN (Registered Nurse), who was the Director of Nursing (DON) at that time, had come to the gym to calm him down. S3RN escorted Resident #2 back to his room, where he told S3RN what had happened to make him so upset.
On 08/15/2023 at 1:12 p.m., an interview was conducted with S6PT (Physical Therapist) who recalled Resident #2 being upset last month because something happened near the whirlpool room before the resident came to therapy. When Resident #2 came to therapy, he and another resident were arguing with each other and S3RN (Registered Nurse) intervened and escorted Resident #2 back to his room. S6PT stated S7PTA (Physical Therapy Assistant) was on Hall B and attempted to get Resident #2 for therapy but Resident #2 was on his way to the whirlpool room.
On 08/15/2023 at 1:22 p.m., an interview was conducted with S7PTA who recalled Resident #2 being upset in therapy last month. S7PTA reported he went to get Resident #2 for therapy and Resident #2 told him that he would come when he was done with his shower. S7PTA explained he returned to the therapy gym and shortly after, Resident #2 walked in and was voicing how upset he was because the resident was not able to shower. S7PTA confirmed S3RN, who was the former DON, came in the therapy room and assisted Resident #2 back to his room.
On 08/15/2023 at 1:42 p.m., a phone interview was attempted with S3RN with no answer.
On 08/15/2023 at 2:30 p.m., a second attempt was made to interview S3RN by phone with no answer.
On 08/15/2023 at 4:00 p.m., S2CRN (Corporate Registered Nurse) stated she attempted to notify S3RN by phone and S3RN did not answer.
On 08/15/2023 at 4:13 p.m., an interview was conducted with S1ADM (Administrator) who confirmed there was no documentation of the incident involving Resident #2 being upset after S8CNA reportedly told him that he had to wait to shower because he should have walked faster. S1ADM confirmed S3RN was involved and that S3RN should have initiated a grievance and did not.
Apr 2023
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to maintain a comfortable and homelike environment by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to maintain a comfortable and homelike environment by failing to ensure the window air conditioner (AC) unit was working for 1 (#3) of 5 (#3, #28, #33, #42 and #53) residents investigated for environment.
Findings:
Review of the facility's policy, Homelike Environment revealed, in part, the following: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting . h. comfortable temperatures.
Review of Resident #3's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Epilepsy, Hypothyroidism, Shortness of Breath, Body Mass Index 45.0-49.9 and Peripheral Vascular Disease.
Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating her cognition was intact.
Record review of the facility's maintenance log from 01/18/2023 to 04/18/2023 revealed no report of Resident #3's window AC unit was not working.
Observation on 04/17/2023 at 6:29 a.m., revealed Resident #3's window AC unit was plugged in and not working. No fan was observed in Resident #3's room. Resident #3's room felt warm.
A follow up observation on 04/18/2023 at 12:42 p.m., revealed Resident #3's window AC unit was plugged in and not working. No fan provided to Resident #3. Resident #3's room felt warm.
On 04/18/2023 at 3:45 p.m., an interview was conducted with Resident #3. Resident #3 stated her window AC unit has not worked for months and she was hot in her room. She stated she told S9Maint about this issue months ago, it was still not fixed and she was not provided a fan.
On 04/18/2023 at 4:00 p.m., an interview was attempted with S9Maint. Was informed by S1Adm (Administrator) that S9Maint has left for the day.
On 04/18/2023 at 4:04 p.m., an interview and room observation was conducted with S1Adm. S1Adm plugged in Resident #3's wall AC unit and pressed the power button. S1Adm confirmed that the wall AC unit was not working. S1Adm confirmed that Resident #3's room felt warm. S1Adm confirmed that the wall AC unit should have been fixed by S9Maint at the time Resident #3 told S9Maint it was not working and in the meantime, a fan should have been provided. S1Adm confirmed that this was not a comfortable and homelike environment.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #57
Review of Resident #57's electronic health record revealed he was admitted to the facility on [DATE] with the follo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #57
Review of Resident #57's electronic health record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses: Obesity, Chronic Obstructive Pulmonary Disease, Rheumatoid Arthritis, Paralytic Gait, Gout and Depression.
Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 12 indicating he had intact cognition.
Review of admission MDS assessment dated [DATE] under Section F: Preferences for Customary Routine and Activities revealed a score of 1. Very important to have snacks available between meals, do things with groups of people and to do favorite activities .
Review of facility's Grievance Logs dated 11/2022 to 04/17/2023 revealed no documentation of a grievance being filed on behalf of Resident #57 for not receiving a meal tray involving S12AC (Activity Coordinator).
On 04/18/2023 at 12:34 p.m., an interview was conducted with Resident #57 who stated he enjoyed going to group activities like bingo, sundae social and visiting with other residents. Resident #57 further stated he has not attended group activities since he got into an argument with S12AC earlier this year when he requested a meal tray and it was not delivered. Resident #57 explained that he was informed that S12AC canceled his meal. Resident #57 confronted S12AC about his meal being cancelled and stated he and S12AC argued. Since then, Resident #57 stated he has not been offered to go to group activities. Resident #57 further stated S1Adm (Administrator) talked to him shortly after the argument, but reported he was never informed of a resolution.
On 04/19/2023 at 9:46 a.m., an interview was conducted with S14LPN (Licensed Practical Nurse), who stated Resident #57 told her he got into it with S12AC while S14LPN was off shift. S14LPN added that Resident #57 was actively involved in group activities prior to his alleged argument with S12AC.
An interview was conducted with S13CNA (Certified Nursing Assistant) on 04/19/2023 at 12:08 p.m. S13CNA recalled the argument between Resident #57 and S12AC but was unable to recall an approximate date. S13CNA stated she believed it was a misunderstanding about Resident #57 requested a bowl of rice only, not the entire meal being served and something happened that his request was cancelled. She further stated that S12AC attempted to explain what happened to Resident #57, but he became really upset and began screaming at S12AC. S12AC had to go get S1Adm to talk to the resident.
On 04/19/2023 at 4:21 p.m., an interview was completed with S12AC. S12AC recalled the incident when Resident #57 screamed at her because the resident blamed her for his meal being cancelled. S12AC stated Resident #57 was screaming so loud that she had to go get S1Adm to go talk to the resident to try and calm him down. S12AC confirmed Resident #57 has not attended group activities since he hollered at her.
An interview was conducted on 04/19/2023 at 4:29 p.m. with S1Adm, who stated Resident #57 had cussed S12AC out in front of a lot of people and that S1Adm talked to the resident shortly after the argument. S1Adm confirmed there was no documentation of the incident or a filed grievance for Resident #57's voiced concerns about not getting his meal tray and sudden absence from group activities. S1Adm further confirmed per the facility's policy, he should have filed a grievance.
Based on observations, records reviewed and interviews the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 2 (#21 and #57) of 2 ( #21 and #57) residents investigated for grievances
Findings:
Record review of the policy titled, Filing Grievances/Complaints read in part, Our facility will assist residents, their representatives .in filing grievances .when such request are made .2. Grievances may be submitted orally or in writing .3. Actions on such issues will be responded to in writing, including a rational for the response .6. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer. 7. Upon receipt of a written grievance .the grievance officer will review and investigate the allegations and summit a written report of such findings to the administrator within 72 hours of receiving the grievance. 10. The Administrator will review the findings with the Grievance Officer to determine what corrective action .to be taken .11. The person filling the grievance .will be informed verbally and/or in writing of the findings of the investigation and action to be taken to correct any .problem. 13. The results of all grievances filed, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.
Resident #21
Record review revealed Resident #21 was admitted to the facility on [DATE]. Her Responsible party was her daughter who lived locally. She had an accumulative diagnoses in part, of Cerebral Infarction, Insomnia, Dysphagia, Ataxia Gait, Cognitive Communication Deficit, Symbolic Dysfunctions, Cochlear Implant, Major Depressive Disorder, Repeated Falls, Muscle weakness and Need for assistance with personal Care.
Review of Grievance Log from 11/2022 to 04/17/2023 revealed there was no documentation on the log that Resident #21 or her Responsible Party (daughter) had complained since she was admitted to the facility on [DATE].
Record review of Grievance for Resident #21 received on 4/17/2023 at 11:28 a.m., read, Resident's daughter concerned about resident at times saying she still has discomfort.
On 04/17/2023 at 10:17 a.m., Resident #21 stated C.N.A. (Certified Nursing Assistant) was ugly to her 2 to 3 times and she told S2DON (Director of Nursing). The resident stated she needed to go to the bathroom and the C.N.A. told her that she needed to control her bowels and that she didn't have time to run into her room and bring her to the bathroom. She also stated she was using the bathroom and the C.N.A. asked her if she was grunting and if so she had to get off the toilet that she was finished. Resident #21 stated this hurt my feelings. The resident stated the same C.N.A. got real mad at her when she needed to go to the bathroom. She stated the C.N.A. left her room and did not come back to bring her to the toilet. She stated she told her daughter about these issues regarding the C.N.A.s.
On 04/18/2023 at 2:19 p.m., an interview with Resident #21's daughter confirmed she had complained to the DON that the CNA was abrasive and rude leaving her mother in soiled underpants and the toilet was soiled with feces around 03/15/2023. The daughter stated S2DON did not get back with her regarding what was done to resolve the issues. She stated on two other occasions S2DON came into her Mothers room and they talked about these issues again. She stated she stopped by S2DON's office on 04/17/2023 and complained again about all the previous issues. The resident's daughter stated her Mother was scared to talk to the LPN (Licensed Practical Nurse) when she needs help going to toilet and getting out of bed. She stated the C.N.A. told her mother that she needed to hurry and get off the toilet. The resident's daughter stated that one C.N.A. said she needed to get control of her bowels. They also told her she needed to stop walking so much because this was why she stays in pain.
On 04/18/2023 at 11:29 a.m., an interview was conducted with S2DON. She stated Resident #21 was admitted to the facility on [DATE] and shortly after admission, the resident's Daughter had complained how the Resident was being talked to rudely by the C.N.A.'s. She stated she did not document what staff was interviewed or fired or that she had talked to the Daughter for resolution. S2DON stated the Daughter called yesterday (04/17/2023) and complained that her mother had dried blood in her ear and head. She stated she did not fill out a grievance on this issue or document this in the nurse's notes.
On 04/19/2023 at 12:40 p.m., an interview with S1Adm (Administrator) confirmed that when a staff member received a grievance from a resident or responsible party the staff should document this on the grievance log. He was asked if he had documented who he talked to during the investigation and he said, No. He stated he did not put this grievance on the Grievance Log.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to implement a comprehensive person-centered care plan by failing to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to implement a comprehensive person-centered care plan by failing to follow physician order to document a resident's (#177) meal intake percentages for 1 (#177) of 2 (#64, #177) sampled residents for nutrition.
Findings:
Review of the facility document titled Charting and Documentation read in part, policy Interpretation and Implementation: .2. The following information is to be documented in the resident medical record: a. Objective observations .; f. Progress toward or changes in the care plan goals and objectives.
Record review revealed Resident #117 was admitted on [DATE]. Further review of the record revealed, in part, diagnoses of Anorexia, Chronic kidney disease, Iron deficiency anemia, Vitamin deficiency, and Unspecified protein calorie malnutrition.
Review of the resident's monthly weights revealed:
10/07/2022 - 179.0
11/07/2022 - 165.2
12/07/2022 - 159.4
01/07/2023 - 151.4
02/14/2023 - 154.4
03/07/2023 - 151.8
Review of physician orders revealed that Resident #177 was on a diet of renal pureed texture, nectar thickened consistency diet. On 01/25/2023, an order for a magical cup with meals was ordered for weight loss. Staff were to document amount consumed.
Review of Resident #177's care plan dated 03/03/2023 read in part, resident receives mechanically altered diet - assist resident with meals as needed, document amount consumed
Review of the facility Nutritional Intake flow sheet dated 01/2023 revealed that on 01/01/2023 - 01/08/2023, 01/10/2023, 01/15/2023, 01/17/2023, 01/19/2023, 01/22 - 01/25/203, and 01/27 - 01/31/203 meal consumption percentage were not recorded for all three meals. On 02/01/2023 - 02/04/2023, 02/06 - 02/07/2023, 02/09/2023, 02/11 - 02/12/2023, 02/15 - 02/18/2023, 02/21/2023, 02/23 - 02/24/2023, and 02/26 - 02/27/2023 meal consumption percentages were not recorded for all three meals. On 03/03/2023, 03/12 - 03/18/2023, 03/20 - 03/21/2023, and 03/23 - 03/31/2023 meal consumption percentages were not recorded. On 04/01 - 04/13/2023, and 04/16/2023 meal consumption were not recorded for all three meals.
On 04/19/2023 at 1:11 p.m., an record review and interview was conducted of the resident's meal consumption sheet with S16LPN (License Practical Nurse) who confirmed that the certified nursing assistants are supposed to record the percentage of meal consumed for each meal.
On 04/19/2023 at 1:45 p.m., an interview was conducted with S17RD (Registered Dietician) who confirmed stated that staff were supposed to record the Resident #117's meal intake. She added that when a resident is losing weight, it is important that the staff accurately record the meal intake percentage.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#45) of 3 (#45, #53 and #71) residents reviewed for ADLs. The facility failed to provide toenail care for Resident #45.
Findings:
Review of Resident #45's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses of Type 2 Diabetes Mellitus, Cerebral infarction, Aphasia, and Flaccid hemiplegia affecting right dominant side.
Review of physician orders dated 08/04/2022 read in part, podiatry consult for complaint of overgrown thick and painful toenails.
Review of care plan dated 03/29/2023 read in part, nail care as needed; nurse to cut nails since diabetic.
On 04/17/2023 at 11:27 a.m., an observation was conducted of Resident #45's toe nails. The resident's family stated that his toe nails were too long and needed to be cut. Upon Further observation revealed on the resident's left foot, his great toe nail was very long and growing sideways. The great toe nail on his right foot was thick and long.
On 04/19/2023 at 9:00 a.m., an observation of Resident #45 toe nails was conducted with S18LPN (License Practical Nurse) who confirmed that the residents toe nails needed to be cut.
On 04/19/2023 at 3:00 p.m., an interview was conducted with S3CP (Corporate Nurse) who stated that the facility had tried to get a podiatrist to come to the facility, but no one will accept the resident's insurance. S3CP confirmed that the podiatry consult was written on 08/04/2022 and it had been 8 months the facility had not located anyone to trim the residents toe nails.
On 04/19/2023 at 3:10 p.m., an interview was conducted with S19SS (Social Services) who stated that she had tried to reach out to different physicians and no one would accept the resident's insurance. She stated that after she was unable to obtain a physician who would accept the resident's insurance, she informed S1Adm (Administrator), and S20NP (Nurse Practitioner)
On 04/19/2023 at 3:14 p.m., a phone interview was conducted with S20NP who stated that he was aware that the resident needed his nails cut, but he does not cut the nails. S20NP stated that he used to have the tool to cut the toe nails, but he no longer had the tool, so he refer the residents to a podiatrist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure each resident with pressure ulcers received th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure each resident with pressure ulcers received the necessary treatment and services to promote healing as evidenced by the staff failing to follow physician's orders for wound care for 2 (#51, #126) out of 4 (#20, #43, #51, #126) residents investigated with pressure ulcers out of a total sample of 36 residents.
Findings:
1. Resident #51
Review of Resident #51's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Other Encephalitis and Encephalomyelitis, Osteomyelitis, Bacteria Infection, Type Two Diabetes Mellitus, and Unspecified Protein-Calorie Malnutrition.
Review of Resident #51's current physician's orders list revealed an order on 03/21/2023 Left bottom of foot: Clean with wound cleanser, pat dry apply non-adherent dressing cover with ABD (abdominal) wrap with kerlix and secure with tape daily until resolved every day shift.
A review of Resident #51's April 2023 TAR (Treatment Administration Record) revealed Left bottom of foot: Clean with wound cleanser, pat dry apply non-adherent dressing cover with ABD wrap with kerlix and secure with tape daily until resolved every day shift had blanks for April 1, 2, 7, 8, 9, 11, 12, 13, and 17, 2023.
On 04/18/2023 at 12:50 p.m., an interview was conducted with S4ADON (Assistant Director of Nursing). S4ADON stated she was currently the wound care treatment nurse for the facility. She confirmed Resident #51 has a wound to the bottom of his left foot that was not resolved. She stated the wound care treatment was documented on the TAR or progress notes after completion. She stated on the TAR if there was a blank in the box under the date that means the treatment was not completed. S4ADON confirmed that there was no documentation for April 1, 2, 7, 8, 9, 11, 12, 13, and 17 in the April 2023 TAR or progress notes and this meant the wound care was not done as ordered.
On 04/18/2023 at 1:45 p.m., an interview was conducted with S11LPN (Licensed Practical Nurse). S11LPN stated that S4ADON and floor nurses that were taking care of Resident #51 are were responsible for Resident #51's wound care treatment. She stated wound care treatment is was documented on the TAR or progress notes after completion. S11LPN confirmed that she worked on 4/17/2023 and she denied completing wound care to the resident's left foot and stated I assumed S4ADON did it. She confirmed the blank squares on April 2023 TAR for Resident #51's left bottom of foot wound care treatment for April 1, 2, 7, 8, 9, 11, 12, 13, and 17 meant the wound care was not done as ordered.
On 04/18/2023 at 1:45 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that wound care treatment was documented on the TAR or progress notes. S2DON reviewed April 2023 TAR and progress notes. S2DON confirmed that there was no documentation for wound care treatment to Resident #51's left bottom of foot for April 1, 2, 7, 8, 9, 11, 12, 13, and 17 and meant the wound care was not done as ordered.
2. Resident #126.
Review of the resident's electronic clinical record revealed that the resident was admitted to the facility on [DATE]. The resident's admitting diagnoses included Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, Neuromuscular Dysfunction of Bladder, Fusion of Spine, Colostomy, Congestive Heart Failure, and Ischemic Cardiomyopathy.
Review of the resident's physician's orders revealed an order . Coccyx, right hip -NPWT (Negative Pressure Wound Therapy) 120 MMHG (Millimeters of Mercury) continuous negative pressure therapy. Clean with Dakin's solution. Pack with black foam, cover with transparent dressing. Attach wound vac. Change 2 x week. (start date 04/13/2023).
On 04/19/2023 beginning at 10:15 a.m., wound care was performed to sacral and right hip wounds by S5PT (Physical Therapist) with the assistance of S4ADON (Assistant Director of Nursing). During wound care, S5PT applied black foam to the sacral wound and to an area covering the right hip wound. Below the area of black foam that was applied to the right hip wound, S5PT applied calcium alginate. There was no evidence in the resident's clinical record that there was a physician's order for calcium alginate.
On 04/19/2023 at 11:27 a.m., an interview was conducted with S5PT. S5PT stated that she did not know if there was an order for the calcium alginate. S5PT stated that she did not get a wound care order to use calcium alginate to the resident's right hip wound.
On 04/19/2023 at 11:30 a.m., an interview was conducted with S4ADON. S4ADON reviewed the resident's physician's orders and confirmed that there was no wound care order for calcium alginate. During this interview, S3CN (Corporate Nurse) stated the physical therapy department might have the order for calcium alginate.
On 04/19/2023 at 11:35 a.m., an interview was conducted with S4ADON and S5PT and both confirmed that there was no wound care order for calcium alginate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on record review, observations and interview the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range...
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Based on record review, observations and interview the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (#45) of 2 (#33, #45) resident reviewed for position and mobility. The facility failed to ensure resident #45 wore a splint 4 hours daily for a right hand contracture and received restorative services as ordered.
Findings:
Review of Resident #45's electronic medical record revealed an admit date of 10/22/2020 with diagnoses that included Cerebral vascular accident, Flaccid hemiplegia affecting right dominant side, and Aphasia.
Review of Resident 45's physician orders dated 10/12/2022 read in part, restorative nursing program 6-7 days a week for bed mobility; active range of motion (AROM) related to muscle weakness.
Review of Resident 45's care plan dated 3/29/2023 read in part, risk for loss of range of motion right dominant sided hemiplegia secondary to cerebral vascular accident. Intervention included the following: nursing staff to perform range of motion (ROM) with care. Restorative nursing program 6-7 days a week for bed mobility. AROM of bilateral upper extremity in sitting with #2 dowel shoulder flex/extend 3x15 repetitions AROM of bilateral lower extremity knee flex/extend, hip abdomen/add with #2 ankle weights 3 x 25 repetitions. A new order on 01/23/2023 for the resident to wear right hand splint at least 4 hours per day for contracture management.
Review of the facilities restorative aid flow sheet revealed the following:
01/01 - 01/08/2023 resident received 3 treatments.
01/8 - 01/15/2023- 4 treatments.
01/15 - 01/22/2023- 2 treatments;
01/22 - 01/29/2023- 5 treatments. No treatments for the remaining of the month. 02/01-02/08/2023- 5 treatments
02/08 - 02/15/2023- 3 treatments
02/15 - 02/22/2023- 3 treatments
02/22 - 02/28/2023- 1 treatments. No treatments for the remaining of the month.
03/01 - 03/08/2023- 2 treatments
03/08 - 03/15/2023- 1 treatment
03/15 - 03/22/2023- 1 treatment
03/22 - 03/29/2023- 2 treatments. No treatments for the remaining of the month.
04/01 - 04/08/2023-no treatment
04/ 08 - 04/15/2023- 4 treatments
On 04/17/2023 at 8:54 a.m., an observation of Resident #45 was conducted. His right hand was observed contracted, and there was no splint on his right hand.
On 04/18/2023 at 12:51 p.m., resident observed in the dining room area sitting in his wheelchair watching television. Right hand observed resting on the seat of the wheelchair, moderate amount of edema noted, and no right hand splint present.
On 04/18/2023 at 2:00 p.m., another observation of the resident was conducted. Resident still sitting up in the wheelchair in the dining area watching television. Further observation revealed no right hand splint. Right hand was in the same position as previous observation.
On 04/18/2023 at 4:46 p.m., a follow up observation was conducted of the resident. Resident was inside his room, and his right arm was resting on the bed at the resident's side. No splint was observed to right hand.
On 04/19/2023 at 9:10 a.m., an observation of the resident's physician orders and care plan was conducted with S18LPN (License Practical Nurse). S18LPN stated that she was not aware that the resident had an order for a right hand splint. A review of the resident's restorative treatment log was conducted with S18LPN. She confirmed that the resident had not received restorative services as per physician orders.
On 04/19/2023 at 10:10 a.m., an interview was conducted with S21OT (Occupational Therapy) who confirmed that Resident #45 should wear a splint on his right hand for 4 hours daily and receive restorative services.
On 04/19/2023 at 10:25 a.m., an interview was conducted with S22CNA (Certified Nursing Assistant), who was a restorative aid. She confirmed that the resident was supposed to receive restorative services 6 - 7 days per week. Review of the restorative aid's flow sheet was conducted with S22CNA. She confirmed that the resident had not received restorative services as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to minimize the risk of contamination of a resident's tu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to minimize the risk of contamination of a resident's tube feeding for 1 resident (# 73) investigated for tube feeding out of a total sample of 36 residents. This deficient practice had the potential to affect the 6 residents who received tube feedings in the facility.
Findings:
Review of the facility's policy titled Enteral Feedings- Safety Precautions read in part .2. The facility will remain current in and follow accepted best practices in enteral nutrition.
Resident #73 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Aphasia, Dysphagia Following Cerebral Infarction, and Flaccid Hemiplegia Affecting Right Dominant Side.
Review of Resident #73's MDS (Minimum Data Set) revealed she received 51% or more of total calories and 501 cc's (Cubic Centimeters) per day or more of fluid intake by tube feeding.
Review of Resident #73's April 2023 physician's orders revealed an order dated 03/23/2023 that read: Tube Feeding: Free Water: Administer Glucernia 1.2 at 55cc/hr x (times) 22 hr/day (hours per day). Flush tube with 50 cc free water q (every) 2 hours.
Review of Resident #73's Plan of Care revealed the resident required tube feeding related to Dysphagia Following CVA (Cerebrovascular Accident), Metabolic Encephalopathy, Potential For Protein Calorie Malnutrition, Aphasia Following CVA, Right Dominant Sided Hemiplegia Following CVA, and Hyperlipidemia. Goal: The resident will remain free of side effects or complications related to tube feeding through review date.
On 04/17/2023 at 9:05 a.m., an observation was made in Resident #73's room. Resident #73 was not in the room at this time. Resident #73's tube feeding set up was observed. The change date on the tube feeding bottle read 04/17/2023 at 2:00 p.m. The tube feeding line was wrapped around the feeding pump. There was no protective cap on the end of the port that would be connected to the Resident's PEG (Percutaneous Endoscopic Gastrostomy) tube.
On 04/17/2023 at 12:16 p.m., a second observation was made in Resident #73's room. The tube feeding line was wrapped around the feeding pump. There was no protective cap on the end of the connection port.
On 04/17/2023 at 12:40 p.m., an observation and interview was conducted with S2DON (Director of Nursing) who stated nurses disconnected residents' from their tube feeding when required. A third observation was made in Resident #73's room with S2DON. The tube feeding line remained wrapped around the feeding pump, and there was no protective cap on the end of the connection port. The resident was lying in bed. S2DON stated that it was not protocol for there to be no protective cap or covering on the tube feeding connection port when it was not in use. She confirmed that there should be a protective cap or covering on the connection port when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure nasal cannulas were stored in plastic bags as ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure nasal cannulas were stored in plastic bags as required by their policy for 1 (#176) of 4 (#59, #70, #71, #176) residents investigated for respiratory care.
Findings:
Record review of policy titled, Departmental (Respiratory Therapy) Prevention of Infection read in part, Purpose .prevention of infection associated with respiratory therapy .8. Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use.
Record review revealed Resident #176 was admitted to the facility on [DATE] with diagnoses of Lobar Pneumonia, Cardiac Arrest, Pneumonitis, Acute and Chronic Respiratory Failure, Hypoxia, Chronic Kidney disease, Chronic Systolic Heart Failure, Iron Deficiency Anemia, Atherosclerotic Heart Disease, and Transient ischemic Attack.
Record review of Resident #176's active Physicians Orders read in part, 02 (Oxygen) at 2 liters per minute via nasal cannula PRN (as needed) Keep O2 sats (Saturation) > (greater than) 94 % (percent) wean as tolerated as needed for SOB (Shortness of Breath).
On 04/17/2023 at 10:36 a.m., an observation with S8LPN (Licensed Practical Nurse) confirmed Resident #176's oxygen nasal cannula was on the floor and not in a plastic bag. At this time she stated the tubing should not be on the floor and should be in a plastic bag attached to the oxygen concentrator.
On 04/18/2023 at 10:58 a.m., S4ADON (Assistant Director of Nursing) confirmed Resident #176's Nasal Cannula was on the floor. She stated the oxygen nasal cannula, when not in use, should be in a plastic bag attached to the oxygen concentrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#53) resident in a final sample of 36 residents. The facility failed to ensure nurses' medication administration documentation was accurate for Resident #53.
Findings:
Review of Resident #53's Electronic Health Record revealed resident was admitted to the facility on [DATE] with diagnoses in part: .[NAME] Syndrome, Ileostomy Status, Type 2 Diabetes Mellitus, Obesity, Rash and Other Nonspecific Skin Eruption.
Review of March 2023 Medication Administration Record (MAR) revealed an order dated 03/30/2023 for Betamethasone Dipropionate Augmented External Gel 0.05%- Apply to back rash topically two times a day for rash for 14 days. Further review of the MAR revealed the medication was documented as administered on 03/31/2023 by S15LPN (Licensed Practical Nurse).
Review of April 2023 MAR revealed Betamethasone Dipropionate Augmented External Gel 0.05% was documented as administered on 04/01 & 04/02 during morning medication pass by S14LPN and documented as administered on 04/07 by S11LPN. On 04/05, 04/10 and 04/11 during night medication pass, S15LPN had documented that the 0.05% Gel was administered.
Review of S20NP's (Nurse Practitioner) progress notes revealed the following entries:
Dated 03/30/2023 with reason for visit was Acute Problem/ Change in Condition/ Nurse Request following handwritten Chief Complaint of .has rash covering entire back and buttock, open lesions, states itches. Stays in bed all day .Treatment Plan .Betamethasone Ointment BID (two times daily) x14d (days) .
Dated 04/12/2023 with reason for visit was Acute Problem/ Change in Condition/ Nurse Request following handwritten Chief Complaint of .still has rash on back, ointment ordered was not covered .Treatment Plan .Triamcinolone cream BID x 10d .
Review of nursing progress note created by S4ADON (Assistant Director of Nursing) on 04/12/2023 at 4:52 p.m. revealed S4ADON assessed Resident #53's skin and identified rash remained and noted under resident's chin .Resident stated her back does itch .S20NP will be changing the cream for resident's back .
On 04/19/2023 at 3:44 p.m., an interview was conducted with S4ADON who stated the facility had received a bill for Resident #53's medication of Betamethasone Dipropionate Augmented External Gel 0.05% due to insurance not covering it. Due to the expensive price, S4ADON notified Resident #53's provider for an order to change the medication. S4ADON stated she notified the pharmacy on 04/11/2023 and confirmed that the medication that was ordered by S20NP on 03/30/2023 was never received nor present in the facility. S2DON (Director of Nursing) also present was reviewing Resident #53's March and April 2023 MARs and confirmed multiple nursing staff documented that the medication, that was never ordered, was documented as administered on 03/31, 04/01, 04/02, 04/05, 04/07, 04/10 and 04/11. S4ADON added that nursing staff should have notified either her or S2DON of the medication not being delivered after the order was received on 03/30/2023 and confirmed the medication was not changed until 04/11/2023.
On 04/19/2023 at 4:06 p.m., S14LPN was interviewed and she confirmed Resident #53's previously ordered Betamethasone Dipropionate Augmented External Gel 0.05% was never delivered to the facility. S14LPN confirmed she documented the medication as administered on 04/01 and 04/02 even though the gel was not delivered or in the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to make an appointment with a dentist for 1 (#21) of 3 (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to make an appointment with a dentist for 1 (#21) of 3 (#21, #45 and #176) residents investigated for dental care.
Findings:
Record review revealed Resident #21 was admitted to the facility on [DATE] with accumulative diagnoses including Dysphagia, Cognitive Communication Deficit, Symbolic Dysfunctions, Cochlear Implant, Major Depressive, Repeated Falls, Muscle weakness, Need for assistance with personal Care, Lack of Coordination, Anxiety and Parkinson's disease.
Record review of Resident #21's Care plan read in part, The resident has oral/dental health problems r/t (Related to) has dentures but they are loose for resident .Coordinate arrangements for dental care .Document/Report PRN (as needed) any .dental problems needing attention .loose .in mouth.
On 04/17/2023 at 10:21 a.m., an observation revealed Resident #21's upper dentures were loose and falling down while she spoke. At this time, Resident #21 stated her dentures were brand new and the upper dentures were too big and would not adhere to her upper pallet with adhesive. She stated no one had asked her if she would like to see a dentist.
On 04/18/2023 at 10:23 a.m., an observation revealed Resident #21's upper dentures falling out of her mouth while she spoke.
On 04/18/2023 at 3:12 p.m., Resident #21confirmed her dentures would not adhere to her upper pallet with the denture cream. She stated she asked the nurse if she could get her denture fixed and no one had gotten her a dentist appointment. She stated it was difficult to eat because her dentures would fall down while she would chew her food.
On 04/18/2023 at 3:14 p.m., an interview with S8LPN (Licensed Practical Nurse) confirmed she was aware that Resident #21's upper denture would not adhere to her upper pallet. She stated she was not aware if anyone had talked to her about getting a dental appointment.
On 04/18/2023 at 4:06 p.m., S12SSD (Social Services Department) confirmed she had seen Resident #21's upper dentures falling down off her upper pallet while she was in the rehab gym. She stated no one had informed her that Resident #21 was having issues with her dentures.
On 04/19/2023 at 9:46 a.m., S13LPN confirmed Resident #21 had upper and lower dentures. She stated Resident #21's upper dentures would always fall out. She stated she had never asked the resident if she had any problems with her dentures. S13LPN stated if the resident's dentures didn't fit, S12SSD could put her on the list to see the dentist.
On 04/19/2023 at 1:08 p.m., S14Case Manager reviewed Resident #21's care plan and stated it was documented that the resident had a problem that read, she has dentures but they are loose for resident. S14CaseManager further stated that at the time of that documentation the MDS Coordinator should have notified S12SSD. S14 Case Manager also stated that if Resident #21 had an issue with keeping her upper dentures in her mouth, the staff should have reached out to S12SSD so she could have put the resident on a list to see the dentist.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have ...
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Based on interview and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 70 residents who consumed food from the kitchen. The facility's census was 73.
Findings:
On 4/17/2023 at 7:10 a.m., S6DM (Dietary Manager) was asked to provide her certification for food service management and safety. S6DM stated that she completed trainings but did not have a certification. She further stated that she has been the dietary manager for 2 years and was not certified. She stated the registered dietitian, who made rounds at the facility once a month, was supposed to schedule the class for her, but she did not.
On 4/17/2023 at 8:44 a.m., an interview was conducted with S1Adm (Administrator) who stated that the facility was in the process of ensuring S6DM was certified. He stated S6DM completed online trainings, but failed the test.
On 04/18/2023 at 10:04 a.m., an interview was conducted with S3CP who stated S6DM was hired in 2018. She further stated the facility had a registered dietitian, but she was a contracted employee who was not full-time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interviews, the facility failed to maintain an accurate record in accordance with accepted professional standards and practices. The facility failed to accurat...
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Based on observation, record review, and interviews, the facility failed to maintain an accurate record in accordance with accepted professional standards and practices. The facility failed to accurately document temperatures on Resident # 3's Personal Refrigerator Temperature Log for April 2023.
Findings:
Review of the facility's policy, titled Charting and Documentation revealed, in part, the following: Policy Interpretation and Implementation: . 3. Documentation . will be objective (not opinionated or speculative), complete, and accurate.
Review of Resident #3's Personal Refrigerator Temperature Log on 04/17/2023 revealed no temperatures documented on April 12, 13, 14, 15, and 16, 2023.
Review of Resident #3's Personal Refrigerator Temperature Log on 04/18/2023 revealed 42 degrees documented on April 12, 13, 14, 15, 16, and 17, 2023 with S10CNA's (Certified Nursing Assistant) signature for those dates.
On 04/18/2023 at 8:35 a.m., an interview was conducted with S10CNA. S10CNA stated she was the designated personnel to document on Resident #3's Personal Refrigerator Temperature Log. April 2023 Personal Refrigerator Temperature Log for Resident #3 was reviewed with S10CNA with the copy that was made on 04/17/2023 that had no temperatures documented on April 12, 13, 14, 15, and 16, 2023. She confirmed she did not check Resident #3's personal refrigerator on April 12, 13, 14, 15, and 16, 2023 and had assumed since the temperature on 04/17/2023 was 42 degrees she would put the same temperature for April 12, 13, 14, 15, and 16, 2023. She confirmed that was not accurate documentation.
On 04/18/2023 at 8:45 a.m., an interview was conducted with S1Adm. S1Adm reviewed copies of Resident #3's Personal Refrigerator Temperature Log from 04/17/2023 and 04/18/2023. He confirmed that on 04/17/2023 there are no temperatures documented on April 12, 13, 14, 15, and 16, 2023 and confirmed on 04/18/2023 there was the same temperature documented by S10CNA on April 12, 13, 14, 15, and 16, 2023. S1Adm confirmed that was not accurate documentation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #378
Resident #378 was admitted to the facility on [DATE] with diagnoses including, Alzheimer's Disease, Dementia, Dysp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #378
Resident #378 was admitted to the facility on [DATE] with diagnoses including, Alzheimer's Disease, Dementia, Dysphagia, and Unspecified Protein Calorie Malnutrition.
Review of Resident #378's April 2023 physician's orders revealed an order dated 04/06/2023 that read in part: Admit to .hospice with diagnosis of Alzheimer's secondary to dementia .
On 04/18/2023 at 4:45 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S4ADON (Assistant Director of Nursing) who stated that there was no hospice binder, notes, or Plan of Care for Resident #378 in the facility. S2DON stated the hospice agency was contacted and informed them that the Resident had a binder with his Plan of Care, visits, and visit notes, but they had not brought it to the facility. Both S2DON and S4ADON stated that they did not think that they had to have that information from the hospice agency at the facility.
On 04/19/2023 at 4:25 p.m., an interview was conducted with S3CP who stated that the facility's administrative nurses were responsible for coordinating care for hospice residents , including ensuring a binder was maintained at the facility with the hospice Plan of Care and visit notes. She stated that the administrative nurses were the DON and ADON. S3CP further stated that the hospice agency should have brought hospice binders for each of the residents that were under their care, but the administrative nurses were responsible for ensuring it was available in the facility for coordinating care.
Based on interview and record review, the facility failed to collaborate with a hospice agency to ensure residents had a Hospice Plan of Care for 2 (#17, #378) out of 2 residents reviewed for hospice services in a total investigative sample of 36 residents. This deficient practice had the potential to affect the 2 residents receiving hospice services as documented on the facility's Resident Census and Conditions form (CMS-672).
Findings
Review of the facility's policy titled Hospice Program read in part .12. Our facility has designated .to coordinate care provided to the resident by our facility staff and the hospice staff.d. Obtaining the following information from the hospice: 1. the most recent hospice plan of care specific to each resident .13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility.
Resident #17
Resident #17 was admitted to the facility on [DATE] with pertinent diagnoses including, Chronic Total Occlusion of Artery of the Extremities, Anorexia, Unspecified Diastolic (Congestive) Heart Failure, Subsequent Non-ST-Elevation Myocardial Infarction (NSTEMI), Cerebrovascular Accident, Hemiplegia and Hemiparesis Affecting Left Dominant Side, Metabolic Encephalopathy, Dysphagia and Tobacco Use.
Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating her mental status was severely impaired. Section O of the MDS revealed resident received hospice care while a resident.
Review of Resident #17's current April 2023 physician's orders revealed an order entry dated 10/14/2022 to Admit to hospice-Diagnosis Cerebrovascular Accident and secondary diagnosis Dysphagia.
On 04/18/2023 at 4:45 p.m., a joint interview was conducted with S2DON (Director of Nursing) and S4ADON (Assistant Director of Nursing) who both stated that there was no hospice binder, notes, or Plan of Care for Resident #17 in the facility. S2DON stated the hospice agency was contacted and informed them that the Resident had a binder with his Plan of Care, visits, and visit notes, but they had not brought it to the facility. S2DON and S4ADON stated that they did not think that they had to have that information from the hospice agency at the facility.
On 04/19/2023 at 4:25 p.m., an interview was conducted with S3CP (Corporate Nurse) who stated that the facility's administrative nurses, the DON and ADON, were responsible for coordinating care for hospice residents , including ensuring a binder was maintained at the facility with the hospice Plan of Care and visit notes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the k...
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Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to:
1.
Ensure kitchen staff wore hair coverings while in the kitchen;
2.
Ensure expired food items were removed from the cooler;
3.
Ensure expired food items were removed from the dry goods storage room;
4.
Ensure food items were labeled with the date and time it was opened;
5.
Ensure the refrigerator was clean;
6.
Ensure beverages that were not for residents were not stored the refrigerator; and
7.
Ensure air conditioning vents were free of dust and debris.
This deficient practice had the potential to affect the 70 residents who consumed food and beverages from the kitchen. The facility's census was 73.
Findings:
Review of the facility's policy titled Refrigerators and Freezers read in part .The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .7. All food shall be appropriately dated to ensure proper rotation by expiration dates .Expiration dates on unopened food will be observed and use by dates indicated once food is opened.
Review of the facility's policy titled Dry Storage read in part .All expired foods must be removed from the store room .If an item is opened .it should be dated with the date that it was opened.If using large bags to seal open items in the original packaging, the bag may be reused, but needs to be re-dated. If the food is directly in the bag, the bag must be labeled and dated.
On 04/17/2023 at 6:00 a.m., an observation of the kitchen was conducted with S6DM (Dietary Manager). Upon entering the kitchen, S6DM and S7CK (Cook) did not have on hair coverings. S6DM Hill and S7CK confirmed that they were not wearing hair coverings and should wear hair coverings while in the kitchen.
An observation of the cooler was conducted with S6DM. Observation of the cooler revealed the following expired food items:
- one 138 oz (ounce) opened and used bottle of Picante Sauce with an expiration date of 11/23/2022. There was green mold inside the rim and lid of the bottle. S6DM agreed that it was mold.
-one 5 lb (pound) container of sour cream with an expiration date of 03/06/2023
-one gallon of honey mustard with an expiration date of 07/01/2022
-two 5 lb containers of cottage cheese with expiration dates of 11/01/2022 and 01/16/2023. The containers were opened and used. Both containers revealed foul odors and liquid that separated from the cheese. S6DM confirmed that the cottage cheese was spoiled and had a foul odor.
-two 5 lb bags of parmesan cheese with expiration dates of 10/05/2022 and 03/15/2023
-four blocks of pasteurized cream cheese. Three blocks had an expiration date of 10/04/2022, and one block had an expiration date of 06/04/2022.
-one container of sliced strawberries with an expiration date of 04/09/2022
Further review of the cooler revealed the following opened and unlabeled food items:
-one 20 oz bottle of mustard
-one 20 oz bottle of grape jelly
-one 5lb container of pimento cheese spread
-one 5 lb bag of shredded cheese
-one package of lettuce
-one bag of pork chops
S6DM confirmed that the food items were expired and food items were not labeled with the date and time they were opened. She confirmed the expired food items should not be in the cooler and should have been removed. She also confirmed the opened food items should have been labeled with the date and time they were opened. S6DM further stated that she was responsible for checking the cooler, refrigerator, and dry goods storage area for expired or unlabeled food items but she had not been checking.
On 04/17/2023 at 6:35 a.m., an observation of the dry goods storage room was conducted with S6DM. Observation of the dry goods storage room revealed the following expired food items:
-three 14 oz cans of condensed milk with expiration dates of 08/26/2022
-twelve 10 oz cans of green chilies. 2 cans had an expiration date 03/18/2023 and 10 cans had an expiration date of 03/13/2023.
-two 1 gallon jugs of picante sauce with an expiration date of 11/23/2022
Further observation of the dry goods storage room revealed the following opened and unlabeled food items:
-one 4.5 lb bag of white frosting mix
-one opened bag of dry pasta
S6DM confirmed the items were expired and should have been removed from dry goods room. She also confirmed the opened items should have been labeled with the date and time that they were opened.
On 04/17/2023 at 7:00 a.m., an observation was made of the refrigerator. S6DM stated they used the refrigerator for storage of cold food items that could be accessed quickly when preparing food for residents. The contents of the refrigerator included 1 opened package of sliced cheese and 2 opened bottles of milk, and 3 beverages. The package of sliced cheese and bottles of milk were not labeled with the date or time that they were opened. S6DM confirmed that they should have been labeled with the date and time they were opened. There was dried, red liquid on the refrigerator's shelves. S6DM stated that any kitchen staff could have cleaned the refrigerator, and that it had not been cleaned. There were 3 beverages in the refrigerator. S6DM stated that the beverages were not for residents and should not have been in the refrigerator.
On 04/17/2023 at 8:49 a.m., an interview and observation of the kitchen was conducted with S1Adm (Adminstrator) and S6DM. An observation of the air conditioning vents over the food serving line was conducted with S1Adm. A moderate amount of dust was on the air conditioning vents. S1Adm stated that it was unacceptable to have a moderate amount of dust on the air conditioning vents because they were over the food service line. S1Adm and S6DM both confirmed that the number of expired and unlabeled food items were concerning, and it was unacceptable for the kitchen and residents who consumed food from the kitchen.
Dec 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate nursing competencies to assure resident safety and maintain the highest practicable physical well-being as evidenced by nursing staff failing to ensure accu-checks were initiated for Resident #1.
Findings:
Review of Resident #1's medical record revealed an admission date of 11-04-2022 with diagnoses that included Central Cord Syndrome, Cervical Spine Canal Stenosis Post Laminectomy (10-12-2022), Disruption of External Operation (Surgical) Wound (11-10-2022), Diabetes Mellitus and Hypertension.
A review of an MDS (Minimum Data Set) assessment conducted on 11-24-22 revealed a BIMS (Brief Interview of Mental Status) score of 12, indicating that Resident #1 had moderately impaired cognition.
Review of Resident #1's MAR (Medication Administration Record) dated November, 2022 revealed that monitoring of the resident's blood sugars began on 11-17-2022.
Review of Resident #1's Physician orders revealed that the resident was admitted to the facility on [DATE]. Further review revealed an order for accuchecks twice per day and prn (as needed) with a date of 11-17-2022.
On 12-12-2022 at 10:20 a.m., an interview conducted with the resident in his room revealed that he had surgery in October and that the surgical site had become infected. He stated that he is now was currently receiving IV (intravenous) antibiotics for the infection and that he was also diabetic, which meant slower healing time. He stated that he was not sure why they were not checking his blood sugars when he was first admitted and that he asked about it but that no one ever gave him an answer other than they were waiting to hear back from the doctor.
On 12-13-2022 at 1:30 p.m., an interview was conducted with S5LPN (Licensed Practical Nurse) who confirmed that Resident #1 was admitted to the facility on [DATE] with a diagnoses of Type 2 Diabetes Mellitus and a Status-Post Surgical Wound related to a Cervical Laminectomy that the resident underwent on 10-12-2022. She stated that the reason the resident's blood sugars were not being monitored at first was because there was not an order. She stated that the nursing staff realized that accuchecks should have been ordered due to the fact the resident was a diabetic and was admitted with a surgical wound. S5LPN confirmed that no one ever followed up on getting the order and that on 11-10-2022, the resident was discharged back to the hospital due to the wound becoming infected.
On 12-13-2022 at 2:30 p.m., an interview was conducted with S2DON (Director of Nursing) who confirmed that when staff realized Resident #1 was admitted without orders to monitor blood glucose levels and had diagnoses that included Diabetes and a post-operative wound, the nursing staff should have phoned the doctor right away to verify whether or not Resident #1 required an order for accuchecks. S2DON confirmed Resident # 1 had not received orders for accuchecks until the resident returned to the facility on [DATE].
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure facility staff followed the facility's policy and procedure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure facility staff followed the facility's policy and procedure when administering a controlled medication for 1 (#5) out of 5 (#1, #2, #3, #4 and #5) sampled residents as evidenced by S4LPN (Licensed Practical Nurse) failing to accurately document on Resident # 5's individual narcotic record and medication administration record the dates and time the controlled medication was administered.
Findings:
Review of the facility's policy and procedure titled Administering Medications revealed, in part:
Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.
.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:
a. the date and time the medication was administered;
b. the dosage;
c. the route of administration; .
e. any complaints or symptoms for which the drug was administered;
f. any results achieved and when those results were observed; and
g. the signature and title of the person administering the drug.
Review of the facility's policy and procedure titled Controlled Substances revealed, in part:
Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications .
9. Upon receipt:
.c. An individual resident controlled substance record is made for each resident who is receiving a controlled substance. The record contains : .(8) date and time received .
10. Upon administration:
a. The nurse administering the medication is responsible for recording:
(1) name of resident receiving the medication;
(2) name, strength and dose of the medication;
(3) time of administration;
(4) method of administration;
(5) quantity of medication remaining; and
(6) signature of nurse administering medication.
Review of Resident # 5's 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Gastrointestinal bleed, Bipolar Disorder, Depression, Anxiety, history of Pulmonary Embolism, Senile degeneration of brain, Normal pressure hydrocephalus and pain in right & left knee.
Further review of Resident # 5's MDS assessment revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident had moderately impaired cognition.
Review of Resident # 5's current physician orders revealed an order entry dated 09/20/2022 for Ultram tablet 50 MG (milligram) (tramadol HCL) Give 2 tablet by mouth every 6 hours as needed for Pain-Severe.
Review of Resident # 5's individual narcotic record revealed Ultram 50 MG tab Give 2 tablets by mouth every 6 hours as needed. S4LPN administered Ultram to Resident # 5 on 10/18 at 6:55 p.m., 10/21 at 9:50 p.m., 10/22 at 7 p.m. & 8:04 p.m., 10/27 at 9:24 p.m., 11/04 at 8 p.m., 11/05 at 8 p.m., 11/06 at 8 p.m., 11/09 at 9 p.m., 11/10 at 9 p.m., 11/14 at 9 p.m., 11/15 at 9 p.m., 11/19 at 8 p.m., 11/20 at 8 p.m., 11/23 at 8 p.m., 11/24 at 8 p.m., 11/29 at 8 p.m., 12/02 at 8 p.m., 12/03 at 8 p.m., 12/04 at 8 p.m., 12/07 at 8 p.m. and 12/12 at 8 p.m. as evidenced by documenting on Resident #5's individual narcotic record. S4LPN failed to document she administered Ultram on Resident # 5's electronic medication administration records (eMAR) to reflect the above dates and times.
Review of Resident # 5's eMAR dated October 2022 revealed he received his as needed Ultram 50 MG 2 tablets on 10/17 at 8:50 p.m., 10/24 at 7:21 p.m., 10/25 at 8:20 p.m., 10/26 at 1:08 p.m. & 9:07 p.m. and on 10/31 at 6:18 p.m. There was no evidence that Resident # 5 received the Ultram on 10/18 at 6:55 p.m., 10/21 at 9:50 p.m., 10/22 at 7 p.m. & 8:04 p.m., or on 10/27 at 9:24 p.m.
Review of Resident # 5's November 2022 eMAR revealed the as needed narcotic Ultram was administered on 11/1 at 6:32 p.m., 11/3 at 4:00 p.m., 11/9 at 3:00 p.m., 11/18 at 11:05 a.m. & at 6:53 p.m., 11/20 at 2:10 p.m. and on 11/28 at 10:51 p.m. There was no evidence that Resident # 5 received the Ultram on 11/04 at 8 p.m., 11/05 at 8 p.m., 11/06 at 8 p.m., 11/09 at 9 p.m., 11/10 at 9 p.m., 11/14 at 9 p.m., 11/15 at 9 p.m., 11/19 at 8 p.m., 11/20 at 8 p.m., 11/23 at 8 p.m., 11/24 at 8 p.m., 11/29 at 8 p.m.
Review of Resident # 5's December 2022 eMAR revealed the resident received his as needed Ultram on 12/08 at 6:35 p.m. Further review revealed there was no evidence on the eMAR that Resident # 5 had received the as needed Ultram on 12/02 at 8 p.m., 12/03 at 8 p.m., 12/04 at 8 p.m., 12/07 at 8 p.m. or on 12/12 at 8 p.m.
On 12/13/2022 at 1:45 p.m., a phone interview was conducted with S4LPN who confirmed she forgot to document on Resident #5' eMAR when she administered the resident's as needed ultram. S4LPN explained she documented on Resident #5's individual narcotic record each time she pulled the ultram and should be documenting on Resident #5's eMAR the date and time the medication was administered.
On 12/13/2022 at 2:35 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing) who reported Resident #5's eMAR and narcotic record for Ultram 50 MG tablet should match. S3ADON reviewed Resident #5's narcotic record and confirmed S4LPN failed to document Ultram was administered with the date and time on the resident's eMAR.
On 12/13/2022 at 3:35 p.m., a joint interview was conducted with S1ADM (Administrator) and S2DON (Director of Nursing) who confirmed S4LPN failed to follow the facility's policy and procedure when administering Resident #5's as needed narcotic of Ultram. S1ADM and S2DON confirmed S4LPN failed to accurately document on Resident #5's eMARs for October, November and December that she administered the narcotic to reflect the dates S4LPN administered the narcotic per Resident #5's individual narcotic record.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is New Iberia Manor North's CMS Rating?
CMS assigns NEW IBERIA MANOR NORTH an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is New Iberia Manor North Staffed?
CMS rates NEW IBERIA MANOR NORTH's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 48%, compared to the Louisiana average of 46%.
What Have Inspectors Found at New Iberia Manor North?
State health inspectors documented 49 deficiencies at NEW IBERIA MANOR NORTH during 2022 to 2025. These included: 49 with potential for harm.
Who Owns and Operates New Iberia Manor North?
NEW IBERIA MANOR NORTH 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 NEXION HEALTH, a chain that manages multiple nursing homes. With 101 certified beds and approximately 78 residents (about 77% occupancy), it is a mid-sized facility located in NEW IBERIA, Louisiana.
How Does New Iberia Manor North Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, NEW IBERIA MANOR NORTH's overall rating (2 stars) is below the state average of 2.4, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting New Iberia Manor North?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is New Iberia Manor North Safe?
Based on CMS inspection data, NEW IBERIA MANOR NORTH has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at New Iberia Manor North Stick Around?
NEW IBERIA MANOR NORTH has a staff turnover rate of 48%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was New Iberia Manor North Ever Fined?
NEW IBERIA MANOR NORTH has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is New Iberia Manor North on Any Federal Watch List?
NEW IBERIA MANOR NORTH 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.