How many inspection deficiencies does ST BERNARD NURSING & REHAB have?

ST BERNARD NURSING & REHAB has 41 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at ST BERNARD NURSING & REHAB?

ST BERNARD NURSING & REHAB has a one-star staffing rating from CMS with 0.25 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 ST BERNARD NURSING & REHAB located?

ST BERNARD NURSING & REHAB is located in NEW ORLEANS, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ST BERNARD NURSING & REHAB have?

ST BERNARD NURSING & REHAB has 127 certified beds.

Who owns ST BERNARD NURSING & REHAB?

ST BERNARD NURSING & REHAB is a for profit - limited liability company facility and is part of the VOLARE HEALTH chain.

What questions should families ask when visiting ST BERNARD NURSING & REHAB?

Families visiting ST BERNARD NURSING & REHAB should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does ST BERNARD NURSING & REHAB compare to other nursing homes?

ST BERNARD NURSING & REHAB has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

ST BERNARD NURSING & REHAB

Name: ST BERNARD NURSING & REHAB
Address: 4021 RONEAGLE WAY, NEW ORLEANS, LA, 70122, US
Telephone: (504) 246-7900
Rating: 1.0

4021 RONEAGLE WAY, NEW ORLEANS, LA 70122 · (504) 246-7900

For profit - Limited Liability company 127 Beds VOLARE HEALTH Data: November 2025

Trust Grade

35/100

#244 of 264 in LA

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ST BERNARD NURSING & REHAB nursing home in NEW ORLEANS, LA - Photo 1 of 2

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Last Inspection: June 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

St. Bernard Nursing & Rehab has a Trust Grade of F, indicating significant concerns and a poor overall quality of care. It ranks #244 of 264 facilities in Louisiana, placing it in the bottom half, and #9 out of 11 in Orleans County, suggesting only two local options are worse. The facility is worsening, with issues increasing from 8 in 2024 to 10 in 2025. Staffing is a significant concern, earning only 1 out of 5 stars, and has a high turnover rate of 59%, well above the state average. While there have been no fines, which is a positive sign, recent inspections revealed serious issues, such as staff failing to don personal protective equipment during wound care, not performing necessary hand hygiene before and after administering medications and feeding, and not having funds available for a resident's personal use. These findings highlight both the weaknesses in care practices and the need for improvement in resident support.

Trust Score: F
In Louisiana: #244/264
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Louisiana facilities.
Skilled Nurses: Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 41 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 8 issues

2025: 10 issues

The Good

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

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Louisiana average (2.4)

Significant quality concerns identified by CMS

Staff Turnover: 59%

13pts above Louisiana avg (46%)

Frequent staff changes - ask about care continuity

Chain: VOLARE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (59%)

11 points above Louisiana average of 48%

The Ugly 41 deficiencies on record

Jun 2025 7 deficiencies

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record reviews, the facility failed to assess a resident for self-administration of medications for 2 (Resident #40, Resident #108) of 29 (Resident #8, Resident #16, Resident #20, Resident #23, Resident #24, Resident #26, Resident #31, Resident #38, Resident #39, Resident #40, Resident #48, Resident #53, Resident #57, Resident #60, Resident #65, Resident #73, Resident #79, Resident #83, Resident #84, Resident #94, Resident #100, Resident #103, Resident #108, Resident #110, Resident #111, Resident #112, Resident #113, Resident #164, Resident #215) sampled residents observed for medications available at the bedside. Findings: Review of the facility's Right to Self-Administration Medications policy dated 03/2023 revealed, in part, a resident may self-administer medications after the interdisciplinary team had determined which medications may be self-administered. Further review revealed appropriate documentation of the determinations would be documented in the resident's medical record and care plan. Resident #40 Review of Resident #40's Minimum Data Set with an Assessment Reference Date of 03/18/2025 revealed, in part, Resident #40 had a Brief Interview for Mental Status score of 8, which indicated Resident #40 had moderate cognitive impairment. Review of Resident #40's record revealed, in part, no documented evidence and the facility could not produce any documented evidence Resident #40 was assessed to be appropriate to self-administer medications. Observation on 06/09/2025 at 11:45AM revealed a pink bin on a table in Resident #40's room which contained one 2.5 ounce bottle of muscle rub (topical medication use to relieve minor aches and pain on joints or muscles), one 2.5 ounce bottle of cold and hot rub (topical medication used to relieve minor aches and pain on joints or muscles), and one 3 ounce tube of Rugby muscle rub cream with 10% menthol and 5% Methyl Salicylate (topical medications used to relieve minor aches and pain on joints or muscles). Resident #108 Review of Resident #108's Minimum Data Set with an Assessment Reference Date of 05/08/2025 revealed, in part, Resident #108 had a Brief Interview for Mental Status score of 11 which indicated Resident #108 had moderate cognitive impairment. Review of Resident #108's record revealed, in part, no documented evidence and the facility could not produce any documented evidence Resident #108 was assessed to be appropriate to self-administer medications. Observation on 06/08/2025 at 1:50PM revealed one 4.3 ounce tube of Aspercream (topical medication for relief of joint and muscle pain) and one 0.5 fluid ounce bottle of Advanced eye relief drops (used for dry eyes) on Resident #108's bedside table. Observation on 06/09/2025 at 11:50AM revealed one 4.3 ounce tube of Aspercream and one 0.5 fluid ounce bottle of Advance eye relief drops on Resident #108's bedside table. In an interview on 06/09/2025 at 11:50AM, Resident #108 indicated the above documented medications were hers brought from home. Resident #108 further indicated she used the pain rub two or three times a day and self-administered eye drops in each eye two times a day. In an interview on 06/09/2025 3:20PM, S3Regional Director of Clinical Services indicated medication, whether over the counter or prescribed should not be left at the bedside of residents for self-administration. In an interview on 06/10/2025 at 10:00AM, S2Director of Nursing (DON) confirmed there was no documented evidence, and the facility could not provide documented evidence Resident #40 and Resident #108 had been assessed by the interdisciplinary team and deemed appropriate to self-administer medications.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observations and interview, the facility failed to ensure bathrooms were clean and sanitary for 2 (Room C, Room D) of 2 (Room C, Room D) bathrooms observed for environment requirements. Findings: Observation on 06/08/2025 at 10:10AM revealed a dark colored substance on the rim and in the basin of the bathroom sink in Room C. Observation on 06/08/25 at 11:33AM revealed the bathroom in Room D had a foul urine-like odor. Further observation of Room D revealed a clear substance was present on the floor by the toilet, 6 paper hand towels were on the bathroom floor, and a dried red gel-like substance and a dried white substance was present on the rim and in the basin of the bathroom sink. Observation on 06/09/2025 at 9:10AM revealed a dark colored substance on the rim and in the basin of the bathroom sink in Room D. Observation on 06/09/2025 at 12:30PM revealed the bathroom in Room D had a foul urine-like odor. Further observation of Room D revealed a clear substance was present on the floor by the toilet, 6 paper hand towels were on the bathroom floor, and a dried red gel-like substance and a dried white substance was present on the rim and in the basin of the bathroom sink. In an interview on 06/09/2025 at 12:35PM, S1Administrator indicated the bathrooms in Room C and Room D were not clean and they should have been.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, the facility failed to accurately update a resident's care plan for 2 (Resident #8, Resident #57) of 2 (Resident #8, Resident #57) sampled residents reviewed for accuracy of care plans. Findings: Review of the facility's Comprehensive Care Plans Policy and Guidelines for Implementation, dated 03/2023, revealed, in part, each resident should have a formulated person-centered, comprehensive care plan to address the resident's medical, nursing, physical, mental and psychosocial needs. Resident #57 Record review of Resident #57's Physician's Oders revealed, in part, an order dated 11/01/2024 for Ensure Original (a nutritional formula) three times a day per PEG tube and Jevity (a nutritional formula) 1.5 900 kilocalories at 50 milliliters (ml) an hour starting at 6:00PM and ending at 6:00AM per PEG tube. Review of Resident #57's Comprehensive Care Plan dated 04/21/2025 revealed, in part, Resident #57 was at risk for altered nutrition. Further review revealed Resident #57 was n a mechanically altered therapeutic diet and received water flushes and medications through a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube. Resident #8 Review of Resident #8's Physician's Orders, revealed, in part, an order dated 05/07/2025 for oxygen at 3 liters per minute (LPM) via nasal cannula as needed to maintain an oxygen saturation level greater than 90%. Review of Resident #8's Comprehensive Care Plan dated 04/09/2025 revealed, in part, Resident #8 was at risk for respiratory complications due to a history of Chronic Obstructive Pulmonary Disease and respiratory failure. Further review revealed an intervention for Resident #8 to have continuous Oxygen via nasal cannula at 3LPM via nasal cannula. In an interview on 06/10/2025 at 10:24AM, S8Minimum Data Set Nurse (MDS) indicated the care plans were updated by the floor nurse. S8MDS Nurse further indicated the floor nurse then notified the MDS Nurse of the updated information, and the updated assessments were automatically generated into the resident's care plan. S8MDS Nurse further indicated new and updated physician's orders should have been updated in Resident #8's and Resident #57's care plans and were not. In an interview on 06/10/2025 at 10:34AM, S2Director of Nursing (DON) confirmed the process for updating the care plans indicated by the MDS Nurse. S2DON indicated new and updated physician's orders should have been updated in Resident #8's and Resident #57's care plans and were not. In an interview on 06/10/2025 at 10:37AM, S1Administrator confirmed the process for updating the care plans indicated by the MDS Nurse. S1Administrator indicated new and updated physician's orders should have been updated in Resident #8's and Resident #57's care plans and were not.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observations, interviews and record review the facility failed to ensure call lights were available for resident use for 2 (Resident #20, Resident #53) of 2 (Resident #20, Resident #53) sampled residents investigated for call bell availability. Findings: Review of the facility's Physical Environment Resident Call System policy dated 07/2018 and revised on 03/2023 revealed, in part, the purpose of the resident call system was to provide residents with means to directly contact caregivers from their room, toileting, and bathing areas. Observation on 06/08/2025 at 11:17AM revealed Resident #53 did not have a call light connected to the call light wall system in his room. In an interview on 06/08/2025, Resident #53 confirmed there was not a call light connected to the call light wall system in his room. Resident #53 indicated he ambulated to the hallway to summon assistance from staff. Observation on 06/09/2025 at 10:30AM revealed Resident #20 did not have a call light connected to the call light wall system in her room. In an interview on 06/09/2025 at 10:30AM, Resident #20 confirmed she did not have a call light available. Resident #20 indicated she did not know where her call light was. In an interview on 06/09/2025 at 9:45AM, S7Licensed Practical confirmed that there should be a call light plugged into the call light system in all resident rooms. In an interview on 06/09/2025 at 10:40AM, S2Director of Nursing confirmed a call light should be plugged into the call light system in every resident room and it was not. In an interview on 06/10/2025 at 9:05AM, S1Administrator confirmed that all residents should have a call light connected to the call light wall system located in their rooms and it was not.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observations and interview, the facility failed to maintain a functional environment by failing to ensure a water facet was functional in1 (Room B) of 1 (Room B) rooms observed for a functional environment. Findings: Observation on 06/08/2025 at 10:14AM revealed the hot water was not functional on the bathroom faucet in Room B Observation on 06/09/2025 at 12:35PM revealed the hot water was not functional on the bathroom faucet in Room B. In an interview on 06/09/2025 at 12:35PM, S1Administrator confirmed the hot water faucet should have been functional in Room B.

CONCERN (E)

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

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected multiple residents

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Based on interviews and record review, the facility failed to ensure that funds were available for resident use for 1 (Resident #23) of 1 (Resident #23) sampled residents reviewed for personal funds. Findings: Review of Resident #23's Minimum Data Set with an Assessment Reference Date of 03/18/2025 revealed a Brief Interview for Mental Status score of 9, which indicated Resident #9 had moderate cognitive impairment. In an interview on 06/08/2025 at 10:15AM, Resident #23 indicated the business office never had money upon request. In an interview on 06/10/2025 at 3:06 PM, S1Administrator indicated that petty cash was kept at the receptionist desks, and residents could request money as needed. S1ADM also further indicated that approximately $500.00 was kept on hand for resident requests; however, S1Administrator acknowledged there were times when the facility had no money available on hand to honor the residents' request. In an interview on 06/10/2025 at 3:15 PM, S5Receptionist indicated that the petty cash was kept in a drawer at the nursing station, and she logged the disbursed amount when residents requested cash. S5Receptionist acknowledged that at the time of the interview, there was no cash available for disbursement.S5Receptionist further acknowledged that Resident #23 had made multiple requests for cash, which S5Receptionist could not fulfill. In an interview on 06/10/2025 at 3:20 PM, Resident #23 reported that she had requested $50 the morning of 06/10/2025 and was told no cash was available. Resident #23 that she was frequently denied access to her funds due to the unavailability of cash. In an interview on 06/10/2025 at 3:28 PM, S1Administrator acknowledged that when residents requested cash money under $100 dollars it should be made available to the resident.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure staff donned personal protective equipment (PPE) prior to providing wound care services to residents on Enhanced Barrier Precautions (EBP) (Resident #31); 2. Ensure staff performed hand hygiene before and after administering medications (Resident #89, Resident #91, Resident #97); and, 3. Ensure staff performed hand hygiene before and after feeding residents (S6Activity Director). This deficient practice was identified for 4 (Resident #31, Resident #89, Resident #91, Resident #97 of 29 (Resident #8, Resident #16, Resident #20, Resident #23, Resident #24, Resident #26, Resident #31, Resident #38, Resident #39, Resident #40, Resident #48, Resident #53, Resident #57, Resident #60, Resident #65, Resident #73, Resident #79, Resident #83, Resident #84, Resident #94, Resident #100, Resident #103, Resident #108, Resident #110, Resident #111, Resident #112, Resident #113, Resident #164, Resident #215) sampled residents reviewed. Findings: 1. Review of the facility's Infection Prevention and Control Program: Enhanced Barrier Precautions policy, revised on 03/10/2025 revealed, in part, the purpose of the policy was to prevent the spread of transmission of Multi-drug Resistant Organisms (MDRO). Further review revealed residents who were colonized or infected with MDROs and residents at high risk for contracting MDROs, such as residents with wounds or indwelling catheters, would be placed on EBP. Further review revealed when providing direct care, such as wound care, to residents on EBP, staff should wear personal protective equipment (PPE), which included gowns and gloves. Observation on 06/09/2025 at 10:28AM revealed S3Wound Care Nurse did not don on personal protective equipment (PPE) for enhanced barrier precautions (EBP), prior to initiating wound care on Resident #31. Review of Resident #31's medical record review revealed, in part, Resident #31 had a diagnosis of an unstageable pressure ulcer of left heel, and a stage 3 pressure ulcer of left ankle. In an interview on 06/09/2025 at 11:16AM, S3Wound Care Nurse confirmed that she did not don PPE prior to performing wound care on Resident #31 and she should have. In an interview on 06/09/2025 at 3:31PM, S2Director of Nursing (DON) confirmed S3Wound Care Nurse should have donned PPE prior to performing wound care on Resident #31 2. Observation of medication administration on 06/10/2025 at 10:12AM revealed hand sanitization was not performed by S10Licensed Practical Nurse (LPN) between administering medications to Resident #89, Resident #91, and Resident #97. In an interview on 06/10/2025 at 9:30AM, S10LPN indicated she did not perform hand hygiene between administering medications to Resident #89, Resident #91 and Resident #97, and she should have. In an interview on 06/10/2025 at 10:00AM, S2DON indicated hand sanitization should be performed during medication administration before and between residents. S2DON further indicated S10LPN should have performed hand sanitization between administering medications to Resident#89, Resident #91, and Resident #97. 3. Observation of the lunch meal on 06/08/2025 at 12:10PM revealed S6Activity Director, fed two residents at the same time, without using proper hand hygiene between residents. In an interview on 06/09/2025 at 12:45PM, S6Activity Director confirmed she fed two residents at the same time without using proper hand hygiene, and she should not have. In an interview on 06/09/2025 at 3:31PM, S2DON confirmed that S6Activity Director should have been performed proper hand hygiene between feeding each resident while feeding two residents at the same time.

Feb 2025 3 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

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A resident's indwelling catheter tubing and bag were changed monthly as ordered (Resident #3); and, 2. Indwelling urinary catheter tubing and collection bags were not on the floor (Resident #3, Resident #R4). This deficient practice was identified for 2 (Resident #3, Resident #R4) of 2 (Resident #3, Resident #R4) sampled residents investigated for urinary catheter care and Urinary Tract Infections (UTI). Findings: Review of the facility's Urinary Catheterization policy and procedure dated 03/2023 revealed, in part, indwelling urinary catheters and drainage bags will be changed out as ordered. Resident #3 Review of Resident #3's February 2025 physician's orders revealed, in part, an order dated 12/19/2024 for a size 18 French Foley catheter for a neurogenic bladder. Further review revealed an order for the bedside unit, bag, and tubing to be changed monthly and as needed. Review of Resident #3's January 2025 electronic Treatment Administration Record (eTAR) revealed, in part, no documented evidence Resident #3's urinary catheter bag and tubing was changed monthly as ordered. Observation on 02/24/2025 at 10:15AM, revealed Resident #3's urinary catheter drainage bag and tubing contained rust colored, cloudy urine with sediment. Further observation revealed the inside of the drainage bag appeared dirty with no date of when it was last changed written on the outside of the bag and/or tubing. Further observation revealed Resident #3's urinary catheter tubing and collection bag were lying on the floor under his bed with grey fuzzy debris on the outside of the tubing and collection bag. In an interview on 02/24/2025 at 10:20AM, Resident #3 indicated his urinary catheter bag has had a missing urinary bag hanging clip and was unable to be hung under his bed for over 3 weeks. Observation on 02/24/2025 at 3:00PM, revealed Resident #3's urinary catheter tubing and collection bag were lying on the floor under his bed. Observation on 02/25/2025 at 8:30AM, revealed Resident #3's urinary catheter drainage bag and tubing contained rust colored, cloudy urine with sediment. Further observation revealed, the inside of the drainage bag appeared dirty with no date of when it was last changed written on the outside of the bag and/or tubing. Further observation revealed Resident #3's urinary catheter tubing and collection bag were lying on the floor under his bed with grey fuzzy debris on the outside of the tubing and collection bag. In an interview on 02/25/2025 at 12:00PM, S4Licensed Practical Nurse (LPN) indicated Resident #3's urinary catheter tubing and bag appeared unsanitary and should have been changed monthly and/or as needed as ordered. S4LPN further confirmed Resident #3's urinary catheter bag and tubing were lying on the floor and should not have been. In an interview on 02/26/2025 at 10:17AM, S2Director of Nursing (DON) confirmed Resident #3's urinary catheter bag and tubing should not have been lying on the floor for multiple shifts, and should have been changed out monthly and/or as needed as ordered. In an interview on 02/26/2025 at 11:15AM, S1Administrator confirmed Resident #3's catheter bag and tubing should not have been lying on the floor and should have been changed out monthly and/or as needed as ordered. Resident #R4 Review of Resident #R4's February 2025 physician's orders revealed, in part, an order dated 07/05/2024 for a size 16 French Foley catheter for urinary retention or incontinence. Observation on 02/24/2025 at 2:42PM, revealed Resident #R4's urinary catheter bag was lying in Resident #R4's bedside trashcan. Further observation of Resident #R4's urinary catheter bag revealed the urinary bag hanging clip was missing. In an interview on 02/24/2025 at 2:45PM, Resident #R4 indicated there was no other place to put the bag since the urinary bag hanging clip was missing. Observation on 02/25/2025 at 8:45AM, revealed Resident #R4's urinary catheter bag and tubing were lying on the floor under Resident #R4's bed. In an interview on 02/25/2025 at 12:00PM, S4Licensed Practical Nurse (LPN) confirmed Resident #R4's urinary catheter bag was on the floor and should not have been. In an interview on 02/26/2025 at 10:17AM, S2Director of Nursing confirmed Resident #R4's urinary catheter bag should not have been in the trashcan or lying on the floor. In an interview on 02/26/2025 at 11:15AM, S1Administrator confirmed Resident #R4's urinary catheter bag should not have been in the trashcan or lying on the floor.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on interviews and record reviews, the facility failed to ensure controlled drugs were accurately reconciled for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's undated Licensed Practical Nurse job description, revealed, in part, Licensed Practical Nurses (LPNs) assume responsibility to assure narcotics were accounted for properly in accordance with professional standards. Review of the facility's February 2025 Medication Cart a Nurse's Narcotic Check List revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: - 02/01/2025 on the 7:00AM to 3:00PM shift (on-coming nurse [on]); - 02/01/2025 on the 11:00PM to 7:00AM shift (off-going nurse [off]); - 02/03/2025 on the 7:00AM to 3:00PM shift (off); - 02/03/2025 on the 3:00PM to 11:00PM shift (on); - 02/03/2025 on the 11:00PM to 7:00AM shift (off); - 02/11/2025 on the 3:00PM to 11:00PM shift (on); - 02/11/2025 on the 11:00PM to 7:00AM shift (off); - 02/13/2025 on the 11:00PM to 7:00AM shift (off); - 02/16/2025 on the 7:00AM to 3:00PM shift (off); - 02/17/2025 on the 7:00AM to 3:00PM shift (off); - 02/19/2025 on the 7:00AM to 3:00PM shift (on); and, - 02/19/2025 on the 3:00PM to 11:00PM shift (off). There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart a for the above mentioned dates and/or times. In an interview on 02/25/2025 at 9:15AM, S4Licensed Practical Nurse (LPN) indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the on-coming nurse at the end of their shift, and the nurses should document that the controlled substance reconciliation was completed on the facility's Nurses Narcotic Check List. Review of the facility's February 2025 Medication Cart b Nurse's Narcotic Check List revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: - 02/01/2025 on the 7:00AM to 3:00PM shift (on); - 02/01/2025 on the 3:00PM to 11:00PM shift (off); - 02/01/2025 on the 11:00PM to 7:00AM shift (on); - 02/02/2025 on the 7:00AM to 3:00PM shift (off); - 02/02/2025 on the 11:00PM to 7:00AM shift (off); - 02/04/2025 on the 7:00AM to 3:00PM shift (off); - 02/06/2025 on the 11:00PM to 7:00AM shift (on); - 02/09/2025 on the 7:00AM to 3:00PM shift (off); - 02/10/2025 on the 7:00AM to 3:00PM shift (off); - 02/11/2025 on the 3:00PM to 11:00PM shift (on); - 02/11/2025 on the 11:00PM to 7:00AM shift (on); - 02/11/2025 on the 11:00PM to 7:00AM shift (off); - 02/12/2025 on the 7:00AM to 3:00PM shift (off); - 02/22/2025 on the 7:00AM to 3:00PM shift (on); - 02/22/2025 on the 3:00PM to 11:00PM shift (on); - 02/22/2025 on the 3:00PM to 11:00PM shift (off); - 02/23/2025 on the 7:00AM to 3:00PM shift (on); - 02/23/2025 on the 3:00PM to 11:00PM shift (on); - 02/23/2025 on the 3:00PM to 11:00PM shift (off); - 02/24/2025 on the 7:00AM to 3:00PM shift (off); and, - 02/25/2025 on the 7:00AM to 3:00PM shift (off). There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart b for the above mentioned dates and/or times. In an interview on 02/25/2025 at 9:35AM, S5LPN indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the on-coming nurse at the end of their shift, and the nurses should document that the controlled substance reconciliation was completed on the facility's Nurses Narcotic Check List. Review of the facility's February 2025 Medication Cart c Nurse's Narcotic Check List revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: - 02/01/2025 on the 7:00AM to 3:00PM shift (on); - 02/02/2025 on the 3:00PM to 11:00PM shift (on); - 02/02/2025 on the 11:00PM to 7:00AM shift (on); - 02/02/2025 on the 11:00PM to 7:00AM shift (off); - 02/03/2025 on the 7:00AM to 3:00PM shift (off); - 02/19/2025 on the 11:00PM to 7:00AM shift (off); - 02/20/2025 on the 11:00PM to 7:00AM shift (on); - 02/21/2025 on the 7:00AM to 3:00PM shift (off); and, - 02/25/2025 on the 7:00AM to 3:00PM shift (on). There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart c for the above mentioned dates and/or times. In an interview on 02/25/2025 at 10:00AM, S6LPN indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the on-coming nurse at the end of their shift, and the nurses should document that the controlled substance reconciliation was completed on the facility's Nurses Narcotic Check List. S6LPN further indicated she did not sign the Nurses Narcotic Check List at the beginning of her shift and should have. Review of the facility's February 2025 Medication Cart d Nurse's Narcotic Check List revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: - 02/01/2025 on the 11:00PM to 7:00AM shift (on); - 02/01/2025 on the 11:00PM to 7:00AM shift (off); - 02/02/2025 on the 7:00AM to 3:00PM shift (off); - 02/02/2025 on the 11:00PM to 7:00AM shift (on); - 02/03/2025 on the 7:00AM to 3:00PM shift (off); - 02/03/2025 on the 11:00PM to 7:00AM shift (on); - 02/04/2025 on the 7:00AM to 3:00PM shift (off); - 02/06/2025 on the 11:00PM to 7:00AM shift (on); - 02/07/2025 on the 7:00AM to 3:00PM shift (off); - 02/08/2025 on the 7:00AM to 3:00PM shift (on); - 02/09/2025 on the 11:00PM to 7:00AM shift (off); - 02/10/2025 on the 7:00AM to 3:00PM shift (off); - 02/10/2025 on the 11:00PM to 7:00AM shift (on); - 02/11/2025 on the 7:00AM to 3:00PM shift (off); - 02/12/2025 on the 3:00PM to 11:00PM shift (on); - 02/12/2025 on the 11:00PM to 7:00AM shift (off); - 02/13/2025 on the 11:00PM to 7:00AM shift (on); - 02/14/2025 on the 7:00AM to 3:00PM shift (on); - 02/14/2025 on the 7:00AM to 3:00PM shift (off); - 02/14/2025 on the 3:00PM to 11:00PM shift (off); - 02/16/2025 on the 11:00PM to 7:00AM shift (on); - 02/17/2025 on the 7:00AM to 3:00PM shift (off); - 02/17/2025 on the 11:00PM to 7:00AM shift (on); - 02/18/2025 on the 7:00AM to 3:00PM shift (off); - 02/19/2025 on the 7:00AM to 3:00PM shift (off); - 02/19/2025 on the 11:00PM to 7:00AM shift (on); - 02/20/2025 on the 11:00PM to 7:00AM shift (on); - 02/23/2025 on the 7:00AM to 3:00PM shift (on); - 02/23/2025 on the 3:00PM to 11:00PM shift (off); - 02/23/2025 on the 11:00PM to 7:00AM shift (on); - 02/24/2025 on the 7:00AM to 3:00PM shift (off); - 02/24/2025 on the 11:00PM to 7:00AM shift (on); - 02/25/2025 on the 7:00AM to 3:00PM shift (on); and, - 02/25/2025 on the 7:00AM to 3:00PM shift (off). There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart d for the above mentioned dates and/or times. In an interview on 02/25/2025 at 10:20AM, S7LPN indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the on-coming nurse at the end of their shift, and the nurses should document that the controlled substance reconciliation was completed on the facility's Nurses Narcotic Check List. S7LPN further indicated she routinely waited until after the off going nurse had left to recount the controlled substances alone before signing the Nurses Narcotic Check List. In an interview on 02/26/2025 at 10:17AM, S2Director of Nursing confirmed the above mentioned Nurses Narcotic Check Lists were not completed at the beginning and/or end of each shift as required and should have been. In an interview on 02/26/2025 at 11:15AM, S1Administrator indicated nurses should be performing controlled substance reconciliation at the beginning and end of every shift and documented as such on the above mentioned Nurses Narcotic Check List.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to ensure eight opened insulin (a medication that lowers blood glucose) multi-dose vials were dated when opened and/or discarded as required for 3 (Medication Cart a, Medication Cart b, Medication Cart c) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts observed. Findings: Observation on 02/25/2025 at 9:10AM of Medication Cart a revealed: Resident #R8's open insulin Lispro multi-dose vial did not have an opened date documented; Resident #R9's open insulin Lantus multi-dose vial did not have an opened date documented; Resident #R9's open insulin Humalog 72-25 mixed multi-dose vial did not have an opened date documented; and, Resident #R10's open insulin Novolog multi-dose vial did not have an opened date documented. In an interview on 02/25/2025 at 9:15AM, S4Licensed Practical Nurse (LPN) confirmed the above mentioned multi-dose vials of insulin were opened and should have been labeled with an opened date. S4LPN further confirmed the above mentioned multi-dose vials of insulin should have been discarded and not available for resident use. Observation on 02/25/2025 at 9:30AM of Medication Cart b revealed: Resident #R5's open insulin Lantus multi-dose vial was documented as being opened on 01/20/2025; Resident #R6's open insulin Humalog multi-dose vial was documented as being opened on 01/17/2025; and, Resident #R7's open insulin Novolog multi-dose vial was documented as being opened on 01/20/2025. In an interview on 02/25/2025 at 9:35AM, S5LPN indicated the above mentioned insulin medications should have been discarded after 28 days and not stored in Medication Cart b and available for resident use. Observation on 02/25/2025 at 10:07AM, of Medication Cart c revealed Resident #R11's open insulin Lispro multi-dose vial did not have an opened date documented. In an interview on 02/25/2025 at 10:10AM, S6LPN indicated Resident #R11's insulin medication should have been dated when opened and it was not. S6LPN further indicated Resident #R11's opened and undated insulin should not have been available for Resident #R11's use. In an interview on 02/26/2025 at 10:17AM, S2Director of Nursing confirmed the above mentioned insulin multi-dose vials should have been dated when opened and discarded 28 days after opening per the nursing standards of care. In an interview on 02/26/2025 at 11:15AM, S1Administrator confirmed opened insulin multi-dose vials should be dated and discarded after 28 days, and the insulin should not be available for resident use.

Jun 2024 6 deficiencies

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews, the facility failed to ensure a resident received specialized psychological service recommendations for 1 (Resident #65) of 1 (Resident #65) sampled residents reviewed for PASRR (Preadmission Screening and Resident Review). Findings: Review of Resident #65's Electronic Medical Record (EMR) revealed, in part, Resident #65's was admitted to the facility 03/01/2024, and had medical diagnosis of Bipolar, and Major Depressive Disorder upon admission. Further review revealed no documented evidence that a Level II PASSR recommendations was completed for Resident #65. Review of Resident #65's Social Services' Note dated 06/05/2024 at 11:29 a.m., revealed, in part, S2Social Services received Resident #65's Level II PASSR recommendations on 06/05/24 from the Louisiana Office of Behavioral Health. Review of Resident #65's EMR revealed Resident #65's approved for admission by Level II Authority for a temporary period effective 09/10/2023 through 09/08/2024. Review of Resident #65's Level II PASSR Recommendations and Determination Notice dated 9/11/2023 revealed, in part, recommendations that Resident #65 receive Community Psychiatric Support & Treatment (CPST) and/or psychiatric/psychosocial/psychological evaluation. There was no documented evidence, and the facility did not present any documented evidence, Resident #65 received CPST and/or psychiatric/psychosocial/psychological evaluation. In a telephone interview on 06/05/2024 at 1:33 p.m., the facility's psychiatric services provider's Practice Manager indicated Resident #65 had not received CPST and/or psychiatric/psychosocial/psychological evaluation since her admission into the facility. In an interview on 06/05/2024 at 1:50 p.m., S2Social Services indicated the facility did not have evidence of Resident #65's Level II PASSR recommendations upon the survey team's request, and had to get the documentation from the Louisiana Office of Behavioral Health. S2Social Services further indicated Resident #65's Level II PASSR recommendations were not followed, and Resident #65 had not received CPST and/or psychiatric/psychosocial/psychological evaluation since her admission to the facility.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on record reviews, interviews and observations, the facility failed to ensure a resident's oxygen equipment was dated and stored in a sanitary manner when not in use for 1 (Resident #92) of 1 (Resident #92) sampled residents reviewed for respiratory care. Findings: Review of Resident #92's Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 05/01/2024 revealed, in part, Resident #92 received oxygen therapy. Further review revealed, Resident #92 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #92 was mildly cognitively impaired. Review of Resident #92's June 2024 Physician's Orders, revealed, in part, an order for oxygen at 2 liters (L) via nasal cannula (NC) to maintain oxygen saturation above 92 % every shift and as needed. In an interview on 06/03/2024 at 09:30 a.m., Resident #92 indicated he was short of breath and used his oxygen as needed. Observation on 06/03/2024 at 9:30 a.m., revealed Resident #92's nasal cannula tubing for his oxygen was uncovered and lying on the floor. Further observation revealed the humidifier on Resident #92's oxygen concentrator was dated 04/27/2024. Observation on 06/04/2024 at 3:35 p.m., revealed Resident #92's nasal cannula tubing for his oxygen was uncovered and lying on the floor. Further observation revealed the humidifier on Resident #92's oxygen concentrator was dated 04/27/2024. In an interview on 06/04/2024 at 3:40 p.m., S4Licensed Practical Nurse (LPN) confirmed Resident #92's nasal cannula tubing for his oxygen was uncovered and lying on the floor. S4LPN also confirmed Resident #92's humidifier for his oxygen concentrator was dated 04/27/2024. S4LPN further indicated Resident #92's nasal cannula tubing for his oxygen should not have been uncovered and lying on the floor. S4LPN further indicated that Resident #92's humidifier should have been changed and dated each week on Sundays.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews, the facility failed to ensure a physician was notified of a pharmacist recommendation for 2 (Resident #8 and Resident #94) of 5 (Resident #8, Resident #19, Resident #74, Resident #89, and Resident #94) sampled residents reviewed for unnecessary medications. Findings: Resident #8 Review of the facility's Psychotropic & Sedative/Hypnotic Utilization by Resident form updated in 2017 revealed, in part, Resident #8's last Gradual Dose Reduction (GDR) was completed on 03/10/2024. In a telephone interview on 06/05/2024 at 3:43 p.m., the Pharmacy Consultant for the facility indicated a GDR was recommended for Resident #8 on 03/10/2024 for Seroquel 50mg 1 tablet by mouth at bedtime. In an interview on 06/05/2024 at 3:15 p.m., S1Director of Nursing (DON) indicated the facility did not have documentation to show Resident #8's GDR was reviewed by a physician. Resident #94 Review of Resident #94's GDR revealed, in part, a pharmacist made a recommendation for a dose reduction of Resident #94's Risperdal (a medication used to treat mental disorders) 4.5 mg at bedtime. There was no documentation evidence, and the facility did not present any documented evidence, Resident #94's physician was notified of the pharmacist's recommendation for a dose reduction of Resident #94's Risperdal 4.5 mg. In an interview on 06/05/2024 at 3:55 p.m., S1DON confirmed a dose reduction was recommended for Resident #94 on 01/04/2024. S1DON further confirmed there was no documented evidence that Resident #94's physician was made aware of this recommendation.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on record reviews and interviews, the facility failed to have accurate documentation for the route of medication administration for 2 (Resident #64 and Resident #72) of 3 (Resident #57, Resident #64, and Resident 72) sampled residents investigated for enteral feeding. Findings: Resident #64 Review of Resident #64's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024 revealed, in part, Resident #64 had a Brief Interview for Mental Status (BIMS) score of 9. A Score of 9 indicated moderate cognitive impairment. Further review of Resident #64's MDS revealed she had a feeding tube. Review of Resident #64's Care Plan, revised on 04/29/2024, revealed Resident #64 received medications through a feeding tube. Review of Resident #64's June 2024 Physician Orders revealed, in part, the following: 1. Zinc 50 milligram (mg) tablet give 1 tablet orally one time a day to aid in wound healing and prevention; 2. Vitamin d3 50 microgram (mcg) tablet give 1 tablet orally one time a day; 3. Vitamin C 500mg 1 tablet by mouth once a day; 4. Multivitamin take 1 tablet by mouth daily; 5. Promod 30 milliliter (ml) by mouth daily; 6. Megestrol 40mg/ml liquid give 10 ml orally one time a day for appetite stimulant; and, 7. Losartan potassium 50 mg tablet give 1 tablet orally in the morning In an interview on 06/05/2024 at 1:30 p.m., S1Director of Nursing (DON) indicated Resident #64 received all of her medications through her feeding tube. S1DON confirmed the above mentioned medications were transcribed incorrectly on Resident #64's June 2024 Physician Orders Resident #72 Review of Resident #72's MDS with an ARD of 04/25/2024 revealed, in part, a BIMS score of 13. A score of 13 indicated Resident #72 was cognitively intact. Further review of Resident #72's MDS revealed he had a feeding tube. Review of Resident #72's June 2024 Physician Orders revealed, in part, the following: 1. Ondansetron Tablet 4mg give 1 tablet by mouth every 6 hours as needed for nausea and vomiting; 2. Sucralfate Suspension 1gram/10ml give 1 gram by mouth four times a day for gastric protection; 3. Pantoprazole sodium oral packet 40mg give 40mg by mouth two times a day for prophylaxis; 4. Metoclopramide oral tablet 5mg by mouth before meals for nausea and vomiting; 5. Aspirin enteric coated delayed release give 81mg by mouth one time a day for heart health; 6. Losartan Potassium oral tablet 100mg give 1 tablet by mouth one time a day for hypertension; and, 7. Cardura tablet 4mg give 1 tablet by mouth at bedtime for hypertension. In an interview on 06/05/2024 at 8:45 a.m., Resident #72 indicated he received all of medications through his feeding tube. In an interview on 06/05/2024 at 1:30 p.m., S1DON indicated Resident #72 received all of his medications through his feeding tube. S1DON confirmed the above mentioned medications were transcribed incorrectly on Resident #72's June 2024 Physician Orders.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure a functional call bell was available for 1 (Resident #77) of the 4 (Resident #23, Resident #47, Resident #72, and Resident #77) investigated for environmental issues. Findings: Review of Resident #77's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024 revealed, in part, resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact, and Resident #77 required substantial/maximal assistance with personal hygiene. In an interview on 06/04/2024 at 10:00 a.m., Resident #77 indicated his call bell was broken. Resident #77 further indicated because his call bell does not work, he had to go out into the hall to get assistance. Resident #77 further indicated he would use his call bell if it was functioning. A test of Resident #77's call bell was conducted on 06/04/2024 at 10:00 a.m., which revealed Resident #77's call bell was not functioning, and the indicator light did not illuminate on wall of Resident #77's room or outside of Resident #77's room above the door. A test of Resident #77's call bell was conducted on 06/05/2024 at 9:00 a.m., which revealed Resident #77's call bell was not functioning, and the indicator light did not illuminate on wall of Resident #77's room or outside of Resident #77's room above the door. In an interview on 06/05/2024 at 9:50 a.m., S5Certified Nursing Assistant (CNA) indicated Resident #77 was capable of using his call bell, but often came out into the hall to holler for assistance. Observation on 06/05/2024 at 9:51 a.m., revealed S5CNA tested Resident #77's call bell and found that the call bell was not functioning. In an interview on 06/05/2024 at 9:52 a.m., S5CNA confirmed Resident #77's call bell was not functioning and should be functioning. In an interview on 06/05/2024 at 9:57 a.m., S4Licensed Practical Nurse (LPN) indicated Resident #77's call bell should have been functioning. In an interview on 06/05/2024 at 10:12 a.m., S3Assistant Director of Nurses (ADON) indicated Resident #77's call bell should have been functioning.

CONCERN (E)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

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Based on record reviews, observations and interviews, the facility failed to: 1. ensure a resident's water, used for jejunostomy tube (J-tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. The tube delivers food and medicine) flushes, was labeled properly; and, 2. ensure a resident's feeding syringe was labeled, dated and clean. This deficient practice was identified for 1 (Resident #72) of 3 (Resident #57, Resident #64, and Resident 72) sampled residents investigated for enteral feeding. Findings: Review of Resident #72's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed, in part, a Brief Interview for Mental Status exam score of 13. A score of 13 which indicated Resident #72 was cognitively intact. Further review of Section K revealed Resident #72 had a feeding tube. Observation on 06/03/2024 at 9:45 a.m. revealed Resident #72's feeding syringe was not labeled and was not dated and the feeding syringe had a pink liquid in the tip. Observation on 06/03/2024 at 9:45 a.m. revealed Resident #72's water bag, used for j tube flushes, was not labeled and was not dated. Observation on 06/04/2024 at 9:30 a.m. revealed Resident #72's water bag, used for j tube flushes, was not labeled and was not dated. Observation on 06/05/2024 at 8:45 a.m. revealed Resident #72's feeding syringe was not labeled and was not dated. Observation on 06/05/2024 at 8:45 a.m. revealed Resident #72's water bag, used for j tube flushes, was not labeled and was not dated. In an interview on 06/05/2024 at 8:50 a.m., S6Licensed Practical Nurse (LPN) confirmed Resident #72's feeding syringe and water bag was not labeled and was not dated. In an interview on 06/05/2024 at 12:47 p.m., S1Director of Nursing (DON) indicated feeding syringes should be labeled with the resident's name, date and time opened. S1DON further indicated the water, used for flushes, should be labeled and dated.

May 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on record reviews and interviews, the facility failed to ensure a resident that required two plus person assistance with transfers was transferred with at least two persons and the facility failed to prevent a resident fall for 1(Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for accidents hazards. Findings: Review of the facility's Quality of Care: Accident/Hazards/Supervision/Device Policy with a date of 03/2023 revealed the following, in part, Purpose: To provide an environment that is free from controllable accident hazards and provision of supervision and assistance devices to residents to avoid preventable accidents. Policy: The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents. Guidelines: The facility will develop a culture of safety and commit to implemented systems that address resident risk and environment hazards to minimize the likelihood of accidents. Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risk related to hazards in the environment. Interventions will be modified when necessary. Individualized interventions will be developed to reduce the potential for accidents. Interventions will be based on the results of the evaluation and analysis of information related to hazards and risks. Interventions will be consistent with professional standards. Resident specific interventions will be reflected in the resident's person-centered, individualized care plan. Falls: When a resident experiences a fall, the facility will evaluate potential causal factors to aid in the development and implementation of relevant, consistent and individualized interventions to reduce the likelihood of future occurrences. The facility will initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with history of falls. Assistive Devices/Equipment Hazards: Assistive devices and equipment will be used and maintained according to the manufacturer recommendations. The devices and transfer techniques will be reflected in the resident's comprehensive care plan. Review of the facility's Patient Lifts Safety Guide revealed the following, in part, Prepare Environment: Determine the number of caregivers needed: Most lifts require two or more caregivers to safely operate lift and handle patient. Review of Resident #1's clinical record revealed an admission date of 10/23/2023. Resident #1 had diagnoses of ataxic gait, morbid severe obesity, other lack of coordination, muscle wasting atrophy and need for assistance with personal care. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2024 revealed, in part, Resident #1 required extensive assistance and two plus person physical assistance with transfers and bed mobility. Review of Resident #1's current care plan revealed she was at risk for falls and sustained a fall without injury on 04/27/2024. Further review revealed the following interventions: Staff to provide transfer with lift, with 2 people when transferring resident from bed to chair or chair to bed. Review of Resident #1's Incident Investigation revealed, in part, the following: On 04/27/2024 Resident #1 was being transferred from the bed to a wheelchair when she slipped out of the mechanical lift sling. Further review revealed on 05/02/2024 at 7:19 p.m., S1Administrator wrote: Resident #1 diagnosis included morbid obesity. Resident #1 is care planned for two person transfer with mechanical lift. Resident #1's most current weight was documented as 282 pounds. Resident #1 is alert and oriented and able to make her needs and wants known. Record review revealed staff called to the room by S4CertifiedNursingAssistant (S4CNA), Resident #1 was lying on the floor on her back. S4CNA stated while she transferred Resident #1 from the bed to the chair, the mechanical lift tilted and Resident #1 fell to the floor. In an interview on 05/06/2024 at 1:56 p.m., S4CNA stated she had attempted to move Resident #1 from the bed to the chair on her own because no staff were available to assist with the lift of Resident #1. S4CNA stated while transferring Resident #1, the mechanical lift got stuck and tilted over causing Resident #1 to fall to the floor. S4CNA acknowledged Resident #1 required a 2 person assist when using the mechanical lift but further acknowledged she transferred Resident #1 without an additional person anyway. In an interview on 05/07/2024 at 9:50 a.m., Resident #1 stated she fell from the mechanical lift over a week ago while being assisted by only one staff member. In an interview on 05/06/2024 at 12:45 p.m., S1Administrator acknowledged on 04/27/2024 S4CNA attempted to transfer Resident #1 with the mechanical lift without the assistance of another staff member causing Resident #1 to fall to the floor.

Apr 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on interviews and record review, the facility failed to report and investigate an allegation of physical abuse to the State agency for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents investigated for abuse. Findings: Review of Resident #3's electronic medical record (EMR) revealed, in part, a nurse's note dated 03/11/2024 at 7:15 p.m. which documented Resident #3's refusal of dialysis and medications due to an allegation of physical abuse. Further documented was notification of the allegation to the nurse supervisor, the S3Director of Nursing (DON), and the doctor. Review of the facility incident reports revealed, in part, no documented evidence and the facility did not present any evidence Resident #3's allegation of physical abuse was reported to the State Agency. In a telephone interview on 04/02/2024 at 2:50 p.m., S1Licensed Practical Nurse (LPN) stated she reported Resident #3's allegation of physical abuse to S2Treatment Nurse. S1LPN further stated S2Treatment Nurse called S3DON and reported the allegation of physical abuse. In an interview on 04/02/2024 at 3:15 p.m., S2Treatment Nurse denied that S1LPN informed her about an allegation of physical abuse made by Resident #3. In an interview on 04/02/2024 at 2:25 p.m., S3DON denied receiving an allegation of physical abuse from S2Treatment Nurse or S1LPN. S3DON further stated she was unaware Resident #3 made an allegation of physical abuse on 03/11/2024. In an interview on 04/02/2024 at 2:30 p.m., S4Administrator confirmed the facility did not report to the State Agency Resident #3's allegation of physical abuse in the month of March. S4Administrator further confirmed she had no knowledge of Resident #3's allegation of physical abuse.

Dec 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure staff implemented their Policy & Procedure for abuse for 1(Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse, Neglect, and Exploitation policy with a revision date of 08/14/2023 revealed, in part, the following: Section VII. Reporting/Response: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2023 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated he was moderately cognitively impaired. Review of Statewide Incident Management System (SIMS) Report revealed, in part, Resident #3 had an allegation of staff to resident physical abuse occurred on 10/14/2023 at 11:00 p.m. Review of SIMS report revealed the incident of alleged staff to resident physical abuse was not discovered until 10/15/2023 at 2:30 p.m. Further review revealed, on 10/14/2023 at approximately 8:30 p.m., S8Former Certified Nursing Assistant (S8Former CNA) stated she noticed Resident #3 was bleeding from his lip but thought that he had just bitten or peeled his lip. Review revealed, S8Former CNA did not report that Resident #3 was bleeding from his lip to S5Licensed Practical Nurse (S5LPN) until 10/14/2023 at 9:50 p.m. at this time S5LPN and S8Former CNA went into Resident #3's room where he accused S8Former CNA of striking him. Review of Incident/Accident Analysis dated 10/16/2023 revealed, in part, the allegation of physical abuse to Resident #3 was reported by S5LPN on 10/14/2023 at approximately 10:45 p.m. In an interview on 12/19/2023 at 12:16 p.m., S8Former CNA stated on 10/14/2023 in the evening at approximately 8:00 p.m., she noticed Resident #3's lip was bleeding but did not inform the nurse immediately because she thought Resident #3's lip was just peeling. S8Former CNA further stated she eventually told S5LPN and they both returned to Resident #3's room where he accused S8Former CNA of hitting him in the mouth. In an interview on 12/18/2023 at 2:00 p.m., S1Administrator stated Resident #3 accused S8Former CNA of hitting him in the mouth on 10/14/2023. S1Administrator stated she did not complete the SIMS report for this incident because she was still in training and it was completed by S2Former Administrator in Training. S1Administrator acknowledged on the SIMS report the facility documented that the incident was not discovered until the next day 10/15/2023 at 2:30 p.m.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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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 allegation of physical abuse was reported immediately, but not later than 2 hours after the incident was discovered to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3 ) sampled residents reviewed for abuse. Findings: Review of Resident #1's medical record revealed, in part, he was admitted to the facility on [DATE] with diagnoses, of Blindness, Delusional Disorder, Insomnia, and Generalized Anxiety Disorder. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/2023 revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated Resident #1 was moderately cognitively impaired. Further review revealed, Resident #1 required extensive assistance from one person with bed mobility, transfers, and toileting. Review of Resident #1's nurse's note dated 11/25/2023 at 11:30 a.m., revealed, in part, S7Certified Nursing Assistant (S7CNA) reported to S5Licensed Practical Nurse (S5LPN) that Resident #1 hit her in the mouth with a closed fist and grabbed her by her shirt while she attempted to provide incontinence care for him. Further review revealed, S5LPN did not witness the incident but went into Resident #1's room after being informed. Resident #1 was observed lying in a supine position, and appeared to be in the middle of receiving incontinence care. Resident #1's left forefinger and knuckle had a skin tears. Review of a Statewide Incident Management System (SIMS) report revealed, in part an allegation of staff to resident physical abuse was discovered for Resident #1 on 11/25/2023 at 1:00 p.m. Review revealed, the SIMS report was entered on 11/25/2023 at 2:36 p.m. and the incident occurred 11/25/2023 at 8:30 a.m. Review revealed, on 11/27/2023 at 11:03 a.m., State Survey Agency wrote notification sent to the provider regarding additional information needed for the initial report as noted below, with request made for the report to be updated by 11:00 a.m. on 11/27/2023. Further review revealed, Addendum at 11:20 a.m. on 11/27/2023: Spoke with S1Administrator regarding email sent; S1Administrator stated she received the email; S1Administrator stated she had just opened the SIMS with no information so it was not considered late; it was explained to her all information required by regulation for initial reporting must be submitted for the report to be considered timely; S1Administrator voiced understanding; provider is to update the incident report. In an interview on 12/19/2023 at 1:01 p.m., S1Administrator stated she was made aware of the incident of alleged staff to resident physical abuse on 11/25/2023 in the afternoon around lunch time. S1Adiministrator stated as soon as she learned about the allegation of physical abuse she started a SIMS report but was later emailed by State Survey Agency informing her the SIMS report was late because the form was not completed. S1Administrator acknowledged the SIMS report was started but not completed before two hours as required.

Aug 2023 20 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on record review, observations, and interviews, the facility failed to implement their abuse policies and procedures to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to ensure unlicensed staff who worked in the facility had a completed criminal background on file prior to providing care to residents for 2 (S6Agency Certified Nursing Assistant and S7Agency Certified Nursing Assistant) of 2 unlicensed contract staff personnel files reviewed. Findings: Review of the facility's Abuse, Neglect, and Exploitation policy with an implementation date of 12/01/2021 revealed, in part, potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Further review revealed criminal background, reference, and credentials' checks shall be conducted on contracted temporary staff. Review of the agency's generated time sheets for 08/11/2023 revealed S6Agency CNA worked in the facility from 10:23 a.m. until 4:27 p.m. and S7Agency CNA worked from 11:27 a.m. until 2:41 p.m. Observation on 08/11/2023 at 11:35 a.m. revealed S6Agency CNA introduced himself an agency CNA and provided pericare to Resident #45. In an interview on 08/11/2023 at 11:45 a.m., S3Director of Nursing (DON) stated the facility started using agency CNAs as of 08/11/2023 to assist with staffing. S3DON stated S6Agency CNA and S7Agency CNA were assigned to work in the same section. S3DON stated she did not have a background check for the S6Agency CNA and S7Agency CNA and she was unaware if S6Agency CNA or S7Agency CNA had any criminal convictions that would bar employment. S3DON further stated she would have to contact the agency to get the documentation. Review of S6Agency CNA's background check presented to survey team on 08/11/2023 at 6:00 p.m. revealed, S6Agency CNA was charged on 06/13/2016 with R.S. 40:966- Manufacturing, distribution, and possession of a Schedule 1 (a medication that has a high potential for abuse which may lead to severe psychosocial or dependence). Review of S7Agency CNA's background check presented to survey team on 08/11/2023 at 6:00 p.m. revealed, S7Agency CNA was charged on 06/12/2011 with R.S. 14:67.10 (Misdemeanor) Theft of Goods. Further review revealed, an additional charge on 10/21/2013 for Theft of Goods. In an interview on 08/11/2023 at 5:00 p.m., S1Administrator stated the facility's policy stated all employed staff are to have a background checks on file to ensure they did not have any convictions that bar employment prior to working at the facility. S1Administrator stated a personnel file was not requested prior to agency staff entering the facility to provide care to residents. S1Administrator also stated it was not the facility's responsibility to ensure S6Agency CNA's or S7Agency CNA's criminal background checks were completed prior to them working in the facility. In an interview on 08/11/2023 at 6:20 p.m., S1Administrator stated after reviewing S6Agency CNA's and S7Agency CNA's background check, he realized S6Agency CNA and S7Agency CNA had charges that required a disposition. S1Administrator acknowledged the facility did not have a disposition and S6Agency CNA and S7Agency CNA should not have been allowed to work in the facility with residents.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a new interventions were implemented following a resident's fall to prevent future falls for 1 (Resident #42) of 4 (Resident #42, Resident #106, Resident #264, and Resident #313) sampled residents reviewed for accident hazards. Findings: Review of Resident #42's Minimum Data Set with an Assessment Reference Date of 07/03/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status score of 9, which indicated Resident #42 had moderate cognitive impairment. Further review revealed Resident #42 required limited one person assistance for transfers. Review also revealed Resident #42's balance was unsteady with walking and transferring, and Resident #42 had impaired range of motion to both lower extremities. Review of Resident #42's Quarterly Fall Risk Assessment completed on 06/27/2023 revealed, in part, Resident #42 required fall precautions due to a history of falls, cognitive deficits, impaired judgement, the inability to ambulate independently, increased anxiety, incontinence, cardiac and respiratory disease, and medications that affect blood pressure and level of consciousness. Review of Resident #42's August 2023 physician's orders revealed, in part, a fall precautions order for staff to encourage Resident #42 to call for assistance with all transfers/reaching and to provide safety. Observation on 08/07/2023 at 12:20 p.m. revealed Resident #42 sitting on his buttocks on the floor in front of his wheelchair. In an interview on 08/08/2023 at 12:29 p.m., S12Licensed Practical Nurse stated Resident #42 informed her he fell on [DATE] because he felt weak. Review of Resident #42's fall care plan on 08/14/2023 revealed no new intervention placed following Resident #42's 08/07/2023 fall in order to prevent future falls. In an interview on 08/14/2023 at 12:11 p.m., S14Minimum Data Set Nurse confirmed there had not been a new intervention placed on Resident #42's care plan and implemented following Resident #42's 08/07/2023 fall. In an interview on 08/14/2023 at 12:33 p.m., S3Director of Nursing confirmed there was not a new intervention placed on Resident #42's fall care plan and implemented after the 08/07/2023 fall in order to prevent future falls.

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a resident's indwelling urinary catheter was secured for 1 (Resident #313) of 1 sampled residents reviewed for urinary catheter or urinary tract infection. Findings: Review of the Centers for Disease Controls Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) revealed, in part, properly secure indwelling catheters after insertion was recommended to prevent movement and urethral traction. Review of Resident #313's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/24/2023 revealed, in part, Resident #313 was admitted to the facility on [DATE] and had an indwelling catheter. Review of Resident #313's Care Plan for catheter revealed, in part, Resident #313 required an indwelling catheter related to urinary retention and the staff should check for proper position of Resident #313's catheter every shift. Observation on 08/09/2023 at 2:47 p.m. revealed S10LPN (Licensed Practical Nurse) entered Resident #313's room and Resident #313 asked S10LPN to check his catheter bag because he was uncomfortable and he thought the tubing might have been kinked. Further observation revealed S10LPN assisted Resident #313 to reposition in his wheelchair and Resident #313 sighed. Further observation revealed Resident #313's catheter tubing was not secured to prevent tension. In an interview on 08/09/2023 at 2:47 p.m., Resident #313 stated his catheter was causing discomfort since he transferred from the toilet into his wheelchair earlier that day. Resident #313 further stated after the nurse repositioned the catheter tubing he was no longer hurting. In an interview on 08/09/2023 at 2:47 p.m., S10LPN stated when she checked Resident #313's catheter tubing it was pulled taunt by his diaper. Observation on 08/09/2023 at 3:13 p.m. revealed Resident #313 did not have his catheter tubing secured to prevent tension. Observation on 08/10/2023 at 1:37 p.m. revealed Resident #313 did not have his catheter tubing secured to prevent tension. In an interview on 08/10/2023 at 5:38 p.m., S10LPN stated on 08/09/2023 Resident #313 did not have his catheter tubing secured to prevent tension. S10LPN further stated after Resident #313 complained of catheter discomfort she did not secure Resident #313's catheter tubing and she admitted she should have secured the catheter tubing. In an interview on 08/10/2023 at 5:40 p.m., S9Assistant Director of Nursing stated S10LPN should have secured Resident #313's catheter tubing to prevent tension and discomfort.

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 F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview, the facility failed to administer intravenous (medication administered directly into the vein) medications per professional standards and physician's orders for 1 (Resident #264) of 1 (Resident #264) sampled residents investigated for intravenous medication administration. Findings: Review of the facility's Intravenous (IV) Therapy Policy revealed, in part, prior to medication infusion, the practitioner's order must be reviewed and verified for infusion solution or medication, dose, frequency, and route of administration. Further review revealed hand hygiene must be completed prior to putting on gloves. Review also revealed the medication/solution label must be compared against the practitioner's order for accuracy. The policy also revealed the connector must be disinfected with an antiseptic agent before tubing is connected to the injection port. Review of Resident #264's record revealed, in part, an admit date of 07/28/2023 with diagnoses including bacteremia (the presence of bacteria in the bloodstream), septic joint (infection of a joint) and pyogenic (pus producing) arthritis of the left knee. Review of Resident #264's Minimum Data Set with an assessment reference date of 08/03/2023 revealed, in part, Resident #264 received antibiotics and IV medications. Review of Resident #264's August 2023 physician's orders revealed, in part, an order for Meropenem (an IV medication used to treat bacterial infections) 500 milligrams (mg) in 100 milliliters (mL) of 0.9% Sodium Chloride (solution used to dilute the antibiotic) to be infused over 1 hour at a rate of 100mL per hour (mL/hr) and administered every 6 hours. Review of Resident #264's IV medication label revealed, in part, Meropenem 500mg in 50mL of Sodium Chloride. Further review of the medication label revealed a pharmacy sticker with instructions to infuse the IV medication over 30 minutes at a rate of 100/hr. Review of Resident #264's care plan for IV therapy revealed, in part, interventions for staff to utilize aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) techniques at all times and administer medications as ordered. Observation of Resident #264's IV medication administration on 08/09/2023 at 11:34 a.m. revealed S10Licensed Practical Nurse (LPN) put on gloves without completing hand hygiene. Further observation revealed S10LPN primed the IV tubing and set the flow regulator at 100 mL/hr. Observation then revealed S10LPN removed a green cap from Resident #264's blue injection port of his Peripherally Inserted Central Catheter (PICC) and allowed the blue injection port to come in contact with Resident #264's gown. S10LPN then connected Resident #264's IV tubing to the blue injection port without wiping the blue injection port with an antiseptic agent. In an interview on 08/09/2023 at 11:44 a.m., S10LPN confirmed she did not wash her hands prior to administering Resident #264's IV medication. S10LPN further stated she did not wipe Resident #264's blue injection port of the PICC with an antiseptic agent after the blue injection port had come in contact with Resident #264's gown. Observation on 08/09/2023 at 12:22 p.m. revealed Resident #264's IV medication bag was empty and no longer infusing. In an interview on 08/09/2023 at 12:30 p.m., S10LPN confirmed Resident #264's physician's order for Meropenem 500mg in 100mL of 0.9% Sodium Chloride required the medication to be infused over 1 hour. S10LPN further confirmed she had infused Resident #264's Meropenem 500mg in 50mL of 0.9% Sodium Chloride over 30 minutes. S10LPN stated Resident #264's medication sent from pharmacy did not match the physician's order. S10LPN further stated she did not administer the medication as ordered and she should have clarified Resident #264's IV medication order prior to administering it. In an interview on 08/09/2023 at 3:49 p.m., S3Director of Nursing (DON) confirmed S10LPN should have clarified Resident #264's physician's order for Meropenem 500mg in 100mL of 0.9% Sodium Chloride over 1 hour when pharmacy sent Meropenem 500mg in 50mL of 0.9% Sodium Chloride to infuse over 30 minutes. S3DON stated S10LPN should have washed her hands prior to administering Resident #264's IV medication. S3DON further stated S10LPN should have wiped Resident #264's blue port with alcohol after the blue port came in contact with Resident #264's gown and prior to connecting the IV tubing.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on record reviews, observations, and interviews, the facility failed to ensure medications were locked and not available for use at a resident's bedside for 1 (Resident #264) of 22 (Resident #10, Resident #29, Resident #53, Resident #45, Resident #97, Resident #48, Resident #42, Resident #264, Resident #43, Resident #24, Resident #313, Resident #106, Resident #1, Resident #101, Resident #89, Resident #17, Resident #91, Resident #74, Resident #30, Resident #18, Resident #73, and Resident #49) sampled residents observed for medications left at the bedside. Findings: Review of the facility's Resident Self-Administration of Medication Policy revealed, in part, a resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. Further review revealed bedside medication storage was permitted only when it did not present a risk to confused residents and the manner of storage prevented access by other residents. Review of Resident #264's Minimum Data Set with an Assessment Reference Date of 08/03/2023 revealed, in part, Resident #264 had a Brief Interview for Mental Status score of 12, which indicated Resident #264 had moderate cognitive impairment. Review of Resident #264's care plan revealed, in part, no documented evidence Resident #264 was care planned to self-administer medications or have medications available for use at the bedside. Review of Resident #264's August 2023 physician's orders revealed, in part, no documented evidence of an order for Resident #264 to have medications available for self-administration at her bedside. Review of Resident #264's record revealed no documented evidence and the facility did not present any documented evidence Resident #264 was assessed or care planned to have medications available for self-administration. Observation on 08/07/2023 at 11:50 a.m. revealed Resident #264 had a bottle of antifungal powder, a bottle of Diphenhydramine (a medication used to treat itching or cold and allergy symptoms) 25 milligram (mg) tablets, and a Trelegy (an inhalant medication used to treat chronic respiratory conditions) inhaler unlocked and available for use on the bedside table. Observation on 08/08/2023 at 12:32 p.m. revealed Resident #264 had Ammonium Lactate (a medication used to treat skin conditions and itching) 12% lotion, a bottle of Diphenhydramine 25mg tablets, a bottle of antifungal powder, and a Trelegy inhaler unlocked and available for use on the bedside table. Observation on 08/09/2023 at 4:00 p.m. revealed Resident #264 had a bottle of Diphenhydramine 25mg tablets, a Trelegy inhaler, 2 boxes of Simethicone (a medication used to relieve excess gas symptoms) 125 mg tablets, and a bottle of antifungal powder unlocked and available for use on the bedside table. In an interview on 08/09/2023 at 4:01 p.m., Resident #264 stated he had self-administered the above mentioned medications while being a resident in the facility without the facility's knowledge. Observation on 08/10/2023 at 10:23 a.m. revealed Resident #264 had a bottle of Diphenhydramine 25mg tablets, 2 boxes of Simethicone 125mg tablets, a bottle of antifungal powder, and Ammonium Lactate 12% lotion unlocked and available for use on the bedside table. In an interview on 08/10/2023 at 10:41 a.m., S10Licensed Practical Nurse confirmed Resident #264 did not have a physician's order, nor was Resident #264 assessed and care planned to have medications available at the bedside. S10Licensed Practical Nurse further stated Resident #264 should not have had medications at his bedside. In an interview on 08/10/2023 at 12:35 p.m., S3Director of Nursing confirmed Resident #264 did not have an order to have medications at his bedside. S3Director of Nursing stated Resident #264 should not have had the above mentioned medications unlocked and available at his bedside.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observations and interviews the facility failed to: 1. Failed to discard expired milk in 1 of 1 nourishment refrigerators. 2. Failed to ensure Orange and cranberry juice were stored at a proper temperature to prevent food borne illness. Findings: Observation of the nurse's station's nourishment room on 08/08/2023 at 9:06 a.m. revealed 4 16 ounce cartons of whole milk in the refrigerator with an expiration date of 8/1/2023 and 1 16 ounce carton of whole mile with an expiration date of 08/03/2023 and 3 16 ounce cartons of low-fat milk in the refrigerator with an expiration date of 08/07/2023. Further observation of the nourishment room revealed a tray of 20 8 ounce cartons of cranberry juice cartons and 10 8 ounce containers of orange juice sitting on top of the refrigerator, cool to touch with condensation on outside of containers. Observation of the nurse's station's nourishment room on 08/08/2023 at 12:01 p.m. revealed the same tray of 20 cartons of cranberry juice and 10 containers of orange juice was sitting on top of the refrigerator without ice and warm to touch. Observation further revealed there were 5 expired whole milk cartons and 3 expired low fat milk cartons in the refrigerator. In an interview on 08/08/2023 at 12:50 p.m., S19Dietary Manager acknowledged the tray of cranberry juice cartons and orange juice containers sitting on top of the refrigerator in the nurse's station's nourishment room. S19Dietary Manager stated the juices were sent out this morning with breakfast service and should have been placed on ice or in the refrigerator. In an interview on 08/08/2023 at 1:00 p.m., S3DON stated the carton of juices should have been stored in the ice bucket on the nurses' medication carts. S3DON stated any juice cartons that are left over should have been stored in the refrigerator in the nurse's station's nourishment room. S3DON confirmed the expired milk cartons should have been thrown away and the carton of juices should have been stored on ice or in the refrigerator.

CONCERN (D)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on record review, and interview, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) committee meetings were held quarterly. Findings: Review of the facility's QAPI Committee Meeting Minutes revealed the last documented meeting was completed on 04/30/2023. There was no documented evidence and the facility did not present any documented evidence a QAPI committee meeting was held for the second quarter of 2023. In an interview on 08/14/2023 at 12:04 p.m., S15Regional Clinical Director stated the facility was supposed to have a QAPI committee meeting at the end of July 2023 but did not. S15Regional Clinical Director further stated the last QAPI committee meeting was held on 04/30/2023.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview, the facility failed to ensure residents were provided with privacy during care for 3 (Resident #30, Resident #43 and Resident #313) of 22 (Resident #10, Resident #29, Resident #53, Resident #45, Resident #97, Resident #48, Resident #42, Resident #264, Resident #43, Resident #24, Resident #313, Resident #106, Resident #1, Resident #101, Resident #89, Resident #17, Resident #91, Resident #74, Resident #30, Resident #18, Resident #73, and Resident #49) sampled residents observed for privacy. Findings: Resident #30 Observation on 08/07/2023 at 2:40 p.m. revealed Resident #30 lying in bed with no privacy curtain available around her bed. In an interview on 08/07/2023 at 2:40 p.m., Resident #30's daughter expressed concerns about the missing privacy curtain around Resident #30's bed. Observation on 08/08/2023 at 12:10 p.m. revealed Resident #30 did not have a privacy curtain available around her bed. In an interview on 08/08/2023 at 1:15 p.m., S23Licensed Practical Nurse (LPN) confirmed there was no privacy curtains available for Resident #30. Observation on 08/08/2023 at 1:25 p.m. revealed two CNAs transferred Resident #30 from the wheel chair to the bed and was provided incontinence care with no privacy. During the above mentioned incontinence care, Resident #30's roommate was present in the room. Observation on 08/09/2023 at 8:44 a.m. revealed Resident #30 did not have a privacy curtain available around the bed. Observation on 08/10/2023 at 9:00 a.m. revealed Resident #30 did not have a privacy curtain available around the bed. In an interview on 08/10/2023 at 9:20 a.m., S1Administrator stated the facility was not aware of Room Resident #30's and Resident #43's rooms not having a privacy curtains around their beds. Resident #43 Observation on 08/09/2023 at 8:45 a.m. revealed Resident #43's bed had no privacy curtain available. In an interview on 08/09/2023 at 8:45 a.m., Resident #43 stated it bothered her not having a privacy curtain around her bed. Observation on 08/10/2023 at 9:00 a.m. revealed there was no privacy curtain around Resident #43's bed. In an interview on 08/10/2023 at 9:20 a.m., S1Administrator stated the facility was not aware of Room Resident #30's and Resident #43's rooms not having the privacy curtains around their beds. Resident #313 Review of the facility's Catheter Care Policy revealed, in part, the facility should ensure residents with indwelling catheters maintain their dignity and privacy when indwelling catheters are in use. Further review revealed staff should provide privacy during catheter care by closing the door and curtains. Review of Resident #313's Care Plan for catheter revealed, in part, Resident #313 required an indwelling catheter related to urinary retention with an intervention to check and cleanse the area daily. Observation on 08/10/2023 1:37 p.m. revealed S40CNA (Certified Nursing Assistant) performed catheter care on Resident #313 and did not ensure Resident #313's door or privacy curtain was closed, while Resident #313's genitals were exposed. In an interview on 08/10/2023 at 1:40 p.m., S40CNA stated she did not close Resident #313's door or privacy curtain when she performed catheter and she should have. In an interview on 08/10/2023 at 5:40 p.m., S9ADON (Assistant Director of Nursing) stated S40CNA should have closed Resident #313's door and privacy curtain when she performed catheter care to provide privacy.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview, the facility failed to: 1. Ensure dining room tables were in good repair for 7 of 27 tables present in the dining room; 2. Ensure the residents' bathrooms had soap present in the soap dispensers for 4 (Resident #1, Resident #18, Resident #30, and Resident #101) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; 3. Ensure the residents' bathrooms had paper towels in the dispensers for 2 (Resident #18 and Resident #30) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; 4. Ensure the residents' furniture and window shades were clean and in good repair for 4 (Resident #1, Resident #17, Resident #18, and Resident #30) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; and, 5. Ensure a resident's room was properly cleaned after tube feeding formula had leaked on the resident's equipment and floor for 1 (Resident #24) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled residentrooms observed for environmental concerns. Findings: 1. Observation of the facility's dining room on 08/08/2023 at 12:19 p.m. revealed residents were utilizing 7 tables which had peeling and jagged laminate noted to the tabletops and edges of the tables. Observation on 08/09/2023 12:03 p.m. revealed residents were utilizing 7 tables which had peeling and jagged laminate noted to the tabletops and edges of the tables. In an interview on 08/09/2023 at 4:40 p.m., S1Administrator confirmed the 7 dining room tables were in disrepair and needed to be replaced. 2. Resident #1 Observation on 08/07/2023 at 2:58 p.m. revealed no soap in Resident #1's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/08/2023 at 3:44 p.m. revealed no soap in Resident #1's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/09/2023 at 4:23 p.m. revealed no soap in Resident #1's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Resident #18 Observation on 08/07/2023 at 12:41 p.m. revealed no soap in Resident #18's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/08/2023 at 12:20 p.m. revealed no soap in Resident #18's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/09/2023 at 8:45 a.m. revealed no soap in Resident #18's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/10/2023 at 8:49 a.m. revealed no soap in Resident #18's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Resident #30 Observation on 08/07/2023 at 2:40 p.m. revealed no soap in Resident #30's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/09/2023 at 8:44 a.m. revealed no soap in Resident #30's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Resident #101 Observation on 08/07/2023 at 12:30 p.m. revealed no soap in Resident #101's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/08/2023 at 1:05 p.m. revealed no soap in Resident #101's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. Observation on 08/09/2023 at 12:49 p.m. revealed no soap in Resident 101's bathroom soap dispenser or alcohol based hand rub (ABHR) available for hand hygiene. In an interview on 08/10/2023 at 8:49 a.m., S36Housekeeper stated he was not sure if housekeeping was responsible for filling the soap dispensers. 3. Resident #18 Observation on 08/09/2023 at 8:45 a.m. revealed Resident #18's bathroom had no paper towels in the dispensers. Observation on 08/10/2023 at 8:49 a.m., revealed Resident #18's bathroom had no paper towels in the dispensers. Resident #30 Observation on 08/07/2023 at 2:40 p.m. revealed Resident #30's bathroom had no paper towels in the dispensers. Observation on 08/09/2023 at 8:44 a.m. revealed Resident #30's bathroom had no paper towels in the dispenser. In an interview on 08/10/2023 at 8:49 a.m., S36Housekeeper stated he was not sure if housekeeping was responsible for filling paper towel dispensers in the residents' rooms. 4. Resident #1 Observation on 08/07/2023 at 2:58 p.m. revealed Resident #1's dresser was leaning forward and to the left. Further observation revealed the bottom of Resident #1's dresser was crumbling and small pieces of crumbled particle board were noted on the floor. Observation on 08/08/2023 at 3:44 p.m. revealed Resident #1's dresser was leaning forward and to the left. Further observation revealed the bottom of Resident #1's dresser was crumbling and small pieces of crumbled particle board were noted on the floor. Observation on 08/09/2023 at 4:23 p.m. revealed Resident #1's dresser was leaning forward and to the left. Further observation revealed the bottom of Resident #1's dresser was crumbling and small pieces of crumbled particle board were noted on the floor In an interview on 08/09/2023 at 4:25 p.m., S28Maintenance Director stated he had been aware of the poor condition of Resident #1's dresser for approximately 3 to 4 weeks due to previous water damage. In an interview on 08/09/2023 at 4:56 p.m., S9ADON stated she was not aware of the poor condition of Resident #1's dresser and confirmed it should have been replaced. Resident #17 Observation on 08/09/2023 at 8:46 a.m. revealed Resident #17's rolling bedside table had dirt, an unknown dry substance and rust on stand of table. Observation on 08/10/2023 at 8:52 a.m. revealed Resident #17's rolling bedside table had dirt, an unknown dried substance and rust on stand of table. Resident #18 Observation on 08/08/2023 at 12:20 p.m. revealed Resident #18's rolling bedside table was peeling along the sides of the table. Further observation revealed Resident #18's rolling bedside table had dirt, rust and an unknown dried substance on the stand of the table. Observation on 08/09/2023 at 8:45 a.m. revealed Resident #18's rolling bedside table was peeling along the sides of the table. Further observation revealed Resident #18's rolling bedside table had dirt, rust and an unknown dried substance on the stand of the table. Observation on 08/10/2023 at 8:49 a.m. revealed Resident #18's rolling bedside table was peeling along the sides of the table. Further observation revealed Resident #18's rolling bedside table had dirt, rust and an unknown dried substance on the stand of the table. Resident #30 Observation on 08/07/2023 at 2:40 p.m. revealed the foot board and the head board of Resident #30's bed was peeling. Observation on 08/09/2023 at 8:44 a.m. revealed the foot board and the head board of the Resident #30's bed was peeling. In an interview on 08/10/2023 at 8:49 a.m., S36Housekeeper stated he did not clean the rolling bedside tables. In an interview on 08/10/2023 at 9:20 a.m., S1Administrator stated maintenance was responsible for fixing, replacing or throwing away resident furniture or equipment that was in disrepair. S1Administrator further stated staff was instructed to throw away rolling bedside tables that were in disrepair and replace them. 5. Resident#24 Observation on 08/07/2023 at 3:39 p.m. revealed Resident #24's tube feeding pole and the floor next to Resident #24's bed had large spots of dried tube feeding formula. Observation on 08/08/2023 at 3:12 p.m. revealed large areas of dried tube feeding formula on Resident #24's floor, tube feeding pump and tube feeding pole. Observation on 08/09/2023 at 12:15 p.m. revealed large areas of dried tube feeding formula on Resident #24's floor, tube feeding pump and tube feeding pole. In an interview on 08/09/2023 at 4:58 p.m., S24Housekeeping Supervisor stated the housekeeping staff was responsible clean all resident rooms which included mopping and wiping furniture in the room. In a joint interview on 08/09/2023 at 4:50 p.m., S24Housekeeping Supervisor and S2AIT confirmed there were large areas of dried tube feeding formula on Resident #24's floor, tube feeding pole and tube feeding pump. S24Housekeeping Supervisor and S2AIT both stated Resident #24's floor and equipment needed to be cleaned.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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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 allegations of physical abuse were reported within 2 hours of the allegation being made for 3 (Resident # 45, Resident #49, and Resident #263) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure revealed, in part, it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Review revealed Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Further review revealed the facility would have written procedures that included reporting of all alleged violations to the administrator, and if applicable it would be reported to state agency, adult protective services and to all other required agencies within specified timeframes as noted by state agency. Review revealed the Administrator would follow up with government agencies, during business hours to confirm the initial report was received, and report the results of the final investigation within 5 working days of the incident, or as required by state agency. Resident #45 Review of Resident #45's medical record revealed, in part, Resident #45 was admitted to the facility on [DATE] with diagnosis of Insomnia, Diabetes Mellitus Type 2, Psychological Disorder, Coronary Artery Disease, Stroke, Hemiplegia, and Communicative Disorder. Review of Resident# 45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/2023 revealed in part, Resident #45 had a Brief Interview for Mental Status (BIMS) with a score of 9, which indicated Resident #45 had moderate cognitive impairment. Further review revealed Resident #45 required extensive assistance with bed mobility. Review of email dated 07/12/2023 at 2:50 p.m. from S5Social Services to S1Administrator and S2Administrator in Training (AIT) revealed, in part; Resident #45 stated 3 weeks ago Resident #45 had fallen on the floor trying to get out of his bed and the Certified Nursing Assistant (CNA) walked in and saw him, and stated he put himself on the floor, let him stay there. In an interview on 08/10/2023 at 12:52 p.m., S5Social Services stated Resident #45 informed her S4CNA verbally abused him. S5Social Services stated she sent an email to S1Administrator and S2AIT to inform them of the alleged verbal abuse complaint stated by Resident #45. In an interview on 08/10/2023 at 1:14 p.m., S1Administrator stated confirmed he did receive the email on 07/12/2023 regarding Resident #45's allegation of verbal abuse. In an interview on 08/10/2023 at 1:36 p.m., S1Administrator stated he did not initiate a Statewide Incident Management System (SIMS) report on Resident #45's incident reported on 07/12/2023, and admitted he should have initiated a SIMS report. In an interview on 08/10/2023 at 1:50 p.m., S2Administrator in Training (AIT) stated the facility should have started an investigation and a SIMS on the situation for Resident #45. In an interview on 08/10/2023 at 4:23 p.m., Resident #45 identified S4CNA as the staff member who had left him on the floor and said mean words to him in July 2023. Review of Resident #45's SIMS report revealed the incident was discovered on 07/12/2023 at 2:50 p.m., but the incident was not entered until 08/11/2023 at 8:29 a.m. Resident #49 Review of Resident #49's Minimum Data Set with an Assessment Reference Date (ARD) dated 05/30/2023 revealed, in part, Resident #49 had a Brief Interview for Mental Status (BIMS) of 10 (a score of 08-12 which indicated moderate cognitive impairment). Further review revealed Resident #49 required one person extensive assistance of one person for bed mobility. Review of email dated 07/12/2023 at 2:50 p.m. from S5Social Services to S1Administrator and S2Administrator in Training (AIT) revealed Resident #49 stated a night aid pulled his covers back, and yanked his diaper. Further review revealed Resident #49 had further stated he was thrown on his side roughly and his leg hit the wall. Review revealed Resident #49 pointed the aid out to me because the aid came in the room, the aid he pointed out was a heavy set Certified Nursing Assistant (CNA). In an interview on 08/10/2023 at 11:08 a.m., Resident #49 stated staff are rough with him at times. Resident #49 further stated in July 2023 a CNA took his diaper off roughly and threw him against the wall. Resident #49 further stated his leg and knee hit the wall. Resident #49 identified the CNA as S4CNA. In an interview on 08/10/2023 at 12:52 p.m., S5Social Services stated she interviewed Resident #49 and he identified S4CNA as the CNA who threw him into the wall hitting his knee and was rough with him. S5Social Services stated this incident was reported to S1Administrator and S2AIT in an email sent on July 12, 2023. S5Social Services further stated she confirmed with S1Administrator and S2AIT on 07/12/2023 they had received the email regarding Resident #49's allegation of abuse. In an interview on 08/10/2023 at 1:36 p.m., S1Administrator stated he did not initiate a Statewide Incident Management System (SIMS) report on Resident #49's incident reported on 07/12/2023, and admitted he should have initiated a SIMS report. In an interview on 08/10/2023 at 1:50 p.m., S2Administrator in Training (AIT) stated the facility should have started an investigation and a SIMS on the situation for Resident #49. Review of SIMS regarding Resident #49 revealed incident discovered on 07/12/2023 at 2:50 p.m., but incident report was not entered until 08/11/2023 at 9:18 a.m. Resident #263 Review of Resident #263's medical record revealed, in part, Resident #263 was admitted to the facility on [DATE] with a diagnosis of, in part, Cerebral Vascular Accident (CVA), and Communicative Disorder. Review of Resident #263's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2023 revealed, in part, Resident #263 had a Brief Interview for Mental Status score of 9, which indicated Resident #263 had moderate cognitive impairment. In an interview on 08/09/2023 at 11:24 a.m., S17Admissions stated on 07/05/2023 the hospital case manager reported Resident #263 stated a staff member at the facility had hit her on the buttock; however, the name Resident #263 gave to the case manager did not match any staff employed by the facility. In an interview on 08/09/2023 at 12:04 p.m., S17Admissions stated she reported the allegation of abuse involving Resident #263 to S1Administrator on 07/05/2023 at 12:23 p.m. In an interview on 08/09/2023 at 12:30 p.m., S1Administrator stated he thought he initiated and submitted a SIMS report to State Office, but he could not present any documentation a SIMS report was completed for Resident #263's allegation of abuse. S1Administrator confirmed an allegation of abuse should have been reported per SIMS. In an interview on 08/09/2023 at 1:10 p.m., S3Director of Nursing (DON) stated she was not aware of any allegations of abuse involving Resident #263 on 07/05/2023, and she did not conduct an investigation into Resident #263's allegation of abuse.

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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Based on record review and interview the facility failed to: 1. Thoroughly investigate a resident's allegations of abuse and/or neglect for 3 (Resident # 45, Resident #49, and Resident #263) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse; and, 2. Protect residents from the potential of further abuse during the investigation process for 2 (Resident # 45 and Resident #49) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure revealed, in part, Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Review revealed an immediate investigation was warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Review also revealed the written procedures for investigations included, in part: 1. identify staff responsible for the investigation; 2. exercise caution in handling evidence that could be used in a criminal investigation; 3. investigate different types of alleged violations; 4. identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have had knowledge of the allegations; 5. focus the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, the extent, and cause; and, 6. Provide a complete and thorough documentation of the investigation. Further review revealed the facility would make efforts to ensure all residents were protected from physical and psychosocial harm during and after the investigation. Examples included but were not limited to: respond immediately to protect the alleged victim and integrity of the investigation; examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; provide increased supervision of the alleged victim and residents; protection from retaliation; provide emotional support and counseling to the resident during and after the investigation, as needed. Resident #45 Review of Resident# 45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/21/2023 revealed, in part, Resident #45 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #45 had moderate cognitive impairment. Further review revealed Resident #45 required extensive assistance with bed mobility. Review of an email dated 07/12/2023 at 2:50 p.m. revealed S5Social Services informed S1Administrator and S2Administrator in Training (AIT) revealed Resident #45 stated 3 weeks ago he fell on the floor, and the Certified Nursing Assistant (CNA) walked in and saw him and stated, he put himself on the floor, let him stay there. In an interview on 08/10/2023 at 4:23 p.m., Resident #45 stated S4CNA was the staff member who left him on the floor and also hit him in July 2023. Observation on 08/10/2023 at 12:46 p.m. revealed S4CNA was providing care on Resident #45's hall. In an interview on 08/10/2023 at 12:52 p.m., S5Social Services stated when she interviewed Resident #45, he told her that the CNA who was verbally and physically abusive to him was S4CNA. S5Social Services stated she sent an email to S1Administrator and S2AIT on 07/12/2023 regarding Resident #45's abuse allegation. In an interview on 08/10/2023 at 1:47 p.m., S1Administator confirmed he was informed of S4CNA's alleged abuse of Resident #45, but the facility did not investigate Resident #45's allegations. S1Administrator further stated the facility did not place any staff on leave following the allegation of abuse, therefore S1Administrator had not ensured Resident #45 was protected from further abuse. In an interview on 08/10/2023 at 1:52 p.m., S2AIT confirmed he received S5Social Services' email on 07/12/2023 regarding Resident #45's allegation of abuse. S2AIT further stated an investigation should have been started for Resident #45's abuse allegation. Resident #49 Review of Resident #49's MDS with an ARD dated 05/30/2023 revealed, in part, Resident #49 had a BIMS score of 10, which indicated moderate cognitive impairment. Further review revealed Resident #49 required extensive assistance for bed mobility. Review of an email dated 07/12/2023 at 2:50 p.m. revealed S5Social Services informed S1Administrator and S2Administrator in Training (AIT) revealed Resident #49 stated a night CNA pulled his covers back and yanked his diaper. Further review revealed Resident #49 stated he was recently thrown on his side roughly and his leg hit the wall. Review of the document also revealed Resident #49 identified S4CNA to S5Social Services when S4CNA walked into Resident #49's room. In an interview on 08/10/2023 at 11:08 a.m., Resident #49 stated in July of 2023, S4CNA aggressively removed Resident #49's diaper and threw Resident #49 against the wall, causing Resident #49's leg and knee to hit the wall. Resident #49 further stated he informed S41Former CNA Supervisor about the incident. Resident #45 also stated S4CNA was still caring for him Observation on 08/10/2023 at 12:46 p.m. revealed S4CNA was observed providing care in the facility. In an interview on 08/10/2023 at 12:52 p.m., S5Social Services stated Resident #49 informed her a CNA had thrown him into a wall, causing him to hit his knee. S5Social Services stated S4CNA walked into Resident #49's room during their conversation, and Resident #49 identified S4CNA as the alleged perpetrator. S5Social Services stated she immediately notified administration by an email to S1Administrator and S2AIT. S5Social Services stated on 07/12/2023 she verbally confirmed with S1Administrtor and S2AIT they had received the email regarding Resident #49's abuse allegations. In an interview on 08/10/2023 at 1:14 p.m., S1Administrator confirmed he received the email on 07/12/2023 regarding Resident #49's report of alleged abuse. S1Administrator further stated he thought the nursing department had completed an investigation regarding Resident #49's allegation. In an interview on 08/10/2023 at 1:38 p.m., S3Director of Nursing (DON) stated she was unaware Resident #49 had an allegation of abuse, and an investigation of the allegation of abuse was not completed. In an interview on 08/10/2023 at 1:47 p.m., S1Administrator stated they did not investigate Resident #49's allegation of abuse nor did the facility ever place any staff on leave after the allegation of abuse, therefore had not protected the residents. In an interview on 08/10/2023 at 1:52 p.m., S2AIT stated the facility should have started an investigation, attempted to identify the perpetrator, and if a perpetrator was identified the facility should have placed the CNA on leave while the allegations were being investigated. S2AIT confirmed the facility failed to investigate the alleged abuse, and protect Resident #49 until an investigation on the alleged abuse was completed. Review of S4CNA's Time and Attendance Detail Report by Employee revealed she worked the following days after the allegation of abuse was made by Resident #49: 07/13/2023; 07/14/2023; 07/17/2023; 07/18/2023; 07/19/2023; 07/20/2023; 07/21/2023; 07/25/2023; 07/26/2023; 07/27/2023; 07/28/2023; 07/31/2023; 08/01/2023; 08/03/2023; 08/04/2023; 08/07/2023; 08/08/2023; and 08/09/2023. Resident #263 Review of Resident #263's MDS with an ARD of 07/10/2023 revealed, in part, Resident #263 had a BIMS score of 9, which indicated Resident #263 had moderate cognitive impairment. In an interview on 08/09/2023 at 11:24 a.m., S17Admissions stated on 07/05/2023 the hospital case manager reported to her Resident #263 gave a name of the staff who supposedly hit her; however, the name given did not match any staff employed by the facility. In an interview on 08/09/2023 at 12:04 p.m., S17Admissions stated she reported Resident #263's allegation of abuse involving Resident #263 to S1Administrator on 07/05/2023 at 12:23pm. In an interview on 08/09/2023 at 12:30 p.m., S1Administrator stated he did not conduct an investigation for Resident #263's allegation of abuse, but an investigation should have been completed. In an interview on 08/09/2023 at 1:10 p.m., S3Director of Nursing (DON) stated she was not aware of Resident #263's abuse allegation, nor did S3DON conduct an investigation for Resident #263's abuse allegation.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review and revise the residents' care plan after completion of quarterly review assessment for 2 (Resident #18 and Resident #91) of 24 sampled residents. Findings: Resident #18 Review of Resident #18's medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Coronary Artery Disease, Hypertension, Atrial Fibrillation, Anemia, Colostomy, Nephrostomy Tubes, Foley Catheter, Debility, and Persistent Nausea. Review of Resident #18's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/31/2023 revealed the MDS was completed on 06/14/2023. Review of Resident #18's comprehensive care plan revealed Resident #18's comprehensive care plan was initiated on 02/28/2023, with no updated review dates and the goal dates of 05/28/2023 were past due. Further review of Resident #18's care plan revealed the care plan was not updated with completion of Quarterly MDS with ARD of 05/31/2023. In an interview on 08/10/2023 at 8:47 a.m., S14Minimum Data Set Nurse confirmed Resident #18's care plan with an initial date of 2/29/2023 and a goal date of 5/28/2023 should have been updated in May 2023. Resident #91 Review of Resident #91's medical record revealed Resident #91 admitted to the facility on [DATE] with diagnoses of Hypertension, Seizure, Arthritis, Chronic Alcohol Abuse, Schizophrenia, Anxiety, and Prostate Cancer. Review of Resident #91's Quarterly MDS with an ARD of 05/31/2023 revealed the MDS was completed on 06/14/2023. Review of Resident #91's comprehensive care plan revealed Resident #91's comprehensive care plan had a review date of 03/01/2023 and a past goal date of 06/08/2023. Further review of Resident #91's care plan revealed the care plan was not updated with the Quarterly MDS with an ARD of 05/31/2023. In an interview on 08/09/2023 at 12:40 p.m., S14Minimum Data Set Nurse confirmed Resident #91's care plan with a review date of 03/01/2023 and a goal date of 06/08/2023 should have been updated In June 2023.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to accurately assess and document the presence of pain for 2 (Resident #17 and Resident #101) of 2 (Resident #17 and Resident #101) residents reviewed for pain. Findings: Resident #17 Review of Resident #17's medical record revealed Resident #17 was admitted [DATE] with diagnoses, in part, of arthritis, neuropathy (nerve pain), chronic right hip pain, myopathy (disorder which causes muscle pain), and osteoarthritis (disorder which causes joint pain). Review of Resident #17's August 2023 Physician orders revealed, in part, Hydrocodone/Acetaminophen (medication used to treat pain) 5-325 milligram (mg) tablet every 12 hours as needed for pain, and monitor Resident #17 for indication of pain. Review of Resident #17's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/14/2023 revealed, in part, Resident #17 was on a scheduled pain medication regimen and received as needed pain medication. Further review revealed Resident #17's pain was assessed as pain presented constantly at an intensity of 7 (with scale of 0 being no pain and 10 being the worst pain). Review of Resident #17's Care plan revealed, in part, the problem of pain potential due to chronic hip pain, carpal Tunnel syndrome, IBS, Myopathy, Neuropathy, Parkinson disease with review date of 06/15/2023 and target date of 09/15/2023. Resident #17's Interventions included in part, observe for effectiveness of pain medications and treatments. In an interview on 08/07/2023 at 1:16 p.m., Resident #17 stated she had pain constantly due to a hip problem and had generalize pain. Review of Resident #17's Individual Narcotic Record revealed one Hydrocodone/Acetaminophen 5/325mg tablet was signed out on: 06/12/2023 at 9:00 pm, 06/16/2023 at 9:00 p.m., 06/22/2023 at 1:00 a.m., 06/22/2023 at 5:00 p.m., 06/23/2023 at 4:00 a.m., 06/23/2023 at 9:30 p.m., 06/24/2023 at 5:00 a.m., 06/24/2023 at 4:24 p.m., 06/25/2023 at 6:00 a.m., 06/25/2023 at 6:00 p.m., 06/26/2023 at 6:00 a.m., 06/26/2023 at 6:00 p.m., 06/27/2023 at 6:00 am, 06/27/2023 at 07:00 p.m., 06/28/2023 at 5:00 a.m., 06/29/2023 at 6:00 a.m., 06/30/2023 at 6:00 a.m., 06/30/2023 at 6:00 p.m., 08/01/2023 at 5:00 a.m., 08/02/2023 at 6:00 a.m., 08/02/2023 at 8:45 p.m., 08/03/2023 at 8:00 p.m., 08/04/2023 at 10:00 a.m., 08/05/2023 at 8:00 a.m., 08/06/2023 at 08:00 p.m., 08/07/2023 at 9:20 p.m., and 08/08/2023 at 9:00 p.m. Review of Resident #17's June 2023 MAR revealed Resident #17's Hydrocodone/Acetaminophen was only documented as administered on 06/24/2023, 06/26/2023 and 06/27/2023. Further review of Resident #17's MAR revealed the effectiveness of Resident #17's Hydrocodone/Acetaminophen was only documented on 06/24/2023 and 06/27/2023. Review of Resident #17's August 2023 MAR revealed Resident #17's Hydrocodone/Acetaminophen was only documented as administered on 08/03/2023 and 08/04/2023. Further review of Resident #17's MAR revealed the effectiveness of Resident #17's Hydrocodone/Acetaminophen was only documented on 08/03/2023 and 08/04/2023. In an interview on 08/10/2023 at 1:10 p.m., S9Assistant Director of Nursing (S9ADON) stated when a resident receives prn (as needed) pain medication, the effectiveness of the medication administered for pain should be documented on the back of the MAR. S9ADON confirmed the effectiveness of the pain medication was not documented on Resident #17's MAR each time the as needed pain medication was administered for June 2023 and August 2023. Resident #101 Review of Resident #101's Significant Change MDS assessment with an ARD of 06/13/2023 revealed, in part, Resident #101 was as assessed as having a Brief Interview of Mental Status score of 12 which indicated moderate cognitive impairment. Review revealed, in part, Resident #101 had diagnoses of hemiplegia (paralysis caused by injury to the spinal cord or brain) with left sided weakness, polyneuropathy (nerve damage that causes pain and numbness), and gout (inflammation in joints that causes pain). Further review revealed Resident #101 was assessed as having occasional mild pain and received an opioid (a medication used to treat pain) on 2 days during his assessment. Review of Resident #101's Care Plan revealed, in part, Resident #101 had a potential for pain due to polyneuropathy and arthritis (inflamed joints that causes pain) with interventions for nursing to administer medications as ordered by the physician and observe for effectiveness of pain medications. Review of Resident #101's physician orders for July and August 2023 revealed Resident #101 had an order for Hydrocodone/Acetaminophen 5-325mg (milligram) give 1 tablet by mouth every 6 hours as needed for pain, and an order for pain monitoring every shift. Review of Resident #101's August 2023 MAR revealed Resident #101 was documented as having no signs and symptoms of pain, and no pain medication administered on all shifts (day, evening, and night shift). Review of Resident #101's Individual Narcotic Record revealed Resident #101 was documented as having received Hydrocodone/Acetaminophen 5-325mg tablet on the following dates and times: 08/04/2023 at 11:00 a.m., 08/04/2023 at 6:00 p.m., 08/05/2023 4:00 a.m., 08/05/2023 at 1:39 p.m., 08/06/2023 6:00 a.m., 08/06/2023 6:10 p.m., 08/07/2023 4:00 a.m., 08/07/2023 10:10 a.m., 08/07/2023 6:30 p.m., 08/08/2023 4:00 a.m., 08/08/2023 2:30 p.m., 08/08/2023 at 8:00 p.m., and 08/09/2023 4:00 a.m. In an interview on 08/09/2023 at 12:53 p.m., S12LPN confirmed Resident #101's August 2023 MAR for Hydrocodone revealed there was no documentation for the response to the medication. S12LPN confirmed she should have documented the response to the medication as per Resident #101's plan of care. Review of Resident 101's record revealed no documented evidence and the facility did not provide any documented evidence Resident #101 had signs or symptoms of pain prior to administration of as needed pain medication and was monitored for the effectiveness after administration of as needed pain medications which were administered from 08/04/2023 - 08/08/2023. In an interview on 08/14/2023 at 10:35 a.m., S2Director of Nursing (DON) stated she did not understand why the nurses documented Resident #101 had no pain on his MAR when his Narcotic Record flowsheet indicated he received hydrocodone 14 times from 08/04/2023 - 08/09/2023. S2DON further stated the nurses did not assess and document Resident #101's pain correctly and should have.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure communication with a resident's dialysis facility for 1 (Resident #48) of 1 (Resident #48) sampled residents reviewed for dialysis. Findings: Review of the facility's Hemodialysis policy revealed, in part, the facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice which included the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Review of Resident #48's May, June, July, and August 2023 physician's orders revealed, in part, Resident #48 had a diagnosis of dialysis associated renal failure and orders for outpatient dialysis every Tuesday, Thursday, and Saturday. In an interview on 08/10/2023 at 5:32 p.m., S11Licensed Practical Nurse stated the facility communicated with Resident #48's dialysis facility via the dialysis communication sheet. Review of Resident #48's Dialysis Communication Binder from 05/01/2023 through 08/05/2023 revealed, in part, no documented evidence and the facility was unable to provide any documented evidence of communication with the dialysis facility on Resident #48's following dialysis days: 05/02/2023, 05/04/2023, 05/06/2023, 05/09/2023, 05/11/2023, 05/13/2023, 05/16/2023, 05/18/2023, 05/20/2023, 05/23/2023, 05/25/2023, 05/27/2023, 05/30/2023, 06/01/2023, 06/03/2023, 06/06/2023, 06/08/2023, 06/10/2023, 06/13/2023, 06/15/2023, 06/17/2023, 06/20/2023, 06/22/2023, 06/24/2023, 06/27/2023, 06/29/2023, 07/01/2023, 07/11/2023, 07/13/2023, 07/15/2023, 08/01/2023, and 08/05/2023. In an interview on 08/11/2023 at 12:45 p.m., S3Director of Nursing (DON) confirmed there was no documented evidence of communication with Resident #48's dialysis facility on the above mentioned dates. S3DON stated the facility should have had communication to and from the dialysis center for each appointment.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA's) had completed annual competencies as required for 5 (S4CNA, S31CNA, S33CNA, S37CNA, and S38CNA)of 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) CNAs reviewed for annual competencies. Review of S4CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S31CNA's personnel file revealed, in part, the last annual competency documented was 07/26/2022. Review of S33CNA Supervisor's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S37CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S38CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. In an interview on 08/10/2023 at 1:00 p.m., S8Human Resources (HR) stated the last annual competencies completed were completed in July of 2022. S8HR further stated competencies had not been completed annually. In an interview on 08/10/2023 at 1:30 p.m., S3DON confirmed S4CNA, S31CNA, S33CNA, S37CNA, and S38CNA had not had annual competencies completed and all direct care staff should have up to date annual competencies completed prior to performing direct care to residents. The facility was unable to provide any documented evidence of annual competencies completed annually since the above mentioned dates.

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to complete annual performance evaluations for certified nursing assistants (CNA) for 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) of 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) CNA personnel files reviewed. Findings: Review of S4CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S31CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S33CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S37CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S38CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. In an interview on 08/10/2023 at 1:00 p.m., S8Human Resources (HR) stated annual performance evaluations were not completed for S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA.

CONCERN (E)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to post the required nurse staffing information on a daily basis. Findings: Observation on 08/08/2023 at 12:26 p.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 08/08/2023 03:18 p.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 08/09/2023 at 09:53 a.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 08/10/2023 at 10:02 a.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. In an interview on 08/10/2023 at 10:30 a.m., S3Director of Nursing (DON) stated the certified nursing assistants' assignment sheet was posted every day at the nurse's station by S33Certfied Nursing Assistant (CNA) Supervisor. S3Director of Nursing further stated she does not post the facility census, nursing assignments, or actual hours worked. In an interview on 08/10/2023 at 11:00 a.m., S33CNA Supervisor stated she is not responsible for posting staffing hours. S33CNA Supervisor further stated the assignment sheet only displays what rooms the CNAs are responsible for working. S33CNA Supervisor stated it does not display the census, the hours the staff are working, or the shift the staff are working. In an interview on 08/10/2023 at 11:15 a.m., S1Administrator stated S8Human Resources (HR) is responsible for posting staffing information. In an interview on 08/10/2023 at 11:22 a.m., S1Administrator stated staffing hours should be posted daily in a visible area and they were not posted. In an interview on 08/11/2023 at 11:20 a.m., S8HR confirmed she had not posted daily staffing information on 08/08/2023, 08/09/2023, and 08/10/2023 and she should have.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on record review and interview, the facility failed to implement the facility's policy for the prevention of Legionella Disease. Findings: Review of the facility's Legionella policy with a revision date of 05/23/2023 revealed, in part, the facility should implement primary prevention strategies which include maintenance of cooling towers and potable water systems, store and distribute cold water below 68 degrees Fahrenheit (°F), store hot water above 140°F, and circulate water at a minimum return temperature of 124°F. The facility failed to present documentation of their assessment of where opportunistic pathogens may grow, measures they put into place to prevent the growth of legionella, and/or how they monitor for legionella. In an interview on 08/14/2023 at 10:28 a.m., S28Maintenance Director stated he was unable to present any documented evidence of water temperature checks which were to be completed weekly. In an interview on 08/14/2023 at 10:31 a.m., S1Administrator stated he did not have any documented evidence of the water temperature checks having been completed. In an interview on 08/14/2023 at 10:44 a.m., S15Regional Clinical Director stated the water temperature logs should have been maintained as part of the plan for legionella prevention. S15Regional Clinical Director further stated the facility was unable to present any documented evidence of water temperature checks having been completed.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) within 14 days of the completion date for 6 (Resident #19, Resident #56, Resident #58, Resident #73, Resident #85, and Resident #96) of 6 (Resident #19, Resident #56, Resident #58, Resident #73, Resident #85, and Resident #96) residents reviewed for Resident Assessment. Findings: Review of the facility's MDS 3.0 Completion policy revealed, in part, all assessments shall be transmitted to the designated CMS system within 14 days of completion. Resident #19 Review of Resident #19's Annual MDS with an Assessment Reference Date (ARD) 06/06/2023 revealed, in part, a completion date of 06/07/2023. The facility was unable to provide documented evidence the MDS was transmitted. Resident #56 Review of Resident #56's Quarterly MDS with an ARD of 06/13/2023 revealed, in part, a completion date of 06/27/2023. Review of the MDS 3.0 Final Validation Report revealed, in part, Resident #56's MDS completed on 06/27/2023 was transmitted to CMS on 08/04/2023. Further review revealed the submission date was more than 14 days after the completed date of 06/27/2023. Resident #58 Review of Resident #58's Quarterly MDS with an ARD of 06/09/2023 revealed, in part, a completion date of 06/23/2023. Review of the MDS 3.0 Final Validation Report revealed, in part, Resident #58's MDS completed on 06/23/2023 was transmitted to CMS on 08/04/2023. Further review revealed the submission date was more than 14 days after the completed date of 06/23/2023. Resident #73 Review of Resident #73's Quarterly MDS with an ARD of 06/12/2023 revealed, in part, a completion date of 06/26/2023. Review of the MDS 3.0 Final Validation Report revealed, in part, Resident #73's MDS completed on 06/27/2023 was transmitted to CMS on 08/08/2023. Further review revealed the submission date was more than 14 days after the completed date of 06/26/2023. Resident #85 Review of Resident #85's Quarterly MDS with an ARD of 06/13/2023 revealed, in part, a completion date of 06/27/2023. Review of the MDS 3.0 Final Validation Report revealed, in part, Resident #85's MDS completed on 06/27/2023 was transmitted to CMS on 08/04/2023. Further review revealed the submission date was more than 14 days after the completed date of 06/27/2023. Resident #96 Review of Resident #96's Quarterly MDS with an ARD of 06/12/2023 revealed, in part, a completion date of 06/26/2023. Review of the MDS 3.0 Final Validation Report revealed, in part, Resident #96's MDS completed on 06/26/2023 was transmitted on 08/04/2023. Further review revealed the submission date was more than 14 days after the completed date of 06/26/2023. In an interview on 08/09/2023 at 10:45 a.m., S14MDS Nurse confirmed Resident #96's, Resident #56's, Resident #85's, Resident #19's, Resident #73's and Resident #58's above mentioned MDS assessments were not transmitted to CMS within 14 days.

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Data (Tag F0851)

Minor procedural issue · This affected multiple residents

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Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of the facility's Payroll Based and Journal(PB&J) reporting revealed the facility triggered for no Registered Nurse(RN) hours having been provided on 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/06/2023, 01/11/2023, 01/12/2023, 01/13/2023, 01/17/2023, 01/19/2023, 01/20/2023, 01/31/2023, 02/01/2023, 02/02/2023, 02/03/2023, 02/06/2023, 02/07/2023, 02/08/2023, 02/09/2023, and 02/10/2023. Review of facility Managers Monthly Timesheets revealed documentation of a minimum of 8 hours daily on 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/06/2023, 01/11/2023, 01/12/2023, 01/13/2023, 01/17/2023, 01/19/2023, 01/20/2023, 01/31/2023, 02/01/2023, 02/02/2023, 02/03/2023, 02/06/2023, 02/07/2023, 02/08/2023, and 02/09/2023 completed by the facility's previous Director of Nursing. Further review revealed a minimum of 8 hours was documented for S9Assistant Director of Nursing, a RN, on 02/10/2023. In an interview on 08/09/2023 at 10:30 a.m., S8Human Resources (HR) stated At the time the above mentioned PB&J report was completed, the previous DON and ADON were not clocking into the time clock. S8HR stated due to the RNs not clocking in, PB&J report was submitted incorrectly.

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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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 representative of a resident's change in the resident's pressure ulcer's condition which required hospitalization. This deficient practice was identified for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. Findings: Review of the facility's Notification of Changes Policy revised 07/26/2022 revealed, in part, the facility must notify the resident's family member or legal representative when there is a change requiring such notification including a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, and a transfer of the resident from the facility. Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of, in part, Hemiplegia, and History of Traumatic Brain Injury. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 02/23/2023 revealed, in part, Section C (Cognitive Patterns) revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated severe cognitive impairment. Review of Section M (Skin Conditions) revealed Resident #3 had three Stage 3 pressure ulcers present at admit/re-entry. Review of the Nurse's Notes dated 04/13/2023 revealed, in part, the ambulance arrived at the facility to transfer Resident #3 to the hospital. Further review revealed there was no documented evidence, and the facility did not provide any documentation that Resident #3's Responsible Party was immediately notified of Resident #3's transfer to the hospital on [DATE]. In an interview on 05/30/2023 at 11:26 a.m., S3Treatment Nurse stated Resident #3 was sent to the hospital on [DATE] due to a deterioration of Resident #3's wound. S3Treatment Nurse stated Resident #3 had cellulitis, and Resident #3's sacral wound had purulent (sign of infection) drainage. In an interview on 05/30/2023 at 11:41 a.m., S4Certified Nursing Assistant (CNA) stated she performed incontinence care for Resident#3 on 04/12/2023, and observed Resident #3's sacral wound dressing had come off. S4CNA stated Resident#3 was sent to the hospital on [DATE]. In a telephone interview on 05/31/2023 at 12:38 p.m., S5Licensed Practical Nurse (LPN) stated she had worked on the evening shift on 04/13/2023, and she received report that everything was taken care for Resident#3's transfer to the hospital. S5LPN stated she wrote a note that Resident #3 had left with the ambulance to be transferred to the hospital. S5LPN stated she did not notify Resident #3's Responsible Party of the transfer to the hospital or change in Resident #3's condition, and stated the Responsible Party should have been notified. In an interview on 05/31/2023 at 12:45 p.m., S2Director of Nursing (DON), upon review of the Resident #3's Nurse's Notes dated 04/13/2023 with surveyor, stated S5LPN should have immediately notified Resident #3's Responsible Party of Resident #3's change in pressure ulcer condition which required hospitalization. S2DON stated anytime a resident goes to the hospital the Responsible Party should be notified. S2DON stated she apologized to Resident #3's Responsible Party during a recent care plan meeting because the facility should have notified the Responsible Party of Resident #3's hospitalization and change in condition. In an interview on 05/31/2023 at 1:00 p.m., S1Administrator was aware and acknowledged that Resident #3's Responsible Party should have been notified of Resident #3's hospitalization.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Louisiana facilities.

Concerns

• 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade F (35/100). Below average facility with significant concerns.
• 59% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is St Bernard Nursing & Rehab's CMS Rating?

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

How is St Bernard Nursing & Rehab Staffed?

CMS rates ST BERNARD NURSING & REHAB's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 78%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at St Bernard Nursing & Rehab?

State health inspectors documented 41 deficiencies at ST BERNARD NURSING & REHAB during 2023 to 2025. These included: 39 with potential for harm and 2 minor or isolated issues.

Who Owns and Operates St Bernard Nursing & Rehab?

ST BERNARD NURSING & REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by VOLARE HEALTH, a chain that manages multiple nursing homes. With 127 certified beds and approximately 113 residents (about 89% occupancy), it is a mid-sized facility located in NEW ORLEANS, Louisiana.

How Does St Bernard Nursing & Rehab Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, ST BERNARD NURSING & REHAB's overall rating (1 stars) is below the state average of 2.4, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting St Bernard Nursing & Rehab?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is St Bernard Nursing & Rehab Safe?

Based on CMS inspection data, ST BERNARD NURSING & REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at St Bernard Nursing & Rehab Stick Around?

Staff turnover at ST BERNARD NURSING & REHAB is high. At 59%, the facility is 13 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 78%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was St Bernard Nursing & Rehab Ever Fined?

ST BERNARD NURSING & REHAB has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is St Bernard Nursing & Rehab on Any Federal Watch List?

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

Facility Details

Beds: 127
Avg. Residents: 113
Occupancy: 89.3%
Ownership: For profit - Limited Liability company
Chain: VOLARE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
41 Deficiencies: -10
Final Score: 35/100

Nearby Alternatives

JOHN J HAINKEL JR HOME AND REH... 5-star Willow Wood at Woldenberg Vill... 3-star JO ELLEN SMITH CONVALESCENT CE... 3-star

View all in NEW ORLEANS →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195356