What is New Iberia Manor South's CMS rating?

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

How many inspection deficiencies does New Iberia Manor South have?

New Iberia Manor South has 48 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at New Iberia Manor South?

New Iberia Manor South has a two-star staffing rating from CMS with 0.17 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is New Iberia Manor South located?

New Iberia Manor South is located in NEW IBERIA, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does New Iberia Manor South have?

New Iberia Manor South has 100 certified beds.

Who owns New Iberia Manor South?

New Iberia Manor South is a for profit - corporation facility and is part of the NEXION HEALTH chain.

Is New Iberia Manor South safe?

New Iberia Manor South has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at New Iberia Manor South stick around?

New Iberia Manor South has average staff turnover at 46%, which is typical for the nursing home industry.

Was New Iberia Manor South ever fined?

Yes, New Iberia Manor South has been fined $8,169 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is New Iberia Manor South on any federal watch list?

No, New Iberia Manor South is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at New Iberia Manor South?

Medicare inspectors have found 48 deficiencies at New Iberia Manor South: 1 serious, 47 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting New Iberia Manor South?

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

How does New Iberia Manor South compare to other nursing homes?

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

New Iberia Manor South | 43/100 (Grade D)

Jul 2025 10 deficiencies

CONCERN (D)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure the grievances the resident group voiced in regards to the food that was being served were acted upon and resolved. Review of the mo...

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Based on record review and interview, the facility failed to ensure the grievances the resident group voiced in regards to the food that was being served were acted upon and resolved. Review of the monthly resident council meeting minutes dated from 01/13/2025 to 07/03/2025 revealed there were complaints that the food was cold, improperly cooked, and portion sizes were small. On 07/22/2025 at 10:10 a.m. during the resident council meeting, the residents in attendance stated the food issues were not addressed and was worse. The residents complained the food was served uncooked, cold, and the meat was tough. The residents in attendance were Resident #4, #11, #16, #39, #50, #66, #69, #85, #87, and #90. During the resident council meeting on 07/22/2025 at 10:10 a.m., S15AD (Activity Director) was present during the meeting per the residents' request. S15AD confirmed the complaints about the food had been ongoing since 01/13/2025 to present date.

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to provide evidence that Resident #7's grievance was reported and investigated for 1 (#7) out of 36 sampled residents. Resident #7. On 07/21/2...

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Based on record review and interview, the facility failed to provide evidence that Resident #7's grievance was reported and investigated for 1 (#7) out of 36 sampled residents. Resident #7. On 07/21/2025 at 12:41 p.m., the resident stated that about 6 months ago when he was admitted to the facility his wallet was stolen. The resident stated that his wallet contained 350 dollars, driver's license and social security card. The resident stated he reported it to the administrative staff. The resident stated that no one has followed up with him concerning his stolen wallet. The resident stated that he does not know if there was an investigation.Review of the resident's general nurses notes dated 10/27/2024 at 11:30 a.m. revealed, Resident reported theft of a wallet (containing: bank card, social security card, driver's license, insurance card and $350.00 cash) and a pair of sunglasses. He says that this occurred the first week he got here . On 07/23/2025 at 3:00 p.m., an interview was conducted with S16RN (Registered Nurse). S16RN stated she remembers the resident reporting to her that his wallet with money and cards were stolen when he was on the rehabilitation side of the facility. S16RN stated she does not remember if she reported the grievance to anyone.On 07/23/2025 at 3:15 p.m., an interview was conducted with S1ADM (Administrator). S1ADM stated she was aware of the grievance and that she would look for documentation addressing the grievance. S1ADM did not provide evidence the resident's grievance was addressed and investigated by the time of the exit conference on 07/23/2025 at 5:45 p.m.

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 observation, interview and record review, the facility failed to implement physician's orders by failing to change the ...

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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 implement physician's orders by failing to change the dressing on a peripherally inserted central catheter site for 1(#56) of 5 (#9, #11, #43, #56, and #58) residents investigated for infections.Resident #56 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to, urinary tract infection, extended beta lactamase (ESBL) resistance, and enterococcus as the cause of diseases.Review of physician's orders revealed an order written on 07/11/2025 to change midline dressing following technique and apply BIO (round antimicrobial dressing used to prevent infections at catheter insertion sites) patch every day shift every Fri (Friday).On 07/21/2025 at 10:54 a.m., an observation was made of Resident #56. The resident had a midline catheter with an exit site on her left arm which was dated 07/11/2025. Further observation revealed a sign taped over the residents bed which read, midline was inserted 07/11/2025.On 07/21/2025 at 3:27 p.m., an interview was conducted with S3ADONIP (Assistant Director of Nursing/Infection Preventionist). She confirmed that Resident #56's midline dressing was dated 07/11/2025. She further stated the dressing should have been changed on 07/18/2025 and was not.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance ...

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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 residents received all care and treatment in accordance with professional standards of practice by failing to inform the resident's physician/nurse practitioner that resident (#4), who has a diagnosis of Heart Failure, was having difficulty breathing and had a low O2 sat (oxygen saturation- the amount of oxygen circulating in blood) reading of 88% for 1 (#4) out of 4 (#4, #7, #13, #92) residents investigated for hospitalizations out of a total sample of 36 residents.Resident #4. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction, Heart Disease, Heart Failure, Hepatitis C, and Diabetes. Review of the resident's significant change MDS (Minimum Data Set) dated 06/12/2025 revealed the resident's BIMS score was 14 for being cognitively intact. Further review of the MDS revealed the resident had respiratory issues that included COPD (Chronic Obstructive Pulmonary Disease). Review of the resident's weekly vital sign log revealed the resident's vital signs on 03/19/2025 was, temperature 98.1; blood pressure 150/72; pulse 56; respirations 18; and oxygen saturation was 96%. Review of the resident's general nurses notes dated 03/24/2025 at 1:06 p.m. revealed, Resident left with . driver for appt (doctor's appointment) with 2L (liters) of oxygen applied r/t (related to) hypoxia. Review of the resident's general nurses notes dated 03/24/2025 at 2:56 p.m. revealed, Spoke with RP (Responsible Party) . RP is at . appt with resident and RP explained that the nurse from (doctor's appointment) recommended resident to go to hospital. RP wants resident to be transferred to (hospital) . Review of the resident's general nurses notes dated 03/24/2025 at 9:17 p.m. revealed, Received report from (nurse at the hospital) in ER (Emergency Room). Nurse reported to writer that resident presented with SOB (Shortness of Breath) to ER . is in fluid overload. Resident is breathing slower than when first entering the ER . Review of the resident's ED (Emergency Department) provider notes dated 3/24/2025 at 5:09 p.m. revealed, .chief complaint: patient presents with Shortness of Breath onset this AM and BLE (bilateral lower extremity) edema for 1 week. [AGE] year-old male with a history of chronic kidney disease as well as cirrhosis presents to the emergency department because of increased shortness of breath and swelling of the lower extremities and abdomen. Patient has chronic kidney disease reports that over the past 2 to 3 days has had increased swelling and increased shortness of breath . On 07/23/2025 at 10:55 a.m., an interview was conducted with S13TD (Transportation Driver). S13TD stated she remembers transporting Resident #4 to his scheduled doctor's appointment. S13TD remembers the resident was having shortness of breath and noticed that he had his oxygen with him. S13TD stated she encouraged the resident to use his oxygen. S13TD stated that no one reported to her the resident was having trouble breathing that day. On 07/23/2025 at 12:55 p.m., an interview was conducted with S12LPN (Licensed Practical Nurse). S12LPN stated the day the resident was transported to his doctor's appointment that she remembers the resident's O2 saturation being low. S12LPN stated the resident normally has an O2 saturation of 96% and on that day it was 88%. S12LPN stated she applied oxygen at 2 liters for his low O2 saturation. S12LPN stated she did not document the resident's O2 saturation or an assessment of the resident's condition prior to him going out to his scheduled doctor's appointment and stated that she should have. S12LPN stated she did not report the resident's low O2 saturation to the nurse practitioner. On 07/23/2025 at 2:11 p.m., an interview was conducted with S11MDS (Minimum Data Set). S11MDS reviewed the resident's electronic clinical record and confirmed that there was no evidence of the resident's clinical condition prior to being transported to his scheduled doctor's appointment. S11MDS stated the nurse should have documented the resident's condition. On 07/23/2025 at 3:30 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON reviewed the resident's electronic clinical records and confirmed there was no evidence of the resident's condition prior to being transported to his scheduled doctor's appointment and there should have been. S2DON confirmed there was no evidence the physician or nurse practitioner was informed of the resident's condition prior to being transported to the doctor's appointment.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to provide a sanitary and homelike environment for 1 (#9) out of 36 sampled residents.Resident #9. On 07/21/2025 at 10:23 a.m., the resident was...

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Based on observation and interview, the facility failed to provide a sanitary and homelike environment for 1 (#9) out of 36 sampled residents.Resident #9. On 07/21/2025 at 10:23 a.m., the resident was observed siting up in bed in his room. During this observation, a suction canister was observed on the resident's dresser. There was drainage noted in the canister. The resident stated that the suction canister had been on the dresser for days. On 07/21/2025 at 10:24 am, S17LPN (Licensed Practical Nurse) entered the room and observed the canister on the dresser. S17LPN stated she did not know how long the canister had been on the dresser and that it should have been discarded. On 07/23/2025 at 10:33 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated the facility did not have a policy and procedure on suction equipment but stated the canister should have been changed out.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

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 nursing staff provided services reflecting ...

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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 nursing staff provided services reflecting accepted standards of quality care as evidenced by medications being left at the bedside for 3 residents (#17, #84 and #90) out of a finalized sample of 36 residents. Resident #17:Resident #17 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to history of falling and allergic rhinitis.Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident's cognitive function was intact.Review of physician's orders revealed an order written on 07/14/2025 for Zyrtec allergy oral tablet 10 mg (Cetirizine HCL [hydrochloride]) give 10 mg (milligrams) by mouth one time a day for allergic rhinitis.On 07/21/2025 at 10:38 a.m., an observation and interview was conducted with Resident #17. An oval shaped white pill was observed on the resident's bed. The resident picked up the pill and stated that it was her pill that the nurse had given her. The resident stated that she did not sign a form to be able to self-administer her medications. The resident put her call light on to call the nurse.On 07/21/2025 at 10:38 a.m., an interview and observation of the pill was conducted with S4LPN (Licensed Practical Nurse). She stated it was Resident #17's Zyrtec, and confirmed it should not have been left in the resident's room.Resident #84:Resident #84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to history of falling, other fracture of head and neck of left femur, and aftercare following joint replacement surgery.Review of Resident #84's admission Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment.Review of Resident's EHR revealed no signed document that she was able to self-administer her medications.Review of Resident #84's physician's orders revealed an order written on 06/27/2025 for Cholecalciferol (Vitamin D3) oral tablet 25mcg (microgram) (1000 UT [units]) (Cholecalciferol) Give 1000 unit orally one time a day for vitamin deficiency related to vitamin deficiency, unspecified.On 07/21/2025 at 10:17 a.m., an observation was made of Resident #84 in her room. A whitish round pill was noted on the over bed table in the corner of the resident's room. On 07/21/2025 at 10:19 a.m., an observation and interview was conducted with S4LPN. She stated the pill looked like Resident #84's Vitamin D because it had no writing on it. S4LPN took the pill and walked to her medication cart then returned and stated the pill matched Resident #84's Vitamin D in her cart. She stated she didn't know how the pill got to the resident's over bed table and was not supposed to be left in her room.Resident #90Resident #90 was admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to bipolar disorder, depression, dysphagia following cerebral infarction and shortness of breath. Review of Resident #90's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating the resident's cognition was intact. Review of Resident #90's July 2025 physician's orders revealed an order dated 06/03/2025 for Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) MCG/ACT(microgram/actuation) (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for SOB. Review of nursing progress notes revealed an entry on 07/17/2025 per S10LPN read: RP called the facility and stated that her brother (Resident #90) needs assistance with getting inhaler from jacket pocket. Nurse went into the room and grabbed inhaler from jacket pocket and handed it to the resident.On 07/21/2025 at 2:19 p.m., an observation was made of Resident #90 propelling himself in his wheelchair towards his room to get his Albuterol inhaler. An observation was made of Resident #90 grabbing his inhaler from his window seal in his room.On 07/22/2025 at 10:01 a.m., an observation was made of Resident #90's resident's Albuterol inhaler located on the resident's window seal in his room.On 07/23/2025 at 4:15 p.m., an interview was conducted with S18LPN who confirmed Resident #90 kept his Albuterol inhaler on him and stated the S11MDS (Minimum Data Set Nurse) would provide the documentation supporting the resident had been assessed to safely administer his Albuterol inhaler.On 07/23/2025 at 5:30 p.m., during exit conference, S11MDS (Minimum Data Set Nurse) confirmed the facility did not have documented evidence that Resident #90 was assessed to safely self-administer his Albuterol inhaler.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents' environment remained free of acci...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents' environment remained free of accident hazards, by failing to lower and lock beds for 2 (#17 and #84) of 3 (#10, #17, and #84) residents investigated for accidents.On 07/23/2025, a review of the facility's policy titled, Fall Prevention Program with a last review date of 06/18/2025, read in part.All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis.Based on the results of this assessment, interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. 3. The following is a list of commonly used interventions that may be considered to minimize falls and injury.c. Bed maintained in low position.Resident #17:Resident #17 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to history of falling, fracture of left pubis, and aftercare following joint replacement surgery.Review of a therapy screen dated 07/02/2025, revealed safety awareness/safety concerns: Resident has had a change in level of safety awareness and has a potential for safety concerns to develop. Fall risk status: Resident is a fall risk.On 07/21/2025 at 10:38 a.m., an observation was made of Resident #17. A yellow falling star was observed outside the resident's room indicating she was at risk for falls. Resident #17 was in her bed and sat up as surveyor entered room. Further observation revealed the red lever on the resident's bed was up and the green down.On 07/21/2025 at 10:39 a.m., an interview and observation of Resident #17's bed was conducted with S4LPN. She confirmed the bed was not locked and should have been. S4LPN further stated that the bed is locked when the red lever is down and the green up.Resident #84:Resident #84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to history of falling, other fracture of head and neck of left femur, and aftercare following joint replacement surgery.Review of Resident #84's care plan revealed a focus area dated 06/30/2025 the resident is at risk for falls r/t (related to) history of falls.Interventions included place bed in lowest position. On 07/21/2025 at 10:17 a.m., an observation and interview conducted with Resident #84. There was a yellow falling star posted outside the resident's room indicating she was a fall risk. The resident was lying on her lifter pad in bed, and the bed was in the highest position. There was a hoyer lift at the resident's bedside, but no staff was present. Resident #84 stated staff had been in her room to get her up for therapy, but left.On 07/21/2025 at 10:19 a.m., an observation and interview was conducted with S4LPN (Licensed Practical Nurse). She confirmed the resident's bed was left on the highest position. S4LPN stated that the resident's bed should not have been left on the highest position.

CONCERN (E)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, ...

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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 that residents who require dialysis receive such services, consistent with professional standards of practice, by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 (#37) of 1 (#37) resident investigated for dialysis.On 07/23/2025, a review of the facility's dialysis protocols with a reviewed date of 07/11/2025 read in part.2. Implement dialysis communication regarding plan of care. Resident #37 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to end stage renal disease and dependence on renal dialysis. Review of Resident #37's July 2025 Physician's orders revealed an order written on 06/30/2025 for Resident #37 to receive dialysis 3 days a week on Monday, Wednesday, and Friday at a dialysis provider center. Review of Resident #37's dialysis communication sheets between the facility and the dialysis provider revealed the following:06/27/2025 the form was missing pre-dialysis information for meal provision and condition alert.06/30/2025 the resident specific pre-dialysis information for medication administered, meal provision, and condition alert were left blank. 07/07/2025 there was no resident specific pre-dialysis information and the form was not signed.07/09/2025 there was no resident specific pre-dialysis information and the form was not signed by facility staff.07/11/2025 there was no resident specific pre-dialysis information.07/14/2025 there was no resident specific pre- dialysis information07/16/2025 there was no resident specific pre-dialysis information and the form was not signed.07/18/2025 there was no form for that date07/21/2025 there was no form for that date.On 07/23/2025 at 8:30 a.m., an interview was conducted with S2DON (Director of Nursing). She confirmed the missing information and stated that she would check the facility's policy.On 07/23/2025 at 8:59 a.m., an interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed the missing information and forms. She stated that the form was to be completed with vital signs, whether they ate, refused meal or was sent with a snack, and whether they are awake, alert, oriented. S5LPN also stated when the resident returned from dialysis, the assigned nurse should have checked the section filled out by the dialysis agency, then signed the form. S5LPN further stated the form must be completed because that's how they communicate with the dialysis provider. On 07/23/2025 at 9:47 a.m., S5LPN provided the form for 07/21/2025 and stated she took it off the fax machine.On 07/23/2025 at 10:35 a.m., a follow up interview was conducted with S2DON. She stated that she reviewed the dialysis protocols and the communication sheets were supposed to have been completed and signed by the nurse per the facility's protocol.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure food was served to residents that was palatable...

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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 food was served to residents that was palatable, attractive, and at a safe and appetizing temperature for 3 (#4, #7, #37) out 3 (#4, #7, #37) residents investigated for food out of a total sample of 36 residents1. Resident #4. On 07/21/2025 at 11:43 a.m., the resident stated that he did not like the way the food was prepared. On 07/22/2025 at 10:10 a.m. during the resident council meeting, the resident stated the food was served cold and the portion sizes were too small. 2. Resident #7. On 07/21/2025 at 12:47 p.m., the resident stated the food was not good, not seasoned, the meat was tough, and the portion sizes were for a child. On 07/22/2025 at 8:55 a.m., S14CNA (Certified Nursing Assistant) was observed picking up the resident's breakfast tray out of his room. On 07/22/2025 at 9:08 a.m., an interview was conducted with S14CNA. She stated the resident did not eat his meals because he did not like the food that was served. 3. Resident #37: Resident #37 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified severe protein-calorie malnutrition, and end stage renal disease. Review of Resident #37’s admission Minimum Data Set (MDS) dated [DATE] revealed in “Section C” that she had a Brief Interview for Mental Status of 14, indicating her cognition was intact. Further review revealed in “Section K” that the resident had complaints of difficulty or pain when swallowing. Review of Resident #37’s Physician’s Orders revealed she was on a renal diet, regular texture, thin consistency. On 07/21/2025 at 12:11 p.m., an observation was made of Resident #37 during lunch. The resident received a dinner roll, a hamburger patty and steamed vegetables on her plate. The hamburger patty looked burnt and hard and Resident #37 was observed struggling to cut it. On 07/21/2025 at 12:11 p.m., S4LPN (Licensed Practical Nurse) tried cutting the hamburger on Resident #37’s plate and stated that she would not serve that hamburger to anyone. S7CNA (Certified Nursing Assistant) also tried cutting the resident’s hamburger and stated that it was hard and she would not serve it to anyone. On 07/21/2025 at 12:19 p.m. S6RD (Registered Dietician) cut Resident #37’s hamburger patty with a metal knife and fork and told S1ADM (Administrator) who was called to the dining room that the meat was hard and dry.

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 interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evi...

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Based on observations, 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 as evidenced by: opened food items in the walk in cooler not labeled with the date and time; thick layer of debris and food residue on the deep fryer cooking oil collection area; andexposed facial hairThe facility had a census of 84 residents.Findings:On 07/21/2025, a review of the facility's policy titled, Food Receiving and Storage, with a last revision date of 06/23/2025, revealed in part. Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation:.8. All food stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).On 07/21/2025, a review of the facility's policy titled, Refrigerator and Freezer, with a last reviewed date of 06/25/2025, revealed in part.Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation.7. Use by dates will be completed with expiration dates on all prepared food in refrigerators.On 07/21/2025, a review of the facility's policy titled, Dietary Employee Dress Code, with a last revision date of 07/03/2025, revealed in part.Protocol: All employees will wear approved attire to perform their assigned duties. Procedure: 1. All staff will have their hair off their shoulders, confined in a hairnet or cap-facial hair covered properly.a. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad.On 07/21/2025 at 9:09 a.m., a tour of the facility's kitchen was conducted with S8DA (Dietary Aide), who stated that she was the in charge for the day shift.On 07/21/2025 at 9:25 a.m., an observation of the walk in cooler was conducted with S8DA and revealed the following items were opened and not labeled with the date and time they were opened nor the use by date: large container of minced garliclarge container of mayonnaiselarge container of cherrieslarge container of mustardlarge block of margarineplastic gallon bag of shredded carrotsplastic gallon bag of green bell pepperplastic gallon bag of celeryplastic gallon bag of onionsplastic gallon bag of baconplastic gallon bag of apple slicesplastic gallon bag of cinnamon rollsplastic gallon bag of sliced cheddar cheese(2) large containers of green grapes S8DA confirmed the food items listed above were opened, and not labeled with the date and time they were opened nor the use by date, and should have been. On 07/21/2025 at 9:36 a.m., an observation of the deep fryer was conducted with S8DA that revealed the cooking oil collection area had a thick layer of debris, and large pieces of fried food material. S8DA stated the deep fryer was last used sometime last week, and confirmed that is was not cleaned after it was used and should have been. On 07/21/2025 at 10:39 a.m., S9COOK was observed in the kitchen with facial hair exposed while he was preparing to puree the lunch meal. S9COOK confirmed that his facial hair should be covered and was not.

Apr 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the residents right to be free from physical restraints imposed for purposes of discipline or convenience, for 1 (#2) of three (#1, #2, and #3) sampled residents. This deficient practice was evidenced by Resident #2's use of a wheelchair seat belt the resident was unable to remove. Findings: On 04/30/2025, a review of the facility's policy titled Facility Policy on PSDs (Personal Safety Devices) -Enablers-Side Rails & Restraints with a last revised date of 02/2025, read in part .Restraint Policy Intent: Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience and when not required to treat the patient's/resident's medical condition. Patients/Residents have the right to function at their highest practicable level in the least restrictive environment possible. Policy: 1. Restraints will not be used unless the facility's Interdisciplinary Team has completed an assessment and evaluation to identify causative medical or environmental factors and considered less restrictive alternatives . Review of Resident #2's electronic face sheet revealed she was admitted to the facility on [DATE], with diagnoses which included, but were not limited to cerebral palsy, severe intellectual disabilities and aphasia. On 04/29/2025 at 5:25 a.m., an observation was made of Resident #2 sitting in her wheelchair at the nurses' station on Hall W. The resident was awake and had a seat belt secured across her lap. The resident was asked if she could remove the seat belt and she looked at surveyor and did not respond. During an interview with S6CNA (Certified Nursing Assistant) on 04/29/2025 at 5:25 a.m., she confirmed Resident #2 was using a seat belt and stated that staff used the seat belt to prevent her from falling. She confirmed the resident was not able to remove the seat belt. During an interview and observation of Resident #2 with S7LPN (Licensed Practical Nurse) on 04/29/2025 at 6:08 a.m., she confirmed the resident had a seat belt secured across her lap. S7 LPN confirmed Resident #2 had been using the seat belt since she came to the facility. She confirmed Resident #2 was unable to remove the seat belt after it had been secured. Review of Resident #2's admission MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99 in section C0500, indicating the resident was unable to complete the assessment. The resident received a score of 3 in section C1000 indicating her cognitive skills for daily decision making were severely impaired. Further review of the MDS assessment revealed the resident was not coded for using restraints in section P0100. Review of Resident #2's current physician orders revealed no order for a seat belt or any other type of restraint. Review of Resident #2's current care plan report revealed no focus area or intervention for the use of a seat belt. During a follow-up interview with S7LPN on 04/29/2025 at 10:40 a.m., she stated Resident #2 should not have been wearing a seat belt because she had not been assessed, care planned, or had a physician order for it. During an interview with S2DON (Director of Nursing) on 04/29/2025 at 1:07 p.m., she confirmed that she became aware Resident #2 was using the seat belt last week. She stated that her MDS nurse told her the resident was unable to remove the seat belt after the surveyor asked about it. S2DON stated that the resident should not have been using a seat belt because the Interdisciplinary team (IDT) did not complete an assessment and evaluation, and there were no physician orders or care plans for its use.

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

Transfer Notice (Tag F0623)

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 notify the State Long Term care Ombudsman of a facility-initiated t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#3) out of 3 (#1, #2, and #3) residents sampled. Findings: A review of Resident #3's admission record revealed an initial admission date of 08/29/2024 and a re-admission date of 04/15/2025 with diagnoses that included but were not limited to, End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #3's nurse's notes revealed on 03/30/2025 at 11:45 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 04/15/2025 the resident returned from the hospital back to the facility. A review of the Emergency Transfer Log for March 2025 and April 2025 revealed Resident #3's transfer to the hospital on [DATE] was not identified on the list. On 04/30/2025 at 1:49 p.m., an interview and record review were conducted with S5SSD (Social Service Director). S5SSD stated she is responsible for completing and sending the Emergency Transfer Log to the State Long Term Care Ombudsman. A review of Resident #3's nurse's notes with S5SSD was conducted at this time, she confirmed Resident #3 was transferred to the hospital on [DATE] and returned 04/15/2025. A review of the Emergency Transfer Log for March 2025 and April 2025 was conducted, and S5SSD confirmed that Resident #3's facility-initiated transfer was not on the notification list sent to the State Long-Term Care Ombudsman, and should have been. On 04/30/2025 at 2:11 p.m., an interview and record review were conducted with S1ADM (Administrator). S1ADM stated Resident #3 was transferred to the hospital on [DATE] and returned on 04/15/2025. A review of the Emergency Transfer Log for March 2025 and April 2025 was conducted, and S1ADM confirmed the State Long Term Care Ombudsman was not notified of Resident #3's facility-initiated transfer was not notified to the State Long-Term Care Ombudsman, and should have been.

CONCERN (D) 📢 Someone Reported This

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

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

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 reviews and interviews, the facility failed to ensure an assessment and ongoing communication with the dialysis ...

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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 an assessment and ongoing communication with the dialysis facility by using dialysis communication forms for 1 (#3) out of 3 (#1, #2, and #3) residents sampled. Findings: A review of the facility's agreement with the Contracted Dialysis Agency with an effective date of 02/15/2019 read in part, Responsibilities of Long Term Care Facility (LTCF): LTCF healthcare staff will make an assessment of each patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis . This assessment and communication will occur prior to each and every transfer of a patient to the contracted dialysis agency for hemodialysis on an outpatient basis regardless of the number of time any particular patient may be transferred and dialyzed . A review of Resident #3's admission record revealed a re-admission date of 04/15/2025 with diagnoses that included but were not limited to, End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #3's most recent Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] read in part, Section O: Special Treatments, Procedures, and Programs revealed the resident was receiving dialysis. A review of Resident #3's care plan initiated on 03/25/2025 revealed the resident needs dialysis. Interventions read in part, dialysis 3 days a week on Monday, Wednesday, & Friday at a contracted dialysis agency. A review of Resident #3's dialysis communication record form located in the resident's electronic health record (EHR) from the re-admission date of 04/15/2025 to the present was reviewed. The EHR revealed no documented evidence of a dialysis communication record form on Friday 04/18/2025 and Friday 04/25/2025. On 04/30/2025 at 11:47 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse). She stated dialysis communication forms which consist of assessing the resident are to be completed before each time the resident goes to dialysis. She stated when the resident arrived back to the facility from dialysis this form was to be returned to the nurse who was working so they could look at what happened at dialysis such as how many liters were taken off, compare the resident's weight and see if the dialysis nurse or doctor added any new medications, and this was all documented on the form. She stated after the nurse reviewed the form it was then given to medical records to scan into the EHR. She confirmed that it was their communication method between the facility and the dialysis agency. On 04/30/2025 at 1:25 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing), and she confirmed that Resident #3's dialysis communication forms were not in the facility and they had to reach out to the contracted dialysis agency to get the dialysis communication forms. On 04/30/2025 at 1:35 p.m., an interview was conducted with S2DON (Director of Nursing), and she confirmed there were no dialysis communication forms on Friday 04/18/2025 and Friday 04/25/2025 and should have been.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a yearly performance review was completed on every Certified Nurse Assistant (CNA) for 1 (S8CNA) of 4 (S8CNA - S11CNA) CNAs personne...

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Based on interview and record review, the facility failed to ensure a yearly performance review was completed on every Certified Nurse Assistant (CNA) for 1 (S8CNA) of 4 (S8CNA - S11CNA) CNAs personnel records reviewed. Findings: During an interview with S8CNA on 04/29/2025 at 5:25 a.m., the CNA stated she had not received a performance evaluation since she started working at the facility. Review of S8CNA's personnel records revealed a Personnel Action Form with a hire date of 06/06/2023. Further review of the CNA's personnel records revealed no performance evaluation. During an interview with S2DON (Director of Nursing) on 04/30/2025 at 12:04 p.m., she stated that S8CNA is a PRN (as needed) staff and had not received a performance evaluation because she did not receive raises. During an interview with S1ADM (Administrator) on 04/30/2025 at 3:55 p.m., she stated that she was not aware that performance evaluations were required for PRN staff.

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

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 pain management was provided to residents complaining of pa...

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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 pain management was provided to residents complaining of pain for 1 (Resident #3) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This had the potential to affect the 82 residents that resided in the facility. Findings: On 03/25/2025 a review of the facility's policy titled, Pain Management Program Policy, with a revised and reviewed dated of 01/2025 read in part . The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices, related to pain management. If pain is identified, the following steps are initiated:-Created a Pain Care Plan using standardized pain assessment tools, obtain orders for pharmaceutical and/or non pharmaceutical interventions. Nurses will assess residents' pain every shift using the appropriate pain evaluation tool and document the effectiveness of interventions. Review of Resident #3's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, atrial septal defect as current complication following acute myocardial infarction, encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft (CABG), spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure and dysarthria following cerebrovascular disease. Review of Resident #3's March 2025 physician's orders revealed an order dated 03/11/2025 for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's current care plan revealed Resident #3 was at risk for Potential/actual pain r/t (related to) spasticity, Cerebral palsy, recent CABG, history of angina (chest pain) with interventions including, but not limited to: Hydrocodone-Actaminophen, Monitor/record/report to nurse if resident complaints of pain or requests for pain treatment, Monitor /record pain characteristics Q (every) shift and PRN as needed, Monitor/record/report to nurse any signs and symtoms of non-verbal pain and Notify physician if interventions are unsuccessful. Review of Resident #3's electronic clinical record revealed the following nursing progress notes: Dated 03/12/2025 at 11:30 AM per S3LPN (Licensed Practical Nurse) read: The resident's mother came to the nurse's station asking when the resident's pain meds will be in. S3LPN went through all the bins that the pharmacy sent and no pain meds were in the bin for the resident. S3LPN explained to the mother that a hard script from the NP (Nurse Practitioner) will be needed for the pharmacy to fill his med (medication). Dated 03/13/2025 at 1:00 AM per S3LPN read: Resident c/o (complains of) chest pain. Tylenol was offered d/t (due to) pain medication not in, the patient refused and stated he needed something stronger. S3LPN explained to the resident and his mother that need a physician's order to give pain meds. A note was left for S5NP (Nurse Practitioner) to review the resident's medications. Dated 03/13/2025 at 1:30 AM per S3LPN read: The resident's mother asked if S3LPN could give the resident someone else's pain med. S3LPN explained that nurses are not allowed to share medications. Dated 03/13/2025 at 14:30 (2:30 PM) per S4LPN read: therapist stated to S4LPN that resident would like to see a nurse, for pain relief. S4LPN went in to assess Resident #3 for pain, he stated that he is in pain. S4LPN stated that she could possibly give a standing order pain relief medication, expressing that, the hydrocodone pain medication is on order and has not been delivered at this time. Resident called mother and gave the phone to S4LPN. S4LPN spoke with Resident #3's mother and the mother stated that the doctor okayed pain medication administration to the resident there is no narcotic available to administer presently. S4LPN informed resident's mother of this and stated that she would have to clarify giving anything other than standing order medications with the NP or DON (Director of Nursing). Review of Resident #3's eMAR (electronic Medication Administration Record) for March 2025 revealed Hydrocodone-Acetaminophen 5-325 mg was not administered on 03/12/2025 or 03/13/2025. Further review of the resident's eMAR revealed that on 03/12/2025 the resident complained of pain of 5 on a pain scale of 0-10 with 5 being moderate pain on the night shift. There was no documentation the resident received anything for pain on 03/12/2025. On 03/24/2025 at 4:30 PM, a phone interview was attempted with Resident #3's representative but no answer was received. On 03/25/2025 at 8:00 AM, a second attempt was made to notify Resident #3's representative via phone but no answer was received. On 03/25/2025 at 12:35 PM, an interview was conducted with S7LPN. S7LPN verified medications were ordered through an out of town pharmacy. S7LPN stated there was confusion with Resident #3's Hydrocodone-Acetaminophen 5-325 mg prescription and S5NP ended up having to write a second prescription on 03/13/2025. On 03/25/2025 at 12:45 PM, a third attempt was made to notify Resident #3's representative via phone but no answer was received. On 03/25/2025 at 2:38 PM, a phone interview was conducted with S3LPN. S3LPN stated Resident #3 had complained of pain and she went to look for his medication but it had not yet been delivered. S3LPN stated she had notified S5NP via text message about Resident #3's pain medication not being delivered, but did not get a response. S3LPN denied notifying administrative staff about not having the resident's ordered pain medication in the facility upon the resident's admit to the facility on [DATE]. On 03/25/2025 at 3:50 PM, an interview was conducted with S4LPN. S4LPN stated Resident #3 was newly admitted to the facility on [DATE] and when the resident's mother inquired about the resident's Hydrocodone-Acetaminophen 5-325 mg prescription, S4LPN attempted to give Tylenol but the resident had refused. S4LPN was unable to recall if S5NP was aware of the delivery delay of the Hydrocodone-Acetaminophen 5-325 mg. S4LPN explained the facility had a white binder where the receipt of prescriptions faxed and delivered from the out of town pharmacy were kept. On 03/25/2025 at 4:02 PM, an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed she reviewed Resident #3's admit orders on 03/11/2025. She explained at times the discharging hospital will electronically file the prescriptions. S2ADON review the electronic health record system and the white binder. She was unable to find confirmation that the resident's prescription for Hydrocodone-Acetaminophen 5-325 mg-Give 1 tablet by mouth every 6 hours as needed for pain was sent to the pharmacy. On 03/25/2025 at 4:33 PM, a phone interview was conducted with S5NP. S5NP confirmed he was made aware that Resident #3's prescription for Hydrocodone-Acetaminophen 5-325 mg 1 tablet by mouth every 6 hours as needed for pain was delayed since admit. S5NP was unable to recall exactly when he was notified of the delay. S5NP denied implementing an alternative order until the medication was delivered.

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 pain medication was available for 1 (Resident #3) out of 3 ...

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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 pain medication was available for 1 (Resident #3) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This had the potential to affect the 82 residents that resided in the facility. Findings: Review of Resident #3's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: atrial septal defect as current complication following acute myocardial infarction, encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft (CABG), spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure and dysarthria following cerebrovascular disease. Review of Resident #3's March 2025 physician's orders revealed an order dated 03/11/2025 for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's electronic clinical record revealed the following nursing progress notes: Dated 03/12/2025 at 11:30 AM per S3LPN (Licensed Practical Nurse) read: The resident's mother came to the nurses station asking when the resident's pain meds will be in. S3LPN went through all the bins that the pharmacy sent and no pain meds were in the bin for the resident. S3LPN explained to the mother that a hard script from the NP (Nurse Practitioner) will be needed for the pharmacy to fill his med. Dated 03/13/2025 at 1:00 AM per S3LPN revealed: Resident c/o (complains of) chest pain. Tylenol was offered d/t (due to) pain medication not in. S3LPN explained to the resident and his mother that need a Physician's order to give pain meds. A note was left for S5NP (Nurse Practitioner) to review the resident's medications. Dated 03/13/2025 at 14:30 (2:30 PM) per S4LPN revealed: The hydrocodone pain medication is on order and had not been delivered at this time. Resident called mother and gave the phone to S4LPN. S4LPN spoke with Resident #3's mother and the mother states that the doctor okayed pain medication administration to the resident there is no narcotic available to administer presently. Review of Resident #3's eMAR (electronic Medication Administration Record) for March 2025 revealed Hydrocodone-Acetaminophen 5-325 mg was not administered on 03/12/2025 after the resident complained of pain due to medication not being available. On 03/25/2025 at 2:33 PM, a phone interview was conducted with S6Pharm (Certified Pharmacy Technician) who verified the only pain medication prescription the pharmacy received for Resident #3 was on 03/13/2025 for Hydrocodone-acetaminophen 7.5-325 mg per S5NP. On 03/25/2025 at 4:02 PM, an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed she reviewed Resident #3's admit orders on 03/11/2025. S2ADON was unable to find confirmation that the resident's prescription for Hydrocodone-acetaminophen 5-325 mg-Give 1 tablet by mouth every 6 hours as needed for pain was sent to the pharmacy on 03/11/2025.

Dec 2024 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

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 record review and interviews, the facility failed to ensure the resident's comprehensive plan of care was implemented f...

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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 resident's comprehensive plan of care was implemented for 2 (#1, #3) residents out of 6 (#1-#6) sampled residents. The facility failed to: 1. Monitor a hematoma and perform wound care for a laceration as ordered for Resident #1; and 2. Perform wound care as ordered for Resident #3's surgical incisions. Findings: Resident #1 Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, End Stage Renal Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Diabetes Mellitus, Severe Protein Malnutrition, and Muscle Wasting and Atrophy. Review of Resident #1's October 2024 physician's orders revealed the following orders dated 10/18/2024: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for laceration from fall. Review of Resident #1's October 2024 TAR (Treatment Administration Record) revealed the following: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from Fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for laceration from fall. There was no documentation that monitoring for the hematoma or treatment for the laceration was done for the resident on the date of 10/31/2024. Review of Resident #1's November 2024 physician's orders revealed the following orders dated 10/18/2024: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for laceration from fall. Review of Resident #1's November 2024 TAR revealed the following: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from Fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for Laceration from fall. There was no documentation that monitoring for hematoma or treatment for the laceration was done for the resident on the dates of 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024, and 11/17/2024. Resident #3 Review of Resident #3's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Displaced Intertrochanteric Fracture of Left Femur, Dementia, Diabetes Mellitus, Major Depressive Disorder, Schizophrenia, Severe Protein Malnutrition, and Muscle Wasting and Atrophy. Review of Resident #3's December 2024 physician's orders revealed the following orders dated 11/29/2024: Wound #2-Surgical Incision to Left Knee: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD (every other day) and PRN (as needed) soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur; Wound #3-Surgical Incision to Left Thigh: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD (every other day) and PRN (as needed) soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur. Review of Resident #3's December 2024 TAR revealed the following: Wound #2-Surgical Incision to Left Knee: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD (every other day) and PRN (as needed) soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur; Wound #3-Surgical Incision to Left Thigh: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD and PRN soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur. There was no documentation that treatment was done for the resident's surgical incisions on the dates of 12/02/2024, 12/07/2024, and 12/08/2024. On 12/11/2024 at 3:30 p.m., an interview and record review was conducted with S2TN (Treatment Nurse). She reviewed Resident #1's TAR and confirmed the resident's monitoring and treatments were not completed as ordered in October and November 2024. She also reviewed Resident 3's TAR and confirmed the resident's treatments were not completed as ordered in December 2024.

CONCERN (E) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Review of Resident #4's electronic health record revealed and admission date of 08/24/2023 with diagnoses which incl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 Review of Resident #4's electronic health record revealed and admission date of 08/24/2023 with diagnoses which included, but were not limited to, Muscle Wasting and Atrophy, Chronic Kidney Disease, Stage 4 (Severe), Type 2 Diabetes Mellitus and Anorexia. The resident was discharged from the facility on 04/15/2024. Review of Resident #4's monthly physician orders and TARs from her admission through discharge revealed orders for wound care with missing documentation that wound care had been administered: -Wound #1- Pressure Injury to sacrum: Cleanse with wound cleanser, pat dry, apply Dakins moistened gauze and cover with optifoam SA (Silicone Adhesive) Dressing. Change Daily and prn (as needed) soilage every day shift related to Pressure Ulcer of Sacral Region, Unstageable. Order Date: 08/25/2023 Review of TARs revealed wound care was not administered for dates: 08/27/2023, 09/02/2023, and 09/11/2023. -Wound #5- Pressure Injury to right hip: cleanse with wound cleanser, pat dry, apply Mesalt and cover with optifoam SA dressing. Change daily and prn soilage every day shift related to Pressure Ulcer of Right Hip, Unstageable. Order Date: 08/25/2023 Review of TARs revealed no documentation wound treatment was administered on 09/02/2023 and 09/11/2023. -Wound #5- Pressure Injury to Right Hip: Cleanse with wound cleanser, pat dry, apply Mesalt and cover with Optifoam SA Dressing. Change daily and prn soilage every day shift related to Pressure Ulcer of Right Hip, Unstagable. Order date: 03/22/2024 Review of TARs revealed no evidence wound treatment was administered on 03/24/2024. On 12/11/2024 at 12:04 p.m., a review of Resident #4's TAR was conducted with S2TN (Treatment Nurse) and S1DON/IP (Director of Nursing/Infection Preventionist) who confirmed missing documentation in the months of August 2023, September 2023, and March 2024 for wound care treatments. S2TN and S1DON were unable to provide evidence that the treatments had been administered as ordered. Resident #5 Review of Resident #5's electronic health record revealed an admission date of 11/02/2023 with diagnosis which included, but were not limited to, Unspecified Protein- Calorie Malnutrition, Anorexia, and, Paraplegia. Review of Resident #5's monthly physician orders and TARs August 2024-December 2024 revealed orders for wound care with missing documentation that wound care had been administered: -Gentamycin Sulfate External Ointment 0.1% (Topical). Apply to wounds topically every day shift related to Pressure Ulcer of Sacral Region, Stage 4; Pressure Ulcer of Left Buttock, Stage 4; Pressure Ulcer of Left Hip, Stage 4. Order Date: 08/30/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024, 09/03/2024, and 09/13/2024. -Santyl Ointment 250 Unit/GM (gram) (Collagenase). Apply to per additional directions topically every day shift for wound care. Order Date: 08/30/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024, 09/03/2024, and 09/13/2024. -Wound #1- Pressure Injury to Sacrum; Cleanse with Vashe, pat dry, Santyl nickel thick, Gentamycin 0.1%, Hydrofera Blue, Gent (Gentian) [NAME] to periwound, then cover with ABD pad, secure with tape. Change daily and prn soilage every day shift related to Pressure Ulcer of Sacral Region, Stage 4. Order date: 08/28/2024. Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024 and 09/13/2024. -Wound #2- Pressure Injury to Left Ischium: Cleanse with Vashe, pat dry, apply Santyl nickel thick, Gentamycin 0.1%, apply saline moistened gauze to undermining with Santyl and Gentamycin to gauze, Hydrofera Blue, Gent [NAME] to periwound, optilock and secure with tape. Change daily and prn soilage every day related to Pressure Ulcer of Left Buttock, Stage 4. Order date: 08/28/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024 and 09/13/2024. -Wound #3- Pressure Injury to Left Hip: Cleanse with Vashe, pat dry, apply Santyl nickel thick, Gentamycin 0.1%, apply saline moistened gauze to undermining with Santyl and Gent to gauze, Hydrofera Blue, Gen violet to periwound, ABD Pad and secure with tape. Change daily and prn soilage every day shift related to Pressure Ulcer of Left Hip, Stage 4. Order date: 08/28/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024 and 09/13/2024. -Wound #1- Pressure Injury to Sacrum: Cleanse with Vashe, pat dry, apply Meropenem 1 GM and Colistimethate 150 mg, sprinkle powder onto saline moistened gauze, apply saline soaked gauze, Gent [NAME] to periwound, ABD pad and secure with tape, change daily and prn soilage every day shift related to Pressure Ulcer of Sacral Region, Stage 4. Order date: 10/02/2024. Review of TARs revealed no documentation that wound treatments were administered for dates: 10/19/2024, 10/26/2024, 10/28/2024, 11/01/2024, 11/07/2024, 11/09/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/29/2024, 12/02/2024, 12/07/2024, 12/08/2024. -Wound #2- Pressure Injury to Left Ischium: cleanse with Vashe, pat dry, apply Meropenem 1gm and Colistimethate 150mg power sprinkle onto wound bed, Gent [NAME] to periwound, apply saline soaked gauze, ABD pad and secure with tape. Change daily and prn soilage every day shift relate to Pressure Ulcer of Left Buttock, Stage 4. Order date: 10/02/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 10/19/2024, 10/26/2024, 10/28/2024, 11/01/2024, 11/07/2024, 11/09/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/29/2024, 12/02/2024, 12/07/2024, and 12/08/2024. -Wound #3- Pressure Injury to Left Hip: Cleanse with Vashe, pat dry, apply Meropenem 1gm and Colistimethate 150mg , sprinkle powder onto saline moistened gauze, apply saline soaked gauze, Gent violet to periwound, ABD pad and secure with tape. Change daily and prn soilage every day shift related to Pressure Ulcer of Left Hip, Stage 4. Order date: 10/02/2024. Review of TARs revealed no documentation that wound treatments were administered for dates: 10/19/2024, 10/26/2024, 10/28/2024, 11/01/2024, 11/07/2024, 11/09/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/29/2024, 12/02/2024, 12/07/2024, and 12/08/2024. On 12/11/2024 at 03:00 p.m., a review of Resident #5's TARs was conducted with S2TN (Treatment Nurse) who confirmed there was no documentation that treatments were administered as ordered above in the months of September 2024, October 2024, November 2024, and December 2024. S2LPN was unable to provide evidence that the treatments had been administered as ordered. Based on record review, and interview, the facility failed to provide care and services to prevent and treat pressure ulcers for 5 (#1, #2, #3, #4 and #5) residents of 5 (#1, #2, #3, #4 and #5) sampled residents investigated for pressure ulcers. The facility failed to provide wound care as ordered by the physician for Residents #1, #2, #3, #4 and Resident #5; and monitor proper functioning of a low air loss mattress for Resident #1 per the resident's plan of care. Findings: Resident #1 Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, End Stage Renal Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Diabetes Mellitus, Severe Protein Malnutrition and Muscle Wasting and Atrophy. October 2024 Review of Resident #1's October 2024 physician's orders revealed the following orders dated 10/07/2024: -Wound #1 Pressure Injury to the Left Ankle: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Ankle; -Wound #2 Pressure Injury to the Left Foot: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Heel; -Wound #3- Pressure Injury to the Right Heel: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel. Review of Resident #1's October 2024 TAR (Treatment Administration Record) revealed the treatment orders as noted above for wounds #1-#3. There was no documentation that treatment was administered for the resident's wounds on the dates of 10/07/2024, 10/10/2024, and 10/31/2024. November 2024 Review of Resident #1's November 2024 physician's orders revealed the following orders dated 10/07/2024: -Wound #1 Pressure Injury to the Left Ankle: Apply Gentia [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Ankle; -Wound #2 Pressure Injury to the Left Foot: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Heel; -Wound #3- Pressure Injury to the Right Heel: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel. Further review revealed orders dated 11/14/2024: -Wound #6-Pressure Injury to Left Ischium: Cleanse with wound cleanser, pat dry, apply Therahoney, and cover with Optifoam SA (Silicone Adhesive) dressing. Change Q3D (every three days) and PRN (as needed) soilage every day shift related to Pressure Ulcer to Left Hip; -Low air loss mattress to bed, check for proper function q (every) shift every day shift related to Pressure Ulcer of left hip. Another order dated 11/19/2024 revealed: -Wound #6-Pressure Injury to Left Ischium: Cleanse with wound cleanser, pat dry, apply Therahoney, Calcium Alginate, cover with Optifoam SA dressing. Change Q3D and PRN soilage every day shift related to Pressure Ulcer to Left Hip. Review of Resident #1's November 2024 TAR revealed the revealed the following: Wound #1 Pressure Injury to the Left Ankle: no documentation the treatment was administered on 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024 and 11/17/2024. Wound #2 Pressure Injury to the Left Foot: no documentation the treatment was administered on 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024, 11/17/2024, 11/23/2024 and 11/30/2024. Wound #3- Pressure Injury to the Right Heel: no documentation the treatment was administered on 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024 and 11/17/2024. Wound #6-Pressure Injury to Left Ischium: no documentation the treatment was administered on 11/16/2024 and 11/17/2024. Low air loss mattress to bed, check for proper function q shift every day shift related to Pressure Ulcer of left hip. There was no documentation that checking for proper function of low air loss mattress was completed for the resident on the dates of 11/16/2024, 11/17/2024, and 11/30/2024. Wound #6 Pressure Injury to Left Ischium: no documentation that treatment was administered on 11/30/2024. December 2024 Review of Resident #1's December 2024 physician's orders revealed the following orders dated: -10/07/2024 Wound #2 Pressure Injury to the Left Foot: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Heel. -11/14/2024 Low air loss mattress to bed, check for proper function q shift every day shift related to Pressure Ulcer of left hip; and -11/19/2024 Wound #6-Pressure Injury to Left Ischium: Cleanse with wound cleanser, pat dry, apply Therahoney, Calcium Alginate, cover with Optifoam SA dressing. Change Q3D and PRN soilage every day shift related to Pressure Ulcer to Left Hip. Review of Resident #1's December 2024 TAR revealed the following: Low air loss mattress to bed, check for proper function q shift every day shift related to Pressure Ulcer of left hip. There was no documentation that checking for proper function of low air loss mattress was done for the resident on the date of 12/01/2024. Wound #6-Pressure Injury to Left Ischium: no documentation that treatment was administered on 12/01/2024. Resident #2 Review of Resident #2's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Post Hemorrhagic Anemia, Acute Gastric Ulcer with Hemorrhage, Pneumonia, Atherosclerotic Heart Disease of Native Coronary Artery, Peripheral Vascular Disease, Severe Protein Malnutrition and Muscle Wasting and Atrophy. Review of Resident #2's December 2024 physician's orders revealed the following orders dated 11/29/2024: -Wound #2 Pressure Injury to the Left Buttocks: Cleanse with normal saline, pat dry, apply Therahoney, and cover with Optifoam SA dressing. Change Q3D and PRN soilage; -Wound #3 Pressure Injury to the Right Lower Lateral Leg: Cleanse with normal saline, pat dry, apply Therahoney and cover with Optifoam SA dressing. Change Q3D and PRN soilage; daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel; -Wound #4 Pressure Injury to the Right Heel: Apply Optifoam SA dressing. Change Q3D and PRN soilage daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel. Further review revealed orders dated 12/05/2024: -Gentamicin Sulfate External Cream 0.1% Topical. Apply to right buttocks topically every day shift related to Pressure Ulcer of Right Buttock; Santyl Ointment 2500 unit/gm (gram). Apply to right buttocks wound topically every day shift related to Pressure Ulcer of Right Buttock; -Wound #1-Pressure Injury to the Right Buttocks: Cleanse with Vashe, pat dry, apply Santyl [NAME] thick and Gentamicin 0.1% ointment, Vashe soaked gauze, skin prep wound edges, ABD (abdominal pad) and secure with tape. Change daily and PRN soilage. Review of Resident #2's December 2024 TAR revealed the wound treatment orders as noted above and the following: Wound #2 Pressure Injury to the Left Buttocks & Wound #1-Pressure Injury to the Right Buttocks: no documentation that treatment was administered on 12/7/2024. Wound #3 Pressure Injury to the Right Lower Lateral Leg & Wound #4 Pressure Injury to the Right Heel: no documentation that treatment was administered on 12/07/2024 and 12/08/2024. Resident #3 Review of Resident #3's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Displaced Intertrochanteric Fracture of Left Femur, Dementia, Diabetes Mellitus, Major Depressive Disorder, Schizophrenia, Severe Protein Malnutrition and Muscle Wasting and Atrophy. Review of Resident #3's December 2024 physician's orders revealed the following orders dated 11/29/2024: -Wound #5 Pressure Injury to the Right Buttocks: Apply Calazime skin paste daily and PRN every day shift related to Pressure Ulcer of Right Buttock; -Wound #6-Pressure Injury to the Sacrum: Apply Optifoam SA dressing. Change Q3D and PRN soilage every day shift related to Pressure Induced Deep Tissue Damage of Sacral Region. Further review revealed the following orders dated 12/05/2024: -Wound #4-Pressure Injury to Left Ankle: Cleanse with wound cleanser, pat dry, apply Medihoney, cover with Optifoam SA dressing. Change 3x a week and PRN soilage every day shift related to Pressure-Induced Deep Tissue Damage of Left Ankle; -Wound #6-Pressure Injury to the Sacrum: Apply Calazime skin paste daily and PRN every day shift related to Pressure Induced Deep Tissue Damage of Sacral Region. Review of Resident #3's December 2024 TAR revealed a listing of the orders noted above and the following: Wound #6 Pressure Injury to the Sacrum: no documentation that the treatment was administered on 12/02/2024. Wound #4 Pressure Injury to Left Ankle & Wound #6 Pressure Injury to the Sacrum: no documentation that the treatment administered on 12/7/2024 and 12/08/2024. Wound #5 Pressure Injury to the Right Buttocks: no documentation that the treatment was administered on 12/02/2024, 12/07/2024, and 12/08/2024. On 12/11/2024 at 3:30 p.m., an interview and record review was conducted with S2TN (Treatment Nurse). She reviewed Resident #1's TAR and confirmed the resident's treatments were not completed as ordered in October, November and December 2024. She further stated checking the proper function of Resident #1's mattress was not completed in November and December of 2024. S2TN reviewed Resident #2's and 3's TAR and confirmed the residents' treatments were not completed as ordered in December 2024.

Jul 2024 13 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's dignity by failing to provide a c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's dignity by failing to provide a covering for a urinary catheter bag for 1 resident (#428) out of 35 sampled residents. Findings: Review of Resident #428's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Heart Failure. On 07/21/2024 at 9:00 a.m., an interview and observation was made of Resident #428 with S12RNS (Register Nurse Supervisor). Resident #428's urinary catheter drainage bag was observed containing urine and there was no covering for the drainage bag. S12RNS confirmed that the catheter bag did not have a privacy cover. She was unsure of the policy on covering catheter drainage bags, but stated that she thought the bag should be covered. On 07/23/2024 at 11:42 a.m., an interview with S6Corp was conducted. She confirmed that a privacy cover should have been placed on Resident 428's urinary drainage bag.

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 observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#23) out of 2 (#23 and #33) residents investigated for a clean, comfortable and homelike environment. The final sample size was 35 residents. Findings: On 07/22/2024, a review of the facility's policy titled, Homelike Environment with a last reviewed date of 07/08/2024, read in part .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .e. clean bed and bath linens that are in good condition. Review of Resident #23's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Muscle Weakness, Unspecified Lack of Coordination and Need for Assistance with Personal Care. On 07/21/2024 at 11:04 a.m., an observation was made of Resident #23's bedroom. Resident #23 was sitting on his bed. The resident's pillow case was observed with a large red and brown stain. On 07/22/2024 at 9:02 a.m., a second observation was made of Resident #23's bedroom. Resident #23 was standing next to his bed. The resident's bed was made, and the large red and brown stain observed yesterday remained on the resident's pillow case. On 07/22/2024 at 9:05 a.m. an interview and observation of Resident #23's bedroom was conducted with S16LPN (Licensed Practical Nurse). She confirmed that Resident #23's bed was made and confirmed the stain on the pillow case. S16LPN confirmed bed linens should be clean, and the pillowcase should have been changed when the bed was made.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 Review of Resident #1's EMR revealed he was admitted to the facility on [DATE] and was diagnosed with Schizophrenia ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #1 Review of Resident #1's EMR revealed he was admitted to the facility on [DATE] and was diagnosed with Schizophrenia on 01/22/2018. Further review of Resident #1's EMR (electronic medical record) revealed a Level 1 PASARR screening dated 05/07/2018 that was completed at another facility. Section 3 titled Mental Illness, was checked yes, and only Major Depression Disorder was checked. On 07/22/2024 at 1:13p.m., an interview was conducted with S6Corp. She stated Resident #1 was diagnosed with Schizophrenia on 01/22/2018. S6Corp confirmed the Level 1 PASARR screening was not answered correctly because Schizophrenia was not checked. She confirmed no other PASARRs were found and was unable to confirm a corrected submission was sent. Based on record reviews and interviews, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level 1 screening was completed accurately for 2 (#1, #43) out of 2 (#1, #43) residents investigated for PASARR in a final sample of 35 residents. Findings: Resident #43 Review of Resident #43's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Bipolar Disorder, End Stage Renal Disease, Dependent on Renal Dialysis, and Essential Hypertension. Further review of her record contained a Level 1 Preadmission Screening and Resident Review, (PASARR) without any diagnosis checked to indicate she had any of the serious mental health diagnoses. Further review of Resident #43's record revealed no evidence the provider had submitted a corrected PASARR request to the appropriate state-designated authority with the diagnosis of Bipolar Disorder. On 07/21/2024 at 8:29 a.m., an interview was conducted with S10AAdm (Acting Administrator). She reviewed Resident #43's Level I Pre-admission screening dated 06/05/2024 and confirmed Section III question #1 had no diagnoses checked. Further review of the list of her diagnoses revealed a diagnosis of Bipolar Disorder unspecified in which S10AAdm confirmed Resident #43 had a qualifying diagnosis which required further review for a Level II PASARR. On 07/23/2024 at 09:45 a.m., during an interview, S1Director of Nursing (DON) stated Resident #43's Level 1 PASARR was submitted by the hospital before she was admitted confirming that staff from the nursing home failed to review the Level 1 for accuracy. On 07/23/24 at 12:28 p.m., S6Corp (Corporate Nurse) stated she reviewed all of the admission documents for Resident #43. She confirmed a request for review had been submitted to the state designated authority.

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 observation, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific compe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#428) of 35 sampled residents. This was evidenced by S18LPN (Licensed Practical Nurse) leaving Resident #428's medication at the bedside. Findings: On 07/08/2024, a review of the facility's policy titled, Medication Administration, with a review date of July 8, 2024, revealed in part .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Resident #428 was admitted to the facility on [DATE], with diagnoses that included Chronic Kidney Disease and Heart Failure. Review of the resident's BIMS (Brief Interview for Mental Status) performed on 07/18/2024 revealed a score of 15, indicating that the resident's cognition was intact. On 07/21/2024 at 08:40 a.m., an observation was made of Resident #428. A medicine cup with seven pills was observed on her over-bed table. Resident #428 stated that the nurse left the medications with her so that she could take them after her she ate breakfast. On 07/21/2024 at 11:25 a.m., an interview and observation was conducted with S12RNS (RN Supervisor). Resident #428's medicine cup remained on her over-bed table with no pills observed in it. Resident #428 stated that she had just administered her own medications. S12RNS stated that she was unaware of the facility's policy on self-administration of medications, but believed the nurse should watch the residents take their medications. On 07/23/2024 at 11:43 a.m., an interview with S1DON (Director of Nursing) stated that Resident #428 should have had a physician's order to administer her own medications. S1DON stated that she would have also had to be evaluated by the facility, to determine if she was competent to administer her own medications. She confirmed that Resident #428 did not have a physician order or evaluation to administer her own medication and should not have administered her own medications. She confirmed that nurse should not have left Resident #428's medications at the bedside. On 07/23/2024 at 03:00 p.m., an interview with S11Adm (Administrator) was conducted. S11Adm reported that S18LPN was the nurse responsible for administering Resident #428's medications on 07/21/2024 at 8:40 a.m.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on interviews and record reviews, the facility failed to provide pharmaceutical services that were in order and accounted for the drug record reconciliation of all controlled drugs during shift ...

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Based on interviews and record reviews, the facility failed to provide pharmaceutical services that were in order and accounted for the drug record reconciliation of all controlled drugs during shift changes for 1(Medicine Cart 1) MC1 of 3 Medicine carts reviewed during their annual survey. This deficient practice had the potential to affect the 80 residents residing in the facility. On 07/23/2024, a review of the facility's policy titled, Controlled Substances, with a review date of July 8, 2024, revealed in part .4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. On 07/22/2024 at 09:09 a.m., an interview and review of the July 2024 Controlled Drugs-Count Record for MC1 was conducted with S19LPN (Licensed Practice Nurse) and S20ADON (Assistant Director of Nursing). Both S19LPN and S20ADON stated that the off going nurse for each shift should have reconciled the narcotics in each medicine cart with the oncoming nurse. Both S19LPN and S20ADON confirmed that there was no signature present for the off going nurse to indicate that the narcotics in MC1 were reconciled for the 7:00 a.m. -3:00 p.m. shift on 07/22/2024. Both S19LPN and S20ADON confirmed that there should be a signature for both the oncoming and the off going nurses that reconcile narcotics each shift, and the off going nurse's signature was missing for the 7:00 a.m. -3:00 p.m. shift on 07/22/2024. 07/23/2024 at 11:31 a.m., an interview and review of the July 2024 Controlled Drugs-Count Record for MC1 was conducted with S1DON (Director of Nursing). This review revealed missing signatures for the narcotic reconciliations below: 1. 07/20/2024 - oncoming nurse 3-11 2. 07/21/2024- off going nurse 7-3 3. 07/21/2024- oncoming nurse 3-11 4. 07/22/2024- off going nurse 7-3 S1DON reported that the nurses for these shifts, per facility policy, should have signed indicating that the narcotics were reconciled, and confirmed they had not.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

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 properly store drugs as evidenced by 1. Loose pills found in the bo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly store drugs as evidenced by 1. Loose pills found in the bottom drawers of 1(MC2 (Medicine Cart 2) out of 3 medication carts reviewed. 2. Failure to label a multi-use vial found in 1(MS1) out of 2 medicine storage rooms reviewed This deficient practice had the potential to affect the 80 residents residing in the facility. Findings: On 07/23/2024, a review of the facility's policy titled, Storage of Medications, with a review date of 07/08/2024, revealed, in part, the following: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. Nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 07/22/2024 at 9:57 a.m., an interview along with an observation of MS1 (Medication Storage room [ROOM NUMBER], 100 hall) was conducted with S22LPN (Licensed Practical Nurse). A multi-use vial of flu vaccine was observed open, with no labeled opening date of the vial. S22LPN verified that the flu vaccine vial should have been labeled with the date it was opened and it was not. On 07/22/2024 at 3:31 p.m. an interview along with an observation of MS1 (Medication Storage room [ROOM NUMBER], 100 hall) was conducted with S6Corp (Corporate Nurse) and S20ADON (Assistant Director of Nursing). They both confirmed the multi-use vial of flu vaccine was not labeled with the date it was opened and that it should have been. On 07/23/2024 at 11:03 a.m. an interview and observation of MC2 was made with S21LPN. Two round white pills were found at the bottom of the second medicine drawer and 1 white round pill was found on the bottom medicine drawer of MC2. S21LPN confirmed that these pills should not have been loose in the drawers.

CONCERN (E)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected multiple residents

Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal repre...

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Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 80. Findings: On 07/21/2024 at 10:23 a.m., an observation was made of a clear plastic file holder mounted to the wall outside of the human resources office door near the facility's main entrance. A clear colored binder containing licensing surveys was observed inside the plastic file holder, and inside the binder were survey results and plan of corrections from the annual surveys and complaints conducted in 2018, 2019, 2020, and 2021. There was no evidence of the last three year's of annual or complaint surveys in the folder. On 07/23/2024 at 12:44 p.m., an interview was conducted with S1DON (Director of Nursing) and S11Adm (Administrator). They stated the results for the survey were posted at the entrance of the nursing home in a clear binder holder outside of the human resources office, but nowhere else. S11Adm confirmed the annual and complaint survey results from 2022 through 2024 were not in the binder holder, and should have been posted in a place readily accessible to residents, family members, or legal representatives.

CONCERN (E)

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 record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered plan of car...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered plan of care for each resident as evidenced by: 1. failing to follow the plan of care to address Resident #33's elevated blood sugar; and 2. failing to ensure Resident #1 had enabler bars attached to the bed as ordered. Findings: 1. Resident #33. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included, but were not limited to, Type 2 Diabetes Mellitus. Review of the resident's physician's orders dated revealed an order for Humulin R inject as per sliding scale 60-150 mg/dL (milligram per deciliter): 0 units, 151-200 mg/dL: 2 units, 201-250 mg/dL: 4 units, 251-300 mg/dL: 6 units, 301-350 mg/dL: 8 units, 351-400 mg/dL: 10 units, 401 mg/dL: 12 units, recheck blood sugar in 2 hours if still greater than 400 call the physician. Review of the resident's June 2024 MAR (Medication Administration Record) revealed on 06/27/2024 Resident # 33 had a blood glucose level of 404 mg/dl, Humulin R was not given, nor was there a recheck. On 07/22/2024 at 3:06 p.m., an interview and record review conducted with S1DON (Director of Nursing). She reviewed Resident #33's medical record and confirmed Resident #33 on 06/27/2024 had a blood sugar of 404mg/dl. S1DON further stated the Resident should have received 12 units and had a recheck in two hours. S1DON reviewed the chart and stated there was no documentation of the Resident receiving the 12 units of Humulin R, a recheck of the blood sugar in 2 hours, or refusal from the Resident. She stated the nurse should have followed the orders. 2. Resident #1. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included, but were not limited to, Functional Quadriplegia. Review of Resident #1's July 2024 care plan revealed he had ADL (Activities Daily of Living) self-care performance deficit R/T (related to) quadriplegia . Enabler bars bilaterally to aide in turning and positioning. On 07/21/2024 at 11:09 a.m., an observation was conducted of Resident #1's room, which did not reveal enabler bars attached to his bed. On 07/22/2024 at 11:32 a.m., another observation was conducted of the Resident #1's room. He had no enabler bars attached to his bed. On 07/22/2024 at 12:24 p.m., an interview and observation was conducted with S9LPN (Licensed Practical Nurse). After his observation he confirmed in Resident #1's room, the resident did not have any enablers bar attached to his bed. S9LPN further stated the resident needed enabler bars because to assist the resident in performing bed mobility and with turning during care.

CONCERN (E)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure that recipes were followed for 4 of 4 (#11, ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure that recipes were followed for 4 of 4 (#11, #34, #45, and #55) residents who received pureed diets, by failing to follow a recipe for mashed potatoes. Findings: On 07/22/2024, a review of the facility's policy titled Therapeutic diets with a revision date of 06/12/2024, read in part, Policy Statement: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care .Policy Interpretation and Implementation: 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example .d. Altered consistency diet. A review of Resident #11's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Dysphagia Following Cerebral Infarction. A review of Resident #11's Physician's orders revealed an order for a Pureed diet written on 08/15/2023. A review of Resident #34's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, and Dysphagia Following Unspecified Cerebrovascular Disease. A review of Resident #34's Physician's orders revealed an order for a Pureed diet written on 09/13/2023. A review Resident #45's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Dysphagia Oropharyngeal Phase, and Moderate Protein Calorie Malnutrition. A review of Resident #45 Physician's orders revealed an order for a Regular diet, pureed texture written on 02/12/2024. A review Resident #55's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Dysphagia Following Other Cerebrovascular Disease, and Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. A review of Resident #55 Physician's orders revealed an order for CC/RCS (Controlled Carbohydrate/Reduced Concentrated Sweets) Diet pureed written on 06/01/2023. On 07/21/2024 at 10:34 a.m., an observation was conducted of S5Cook (Cook) as she prepared pureed potatoes for the residents' lunch. S5Cook poured the potato powder from a bag in a preparation bowl, then poured hot water which she collected in an aluminum pot from the faucet into the container with the potato powder. She placed the potato mixture in a blender and added more hot water from the aluminum pot. S5Cook did not use a measuring spoon or cup to measure the potato mixture or water. After blending the potato mixture she used a spoon to check the consistency. S5Cook was asked about her process for preparing the potatoes. She stated she had never measured the ingredients or had been given a recipe to use. S5Cook also stated she had never followed the recipe on the bag. An observation of the bag from which the potato powder was poured revealed recipes for 5, 10, and 20 four ounce servings. On 07/21/2024 at 3:45 p.m., an interview was conducted with S6Corp (Corporate Nurse) who stated that recipes were available for the cooks to use in the kitchen, and S5Cook should have used a recipe to prepare the pureed meal. On 07/22/2024 at 2:08 pm., an interview was conducted with S8RD (Registered Dietician). She stated a recipe book was printed to go with the menus three weeks ago, so the kitchen staff should have used a recipe to prepare the pureed meal. She further stated she is available by phone when she is not in the facility, and did not receive a call from the facility to address any concerns with the recipes.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

2. On 07/22/2024 at 7:43 a.m., an observation and interview was conducted with S3HSK (Housekeeper) as she mopped the floor on Hall W. S3HSK removed the used mop pad from the mop with her bare hands, w...

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2. On 07/22/2024 at 7:43 a.m., an observation and interview was conducted with S3HSK (Housekeeper) as she mopped the floor on Hall W. S3HSK removed the used mop pad from the mop with her bare hands, wrapped it up in her hand, and placed it in a bag on her cart. She then proceeded to push her cart down the hall without performing hand hygiene. S3HSK confirmed that she did not use gloves to remove the dirty mop pad, and did not perform hand hygiene after handling the mop. She stated she should have worn gloves to handle the dirty mop pad and performed hand hygiene afterwards. On 07/22/2024 at 7:44 a.m., an interview was conducted with S2HSKSup (Housekeeping Supervisor). She confirmed that handling the soiled mop pad with bare hands and not performing hand hygiene was not good infection control practice, and S3HSK should have known better. On 07/22/2024 at 10:12 a.m., an interview was conducted with S4IP (Infection Preventionist). She stated that S3HSK handling of the dirty mop with her bare hands and not performing hand hygiene afterwards was against the facility's infection control procedures. Based on observation, interview, and records reviewed the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help prevent and control the spread of an infectious communicable disease, COVID-19, as evidenced by staff: 1. Failing to remove Personal Protective Equipment (PPE) prior to exiting a positive COVID-19 room and perform hand hygiene upon removing PPE; and 2. Failing to ensure housekeeping staff used gloves and performed hand hygiene while handling a dirty mop. Findings: On 07/22/2024, a review of the facility's policy titled Infection Prevention and Control Program with a revision date of 01/01/2024, read in part, Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections .Policy Interpretation and Implementation .11. Prevention of Infection a. important facets of infection prevention include: 3. educating staff and ensuring that they adhere to proper techniques and procedures. 1. On 07/21/2024 at 3:30 p.m., an observation was conducted on Hall A. S13CNA (Certified Nursing Assistant) was observed exiting Resident #178's room who was positive for COVID-19. Further observation revealed S13CNA removing the blue plastic disposable isolation gown as she walked down Hallway A. S13CNA discarded the blue plastic gown in a room, and did not sanitize her hands after throwing the isolation gown in the trash can. S13CNA was observed entering the nurse's station. On 07/21/2024 at 3:31 p.m., an interview was conducted with S12RNS (Registered Nurse Supervisor), who was sitting in the nurses station. She confirmed that PPE had to be removed prior to exiting an isolation room. On 07/21/2024 at 3:32 p.m., an interview was conducted with S13CNA and S12RNS. S13CNA was asked if she was aware that PPE was to be removed prior to leaving an isolation room, and she replied I know all that! as she walked away. S12RNS stated Well if she knew all that, why did she do it?! S12RNS stated S13CNA should have removed the PPE prior to leaving the isolation room, and should have sanitized her hands upon discarding the isolation gown.

CONCERN (F)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected most or all residents

Based on observation and interview, the facility failed to post daily nursing staffing that included the facility name, date, census, and the total number and actual hours worked by staff responsible ...

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Based on observation and interview, the facility failed to post daily nursing staffing that included the facility name, date, census, and the total number and actual hours worked by staff responsible for resident care in a prominent place readily accessible to residents and visitors. Findings: On 07/22/2024 at 3:30 p.m., an observation was made throughout the entire facility, and there was no evidence that the daily nursing staffing was posted. On 07/22/2024 at 4:00 p.m., an interview was conducted with S6Corp (Corporate Nurse) who confirmed that the census should be posted daily. She stated that staff had been posting it on Hall B. At that time, an observation was conducted with S6Corp on Hall B. A white dry-eraser board was observed located under the TV against the back wall. A closer observation revealed that the board did not contain any information. S6Corp stated that the board should have the census, the number of staff, and the total number and actual hours worked. She also confirmed that the board was not and should have been in an area where it was visible for all residents and visitors.

CONCERN (F)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

Based on observation, and interviews, the facility failed to ensure that menus were followed for residents. This had the potential to affect a census of 80 residents. Findings: On 07/21/2024 at 12:05...

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Based on observation, and interviews, the facility failed to ensure that menus were followed for residents. This had the potential to affect a census of 80 residents. Findings: On 07/21/2024 at 12:05 p.m., an observation was made of the meal service during lunch. The residents were served [NAME] Pilaf, Glazed Ham, Baked beans, Pureed Ham, Chopped Ham, [NAME] Mashed Potatoes, Pork Chops with Gravy, Pureed [NAME] Beans, Dinner Rolls, and Lemon Cake. There was no pureed dinner rolls or cornbread available. Review of the facility's lunch menu revealed the residents should have received: Glazed Ham, Baked sweet potato, Braised cabbage, Cornbread, and Frosted cake. On 07/21/2024 at 1:10 p.m., an interview was conducted with S5Cook. She confirmed there was a difference in what was served from the scheduled menu. S5Cook also confirmed that she did not prepare and serve pureed bread for residents receiving pureed meals. S5Cook stated she should have checked the menu. On 07/22/2024 at 2:08 p.m., an interview was conducted with S8RD (Registered Dietician) who stated the kitchen staff should not change the menu on their own. S8RD stated there was a substitution list to ensure the residents' nutritional needs were met and confirmed the kitchen staff did not use the substitution list. She also stated that she is available by phone when she is not in the facility, but did not receive a call from the facility with any concerns regarding the menu.

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 observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintain...

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Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Clean the kitchen fryer, fryer baskets, floor beside fryer and oven; 2. Label refrigerated foods and discard expired foods in the refrigerator; 3. Monitor refrigerator and freezer temperatures; 4. Monitor dishwasher temperature and chemicals; and 5. Ensure staff wore hair restraints in the kitchen. This deficient practice had the potential to affect the 80 residents who consumed food from the kitchen. Findings: On 07/22/2024, a review of the facility's policy titled Sanitization with a revision date of 01/2024, read in part, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation .1. All kitchens, kitchen areas and dining areas shall be kept clean .11 B. Fixed Equipment .1. Fixed equipment will be routinely cleaned and maintained .3. Food contact equipment will be cleaned and sanitized after every use. On 07/22/2024, a review of the facility's policy titled Refrigerator and Freezer Storage read in part .3. If a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated. 4. All left over foods must be labeled and dated with the date in and the date out (date the food is to be discarded)-this date can be no more than 72 hours after it was put in the refrigerator .6. All expired foods must be removed from the refrigerator and freezer .9. If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product . 1. On 07/21/2024 at 8:32 a.m., a tour was conducted of the facility's kitchen with S5Cook (Cook) who stated that she was the cook in charge for the day shift. An observation was conducted of the fryer. The oil was observed to be brown with yellow crumbs, which looked like food coating floating on the corners of the fryer. Splatters of oil were noted on the floor beside the fryer, and the floor was darkened in that area. S5Cook confirmed the splatters on the floor as oil from the fryer. Two fryer baskets were observed to be coated with oil and were dirty with food residue. One of the baskets had two french fries in the bottom. S5Cook stated the fryer baskets and oil were last used for frying french fries on Friday (07/19/2024) and confirmed that they had not been cleaned since then. An observation of the baking oven revealed the inside of its bilateral doors were dirty with caked on grease stains. S5Cook confirmed the oven doors were dirty and was unable to state when they were last cleaned. She stated that the fryer, oven, and floor should have been cleaned. 2. On 07/21/2024 at 8:52 a.m., an observation was conducted of the storage refrigerator with S5Cook. The following items were observed: -One red pitcher and one clear pitcher containing liquid with no label to indicate content or date they were prepared. S5Cook stated they contained juice and should have been labeled with content and date and time prepared. -A metal storage container containing mixed beans out of its original container with a plastic covering with no date or time. S5Cook stated it should have been labeled with date and time. -A metal storage container with a metal lid containing a red paste with no label to indicate content or date and time it was placed in the storage container. S5Cook stated the content was tomato paste and should have been labeled with content date and time. -A container labeled Mousse dated 07/10/2024, one labeled fruit dated 07/14/2024, and another labeled butter scotch which was dated 07/12/2024. S5Cook stated that the foods should have been discarded because they had been in the refrigerator over 72 hours. A pack of cheese slices with use by date of 06/05/2024, and a bag of parmesan cheese with expiration date of 05/13/2024. S5Cook stated the items were expired and should have been discarded. 3. A review of the Refrigerator and Freezer Temperature Logs revealed no refrigerator or freezer temperatures documented for 07/11/2024. S5Cook confirmed the missing temperatures and stated they should have been recorded. 4. A review of the Dishwasher Temperature/Sanitizer Logs revealed no monitoring of temperature and chemicals documented for 07/16/2024. S5Cook confirmed the missing data and stated they should have been checked and documented on the sheet. 5. On 07/21/2024 at 9:16 a.m., S17ACT (Activity Coordinator) was observed in the kitchen with no hair covering. She confirmed she did not have a hair covering and stated that she came to help and should have put on a hair net. S5Cook confirmed S17ACT was in the kitchen without hair covering and stated all staff knew they should cover their hair before entering the kitchen.

Jul 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

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, observations and interviews, the facility failed to ensure the resident was adequately supervised and mo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure the resident was adequately supervised and monitored while exiting off the transportation van's wheelchair ramp resulting in the residents sustaining injuries for 1 (#1) of 3 (#1, #2, #3) residents sampled for accidents. Findings: The facility did not have a policy or procedure for unloading residents from the facility's van wheelchair ramp. Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Bipolar, Depression, and Chronic Obstructive Pulmonary Disease. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 04/05/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated he was cognitively intact. Review of the facility's incident report dated 06/10/2024, written by S6LPN (License Practical Nurse), read in part resident was lowered to the ground on ramp on van outside after returning from a doctor's appointment. The resident unlocked his wheelchair when the ramp hit the ground which caused him to roll back falling backwards. S3VD (Van Driver) was present and witnessed the fall. The resident hit his head. Small laceration bleeding to back of head noted. Complaints of left shoulder pain 10/10 and neck pain 7/10. Local ambulance called and resident transported to local hospital. Review of Resident #1's hospital record titled, After Visit Summary, dated 06/10/2024 revealed in part that Resident #1 suffered a blunt head injury with trauma and contusion of the left shoulder, acute neck muscle strain, and a scalp abrasion. On 07/08/2024 at 11:50 a.m., an observation and immediate interview was conducted with S3VD. She stated on the day of the incident (06/10/2024), Resident #1 was positioned on the van's wheelchair ramp, and she was standing on the side of the ramp with the control in hand letting the van ramp down. She lowered the ramp to the ground. As soon as the ramp hit the ground, Resident #1 unlocked his wheelchair. She stated she remained standing on the side of the van ramp, and did not move behind the resident's wheelchair to assist him off the van ramp. She stated the incident had caught her off guard, and when the resident wheeled himself backwards slightly, his wheelchair flipped over. She stated she was aware Resident #1 locked and unlocked his wheelchair without staff assistance during van unloading procedures. When asked what was the facility's procedure for assisting residents off the van from the ramp. She stated she was trained to stand behind the wheelchair after the ramp contacts the ground, lean forward, unlock the resident's wheelchair, then remove the resident from the ramp. S3VD confirmed on the day of Resident #1's incident, she did not follow the facility's procedure for assisting residents off the van ramp. On 07/08/2024 at 12:20 p.m., an interview was conducted with S1ADM (Administrator) who stated. S3VD was not responsible for Resident #1's fall because Resident #1 unlocked his wheelchair himself which caused him to fall and sustain the injuries. She stated she was unable to provide a policy or procedure on how the van drivers were to assist in unloading residents off the van ramp. On 07/08/2024 at 3:00 p.m., an interview was conducted with Resident #1 who recalled the incident. He stated he was sitting in his wheelchair positioned on the van's wheelchair ramp as it was lowered to the ground. He stated that once the ramp was on the ground he unlocked his wheelchair himself. He stated that that time, S3VD was standing on the side of the ramp, not behind him. He stated that S3VD just looked at him and told him to go. Resident #1 stated staff was supposed to stand behind him after the ramp was lowered, but he didn't realize there was no staff behind him. He stated when S3VD told him to go, he just proceeded to roll himself backward and the wheelchair flipped over with him in it. He stated he fell hard, hitting his head, and hurting his left shoulder. On 07/09/2024 at 9:00 a.m., an interview was conducted with S2MS (Maintenance Supervisor) who is also the Transportation Supervisor, explained the proper procedure for assisting a resident off the van's wheelchair ramp. S2MS stated proper procedure began with the driver parking the van on level ground. The resident should be moved to the wheelchair ramp. The driver should then lower the ramp, stand behind the resident, then transport the resident off the lift. S2MS confirmed that S3VD should have stood behind Resident #1 to assist the resident off the lift ramp. He stated S3VD was responsible for ensuring Resident #1 was safely removed from the van's wheelchair ramp.

Jun 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

Resident Rights (Tag F0550)

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 treated with respect and dignity for 1 resid...

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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 treated with respect and dignity for 1 resident (#1) out of 3 (#1, #2, #3) sampled residents. Findings: On 06/25/2024 , a review of the facility's policy titled Quality of Life- Dignity with a last revised date of February 2020 read in part .1. Residents are treated with dignity and respect at all times .7. Staff speak respectfully to residents at all times . Review of Resident #1's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including Other Post Procedural Complications of Skin and Subcutaneous Tissue, Encounter for Attention to Colostomy, and Anxiety. Review of section C- Cognitive Patterns of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that her cognition was intact. Review of a facility investigation revealed that on 05/23/2024, Resident #1 gave the following statement to S2DON (Director of Nursing): Resident stated that when S3TN (Treatment Nurse) came in to do wound care S4LPN (Licensed Practical Nurse) came in to help her. I was in a lot of pain while they were doing my wound care, so I was hollering. S4LPN told me, If you scream in my ear like that again, I will leave you in here. On 06/24/2024 at 2:21 p.m., a phone interview was conducted with S4LPN. S4LPN stated Resident #1 would scream really loudly during wound care, causing her ears to ring. On 5/23/2024, while assisting with the resident's wound care, she told the resident that she would walk out if she screamed like that again. On 6/24/2024 at 2:45 p.m., a joint interview was conducted with S1ADM (Administrator) and S2DON (Director of Nursing). S2DON stated that S4LPN telling the resident that she would walk out of the room if she screamed was inappropriate. S1ADM and S2DON both agreed that the statement was unprofessional and she could have used other words or offered the resident alternatives for pain control.

Mar 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the Physician and Responsible Party, immediately after an ac...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to notify the Physician and Responsible Party, immediately after an accident involving the resident for 1(#1) of 3 (#1, #2, #3) sampled residents. This deficient practice had the potential to affect any of the 82 residents residing at the facility. Findings: On 03/26/2024 at 1:30 p.m., a review of the facility's policy titled Policy for Resident Incident and Visitor Accident Report with a review date of 01/2023, revealed in part: Policy. The facility will conduct an investigation of all incidents involving residents of the facility .B. Resident Incidents/Accidents: 1. If you witness an incident/accident, you must .2. Licensed nurse must .e. notify the physician, family, legal representative. Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Left Femoral Vein, Generalized Muscle Weakness, and Repeated Falls. On 03/21/2024, a review of a health standards intake form of a complaint filed by Resident #1's family member, revealed that on 02/17/2024, Resident #1 reported to family members that staff members at the facility dropped her while moving her from her chair to bed. Further review revealed that a family member called and spoke to S1ADM (Administrator), asking if an incident had been made. S1ADM stated she would check on it but had not followed up with the family. On 03/23/2024 at 11:00 a.m., an interview was conducted with the resident's family member who filed the complaint. She stated that Resident #1 told the family on 02/18/2024 that staff members dropped her on the floor while transferring her from her chair to her bed. On 03/25/2024 at 3:45 p.m., a review was conducted of an incident report prepared by S3LPN (Licensed Practical Nurse) with a date of 02/17/2024 at 7:40 p.m. It revealed in part: While S6CNA (Certified nursing Assistant) was assisting Resident #1 to transfer from wheelchair to bed, the resident stated her legs were weak. S6CNA called for assistance and S3LPN went in to assist. S3LPN and S6CNA were unable to hold resident up, as she was dead weight. The resident fell to the floor and suffered a skin tear to her left shin and stated her legs were weak and felt tired. The resident was lifted from the floor with assistance of other nursing staff and S6CNA. Further review of the incident report revealed the resident's physician was not notified until 02/19/2024 at 10:00 a.m., and the family member was notified on 02/19/2024 at 3:00 p.m. On 03/26/2024 at 11:04 a.m., an interview was conducted with S1ADM. She confirmed that Resident #1 fell on [DATE]. She further confirmed that the resident's physician and responsible party were not notified immediately after the incident occurred and should have been notified.

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** Based on observations, interviews and record reviews, the facility failed to implement a person centered care plan for 2(#1, #2)...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to implement a person centered care plan for 2(#1, #2) of 3(#1, #2, #3) sampled residents, by failing to ensure the residents received nutritional supplement as ordered by the physician. This deficient practice had the potential to affect the 27 residents who were ordered nutritional supplements. Findings: Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Left Femoral Vein, Unspecified Severe Protein-Calorie Malnutrition, Generalized Muscle Weakness, and Repeated Falls. A review of Resident #1's physician's orders revealed an order written on 02/22/2024 at 12:06 p.m. for Ensure Plus before meals for Anorexia/Malnutrition. On 03/26/2024 at 9:17 a.m., an interview and observation of the rehab unit refrigerator was conducted with S2LPN (Licensed Practical Nurse). She stated that supplements were kept in the refrigerator. An observation was made of the refrigerator revealing that Ensure Plus was not in the refrigerator. S2LPN stated that there was also a milk refrigerator. An observation of the milk refrigerator revealed that the ordered supplement was not stocked. On 03/26/2024 at 10:15 a.m., an interview was conducted with S1ADM (Administrator) who stated that S4LPNMR (Licensed Practical Nurse, Medical Records) was responsible for ordering all nutritional supplements. On 03/26/2024 at 10:20 a.m., an interview and review of the facility's online supplement orders was conducted with S4LPNMR. She confirmed that she was responsible for ordering all supplements for the facility. S4LPNMR could not provide evidence that she had ordered Ensure Plus for Resident #1. She stated that it had been a long time since she had placed an order for that supplement and could not remember the date. S4LPNMR further stated that she had not ordered Ensure Plus in 2024 and was not notified that she needed to fill an order for the supplement. Resident 2 Review of Resident #2's admission Record revealed his initial admission date was 02/16/2024 and he was readmitted on [DATE]. His diagnoses include in part, Cerebral infraction, Hemiplegia and hemiparesis following Cerebral infraction affecting left non-dominant side, Dysphagia, Muscle Wasting and atrophy, multiple sites, Vitamin D and other vitamin deficiency. Review of the resident's MDS (Minimum Data Sheet) dated 02/20/2024 revealed BIMS (Brief Interview for Mental Status) score of 14, cognitively intact. Review of the resident's comprehensive care plan read as follow, Focus: Dietary concern: Dysphagia following cerebral infarction, Unspecified protein-calorie malnutrition, HTN (Hypertension), Vitamin deficiency, GERD (Gastro-esophageal reflux disease), Hypomagnesemia, HLD ( hyperlipidemia-high cholesterol), Iron deficiency, AFIB (Atrial Fibrillation): Date initiated: 03/01/2024 .Interventions: Ensure Clear . Review of the resident's Order Summary Report with active orders as of 03/26/2024 revealed an order for under dietary-supplements for Ensure Clear in the afternoon related to Unspecified Protein-calorie malnutrition. Order date: 03/15/2024. Review of the resident's MAR (Medication Administration Record) for 03/01/2024 to 03/31/2024 revealed on order for Ensure Clear in the afternoon. On 03/01/2024, the number nine was documented indicating that the resident refused his supplement. On 03/15/2024 to 03/25/2024, the number zero was documented indicating that the resident did not consume any of the supplement. On 03/25/2024 at 2:00 p.m., an interview was conducted with Resident #2. The resident stated he was not drinking the Ensure provided because he cannot drink milk products and the ones they were giving him were the milk-based Ensure, not the Ensure Clear. He stated that he was not provided the Ensure Clear since he was admitted . He stated he was told that they did not have the Ensure Clear. On 03/26/2024 at 10:00 a.m., an interviewed was conducted with S4LPNMR (Licensed Practical Nurse/Medical Records). She confirmed that she was responsible for ordering supplements for all the residents in the facility. She stated that she ordered the supplements online. A review of an online order page was reviewed. It showed the last order for Ensure Clear was placed on 2/20/24. S4LPNMR stated she ordered Ensure Clear berry and apple flavor but it was reported to her that the residents did not like them, so she started ordering the regular Ensure chocolate favor instead.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to provide accurate documentation that the resident's nut...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to provide accurate documentation that the resident's nutritional supplement was offered for 1 (#3) out of 3 (#1, #2 and #3) sampled residents. This deficient practice has the potential to affect the 82 residents that resided in the nursing home. Findings: Review of Resident #3's admission record revealed she was admitted on [DATE]. Her diagnoses included in part, Cerebral ischemia, Dementia, Muscle Wasting and Atrophy, right upper arm, right and left shoulder, Pressure ulcer of sacral region-Stage 3, Pressure-induced deep tissue damage of left heel and Vitamin D deficiency. Review of the resident's order summary report of active orders as of 03/01/2024 revealed an order with an order date 02/14/2024 for staff to encourage intake of supplements brought by family in resident's room every shift. On 03/26/2024 at 9:50 a.m., an observation and interview was conducted with S5LPN (Licensed Practical Nurse). S5LPN was asked if she was aware that resident's family members were leaving supplements for the resident in her room. She stated that she was unaware that the resident had nutritional supplements in her room. An observation was conducted in the resident's room with S5LPN. She searched in the resident's two dressers and was unable to find any supplements in the resident's room. She confirmed again that she was unaware of the resident's family providing supplements for the resident. On 03/26/23024 at 11:15 a.m., a second interview and record review was conducted with S5LPN. The resident's MAR (Medication Administration Record) for 03/01/2024 to 03/31/2024 was reviewed with S5LPN. The MAR revealed an order dated 02/14/2024 for staff to encourage intake of supplements brought by family in resident's room every shift. The order was signed on 03/25/2024 and 03/26/204 for Day S (day shift) by S5LPN. S5LPN confirmed she did sign the order on those days and confirmed that she should not have because she had not offered the resident her supplement. On 03/26/2024 at 2:00 p.m., an interview was conducted with S1ADM (Administrator) and S7CN (Corporate Nurse). They both agreed that if the resident did not have the supplement available, S5LPN should not have initialed the MAR. S5LPN should have indicated that the supplement was not available or offered the resident a supplement from the facility that was an equal substitute.

Feb 2024 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse from ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse from other residents for 1 (#1) out of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to protect Resident #1 from being bit by Resident #4. This deficient practice resulted in actual physical harm for Resident #1 on 12/23/2023 at 1:00 p.m. when S4CNA and S3LPN failed to protect Resident #1 from Resident #4 who was known to be verbally and physically aggressive. Both S4CNA and S3LPN observed Resident #4 in an agitated state when she kept repeating that Resident #1 had her baby. S4CNA and S3LPN allowed Resident #4 propel her wheelchair down the hallway towards Resident #1. Ten minutes later, S4CNA heard screaming down the hallway and observed Resident #4 hitting Resident #1 in the face while screaming she has my baby! Resident #4 hit Resident #1 multiple times in the face causing redness to her forehead, right eye, and cheek. Findings: A review of the Facility's Abuse Prohibition Policy, read in part: Each resident has the right to be free from abuse .Physical Abuse includes, hitting .Prevention: 3. Staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to abuse and intervene appropriately. A review of the facility's incident log for December 2023 revealed physical contact between Resident #1 and Resident #4 on 12/23/2023 at 1:00 p.m. Resident #1 Review of Resident #1's clinical record revealed an admit date of 07/07/2021 with diagnoses of Cerebral Palsy, Bipolar Disorder, Anxiety Disorder, and unspecified Dementia with other Behavior Disturbances. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 7, indicating she had severe cognitive impairment. Review of Resident #1's current plan of care revealed on 12/23/2023 she received physical aggression from another resident by being struck on the right side of her head. Review of the facility's incident report for 12/23/2023 at 1:15 p.m. revealed Resident #4 propelled herself to another unit and hit Resident #1 in the face multiple times. Resident #1 was assessed and had redness to her forehead, right eye, and cheek. On 02/07/2024 at 2:25 p.m., an interview was conducted with Resident #1. She denied any knowledge of the incident that occurred on 12/23/2023 and being struck in the face by Resident #4. Resident #4 Review of Resident #4's clinical record revealed an admit date of 08/10/2021 with diagnoses of Alzheimer's disease, Schizoaffective Disorder, Major Depressive Disorder, and unspecified Dementia. Review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating she had severe cognitive impairment. Review of Resident #4's plan of care revealed she is verbally and physically aggressive at times. Interventions included when she became agitated that staff should intervene before the agitation escalated and guide the resident away from the source of distress. On 02/08/2024 at 7:55 a.m., an interview was conducted with S4CNA (Certified Nursing Assistant). She verbalized that on 12/23/2023, Resident #4 was agitated and kept repeating that Resident #1 had her baby. S4CNA stated she informed Resident #4 that Resident #1 did not have her baby. S4CNA stated about 10 minutes later, she heard screaming down the hallway and saw Resident #4 hitting Resident #1 in the face. Resident #4 was screaming she has my baby. S4CNA verbalized she should have taken Resident #4 back to her room when she first noticed she was agitated before it escalated. On 02/08/2024 at 11:32 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). She stated on 12/23/2024, Resident #4 was propelling down the hallway looking for her baby. She reported that S4CNA told the resident that no one had her baby and attempted to redirect her. Resident #4 became more agitated and was allowed to propel her wheelchair down the hallway. Resident #4 then attempted to enter Resident #1's room but Resident #1 stuck her leg out to stop her. Resident #4 began to hit Resident #1 in the face and they both began to scream at each other. S3LPN stated she intervened and separated the residents. Resident #1 was observed to have redness where she was slapped on her forehead, right eye and cheek by Resident #4. During an interview on 02/08/2024 at 12:00 p.m., with S1ADM (Administrator) and S2DON (Director of Nursing) they both confirmed they were aware that Resident #4 had propelled her wheelchair down the hallway and hit Resident #1 in the face multiple times leaving reddened areas where she was hit. S2DON verbalized that staff had attempted to redirect her but she was agitated. She confirmed that Resident #4 has a history of agitation but felt that the incident was not considered abuse due to her diagnosis of dementia.

Aug 2023 7 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure the easy touch call light device was within re...

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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 ensure the easy touch call light device was within reach for 1 (#71) investigated for accommodation of needs in a final sample of 55 residents. Findings: Review of the facility's policy, Answering The Call Light revealed, in part the following: Purpose: The purpose of this procedure is to respond to the resident's request and needs. Steps in the Procedure: . 11. Place the call light within reach of the resident. Review of Resident #71's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Epilepsy, Scoliosis, and Fusion of Spine. Review of Resident #71's comprehensive care plan dated 09/22/2021 revealed in part that the resident had an ADL (Activities of Daily Living) self-care performance deficit related to Cerebral Palsy with an intervention to keep call light within reach. On 08/28/2023 at 10:00 a.m., an observation was made of Resident #71 in bed. The resident's easy touch call light was hanging on the tube feeding pole and not within reach of the resident. On 08/29/2023 at 4:05 p.m., a follow up observation of Resident #71 was conducted with S18LPN (Licensed Practical Nurse) at this time. S18LPN confirmed that Resident #71's easy touch call light was on the floor and not within Resident #71's reach. On 08/30/2023 at 9:45 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON confirmed that Resident #71's easy touch call light should be within reach at all times.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observations and interviews, the facility failed to maintain a clean and homelike environment by failing to clean the wall which had a dried brown and red splattered substance in Room A. Fin...

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Based on observations and interviews, the facility failed to maintain a clean and homelike environment by failing to clean the wall which had a dried brown and red splattered substance in Room A. Findings: Review of the facility's policy, Homelike Environment revealed, in part, the following: Policy Statement: Residents are provided with a safe, clean, comfortable 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 . Review of the facility's form titled, Housekeeping Job Routine revealed, in part, the following: complete this shift checklist daily . 6- Spot clean walls . Review of the Housekeeping Job Routine for Room A revealed all areas for the forms dated 08/25/2023 to 08/29/2022 were checked off as completed. Review of the Housekeeper Job Description revealed, in part, the following: Job Function: Clean walls . On 08/28/2023 at 8:47 a.m., an observation was made of Room A. The wall to the right side of the bed had a dried brown and red splattered substance. On 08/29/2023 at 4:10 p.m., a second observation was made of Room A. The dried brown and red splattered substance on the wall was still present. On 08/30/2023 at 8:24 a.m., a third observation was made of Room A. The dried brown and red splattered substance on the wall was still present. On 08/30/2023 at 8:56 a.m., an interview was conducted with S6HSK (Housekeeping Supervisor) who reported all of the housekeeping staff had a checklist that was followed and completed for each resident's room that was cleaned during their shift. On 08/30/2023 at 9:00 a.m., an observation of was made of Room A with S6HSK. S6HSK observed the dried brown and red splattered substance on the wall. S6HSK stated the red splattered substance on the wall looks like dried blood and confirmed the wall should have been cleaned.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #83 A review of Resident #83's medical record revealed that he had diagnoses that included End Stage Renal Disease and ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #83 A review of Resident #83's medical record revealed that he had diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis with an onset date of 06/29/2023. A further review of the medical record revealed Resident #83 was hospitalized from [DATE] to 06/29/2023 when he began dialysis treatment. A review of Resident #83's MDS (Minimum Data Set) assessments revealed no evidence that a significant change MDS assessment was not completed within 14 days after the resident was diagnosed with End Stage Renal disease requiring dialysis. On 08/29/23 at 2:52 p.m., an interview and review of Resident #83's MDS assessments was conducted with S3MDS. She confirmed that the Quarterly MDS with the ARD (Assessment Reference Date) of 07/02/2023 was completed after the resident returned from the hospital was not a significant change in status assessment. A subsequent telephone interview was conducted with S4MDS who confirmed that the MDS assessment on 07/02/2023 should have been a significant change in status assessment. Based on record review and interview, the facility failed to ensure that a Significant Change in Condition MDS (Minimum Data Set) Assessment was completed for 2 residents (#82, #83) out of a total sample of 55 residents. Findings: Resident #82 Review of the facility's policy tiled MDS Coding Policy read: Nexion affiliated facilities utilize the most up to date resident assessment instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Resident #82 was admitted to the facility on [DATE] with diagnoses including Non-Traumatic Intracerebral Hemorrhage in Brain Stem, Cerebral Infarction, Diabetes Mellitus, and Dysphagia. Review of Resident #82's EHR (Electronic Health Record) revealed a Significant Change MDS Assessment with an ARD (Assessment Reference Date) of 08/16/2023 that was in progress. Further review of the Significant Change MDS Assessment revealed section G was not completed. On 08/29/2023 at 11:00 a.m., an in interview was conducted with S17BOM (Business Office Manager) Manager who stated the Resident #82 was discharged from hospice care on 08/03/2023, but remained at the facility with Medicaid. On 08/29/2023 at 12:55 p.m., a phone interview was conducted with S4MDS (Minimum Data Set). Resident #82's EHR was reviewed, and it was confirmed the resident's ARD for his most recent significant change MDS assessment was 08/16/2023, and that MDS assessment was still in progress. She stated that the Resident had a significant change on 08/03/2023 because he discharged from hospice services, and the Significant Change MDS Assessment should have been completed within 7 calendar days from the ARD date of 08/16/2023. S4MDS confirmed Resident #82's Significant Change MDS Assessment was not completed in the required time frame and was late.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on observation, record review and interviews, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the resident's dialysis status for 1 (#83) out o...

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Based on observation, record review and interviews, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the resident's dialysis status for 1 (#83) out of 55 sampled residents. Findings: A review of Resident #83's medical record revealed that he had diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis with an onset date of 06/29/2023. A further review of the medical record revealed Resident #83 received dialysis on 07/01/2023. A review of Resident #83's medical record revealed a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/02/2023. Section I for Active Diagnoses included in part: I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD) and I800 Dependence on Renal Dialysis. Further review of the MDS assessment revealed under Section O0100-J (Special Treatments, Procedures and Programs) the box for Dialysis While a Resident was not checked. On 08/29/23 at 2:52 p.m., an interview and a review of Resident #83's 07/02/2023 MDS was conducted with S3MDS. After review of the resident's MDS, S3MDS confirmed that the box in Section O0100-J: Dialysis should have been checked, indicating that the Resident #83 did receive dialysis while a resident.

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** Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 resident (#82) out of 1 resident investigated for hospice services. This deficient practice occurred when the facility failed to collaborate with the hospice provider to obtain discharge orders at the time the resident was discharged from hospice care. Findings: Review of the facility's policy titled Hospice Program read in part: In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: b. changing the level of services provided when it is deemed appropriate .10. In general , it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative., and ensure that the level of care provided is appropriately based on the individual resident's needs. These responsibilities include the following: .d. Communicating w/ the hospice provider (and documenting such communication) to ensure that the needs pf the resident are addressed and met 24 hours per day.12. Our facility has designated ______ to coordinate care provided to the resident by our facility staff and hospice staff. He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. Resident #82 was admitted to the facility on [DATE] with diagnoses including Non-Traumatic Intracerebral Hemorrhage in Brain Stem, Cerebral Infarction, Dysphagia, and Diabetes Mellitus. Review of Resident #82's August 2023 Physician's Orders revealed an order dated 02/04/2023 that read in part : admitted to hospice . services dx (diagnosis) Cerebral Infarction. On 08/29/2023 at 11:00 a.m., an in interview was conducted with S17BOM (Business Office Manager) who stated Resident #82 was discharged from hospice care on 08/03/2023, but remained at the facility with Medicaid. Review of Resident #82's health record failed to reveal a physician's order for Resident #82's discharge from hospice care. On 08/29/2023 at 11:28 a.m., a joint interview was conducted with S3MDS (Minimum Data Set) and S17BOM (Business Office Manager). S3MDS stated the nurse who took the discharge order should have discontinued the order in the electronic health record. Resident #82's August 2023 physician's orders were reviewed by S3MDS, revealing that the order for hospice was not removed from the elecctronic health record after discharge. S17BOM stated that the Resident was discharged from hospice on 08/03/2023 because the hospice provider reported he was doing better and hospice was no longer needed. S17BOM stated that the nurse that took the order to discontinue the resident's hospice services should have discontinued the order in the electronic health record at that time. On 08/29/2023 at 11:55 a.m., a joint interview was conducted with S2DON (Director of Nursing) and S3CORP (Corporate Nurse). S2DON confirmed that the nurse who took the hospice discharge order should have discontinued the order in Resident #82's electronic health record. S3CORP stated that the facility did not have the discharge order. She stated there was a care plan meeting on 08/16/2023 revealing that Resident #82 was discharged from hospice. However, she was not sure if the Resident was discharged from hospice on 08/03/2023 or 08/16/2023, but she knew the Resident no longer received hospice services. On 08/29/2023 at 12:34 p.m., a follow up interview was conducted with S3CORP. S3CORP provided a faxed physician's order from Resident #82's hospice provider that read in part: Medical Treatment Orders- Order date: 08/02/2023. - Discharge Order: Discharge from hospice for no longer meeting criteria .The fax was dated 08/29/2023 12:48 p.m. When asked who was responsible for collaborating with hospice and ensuring new orders were updated in the resident's chart. S3CORP stated that typically it would be a collaborative effort between the Director of Nursing, nurses, and social services.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintaine...

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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 failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Remove expired food item from the refrigerator; 2. Label food items with the date and time they were opened; 3. Label cooked items with the date they were cooked; 4. Appropriately label food items taken out of original containers; 5. Remove dust buildup from the kitchen ceiling; 6. Remove dust from the refrigerator blower; and 7. Maintain kitchen equipment. This deficient practice had the potential to affect the 83 residents who consumed food from the kitchen. The facility's census was 89. Findings: A review of the facility's policy titled Refrigerators and Freezers read in part: Policy Interpretation and Implementation .7. All food shall be appropriately dated to ensure proper rotation by expiration dates .Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates . 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition .excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. 10. Refrigerators and freezers will be kept clean, free of debris . A review of the facility's policy titled Dry Storage read in part: .4. If a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated .12. All bins for storage .should be dated with the date that it is filled . On 08/28/2023 at 08:21 a.m., an observation of the kitchen was conducted with S7KIT (Kitchen Supervisor). S7KIT stated she has been working at the facility since 2015 and was in charge of the kitchen. An observation of the walk-in refrigerator was conducted with S7KIT, revealing the following items were opened but not labeled with the date and time they were opened: • 2-gallon bottles of mayonnaise, one with about 1/6 left and another with about 1/4 left. • 2-gallon bottles of coleslaw with about 1/4 left in each. • 1-gallon bottle of ranch dressing with about 1/8 left. • 1-gallon bottle of sweet pickle relish with about 1/8 left. • 1-gallon bottle French dressing with about 1/2 left. S7KIT confirmed that the items were opened and not labeled with the date and time, and should have been labeled with the date and time they were opened. The following items were opened but not labeled with the date they were opened or a use by date: • 1 large bag of lettuce leaves. • 1 large bag of shredded carrot. • 1 aluminum container that was 1/2 full of canned peaches. • 2 packs of sliced cheese. • 2 packs of sliced lunch meat. S7KIT confirmed the items were opened and not labeled with the date they were opened or a use by date and should have been labeled with the date they were opened and a use by date. The following items were observed without labeling to specify what they were and when they were prepared or when to be discarded. S7KIT identified the contents of the following unlabeled items as: • 1large clear plastic bag with cooked macaroni. • 1 plastic bag with 8 baked biscuits. • 1 aluminum container with cooked chicken legs. • 1 hard plastic container with mixed lettuce leaves covered with plastic. S7KIT confirmed the items had no label to specify the contents and when they were prepared. S7KIT further confirmed the items should have been labeled to specify the contents and when they were prepared. The following item was past the use by date: • 1aluminum container of red beans with an opened date of 08/08/23, and a use by date of 08/11/23. S7KIT confirmed the item was past the use by date and stated that it should have been discarded. Further observation of the refrigerator revealed a large cardboard box full of cabbages on a shelf directly below the blower with water dripping from the back of the blower into the box. The fans of the blower had moderate dust build-up in and around them. S7KIT confirmed that water was dripping into the box of cabbages and should not have been. S7KIT also confirmed that there was a build-up of dust in and around the fans and should not have been. On 08/28/2023 at 8:30 a.m., an observation was made of the kitchen's dry goods storage area with S7KIT. The following items were opened but were not labeled and/or had the date they were opened: • A large bin with white powder and no label. • A large clear plastic bag with macaroni pasta and no date. • A large pack of spaghetti noodles wrapped with clear plastic and no date. • A large clear storage bin with dry powdered potatoes with no date. • A large bottle of BBQ sauce with no date S7KIT stated that the white powder was thickener and confirmed that the items should have been labeled and dated but were not. On 08/28/23 at 8:45 a.m., an observation was made of the facility's freezer with S7KIT. The following items were not labeled with the date of opening or freezing: • 1 open pack of hot dogs in a clear plastic bag. • 1 clear plastic bag with 6 croissants. S7KIT confirmed the items were opened and not labeled with the date they were opened or placed in the freezer, and stated that they should have been labeled with the date they were opened and the date they were placed in the freezer. On 08/28/2023 at 8:50 a.m., an observation of the kitchen was made with S2DON (Director of Nursing) and S1ADM (Administrator) who were also interviewed. S2DON and S1ADM both confirmed the items from the refrigerator, freezer, and dry storage were not labeled, and/or dated and stated that they should have been. On 08/28/2023 at 11:50 a.m., an observation of the kitchen and interview was conducted with S8MTN. S8MTN confirmed the water dripping in the refrigerator and the build- up of dust in and around the fans and stated that there should not be water dripping and dust build-up in the refrigerator. S8MTN also confirmed the dust build up in the ceiling of the serving area of the kitchen. S8MTN stated the dust build-up on the kitchen ceiling was unacceptable and should have been cleaned.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 2. A review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions read in part: Pol...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 2. A review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions read in part: Policy Statement: Transmission-based precautions are initiated when a resident .arrives for admission with symptoms of an infection .and is at risk of transmitting the infection to other residents .Contact Precautions .7. Staff and visitors wear gloves (clean, non-sterile) when entering the room .b. Gloves are removed and hand hygiene performed before leaving the room .8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room . Resident #348 was admitted to the facility on [DATE] with diagnoses including in part: Partial Traumatic Amputation of Left Great Toe, Methicillin Susceptible Staphylococcus Aureus Infection, End Stage Renal Disease, Pneumonia due to other Staphylococcus, and MSSA Bacteremia, Endocarditis. On 08/28/2023 at 10:19 a.m., an observation was made of Resident #348's room. The signage on the resident's door was for Contact Precautions with instructions for use of PPE. Upon exiting Resident #348's room, there was no trash container available to discard the used PPE. On 08/28/2023 at 10:19 a.m., an interview was conducted with S9CNA (Certified Nursing Assistant) during observation of Resident #348's room. S9CNA was asked where she placed used PPE when she is exiting the resident's room, and she stated she places the used PPE in a small open trash can by the resident's bedside. S9CNA confirmed there was no container inside the resident's room to discard used PPE. She also confirmed that there should have been one. On 08/28/2023 at 10:21 a.m., an interview was conducted with S10LPN (Licensed Practical Nurse). S10LPN checked the resident's room and confirmed there was only a small waste receptacle by the resident's bed and that there was no container inside the resident's room to dispose of used PPE. S10LPN stated that there should have been a container with a lid inside by the door to dispose of used PPE. 08/30/2023 at12:26 p.m., an interview was conducted with S11IP (Infection Preventionist). S11IP was asked about the procedure for disposal of used PPE after caring for a resident on Transmission-Based Precautions. S11IP confirmed that when a resident is in isolation there is supposed to be a container with a lid inside the resident's room by the exit door to dispose of used PPE. Based on observations and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infections as evidenced by: 1. Failing to ensure hand hygiene was performed between distributing each resident's meal tray for 3 (#197, #198, #199) residents out of a final sample of 55 residents and ; 2. Failing to provide a lidded container to dispose used PPE (Personal Protective Equipment) used for a resident on Contact Precautions out of a final sample of 55 residents. Findings: 1. Review of the facility's policy titled, Handwashing - Hand Hygiene Policy and Procedures, 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: .b. before and after direct contact with residents. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . o. Before and after eating or handling food; p. Before and after assisting a resident with meals. On 08/28/2023 at 12:35 p.m., an observation was conducted of S5CNA (Certified Nursing Assistant) distributing lunch meal trays to residents in Dining Hall A. S5CNA distributed Resident #197 's lunch meal tray to her. She did not sanitize her hands before or after distributing the resident's meal tray to her. S5CNA then distributed Resident # 198's lunch meal tray and was observed assisting Resident #198 with meal tray set up. S5CNA removed the cover from the meal tray and then placed the resident's straw in her juice and assisted the resident to drink from the straw. S5CNA did not sanitize her hands after assisting Resident #198. S5CNA proceeded to remove Resident #199's lunch meal tray from the cart and distribute the tray to the resident. On 08/28/2023 at 12:42 p.m., an interview was conducted with S5CNA. She stated that she was supposed to sanitize her hands after distributing each resident's meal tray. S5CNA confirmed that she should have sanitized her hands after delivering each resident's lunch meal tray, especially after helping Resident #198 with meal setup and assisting Resident #198 to drink from her straw. On 08/30/2023 at 8:56 a.m., an interview was conducted with S11IP (Infection Preventionist). S11IP confirmed that staff members should sanitize hands between distributing each resident's meal tray and assisting with meal set up.

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure physician orders were transcribed and followed for 1 (Reside...

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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 physician orders were transcribed and followed for 1 (Resident #2) of 5 (Resident #1, #2, #3, #4, and #5) sampled residents. Findings: Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Scalp Contusion Status Post Fall, Acquired Absence Of Right Leg Below Knee, Acquired Absence Of Left Leg Above Knee, Peripheral Vascular Disease, and Atrial Fibrillation. Review of Resident #2's Q (Quarterly) MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating his cognition was moderately impaired. Review of the hospital Discharge summary dated [DATE] at 3:15 p.m., revealed, in part, the following: Physician order Hold Eliquis for 48 hours. Review of Resident #2's July 2023 EMAR (Electronic Medication Administration Record) revealed the following Eliquis Oral Tablet 5 mg (milligram) by mouth two times a day scheduled for am (before noon) and hs (hour of sleep) was administered the evening he returned and throughout the 48 hours. Resident#2's anticoagulant was not held for any of the 48 hours as ordered. On 08/01/2023 at 2:35p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN explained that Resident #2 went to the hospital on [DATE] due to an incident resulting in Resident #2 hitting his head. S3LPN stated that when Resident #2 returned from the hospital on [DATE] she was responsible for entering in Resident #2's discharge orders into the EHR (Electronic Health Record). Resident #2's discharge orders dated 07/10/2023 were reviewed with S3LPN who confirmed that she did not put in the order to hold Resident #2's Eliquis for 48 hours. On 08/01/2023 at 3:06 p.m., an interview was conducted with S2CN (Corporate Nurse). S2CN reviewed Resident #2's hospital discharge order dated 07/10/2023 and resident's July 2023 MAR. She confirmed that S3LPN failed to put in the order to hold Resident #2's Eliquis for 48 hours after returning from the hospital. S2CN confirmed this resulted in Resident #2 receiving the Eliquis on 7/10/2023 at hs, 07/11/2023 at am and hs, and on 07/12/2023 in the am.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

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 provider failed to update 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled Residents care plan...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and interviews the provider failed to update 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled Residents care plan. Findings: Record review revealed Resident #3 was admitted to the facility on [DATE] with Diagnosis of Critical illness Myopathy, Peripheral Vascular Disease, Dementia, Moderate Protein-Calorie malnutrition, Anemia and Type II Diabetes Mellitus. Record review of Resident #3's Physician orders read in part, Supra Pubic Catheter order date 03/24/2023, Foley Catheter order date 3/24/23, Enteral Feed every shift Resident has a PEG (Percutaneous Endoscopic gastrostomy) tube order dated 04/14/2023. On 05/8/2023 at 11:00 a.m., Record review of Resident #3's Care Plan revealed she was not care planned for a PEG tube, Foley or Supra Pubic Catheter. On 5/9/23 at 9:00 a.m., review of Resident #3's care plan during a phone conversation with S1 RCMC (Regional Case Mix Coordinator) confirmed Resident #3 was not care planned for a PEG. She stated the Physicians order was written on 04/14/2023. She stated the Resident #3 should have been care planned for the PEG tube. On 05/10/2023 at 1:00 p.m., a review of Resident #3's care plan with S2MDSC (Minimum Data Set Coordinator) confirmed the resident was not care planned for a PEG tube, Foley Catheter and a Supra Pubic Catheter. She confirmed Resident should have been care for the PEG tube, Foley Catheter and Supra Pubic Catheter.

Nov 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's responsible party (RP) of a fall for 1 (#1) o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's responsible party (RP) of a fall for 1 (#1) out of 5 ( #1, #2, #3, #4 and #5) sampled residents by failing to contact the responsible party in a timely manner after the fall occurred. Findings: The facility's policy titled, Policy for Resident Incident and Visitor Accident Report read in part, B. Resident Incidents/Accidents .2. e. Notify the physician, family, legal representative . Resident #1 was admitted to the facility on [DATE]. His diagnoses include in part, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysphagia, Cognitive Communication Deficit, Restlessness, Agitation, Repeated Falls and History of Falling. On 11/10/22 at 4 p.m., a phone interview was conducted with Resident #1's RP. She stated that she reviewed the video monitoring on 9/21/22 and observed the resident falling out of his wheel chair at 12:35 p.m. She stated no one from the nursing home called to let her know that the resident had fallen. She stated that she even talked with the Administrator and the DON (Director of Nursing) on 9/21/22 just a few hours after the resident had fallen and they did not inform her of the fall. She stated that the DON was aware that the resident had fallen because he was standing in the door when it happened. She stated that it was not until the next morning (9/22/22) that the nurse called to inform her that the resident had fallen. Review of the incident report dated 9/21/2022 revealed that the facility notified Resident #1's responsible party on 9/22/22 at 10:30 a.m. A phone interview was conducted with S2DON on 11/15 at 4 p.m. He stated that Resident #1's daughter, who is the resident's responsible party called him on 9/22/22 and informed him that no one had called to inform her that the resident had fallen. He stated that the nurse should have notified Resident #1's responsible party as soon as she completed her assessment of the resident and ensure that the resident was stable. He confirmed that the nurse should have contacted the resident's responsible party within a few hours after the incident, not the next morning. An interview was conducted with S1ADM on 11/15/22 at 4:30 p.m. He confirmed that the nurse should have contacted the responsible party within hours after the incident occurred and not the next morning. S1ADM also confirmed that he and the DON had spoken with Resident #1's responsible party on 9/21/22 and they also failed to inform her of the resident's fall.

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** Resident #3: Review of facility's policy and procedure titled Policy for Resident Incident and Visitor Accident Report read in p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3: Review of facility's policy and procedure titled Policy for Resident Incident and Visitor Accident Report read in part . Policy: The facility will conduct an investigation of all incidents involving residents of the facility .The investigation will be conducted by designated personnel and reported to the Administrator/designee . A. Procedure Reporting of Resident Incidents and Visitor Accidents: Any employee witnessing or having knowledge of an incident or accident involving a resident .must immediately report such occurrence to his/her supervisor. The supervisor and/or employee must immediately notify the charge nurse to ensure proper medical attention can be provided. Regardless of how minor an incident/accident appears to be, it must be reported to the Department Supervisor, Administrator, or DON/designee. As soon as possible after becoming aware of an incident/accident, the Witness Form must be completed by any person witnessing the incident or any person thought to have witnessed the incident. An incident report must be completed by the person reporting the incident or the supervisor on the shift that the incident occurred. The investigation must be initiated by the Department Supervisor or Charge Nurse and completed by the Administrator or DON/designee. B. Resident Incidents/Accidents .3. Pertinent documentation must be completed: a. Incident Witness Statement b. Incident Report c. Incident Investigation d. Nurse Progress Notes . g. Follow up documentation every shift for 72 hours or more frequently if needed . 4. Investigation a. The charge nurse must immediately initiate an investigation to determine the circumstances of the incident/accident . 6. Conclusion a. The Witness Form (s), Incident Report and Investigation Report are submitted to the DON/designee upon their completion. b. The DON/designee then completes the investigation follow up on the Investigation Report form to come to a reasonable conclusion regarding the causative factors surrounding the incident and the actions necessary to prevent further incidents/accidents. Review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03 indicating her cognition was severely impaired. Her functional status was assessed as requiring two-person physical assist for transfers. Resident # 3's balance during transitions and walking was assessed as not steady, only able to stabilize with human assistance. Further review of Resident # 3's MDS revealed she had one fall with no injury since the prior MDS assessment had been conducted. Review of Resident #3's care plan revealed she was admitted to the facility on [DATE]. Resident # 3 had impaired cognitive function or impaired thought processes related to Unspecified Dementia with behavioral disturbances. Further review of Resident # 3's care plan revealed she was at risk for falls related to generalized weakness and confusion. Resident #3 had an unwitnessed fall with no injury on 09/26/2022 due to poor balance, poor communication/comprehension and unsteady gait. There was no evidence of new interventions implemented after the fall that occurred on 09/26/2022. Review of resident's fall risk assessment dated [DATE] revealed a score of 85 which indicated that she was high risk for falling. Review of the facility's incident log with date ranges of 08/14/2022 to 11/14/2022 revealed Resident #3 had a fall without injury on 09/26/2022 at 2:00 p.m. Review of Resident # 3's nursing progress notes revealed an entry dated 09/26/2022 1400 (2:00 p.m.) per S5LPN (Licensed Practical Nurse) that read: Resident was leaning over in chair and fell to her knees. Resident was assisted by two nurses and put in chair. Asked resident if she was in any pain she verbalized NO. Resident stated I was just trying to find family member. Explained to resident she has to stay in wheelchair at all times and ask for assistance. Resident verbalized understanding. Notified NP (Nurse Practitioner) and family member of resident's fall. Resident fall was without injury and witnessed by S4LPN. On 11/15/2022 at 9:00 a.m., surveyor requested documentation of Resident # 3's fall on 09/26/2022 from S1ADM (Administrator). On 11/15/2022 at 12:00 p.m., S1ADM reported an incident report had not been conducted for Resident #3 and should have been per the facility's policy. On 11/16/2022 at 11:25 a.m., a phone interview was conducted with S4LPN who confirmed she had not completed an incident report or completed a witness statement for the fall that occurred on 09/26/2022. On 11/16/2022 at 11:35 a.m., a phone interview was conducted with S5LPN. S5 LPN reported she notified Resident #3's nurse practitioner of the fall that happened on 09/26/2022 and had not notified the S2DON (Director of Nursing) or S3ADON (Assistant Director of Nursing) of Resident # 3's fall and should have. On 11/16/2022 at 11:55 a.m., S3ADON was interviewed. S3ADON confirmed an investigation report had not been conducted for Resident # 3 due to S5LPN not reporting Resident # 3's fall on 09/26/2022. Based on record review and interview, the facility failed to ensure 2 (#1, #3) residents out of 5 (#1, #2, #3, #4, #5) were free from accidents by failing to: 1. ensure adequate supervision and assistance for Resident #1 who fell from his wheelchair, and 2. complete an incident investigation in order to identify, evaluate and implement interventions after Resident #3 sustained a fall. This deficient practice has the potential to effect all resident that reside in the nursing home. The total census was 80. Findings: Resident 1: Resident #1 was admitted to the facility on [DATE]. His diagnoses include in part, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysphagia, Cognitive Communication Deficit, Polyneuropathy Restlessness, Agitation, Repeated Falls and History of Falling. Review of Resident #1's Significant Change MDS (Minimum Data Set) dated 10/13/22 revealed a BIMS (Brief Interview of Mental Status) score of 8, indicating moderate cognitive impairment. His functional status was assessed as total dependence with two-person physical assist for transfers. He had functional impairment on one side in his lower extremities. He required substantial/maximal assistance to come to a standing position from sitting in a chair, wheelchair . Review of Resident #1's care plan revealed that the resident was care planned for at risk for falls related generalized weakness, hemiplegia and polyneuropathy. Review of resident's fall risk assessment dated [DATE] revealed a score of 55 which indicated that he was high risk for falling. Review of the facility's incident log with date ranges of 08/14/2022 to 11/14/2022 revealed that Resident #1 sustained a fall with no injuries on 9/21/22. On 11/14/22 at 12:00 p.m., an observation was made of a picture of a falling star and a picture of two people attached outside of the resident's room door. On 11/14/22 at 12:30 p.m., an interview was conducted with S6CNA (Certified Nursing Assistant) who stated that the falling star meant the resident was at risk for falling and the picture of the two people meant that the resident required two people to assist him with transfer to and from the bed to his wheelchair. She confirmed that Resident #1 was not able to stand up on his own. She stated that on the day the resident fell, she had left the resident's room to get the DON (Director of Nurses). She stated the resident was upset and did not want to let her and S7CNA put him in his bed because he thought his heel lift cushion was dirty. S6CNA confirmed that when the resident fell, she was standing withS2DON outside the resident's room and S7CNA was standing inside the doorway of the resident's room. On 11/15/22 at 1:30 p.m., S3ADON informed surveyor that the nurse and S7CNA who were present at the time of the resident's fall were not available for interview. She stated that nurse went out of town and S7CNA was on vacation. An interview was conducted on 11/16/22 at 11:30 a.m. with S1ADM and S2DON (by phone). S2DON confirmed that at the time of Resident #1's fall on 9/21/22, the resident was assessed as a risk for falls. He stated that the resident had a yellow identifier (falling star) outside his room door that indicated he was a risk for falls due to his history of falls. S2DON stated that prior to resident falling, heard the resident hollering from his office, which was located on the opposite end of the same hall where the resident resided. He stated that Resident #1 was upset and did not want the CNAs to put him back to bed because he believed that his heel booster was dirty. He stated that S7CNA left the room to get him and S7CNA stayed with the resident. He confirmed that when he reached the resident's room, S7CNA was in the resident's doorway with her back to the resident and the resident was in his wheelchair on his side of the room which was next to the window. He confirmed that he, S6CNA and S7CNA were standing in the doorway of the resident's room at the time the resident fell. He agreed that S7CNA should have remained with the resident and not leave him unattended since the resident upset and a risk for falls.

New Iberia Manor South

The Good

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The Ugly 48 deficiencies on record

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About This Facility

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New Iberia Manor South

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