ST JUDE'S HEALTH & WELLNESS CENTER
Non profit - Other
116 Beds
Independent
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#246 of 264 in LA
Photo by St. Jude’s Nursing Facility
Photo by Sunny Deakle
Photo by St. Jude's
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
St. Jude's Health & Wellness Center has received a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #246 out of 264 facilities in Louisiana, placing it in the bottom half, and #10 out of 11 in Orleans County, meaning there is only one facility in the area that performs worse. The trend is worsening, with issues increasing from 18 in 2024 to 21 in 2025, and the facility has accumulated $389,001 in fines, which is higher than 98% of Louisiana facilities, suggesting ongoing compliance problems. While staffing is rated average with a 3/5, the turnover rate is concerning at 69%, significantly above the state average of 47%, which may affect the consistency of care. Specific incidents include allowing untrained staff to work independently with residents, which poses a serious risk, and a failure to obtain timely lab services, leading to a hospitalization due to valproic acid toxicity. Overall, families should weigh these significant weaknesses against the average staffing rating when considering this facility for their loved ones.
- Trust Score
- F
- In Louisiana
- #246/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $389,001 in fines. Higher than 60% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 45 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 7%
Review needed
18 → 21 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 21 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 69%
23pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $389,001
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (69%)
21 points above Louisiana average of 48%
The Ugly 45 deficiencies on record
4 life-threatening 1 actual harm
Mar 2025
5 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Laboratory Services
(Tag F0770)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to obtain laboratory services in a timely manner per physician's ord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to obtain laboratory services in a timely manner per physician's orders for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for pharmaceutical services.
This deficient practice resulted in an Immediate Jeopardy situation on 02/04/2025 when Resident #1's valproic acid level (a blood test to measure the amount of valproic acid in the blood) was not drawn after being ordered by Resident #1's nurse practitioner on 01/29/2025. On 02/17/2025, Resident #1 was observed by the facility to be lethargic and was transferred to the hospital. Resident #1 was hospitalized from [DATE] through 02/19/2025 with a diagnosis of valproic acid toxicity (an excessive accumulation of valproic acid in the body which can lead to coma or death).
S1Chief Operating Officer (COO) and S2Director of Nursing (DON) were notified of the Immediate Jeopardy on 03/12/2025 at 6:50PM.
The Immediate Jeopardy was removed on 03/13/2025 at 4:30PM, after it was verified through observations, interviews, and record reviews, the provider implemented an acceptable Plan of Removal prior to the survey exit.
This deficient practice had the likelihood to affect all residents with medications requiring lab orders.
Findings:
Review of Resident #1's hospital records revealed, in part, Resident #1 was hospitalized from [DATE] through 02/19/2025 with a diagnosis, in part, of valproic acid toxicity. Further review of Resident #1's hospital records revealed on admit, Resident #1's valproic acid level drawn on 02/17/2025 at 12:04PM with a result of 110.7 microgram (µg)/milliliter (ml), which was outside the reference range of 50.0 to 100.0 µg/ml.
Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses which included, in part, dementia and anxiety disorder.
Review of Resident #1's physician's orders revealed the following:
Depakote (medication used for seizures, anxiety, and dementia) Oral Tablet Delayed Release 250 milligrams (mg) tablet. Give 250 mg by mouth two times a day related to dementia with a start date of 12/17/2025 and an end date of 01/03/2025;
Depakote Oral Tablet Delayed Release 500 mg tablet. Give 500 mg by mouth two times a day related to anxiety disorder from 01/03/2025 through 02/01/2025;
Depakote Oral Tablet Delayed Release 250 mg tablet. Give 1 tablet by mouth two times a day related to anxiety disorder. Give 500 mg tablet with 250 MG tablet by mouth twice daily from 02/01/2025 to 02/20/2025;
Depakote Oral Tablet Delayed Release 500 mg tablet. Give 1 tablet twice a day related to anxiety disorder. Give 500 mg tablet with 250 mg tablet twice daily from 02/01/2025 to 02/27/2025;
Depakote Oral Tablet Delayed Release 500 mg tablet. Give 1 tablet by mouth at bedtime for dementia with behavioral disturbances beginning on 02/27/2025; and,
Depakote Oral Tablet Delayed Release 250 mg tablet. Give 1 tablet by mouth in the morning for dementia with behavioral disturbances beginning on 02/28/2025.
Review of Resident #1's medical records revealed Resident #1's nurse practitioner wrote an order dated 01/29/2025, to obtain a valproic acid level.
In an interview on 03/11/2025 at 5:02PM, S2DON indicated routine labs were to be drawn on Tuesdays and Thursdays. S2DON further indicated once the orders were written for the labs, S2DON would hand a copy of the orders to the floor nurse to transcribe and submit a lab requisition. S2DON further indicated she would file the orders once she saw the orders were placed and carried out.
There was no documented evidence, and the facility was unable to present any documented evidence that Resident #1's laboratory service was carried out as ordered prior to Resident #1's 02/17/2025's hospitalization.
Review of Resident #1's Progress Notes revealed a note dated 02/17/2025 at 11:08AM by S3Licensed Practical Nurse (LPN) indicating Resident #1 was slow to respond and Resident #1 gave blank stares when asked questions. Further review revealed S3LPN called Resident #1's doctor and obtained an order to transfer Resident #1 to the emergency room for further evaluation.
In an interview on 03/11/2025 at 3:48PM, the facility's consulting pharmacist, S9Consultant Pharmacist, indicated it was important to get valproic acid levels when residents are taking Depakote due to the risk of toxicity. The facility's consulting pharmacist further indicated signs and symptoms of valproic acid toxicity included gastrointestinal distress, neurological distress, drowsiness, and confusion.
In an interview on 03/12/2025 at 12:27PM, S2DON confirmed Resident #1 did not have any valproic acid levels drawn prior to her acute care hospitalization.
In an interview on 03/12/2025 at 2:09PM, S1Chief Operating Officer (COO) indicated she was currently in charge of quality since administration has been out on leave, and identified problems from grievances, surveys, tracking and trending, and surveys. S1COO indicated she puts Performance Improvement Plans (PIPs) into place after problems are identified.
In an interview on 03/12/2025 at 2:20PM, S2DON indicated she was responsible for ensuring laboratory orders are carried out. S2DON indicated she could not offer any explanation as to why a valproic acid level was not drawn on Resident #1.
In an interview on 03/12/2025 at 6:25pm, S6Chief Executive Officer (CEO) indicated he did not feel that the above deficient practice was an Immediate Jeopardy situation and would review the above mentioned findings.
S6CEO did not provide any additional communication or documentation to dispute the above mentioned findings.
A Plan of Removal was accepted on 03/13/2025 at 4:30PM, which included the following actions to correct the deficient practice:
A daily audit began starting on March 12th, 2025 and will continue for 1 month. After 30 days, the facility will move to weekly reviews that will happen as part of the high-risk meeting. The audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
Education will include the physician and their extenders, clinical managers, and facility nurses. A daily review will be completed for a month starting on 03/12/2024 by S2DON or her designee to ensure nothing is missed or not followed-up o timely. Nurses will receive this in-service prior to their next scheduled shift.
Education started immediately on 03/12/2025 at 8:00PM.
Starting on 03/12/2025 daily monitoring will begin of any lab orders, old or new. Making sure the order has been accurately and successfully carried out and that the results have been communicated to the medical doctor or nurse practitioner office.
The Director of Nursing or her designee will review lab orders in point click care (the facility's charting program), lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
Starting on 03/12/2025 daily review of labs began and will continue for one month after such time this will be reviewed weekly in the high-risk meeting.
Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
Lab orders will be added as one of the agenda items to be discussed during morning stand up meeting.
The facility asserted the likelihood for serious harm to any of its residents no longer existed on 03/12/2025 at 8:05PM.
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility's administrative staff failed to use its resources efficiently and effectiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility's administrative staff failed to use its resources efficiently and effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents by failing to oversee the effective implementation of physician laboratory orders for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for pharmaceutical services.
This lack of administrative oversite resulted in an Immediate Jeopardy situation on 02/04/2025 when Resident #1's valproic acid level (a blood test to measure the amount of valproic acid in the blood) was not drawn after being ordered by Resident #1's nurse practitioner on 01/29/2025. On 02/17/2025, Resident #1 was observed by the facility to be lethargic and was transferred to the hospital. Resident #1 was hospitalized from [DATE] through 02/19/2025 with a diagnosis of valproic acid toxicity (an excessive accumulation of valproic acid in the body which can lead to coma or death).
S1Chief Operating Officer (COO) and S2Director of Nursing were notified of the Immediate Jeopardy on 03/12/20205 at 6:50PM.
The Immediate Jeopardy was removed on 03/13/2025 at 4:30PM, after it was verified through observations, interviews, and record reviews, the provider implemented an acceptable Plan of Removal prior to the survey exit.
This deficient practice had the likelihood to affect all residents with medications requiring lab orders.
Findings:
Cross reference F770.
Review of Resident #1's medical records revealed Resident #1's nurse practitioner wrote an order dated 01/29/2025, to obtain a valproic acid level.
There was no documented evidence, and the facility was unable to present any documented evidence Resident #1's laboratory services was carried out as ordered prior to Resident #1's 02/17/2025's hospitalization.
In an interview on 03/11/2025 at 5:02PM, S2DON indicated after the physician or nurse practitioner places an order for a lab on the lab form, she gives the orders to the floor nurse to enter into the computer. S2DON further indicated once the orders were noted in a resident's record she would file the form, and routine labs were to be drawn on Tuesdays and Thursdays.
In an interview on 03/12/2025 at 2:09PM, S1Chief Operating Officer (COO) indicated she was currently in charge of quality since administration has been out on leave, and identifies problems from grievances, surveys, tracking and trending, and surveys. S1COO indicated she puts Performance Improvement Plans (PIPs) into place after problems are identified.
In an interview on 03/12/2025 at 2:20PM, S2DON indicated she was responsible for ensuring laboratory orders are carried out. S2DON indicated she could not offer any explanation as to why a valproic acid level was not drawn for Resident #1.
In an interview on 03/12/2025 at 6:25pm, S6Chief Executive Officer (CEO) indicated he did not feel that the above deficient practice was an Immediate Jeopardy situation and would review the above mentioned findings.
S6CEO did not provide any additional communication or documentation to dispute the above mentioned findings.
A Plan of Removal was accepted on 03/13/2025 at 4:30PM, which included the following actions to correct the deficient practice:
The facility planned to improved communication between nursing, pharmacy consult, and medical doctors and put more oversight by leadership of the laboratory process.
A daily audit began starting on March 12th, 2025 and will continue for 1 month. After 30 days, the facility will move to weekly reviews that will happen as part of the high-risk meeting. The audit will include ensuring all lab orders are recorded, drawn timely, and responded to timely.
S6Chief Executive Officer (CEO) or his designee will do a visual check to ensure the audits have occurred. He will do this once per week for one month.
S6CEO or his designee will attend one high risk meeting a month to verify lab orders are being reviewed.
Education will include the physician and extenders, clinical managers, and facility nurses. A daily review will be completed for a month starting on 3/12/2025 by S2DON or her designee to ensure nothing is missed or not followed up on timely.
S6CEO or his designee will verify education has been completed as stated through a visual review of the sign in sheets once per week for one month.
All staff nurses will be in serviced prior to their next shift on the lab order protocol.
S6CEO/his designee began providing administrative staff with the same education that is being provided to the nurses on March 13th 2025 around 2PM.
All administrative staff at the facility will be in-serviced by close of business on 3/14/2025.
Starting on 3/12/2025 daily monitoring began of any lab orders, old or new.
Verification that the order has been accurately and successfully been carried out and that the results have been communicated to the medical doctor or nurse practitioner office. These audits are to be done by S2DON or her designee.
S2DON or her designee will review lab orders in point click care (the facility's charting program), lab results in lab portal, and review notification to the medical doctor or nurse practitioner.
S6CEO or his designee will verify the audits weekly for 4 weeks and will participate in one high risk meeting per month to verify compliance.
Starting on 03/12/2025 daily review of labs began and will continue for one month after such time this will be reviewed weekly in the high-risk meeting.
Daily audits will continue with daily frequency until expectations are met. Nurses will be re-educated or counseled when and if there is a deviation from the system.
Lab orders will be added as an agenda item in the daily, weekday, stand-up meeting.
S6CEO or his designee will attend one stand up meeting per week for 60 days to ensure the agenda remains unchanged.
The facility asserted the likelihood for serious harm to any of its residents no longer existed on 03/12/2025 at 8:05PM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure
1.) maintenance services placed an outlet cover over a wall socket in a resident's room (Resident #1); and,
2.) housekeeping servi...
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Based on observations and interviews, the facility failed to ensure
1.) maintenance services placed an outlet cover over a wall socket in a resident's room (Resident #1); and,
2.) housekeeping services cleaned an unknown brown substance off of a resident's floor (Resident #1).
This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for environment.
Findings:
Observation of Resident #1's room on 03/10/2025 at 6:42AM revealed the outlet cover over a wall socket near the foot of Resident #1's bed did not have a wall covering. Observation further revealed an unknown brown substance about an inch long was seen on the side of Resident #1's bed on the floor.
Observation on 03/12/2025 at 9:40AM of Resident #1's room revealed the outlet cover over a wall socket near the foot of Resident #1's bed did not have a wall covering. Observation further revealed an unknown brown substance about an inch long was seen on the side of Resident #1's bed on the floor.
In an interview on 03/12/2025 at 11:50AM, S1Chief Operation Officer (COO) confirmed the wall socket in Resident #1's lacked a cover plate and state it should have one. S1COO also confirmed the presence of an unknown brown substance on Resident #1's floor and indicated it should not be there.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record reviews, the facility failed to provide incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigat...
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Based on observation, interviews, and record reviews, the facility failed to provide incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for activities of daily living (ADLs).
Findings:
Review of Resident #1's Minimum Data Set with an assessment reference date of 01/24/2025 revealed, in part, Resident #1 required substantial/maximal assistance for toileting and personal hygiene.
Review of Resident #1's Care Plan revealed, in part, Resident #1 was incontinent of bowel and bladder. Further review revealed an intervention included to check Resident #1 every 2 hours as required for incontinence.
Observation on 03/10/2025 at 6:32AM revealed S4Certified Nursing Assistant (CNA) and S5CNA pulled back the sheets to provide incontinence care to Resident #1. Resident #1 had a bowel movement leaking from the adult brief onto her abdomen, incontinent pad, and bed sheets. The bowel movement was wet in the center and dry around the edges.
In an interview on 03/10/2025 at 6:40, S4CNA indicated the last time she checked on Resident #1 and changed Resident #1 was around 3AM.
In an interview on 03/10/2025 at 10:25AM, S2Director of Nursing indicated Resident #1 should be checked for incontinence every 2 hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure staff utilized the correct personal protective equipment (PPE) when providing care to a resident on enhanced barrie...
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Based on observations, interviews, and record reviews, the facility failed to ensure staff utilized the correct personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP) for 1 (Resident #10) of 4 (Resident #1, Resident #2, Resident #3, Resident #10) residents observed during incontinence care.
Findings:
Review of the facility's undated Enhanced Barrier Precautions Policy and Procedure revealed, in part, gowns and gloves should be worn when emptying a urinary catheter.
Observation on 03/10/2025 at 5:18AM revealed an EBP sign on the outside of Resident #10's door. Observation further revealed S5Certified Nursing Assistant (CNA) entered Resident #10's room without a gown and proceeded to empty Resident #10's urinary catheter into a graduated cylinder.
In an interview on 03/10/2025 at 5:23AM, S5CNA indicated she did not use a gown when emptying urinary catheters and further indicated she did not know that she needed to.
In an interview on 03/10/2025 at 10:25AM, S2Director of Nursing (DON) indicated gowns should be worn when emptying urinary catheters of residents who are on EBP.
In an interview on 03/10/2025 at 10:48AM, S7Infection Preventionist confirmed gowns should be worn when emptying urinary catheters of residents who are on EBP.
Jan 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to maintain a resident's right to make choices regarding smoking for 1 (Resident #32) of 3 (Resident #26, Resident #32, Resid...
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Based on observations, interviews, and record reviews, the facility failed to maintain a resident's right to make choices regarding smoking for 1 (Resident #32) of 3 (Resident #26, Resident #32, Resident #45) sampled residents reviewed for smoking.
Findings:
Review of the facility's undated Resident Rights policy and procedure revealed, in part, residents should be encouraged to exercise their rights as a resident and citizen, and be treated courteously, fairly, and with the fullest measure of dignity. Further review revealed residents had the right to use tobacco in accordance with applicable policies, rules, and laws.
Review of the facility's undated Smoking policy and procedure, revealed, in part, residents were allowed to smoke only in the designated smoking areas located outside the building. Further review revealed no documented evidence of a set time for smoking hours.
There was no documented evidence, and the facility did not present any documented evidence the facility and residents had any agreed upon facility rules restricting a resident's right to smoke.
Review of the facility's list of smokers revealed, in part, Resident #32 was identified as a safe smoker.
Review of Resident #32's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2025 revealed, in part, Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #32 was cognitively intact.
In an interview on 01/27/2025 at 10:37AM, Resident #32 indicated the staff member who worked at the front desk would not let him go outside to smoke after 7:00PM.
In an interview on 01/29/2025 at 10:29AM, Resident #32 indicated the facility's smoking times were only from 7:00AM to 7:00PM, and residents were not allowed to go outside to smoke after 7:00PM until 7:00AM. Resident #32 further indicated he wanted to go outside to smoke between 7:00PM and 7:00AM.
In an interview on 01/29/2025 at 10:30AM., S6SmokingAide indicated residents were only allowed to smoke from 7:00AM to 7:00PMbecause that was the time frame the facility's Smoking Aide worked. S6SmokingAide further indicated even residents identified as safe smokers were only allowed to smoke from 7:00AM to 7:00PM.
In an interview on 01/29/2025 at 10:35AM, S7Receptionist indicated the residents were only allowed to smoke from 7:00AM to 7:00PM, and a security guard sat at the back door of the facility to ensure no resident was able to go outside to smoke after 7:00PM.
In an interview on 01/30/2025 at 3:40PM, S8Certified Nursing Assistant (CNA)/Receptionist indicated residents were only allowed to go outside to smoke from 7:00AM to 7:00PM. S8CNA/Receptionist further indicated that she did not let residents go outside to smoke after 7:00PM and diverted the residents away from the door to the smoking area, even if the residents were identified as safe smokers.
In an interview on 01/29/2025 at 3:09PM, S2Director of Nursing indicated the facility's smoking hours were only from 7:00AM to 7:00PM.
In an interview on 01/29/2025 at 3:13PM, S1Administrator indicated the facility's smoking times were from 7:00AM to 7:00PM. S1Administrator acknowledged the facility's security guard/staff should not be stopping residents from going outside to smoke after 7:00PM and before 7:00AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's code status documented in the resident's medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's code status documented in the resident's medical record was consistent with the resident's wishes for 1 (Resident #81) of 25 (Resident #1, Resident #3, Resident #4, Resident #8, Resident #11, Resident #12, Resident #15, Resident #24, Resident #26, Resident #31, Resident #32, Resident #33, Resident #38, Resident #45, Resident #51, Resident #55, Resident #56, Resident #59, Resident #61, Resident #70, Resident #73, Resident #75, Resident #76, Resident #78, Resident #81) sampled residents included in the initial pool.
Findings:
Review of Resident #81's chart/medical record revealed a notification signed and dated on [DATE] which indicated Resident #81's wished to be a Full Code (which indicated in the event she no pulse or no breath, medical interventions would take place).
Review of Resident #81's Electronic Medical Record (EMR) revealed, in part, Resident #81's code status was Do Not Resuscitate ([DNR] code status that instructed a healthcare provider not to perform cardiopulmonary resuscitation ([CPR] an emergency procedure that combines chest compressions and rescue breathing to keep blood circulating) and if a resident's heart stopped beating or a resident stopped breathing).
Review of Resident #81's [DATE] physician's orders revealed, in part, an order dated [DATE] which indicated Resident #81's code status was DNR.
Review of Resident #81's care plan, created on [DATE] revealed, in part, Resident #81's code status was DNR. Further review revealed Resident #81's advance directive would be followed according to the resident's wishes.
In an interview on [DATE] at 9:49AM, S11Licensed Practical Nurse (LPN) indicated she would use a resident's chart/medical record to verify their code status in the event of an emergency. S11LPN confirmed per Resident #81's chart/medical record, Resident #81's code status was Full Code, and she would perform CPR on her in the event of an emergency. S11LPN further acknowledged Resident #81's EMR indicated Resident #81's code status was DNR. S11LPN further indicated there should not have been a discrepancy in Resident #81's code status.
In an interview on [DATE] at 9:54AM, S2Director of Nursing (DON) indicated the facility's staff could use both the resident's chart/medical record and the resident's EMR to verify a resident's code status. S2DON further confirmed Resident #81's code status in her chart/medical record was Full Code as of [DATE], but a physician's order for Resident #81 to have a DNR code status was entered into Resident #81's EMR on [DATE]. S2DON further indicated there should not be a discrepancy in Resident #81's code status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form Centers for Medicare and Medicaid Services (CMS)-10055 and/or the Notice of Medicare Non-Coverage (NOMNC) Form (CMS-10123) notices were given, explained, and/or signed by residents prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 3 (Resident #62, Resident #68, Resident #234) of 3 (Resident #62, Resident #68, Resident #234) sampled residents reviewed for termination of Medicare Part A services.
Findings:
Resident #62
Review of Resident #62's medical record revealed, in part, Resident #62 was admitted to the facility on [DATE].
Review of Resident #62's Skilled Nursing Facility Beneficiary Protection Notification Review, Form CMS-20052, completed by the facility, revealed, in part, Resident #62's last day of Medicare Part A Services was on 07/29/2024.
Review of Resident #62's NOMNC Form CMS-10123 revealed, in part, there was no documented evidence, and the facility was unable to present any documented evidence, Resident #62 received a copy, was explained, and/or signed Form CMS-10123 prior to Medicare Part A services being terminated by the facility on 07/29/2024.
In an interview on 01/28/2025 at 1:00PM, S1Administrator confirmed the facility could not provide any documented evidence NOMNC Form CMS-10123 was explained to and signed by Resident #62 or Resident #62's responsible party (RP) and should have been. S1Administrator further indicated SNFABN Form CMS-10055 was signed by Resident #62's RP inadvertently without the facility explaining the SNFABN Form CMS-10055.
Resident #68
Review of Resident #68's medical record revealed, in part, Resident #68 was admitted to the facility on [DATE].
Review of Resident #68's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024 revealed, in part, Resident #68 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated Resident #68 had severe cognitive impairment.
Review of Resident #68's Skilled Nursing Facility Beneficiary Protection Notification Review, Form CMS-20052, completed by the facility, revealed, in part, Resident #68's last day of Medicare Part A Services was on 08/07/2024.
Review of Resident #68's NOMNC Form CMS-10123 revealed, in part, there was no documented evidence, and the facility was unable to present any documented evidence, Resident #68 received a copy, was explained, and/or signed Form CMS-10123 prior to Medicare Part A services being terminated by the facility on 08/07/2024.
In an interview on 01/28/2025 at 1:00PM, S1Administrator confirmed the facility could not provide any documented evidence NOMNC Form CMS-10123 was explained to and signed by Resident #68 or Resident #68's responsible party (RP) and should have been. S1Administrator further indicated SNFABN Form CMS-10055 was signed by Resident #68 inadvertently without the facility explaining the SNFABN Form CMS-10055.
Resident #234
Review of Resident #234's medical record revealed, in part, Resident #234 was admitted to the facility on [DATE]. Further review revealed Resident #234 was discharged home on [DATE].
Review of Resident #234's Skilled Nursing Facility Beneficiary Protection Notification Review, Form CMS-20052, completed by the facility, revealed, in part, Resident #234's last day of Medicare Part A Services was on 12/09/2024.
Review of Resident #234's NOMNC Form CMS-10123 revealed, in part, there was no documented evidence, and the facility was unable to present any documented evidence, Resident #234 received a copy, was explained, and/or signed the CMS-10123 form prior to Medicare Part A services being terminated by the facility on 12/09/2024.
In an interview on 01/28/2025 at 1:00PM, S1Administrator confirmed the facility could not provide any documented evidence the NOMNC Form CMS-10123 was acknowledged and signed by Resident #234 or Resident #234's responsible party (RP) and should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to conduct an accurate comprehensive assessment for 2 (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to conduct an accurate comprehensive assessment for 2 (Resident #61, Resident #75) of 2 (Resident #61, Resident #75) sampled residents reviewed for comprehensive dental status assessment.
Findings:
Resident #61
Review of Resident #61's medical record revealed, in part, Resident #61 was admitted to the facility on [DATE].
Review of Resident #61's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed, in part, A Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Further review revealed Resident #61 was assessed to have no oral and dental issues identified.
Observation on 01/27/2025 at 11:12AM revealed Resident #61 had several upper and lower teeth missing.
In an interview on 01/27/2025 at 11:15AM, Resident #61 indicated he was missing teeth when he was admitted to the facility.
In an interview on 01/30/2025 at 1:30PM, S1Administrator could offer no explanation as to why the above mentioned MDS assessment was not accurate for Resident #61's dental status.
Resident #75
Review of Resident #75's medical record revealed, in part, Resident #75 was admitted to the facility on [DATE].
Review of Resident #75's admission MDS with an ARD of 10/16/2024 revealed, in part, A BIMS score of 15, which indicated cognition was intact. Further review revealed Resident #75 was assessed to have no oral and dental issues identified.
Observation on 01/27/2025 at 11:54AM revealed Resident #75 had several upper and lower teeth missing.
In an interview on 01/27/2025 at 11:56AM, Resident #75 indicated he was missing teeth when he was admitted to the facility.
In an interview on 01/30/2025 at 10:53AM, S13Licensed Practical Nurse (LPN) indicated Resident #75 was missing several upper and lower teeth when he was admitted to the facility in October 2024.
In an interview on 01/30/2025 at 10:55AM, S12LPN confirmed Resident #75 was missing several upper and lower teeth when he was admitted to the facility in October 2024.
In an interview on 01/30/2025 at 1:30PM, S1Administrator could offer no explanation as to why the above mentioned MDS assessment was not accurate for Resident #75's dental status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide documentation of a resident's Level II Pre-admission Scree...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide documentation of a resident's Level II Pre-admission Screening and Resident Review (PASARR) for 1 (Resident #8) of 3 (Resident #8, Resident #59, Resident #70) sampled residents reviewed for PASARR.
Findings:
Review of Resident #8's medical record revealed, in part, Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Schizophrenia, Bipolar Disorder and Unspecified Dementia on 02/15/2022.
Review of Resident #8's Form 142 revealed Resident #8 was approved by the Office of Behavioral Health Level II Appointing Authority for admission for the time period of 11/08/2024 through 11/07/2025.
There was no documented evidence and the facility was unable to present any documented evidence, that the facility had received, reviewed and/or maintained Resident #8's Level II PASARR which was completed by the Office of Behavioral Health.
In an interview on 01/30/2025 at 1:45PM, S3SocialServices acknowledged Resident #8's Level II PASSAR documentation was not maintained in her medical and it should have been.
In an interview on 01/30/2025 at 2:35PM, S1Administrator acknowledged Resident #8's Level II PASSAR documentation was not maintained in her medical record and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record reviews, the facility failed to ensure safe smoking interventions were carried out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record reviews, the facility failed to ensure safe smoking interventions were carried out for a resident identified by the facility as being an unsafe smoker for 1 (Resident #45) of 3 (Resident #26, Resident #32, Resident #45) sampled residents reviewed for safe smoking.
Findings:
Review of the facility's Unsafe Smoker List revealed, in part, Resident #45 was listed as being an unsafe smoker.
Review of Resident #45's medical record revealed, in part, Resident #45 was admitted to the facility on [DATE] with diagnoses, in part, of vascular dementia, tremors, and epilepsy.
Review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #45 had a Brief Interview for Mental Status (BIMS) score of 03 which revealed Resident #45 had severe cognitive impairment.
Review of Resident #45's Care Plan with a start date of 12/04/2025 and a review date of 04/01/2025 revealed, in part, a care plan for unsafe smoking with interventions which included Resident #45 required supervision while smoking and Resident #45 would obtain smoking supplies from the smoke aide.
Observation on 01/29/2025 at 12:44PM revealed S6Smoking Aide was sitting down approximately 10 to 15 feet away from Resident #45 and Resident #45's back was turned toward S6Smoking Aide.
Observation on 01/29/2025 at 12:45PM revealed Resident #45 was given a cigarette to smoke by Resident #34 and Resident #15 lit Resident #45's cigarette with a lighter. Further observation revealed Resident #45 was facing away from S6Smoking Aide with the lit cigarette.
In an interview on 01/29/2025 at 12:46PM, S6Smoking Aide confirmed Resident #45 was an unsafe smoker. S6Smoking Aide further indicated he did not witness how Resident #45 obtained a lit cigarette.
In an interview on 01/30/2025 at 9:40AM, S10Certified Nursing Assistant (CNA) confirmed Resident #45 was an unsafe smoker. S10CNA further indicated Resident #45 must be directly visualized while smoking.
In an interview on 01/30/2025 at 2:00PM, S1Administrator indicated the smoking attendant on duty should be able to visualize unsafe smokers smoking to ensure they were not exhibiting any unsafe behaviors. S1Administrator further indicated unsafe smokers should not be allowed to obtain smoking material from other residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interview and record reviews, the facility failed to ensure a resident's psychotropic medication was not ordered on an as needed basis for greater than 14 days for 1 (Resident #55) of 5 (Resi...
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Based on interview and record reviews, the facility failed to ensure a resident's psychotropic medication was not ordered on an as needed basis for greater than 14 days for 1 (Resident #55) of 5 (Resident #1, Resident #15, Resident #33, Resident #55, Resident #70) sampled residents reviewed for unnecessary medications.
Findings:
Review of Resident #55's January 2025 physician's orders revealed, in part, an order dated 09/28/2024 for Resident #55 to be administered 1 tablet of Lorazepam (a psychotropic medication used to treat anxiety) 0.5 milligrams (mg) every eight hours as needed.
There was no documented evidence, and the provider did not present any documented evidence, Resident #55's physician gave a clinical rational for continuation, or provided a duration of Resident #55's order dated 09/28/2024 to administer Resident #55 1 tablet of Lorazepam 0.5 mg every eight hours as needed.
In an interview on 01/30/2025 at 1:00PM, S2Director of Nursing indicated the facility should have clarified a duration and clarified the physician's rational for the continuation of Resident #55's order for 1 tablet of Lorazepam 0.5 mg every eight hours as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a physician was notified laboratory tests were not complete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure a physician was notified laboratory tests were not completed as ordered for 1 (Resident #55) of 1 (Resident #55) sampled resident reviewed for laboratory services.
Findings:
Review of Resident #55's pharmaceutical consultant report dated 12/10/2024 revealed, in part, a recommendation for a Complete Blood Count ([CBC] a commonly ordered blood test that measured several blood components to evaluate a person's overall health and detect a wide range of disorders) to be completed on Resident #55 every 6 months.
Review of Resident #55's January 2025 physician's orders revealed, in part, an order dated 01/03/2025 to complete a CBC for Resident #55 every 6 months beginning 01/07/2025.
Review of Resident #55's chart/medical record and Electronic Medical Record (EMR) revealed no documented evidence, and the facility did not present any documented evidence, a CBC was completed in January 2025 as ordered for Resident #55.
Review of Resident #55's laboratory results dated [DATE] revealed, in part, Resident #55's CBC was not completed due to the laboratory being unable to obtain a blood specimen. Further review revealed no documented evidence Resident #55's CBC was completed.
Review of Resident #55's laboratory results dated [DATE] revealed, in part, Resident #55's CBC was not completed due to the laboratory being unable to obtain a blood specimen. Further review revealed no documented evidence Resident #55's CBC was completed.
There was no documented evidence, and the facility did not present any documented evidence, Resident #55's physician was notified a CBC was not completed for Resident #55 as ordered.
In an interview on 01/30/2025 at 1:00PM, S2Director of Nursing indicated if Resident #55's CBC was not completed, the physician should have been notified, and the facility should have documentation of the physician's notification.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents received dental services for 2 (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents received dental services for 2 (Resident #61, Resident #75) of 2 (Resident #61, Resident #75) sampled residents reviewed for dental services.
Findings:
Review of the facility's undated Dentist policy and procedure revealed, in part, the facility will ensure residents are seen by the dentist as needed. Further review revealed the facility will assure the dental needs of the resident were met.
Resident #61
Observation on 01/27/2025 at 11:12AM revealed Resident #61 was missing several upper and lower teeth.
In an interview on 01/27/2025 at 11:15AM, Resident #61 indicated he wanted to see the dentist. Resident #61 further indicated he did not have dentures, but wanted them.
Review of Resident #61's medical record revealed, in part, Resident #61 was admitted to the facility on [DATE]. Further review revealed there was no documented evidence, and the provider could not provide any documented evidence, Resident #61 was evaluated for dental services since admit.
Review of the facility's resident dental treatment schedule dated 12/05/2024 revealed, in part, Resident #61 was not listed on the schedule to receive dental services.
In an interview on 01/28/2025 at 1:00PM, S3Social Services confirmed Resident #61 had not been evaluated by dental services and could not explain why.
In an interview on 01/30/2025 at 1:30PM, S1Administrator could not provide a reason Resident #61 was not evaluated for dental services since admit.
Resident #75
Observation on 01/27/2025 at 11:54 AM revealed Resident #75 was missing several upper and lower teeth.
In an interview on 01/27/2025 at 11:56AM, Resident #75 indicated he was missing teeth when he was admitted to the facility. Resident #75 further indicated he had not seen a dentist since arriving at the facility and would like to. Resident #75 further indicated he did not have dentures, but wants them.
Review of Resident #75's medical record revealed, in part, Resident #75 was admitted to the facility on [DATE]. Further review revealed there was no documented evidence, and the provider could not provide any documented evidence, Resident #75 was evaluated for dental services since admit.
Review of the facility's resident dental treatment schedule dated 12/05/2024 revealed, in part, Resident #75 was not listed on the schedule for dental services.
In an interview on 01/28/2025 at 1:00PM, S3Social Services confirmed Resident #75 had not been evaluated by dental services since admission and could not explain why.
In an interview on 01/30/2025 at 1:30PM, S1Administrator could not provide a reason Resident #75 was not evaluated for dental services since admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure the facility's dumpster was maintained in a sanitary manner.
Findings:
Observation on 01/28/2025 at 10:35AM revealed the facility's ...
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Based on observations and interviews, the facility failed to ensure the facility's dumpster was maintained in a sanitary manner.
Findings:
Observation on 01/28/2025 at 10:35AM revealed the facility's dumpster was missing a lid and open to air. Further observation revealed loose trash was on the ground around the dumpster.
Observation on 01/28/2025 at 12:40PM revealed the facility's dumpster was missing a lid and open to air. Further observation revealed loose trash was on the ground around the dumpster.
In an interview on 01/28/2025 at 12:48PM, S4Dietary Manager indicated she was aware the dumpster's right side lid was missing, and it should not have been.
In an interview on 01/30/2025 at 11:46AM, S1Administrator indicated the facility's dumpster's right side lid was missing, and the trash should have been contained. S1Administrator further indicated the facility's dumpster and the area around the dumpster was not maintained in a sanitary manner, and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility assessment included active involvement from dire...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility assessment included active involvement from direct care staff, residents, and residents' representatives in its development.
Findings:
Review of the facility's facility assessment dated [DATE] revealed, in part, there was no documented evidence direct care staff including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) were involved in the development of the facility's facility assessment. Further review revealed there was no documented evidence a resident and/or a resident representative was involved in the development of the facility's facility assessment.
In an interview on 01/30/2025 at 1:00PM, S1Administrator confirmed the facility could not present any documented evidence direct care staff, residents, and residents' representatives were involved in the development of the facility's facility assessment dated [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to administer the pneumococcal (a bacterial infection caused by Streptococcus pneumonia bacterial) vaccine for 2 (Resident #43, Resident #81) ...
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Based on record review and interview, the facility failed to administer the pneumococcal (a bacterial infection caused by Streptococcus pneumonia bacterial) vaccine for 2 (Resident #43, Resident #81) of 5 (Resident #30, Resident #43, Resident #77, Resident #80, Resident #81) sampled residents investigated for pneumococcal vaccines.
Findings:
Resident #43
Review of Resident #43's vaccine consent form revealed Resident #43 signed a consent to receive the pneumococcal vaccine on 04/05/2024.
There was no documented evidence and the facility did not present documented evidence the pneumococcal vaccine was medically contraindicated for Resident #43 or that the pneumococcal vaccine was administered to Resident #43 as per the consent signed on 04/05/2024.
In an interview on 1/30/2025 at 9:16AM, S1Administrator confirmed the consent for the pneumococcal vaccine was signed for Resident #43, but there was no documented evidence the pneumococcal vaccine was medically contraindicated for Resident #43 or administered to Resident #43.
Resident #81
Review of Resident #81's vaccine consent form revealed Resident #81's responsible party signed a consent for Resident #81 to receive the pneumococcal vaccine on 10/11/2024.
There was no documented evidence and the facility did not present documented evidence the pneumococcal vaccine was medically contraindicated for Resident #81 or that the pneumococcal vaccine was administered to Resident #81 as per the consent signed on 10/11/2024.
In an interview on 01/30/2025 at 9:15AM, S1Administrator confirmed the consent for the pneumococcal vaccine was signed for Resident #81, but there was no documented evidence the pneumococcal vaccine was medically contraindicated for Resident #81 or administered to Resident #81.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine was administered for 1 (Resident #81) of 5 (Resident #30...
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Based on record review and interview, the facility failed to ensure the COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine was administered for 1 (Resident #81) of 5 (Resident #30, Resident #43, Resident #70, Resident #80, Resident #81) sampled residents investigated for COVID-19 vaccines.
Findings:
Review of Resident #81's vaccine consent revealed Resident #81's responsible party signed a consent for Resident #81 to receive the COVID-19 vaccine on 10/11/2024.
There was no documented evidence and the facility did not present documented evidence the COVID-19 vaccine was medically contraindicated for Resident #81 or that the COVID-19 vaccine was administered as per the consent signed on 10/11/2024.
In an interview on 01/30/2025 at 9:15AM, S1Administrator confirmed the consent for the COVID-19 vaccine was signed by Resident #81's responsible party, but there was no documented evidence the COVID-19 vaccine was medically contraindicated or administered to Resident #81.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to allow residents unrestricted visitation.
Findings:
Review of the facility's undated visitation policy and procedure, revealed, in part, r...
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Based on interviews and record review, the facility failed to allow residents unrestricted visitation.
Findings:
Review of the facility's undated visitation policy and procedure, revealed, in part, residents and families are encouraged to have visitors between the hours of 8:00AM and 8:00PM. Further review revealed exceptions to these hours must be cleared by the Administrator and/or Director of Nursing.
There was no documented evidence, and the facility was unable to present any documented evidence, the limitations placed on the residents' right to visitation was based on a clinical or safety concern.
In an interview on 01/28/2025 at 10:10AM, Resident #37 indicated residents were not allowed to have visitors after 8:00PM.
In an interview on 01/29/2025 at 11:00AM, S7Receptionist indicated the facility's visiting hours were from 8:00AM to 8:00PM. S7Receptionist further indicated residents are not allowed visitors before 8:00AM or after 8:00PM.
In an interview on 01/29/2025 at 3:40PM, S8Certified Nursing Assistant (CNA)/Receptionist confirmed visitors were not allowed to enter the facility between the hours of 8:00PM and 8:00AM. S8CNA/Receptionist further indicated there were no exceptions to the visitor's policy.
In an interview on 01/30/2025 at 1:45PM, S1Administrator indicated residents should be allowed unrestricted visitation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on interview and record reviews, the facility failed to ensure:
1. A resident's dialysis access site was assessed and vital signs were obtained upon the resident's return from dialysis (Resident...
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Based on interview and record reviews, the facility failed to ensure:
1. A resident's dialysis access site was assessed and vital signs were obtained upon the resident's return from dialysis (Resident #32); and,
2. The facility communicated with a resident's dialysis center regarding the residents condition (Resident #32)
This deficient practice was identified for 1 (Resident #32) of 1 (Resident #32) sampled residents reviewed for dialysis.
Findings:
Review of Resident #32's January 2025 physician's orders revealed, in part, an order dated 12/11/2024 for Resident #32 to attend dialysis every Tuesday, Thursday, and Saturday, and to obtain post dialysis vital signs of blood pressure, pulse, respirations, and temperature.
Review of Resident #32's dialysis communication sheets revealed, in part:
-No documented evidence the facility communicated with the dialysis center on 12/03/2024;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 12/05/2024;
-No documented evidence the facility communicated with the dialysis center on 12/10/2024;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 12/12/2024;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 12/17/2024;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 12/28/2024;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 12/30/2024;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 01/02/2025;
-No documented evidence Resident #32's dialysis access site was assessed after he returned from dialysis on 01/07/2025;
-No documented evidence Resident #32's dialysis access site was assessed after he returned from dialysis on 01/09/2025;
-No documented evidence the facility communicated with the dialysis center on 01/14/2025;
-No documented evidence Resident #32's vital signs were obtained after he returned from dialysis on 01/16/2025;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 01/18/2025;
-No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 01/20/2025;
- No documented evidence Resident #32's dialysis access site was assessed after he returned from dialysis on 01/24/2025; and,
-No documented evidence Resident #32's vital signs were obtained after he returned from dialysis on 01/28/2025.
In an interview on 01/27/2025 at 10:30AM, Resident #32 indicated the facility's staff does not check his dialysis access site when he returned to the facility from the dialysis center.
In an interview on 01/28/2025 at 2:00PM, Resident #32 indicated he had returned from dialysis around 12:00PM today. Resident #32 further indicated no staff member had taken his vital signs since he returned to the facility.
In an interview on 01/28/2025 at 2:15PM, S11Licensed Practical Nurse (LPN) indicated she had not obtained Resident #32's vital signs when he returned to the facility from dialysis today (01/28/2025). S11LPN further indicated the vital signs documented at the bottom of the dialysis communication sheets were from when Resident #32 left to go to dialysis.
In an interview on 01/29/2025 at 3:09PM, S2Director of Nursing (DON) indicated it was the facility's process to use the dialysis communication sheets to communicate with a resident's dialysis center. S2DON further indicated staff should have been assessing Resident #32's dialysis access site and obtaining Resident #32's vital signs upon his return from dialysis, and documenting all of this information on the dialysis communication sheets.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observation, the facility failed to ensure:
1. Opened insulin pens were labeled with the date the pen wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observation, the facility failed to ensure:
1. Opened insulin pens were labeled with the date the pen was opened; and,
2. Expired insulin pens were not available for resident use.
This deficient practice was identified for 1 (Medication Cart a) of 2 (Medication Cart a, Medication Cart b) medication carts reviewed for the storage of medications.
Findings:
Observation of Medication Cart a on [DATE] at 12:44PM revealed:
-Resident #10's open Humulin R insulin pen (a medication used to lower blood sugar) had an opened date of [DATE];
-Resident #36's open Humulin R insulin pen had an opened date of [DATE];
-Resident #36's open Lantus insulin pen (a long acting medication used to lower blood sugar) had an opened date of [DATE];
-Resident #40's open Novolog insulin pen (a medication used to lower blood sugar) had an opened date of [DATE]; and,
-Resident #40's open Humulin 70/30 vial (a medication used to lower blood sugar) was not dated with an opened date.
In an interview on [DATE] at 12:46PM, S16Licensed Practical Nurse (LPN) confirmed Resident #40's Humulin 70/30 was opened and not dated. S16PN further indicated the facility's policy was that insulin should be discarded 30 days after it was opened and not available for resident use. S15LPN further confirmed the above mentioned medications were opened over 30 days ago.
In an interview on [DATE] at 11:28AM, S2Director of Nursing indicated the nurses should dispose of insulin 28 days after it was opened, and all insulin should be labeled with the date it was opened.
Dec 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review it was determined that the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure new individualized fall prevention interventions were implemented and/or reviewed for effectiveness to prevent future falls for 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed for falls.
Findings included:
Review of the facility's undated Fall Prevention Program policy and procedure revealed, in part, the facility will protect residents from injury from falls. Further review revealed, the Minimum Data Set (MDS) coordinator will update interventions on the resident's fall care plan with any new occurrence of falls.
Review of the facility's undated Post-Falls Protocol policy and procedure revealed, in part, the unit nurse will assess the resident from head to toe and document that assessment along with circumstances of the fall in the resident's chart. Further review revealed, one new fall intervention shall be implemented for the resident, documented in the nurse's notes, and the MDS nurse will add new interventions to the resident's fall risk care plan.
Resident #1
Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses of, in part, muscle weakness, Vascular Dementia, and cognitive communication deficit.
Review of Resident #1 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024 revealed, in part, Resident #1 had a brief interview for mental status (BIMS) score of 03, which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 used a manual wheelchair for ambulation and was dependent on staff for activities of daily living.
Review of the facility's Incident Log from 09/2024 through 12/2024 revealed, in part, Resident #1 had an un-witnessed fall with injury on 11/17/2024, an unwitnessed fall with no injury noted on 09/26/2024 and 10/26/2024, and a witnessed fall with no injury noted on 11/12/2024.
Review of Resident #1's Care Plan revealed, in part, Resident #1 was at risk for falls related to impaired mobility, cognitive impairment, and required extensive to total assistance with transfers.
Review of the facility's in-service training documents revealed, in part, there was no documented evidence, and the facility could not provide any documented evidence Resident #1's individualized post fall interventions were implemented and/or reviwed for effectiveness after each fall.
In an interview on 12/05/2024 at 3:00PM, S2Director of Nursing (DON) indicated individualized post fall interventions should be documented after each fall. S2DON further indicted the facility could not provide any documented evidence Resident #1's individualized post fall interventions were implemented.
In an interview on 12/06/2024 at 10:10AM, S4Licensed Practical Nurse (LPN) indicated she was primarily assigned to Resident #1's floor. S4LPN further indicated she has not received individualized post fall intervention updates after each of Resident #1's falls.
In an interview on 12/06/2024 at 11:00AM, S1Administrator indicated the facility could not provide any documented evidence individualized post fall interventions were implemented and/or reviewed for effectiveness after Resident #1's 09/26/2024, 10/26/2024, and 11/12/2024 falls and should have been.
Resident #2
Review of Resident #2's medical record revealed, in part, Resident #2 was admitted to the facility on [DATE] with diagnoses of, in part, muscle weakness, Dementia, cognitive communication deficit, and a history of falling.
Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/2024 revealed, in part, Resident #2 had a brief interview for mental status (BIMS) score of 05, which indicated Resident #2 had severe cognitive impairment. Further review revealed Resident #2 used a manual wheelchair for ambulation.
Review of the facility's Incident Log from 09/2024 through 12/2024 revealed, in part, Resident #2 had a fall on 09/02/2024, a fall with injury on 10/15/2024, and witnessed falls without injury noted on 10/14/2024 and 11/27/2024.
Review of Resident #2's Care Plan revealed, in part, Resident #2 was at risk for falls related to psychoactive drug use, unaware of safety needs, and general weakness.
Review of the facility's in-service training documents revealed, in part, there was no documented evidence, and the facility could not provide any documented evidence Resident #2's individualized post fall interventions were implemented and/or reviwed for effectiveness after each fall.
In an interview on 12/06/2024 at 10:10AM, S4Licensed Practical Nurse (LPN) indicated she was primarily assigned to Resident #2's floor. S4LPN further indicated she has not received individualized post fall intervention updates after each of Resident #2's falls.
In an interview on 12/06/2024 at 11:00AM, S1Administrator indicated the facility could not provide any documented evidence individualized post fall interventions were implemented and/or reviewed for effectiveness for Resident #2's above mentioned falls and should have been.
Resident #3
Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with diagnoses of, in part, muscle weakness, Vascular Dementia, cognitive communication deficit.
Review of Resident #3 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/2024 revealed, in part, Resident #3 had a brief interview for mental status (BIMS) score of 15, which indicated Resident #3 was cognitively intact. Further review revealed Resident #3 used a manual wheelchair for ambulation.
Review of the facility's Incident Log from 09/2024 through 12/2024 revealed, in part, Resident #3 had an unwitnessed fall with injury on 11/17/2024 and unwitnessed falls without injury noted on 11/06/2024 and 11/28/2024.
Review of Resident #3's Care Plan revealed, in part, Resident #3 was at risk for falls related to being unaware of safety needs and vision/hearing impairments. Further review revealed Resident #3's care plan was not updated with new individualized interventions and/or had supervision increased to prevent future falls after the 11/17/2024 fall occurred.
Review of the facility's in-service training documents revealed, in part, there was no documented evidence, and the facility could not provide any documented evidence Resident #3's individualized post fall interventions were implemented and/or reviewed for effectiveness after each fall.
In an interview on 12/05/2024 at 1:10PM, S3Registered Nurse/Material Data Set (RN/MDS) indicated there was no documented evidence new post fall interventions were implemented for Resident #3 after the fall on 11/17/2024 and 11/06/2024 and should have been. S3RN/MDS further indicated Resident #3's care plan was not updated after the fall on 11/17/2024 and should have been.
In an interview on 12/06/2024 at 10:30AM, S5Licensed Practical Nurse (LPN) indicated she has not received individualized post fall intervention updates after each of Resident #3's falls.
In an interview on 12/06/2024 at 11:15AM, S6Certified Nursing Assistant (CNA) indicated she primarily worked on Resident #3's floor. S6CNA further indicated she has not received individualized post fall intervention updates after each of Resident #3's falls.
In an interview on 12/06/2024 at 12:00PM, S7Certified Nursing Assistant (CNA) indicated she primarily worked on Resident #3's floor. S7CNA further indicated she has not received individualized post fall intervention updates after each of Resident #3's falls.
In an interview on 12/06/2024 at 12:30PM, S1Administrator confirmed the facility could not provide any documented evidence new individualized post fall interventions were implemented and/or reviewed for effectiveness after Resident #3's 11/06/2024 and 11/17/2024 falls and should have been.
Nov 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and policy review the facility failed to maintain a sanitary environment for 2 (Resident #1 and Resident #2) of 3 residents reviewed for a sanitary environment.
Find...
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Based on observations, interviews, and policy review the facility failed to maintain a sanitary environment for 2 (Resident #1 and Resident #2) of 3 residents reviewed for a sanitary environment.
Findings included:
Review of facility's Bathroom Policy with revision date of April 2006, revealed, in part, bathrooms should be cleaned daily and daily cleaning included cleaning walls, wash basins, commodes and floors
Resident #1
Observation on 11/21/2023 at 12:36PM, revealed Resident #1's room had a brown smear noted on the wall above the trash can.
Observation on 11/21/2024 at 4:20PM, revealed Resident #1's room had a brown smear noted on the wall above the trash can.
In an interview on 11/21/2024 at 4:22PM, S1Administrator confirmed the brown substance on the wall above the trash can in Resident #1's room. S1Administrator further indicated the substance should not be on the wall above the trash can.
Resident #2
Observation on 11/25/2024 at 8:40AM, revealed an isolation cart at Resident #2's room door. Further observation revealed the isolation cart was visibly dirty with a brown substance in the pockets that hold the isolation supplies.
Observation on 11/25/2024 at 8:41AM, revealed Resident #2's room had a brown substance on the wall on the side of Resident #2's bed and visible dirt on the bedside table and floor. Further observation revealed a chicken bone was noted on the floor under the bedside table. Further observation revealed nutrition shakes on the floor next to two unlabeled and uncovered urinals. Further observation revealed the bedside table had an unopened breakfast plate, a cup with thick white, creamy, ointment remnants, and a water pitcher containing a brownish-colored film-like substance on the surface of the water, scattered hard brown crumbs and a sticky substance on the surface of the bedside table.
Observation on 11/25/2024 at 8:44AM, revealed Resident #2's bathroom had a brown substance smeared on the toilet seat and the toilet base. Further observation revealed a brown substance in the sink with an opened toothpaste tube on the counter with toothpaste spilled out of the tube onto the counter.
Observation on 11/25/2024 at 8:45AM, revealed housekeeping entered Resident #2's room with cleaning supplies in hand and a housekeeping cart in the doorway.
In an interview on 11/25/2024 at 8:46AM, S4Housekeeper, indicated housekeeping was responsible for sanitizing and cleaning Resident #2's room.
Observation on 11/25/2024 at 10:05AM, revealed one urinal on the bedside table, next to the food tray, touching a glass of apple juice. Further observation revealed Resident #2's nutrition shakes on the floor next to the bedside table. Further observation revealed the bedside table had an unopened breakfast plate, a cup with thick white, creamy, ointment remnants, and a water pitcher containing a brownish-colored film-like substance on the surface of the water, scattered hard brown crumbs and a sticky substance on the surface of the bedside table.
Observation on 11/25/2024 at 10:07AM, Resident #2's bathroom was visibly dirty, with brown substance smeared on the toilet seat and the toilet base. Further observation revealed a brown substance in the sink and opened toothpaste tube remained on the counter with toothpaste spilled out of the tube.
In an interview on 11/25/2024 at 10:35AM, S2Director of Nursing (DON) indicated Resident #2's urinal/ urinals should not have been left on the floor or placed on the bedside table next to Resident #2's food tray.
Observation on 11/25/2024 at 10:50AM, with S1ADM, S2DON, and S3Facilities Manager (FM) of Resident #2's room revealed one urinal on the bedside table, next to the food tray, touching a glass of apple juice. Further observation revealed Resident #2's nutrition shakes on the floor next to the bedside table. Further observation revealed the bedside table had an unopened breakfast plate, a cup with thick white, creamy, ointment remnants, and a water pitcher containing a brownish-colored film-like substance on the surface of the water, scattered hard brown crumbs and a sticky substance on the surface of the bedside table.
Observation on 11/25/2024 at 10:52AM revealed Resident #2's bathroom was visibly dirty, with brown substance smeared on the toilet seat and the toilet base. Further observation revealed a brown substance in the sink and opened toothpaste tube remained on the counter with toothpaste spilled out of the tube.
In an interview on 11/25/2024 at 10:51AM, S3FM indicated the condition of Resident #2's room and bathroom were dirty and unsanitary and should not have been.
In an interview on 11/25/2024 at 10:52 AM, S1ADM confirmed Resident #2's room and bathroom were dirty and unsanitary and should not have been.
In an interview on 11/25/2024 at 02:29 PM, Resident #2 indicated he did not like his room and bathroom dirty.
Jul 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect related to an injury of unknown origin for 1 (Resident #1) of ...
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Based on record reviews and interviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect related to an injury of unknown origin for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse/neglect.
Findings:
Review of the facility's Abuse Prevention policy dated 2002 revealed, in part, a full investigation will include any other witness who was in the area, and written and signed statements will be obtained. Further review revealed all records of the investigation will be kept on file.
Review of the facility's initiated incident report dated 07/09/2024 revealed, in part, Resident #1 had a dislocation of the left hip which was discovered on 07/09/2024 at 8:20 a.m. Further review revealed Resident #1 was unable to voice how the injury occurred, and no falls involving Resident #1 were reported. The above mentioned incident report also revealed on 07/08/2024, S7Certified Nursing Assistant (CNA) put resident #1 to bed at approximately 6:15 p.m. in a supine position with an abductor cushion (a cushion that prevents a person from moving following a hip replacement) in place between his legs. Approximately 20 minutes later the CNA heard Resident #1 calling for the nurse and he was found to have rolled over onto his right side without the abductor pillow in place. In the morning the CNA staff who provided care to Resident #1 discovered his hip to be swollen. An order to obtain an x-ray was received and x-ray results showed a dislocation to his left hip.
Review of the facility's Nursing Staff Schedule dated 07/08/2024 revealed 2 nurses and 4 CNA's were assigned to floor x on 07/08/2024.
Review of the facility's investigation documentation revealed, in part, only 2 statements from CNA staff were obtained and maintained in the facility's investigation records. Further review revealed 2 nurse notes dated 07/08/2024 were included in the investigation documentation.
Review of Resident #1's nurse note dated 07/08/2024 documented by S3LPN revealed, in part, S3LPN did not indicate if she observed or assessed Resident #1's left hip.
Review of Resident #1's nurse note dated 07/08/2024 documented by S4LPN revealed, in part, S4LPN did not indicate if she observed or assessed Resident #1's left hip.
Review of S9CNA's statement dated July 17th revealed, in part, S9CNA worked from 7:00 p.m. to 7:00 a.m. on the night of 07/08/2024. Further review revealed Resident #1 required the assistance of two staff members for incontinence care and a nurse assisted S9CNA with incontinence care several times during the shift. Further review revealed S9CNA documented during incontinence care, Resident #1's hip appeared to be swollen.
In an interview on 07/31/2024 at 10:18 a.m. S9CNA stated she provided care to Resident #1 on the night of 07/08/2024 from 7:00 p.m. to 7:00 a.m. S9CNA indicated S3Licensed Practical Nurse (LPN) assisted her multiple times during the shift to provide incontinence care and/or to turn Resident #1. S9CNA stated during care she and S3LPN observed Resident #1's left hip was swollen.
Review of the facility's investigation documentation revealed no evidence a statement was obtained from S3LPN regarding her knowledge of and/or observation of Resident #1's left hip on 07/08/2024.
In an interview on 07/31/2024 at 9:58 a.m. S7CNA stated she worked the day shift on 7/09/2024 and Resident #1 was in the bed when she arrived on shift. S7CNA was informed by S8CNA that she (S8CNA) brought Resident #1 his breakfast tray and she noticed his left hip was swollen. S7CNA indicated she observed Resident #1's left hip and it was found to be swollen, red, and positioned at an odd an angle, so she reported it to S4LPN.
In an interview on 07/31/2024 at 11:49 a.m. S8CNA confirmed she worked the day shift on floor x on 07/09/2024 and indicated when she brought Resident #1 his breakfast tray she noticed his left leg was bent strangely inward, swollen over the entire left hip area, and Resident #1's positioning wedge cushion was not in place. S8CNA indicated she was not questioned by administration or asked to provide a statement as to what she knew about Resident #1's injury of unknown origin
Review of the facility's investigation documentation revealed no documented evidence and the facility did not present any documented evidence that a statement was obtain from S8CNA regarding knowledge of and/or observation of Resident #1's left hip on the morning of 07/09/2024.
In an interview on 07/31/2024 at 1:05 p.m., S4LPN indicated she was responsible for Resident #1 on the night shift of 07/08/2024 and the morning shift on 07/09/2024. S4LPN further indicated she did observe Resident #1's left hip to be swollen during the night when she assisted S9CNA with incontinence care and turning. S4LPN indicated in her opinion Resident #1's left hip was only slightly swollen and felt it was nothing to be concerned with due to his history of surgical repair. S4LPN further indicated Resident #1 slept through the night and did not complain of pain. S4LPN indicated in the morning on 07/09/2024, S7CNA asked her to assess Resident #1's left hip. S4LPN indicated she found Resident #1's left hip had increased swelling and she notified Resident #1's physician. S4LPN was unable to confirm if she documented in Resident #1's record that Resident #1's left hip was slightly swollen on the night shift of 07/08/2024. S4LPN confirmed administrative staff did not ask her to provide a written statement of her observations of Resident #1's left hip during the night shift on 07/08/2024 or the morning shift on 07/09/2024 to see if she had any knowledge as to what happened to Resident #1.
In an interview on 07/31/2024 at 4:21 p.m. S2Director of Nursing (DON) confirmed she did not obtain statements from S8CNA, S10CNA, S3LPN, or S4LPN. S2DON stated she did not question or get a statement from S8CNA because she was not aware of her involvement. S2DON confirmed she did not ask S3LPN or S4LPN to provide a statement as to what they knew about Resident #1's injury of unkown origin. S2DON confirmed she was aware S4LPN had identified Resident #1's left hip was slightly swollen during the night shift on 07/08/2024. S2DON confirmed she could not provide any evidence S4LPN documented Resident #1's left hip was found to be slightly swollen during the night shift on 07/08/2024 in Resident #1's clinical record or in the facility's incident documentation of 07/09/2024's hip injury.
In an interview on 07/31/2024 at 5:13 pm S1Administrator indicated she did not interview and/or get statements from all of the nursing staff who worked on the floor x on 07/08/2024 and believed it was only necessary to get statements from Resident #1's direct care staff. S1Administrator indicated she was aware S4LPN had first observed Resident #1's left hip to be swollen during the night shift on 07/08/2024 and confirmed she did not obtain a statement as to what S4LPN knew about Resident #1's injury of unknown origin.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record reviews, and interviews the facility failed to ensure a resident's care plan:
1. Was revised to include a decline in a resident's activities of daily living [ADLs] (Resident #1); and,
...
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Based on record reviews, and interviews the facility failed to ensure a resident's care plan:
1. Was revised to include a decline in a resident's activities of daily living [ADLs] (Resident #1); and,
2. Was revised after a resident sustained a fall(s) (Resident #1).
This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
Review of Resident #1's Significant Change Minimum Data Set (MDS) with an ARD of 06/11/2024 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated severely impaired cognition. Further review revealed Resident #1 was dependent on staff for transfers and functional mobility, and had one fall which resulted in a major injury since his previous assessment.
Review of Resident #1's Incident Report dated 05/29/2024 revealed Resident #1 had a witness fall from his wheelchair in the dining/day room resulting in a left hip fracture.
Review of Resident #1's Incident Report dated 07/20/2024 revealed, in part, Resident #1 had an unwitnessed fall from his bed with no apparent injury.
Review of Resident #1's care plan revealed, in part, there was no documented evidence and the facility did not present any documented evidence Resident #1's care plan was revised to reflect the above mentioned falls and/or the related interventions to prevent future falls. Further review revealed Resident #1's care plan was not revised to reflect his decline in bed mobility and transfers related to his left hip fracture.
In an interview on 07/30/2024 at 3:27 p.m., S1Administrator reviewed Resident #1's fall care plan and confirmed Resident #1's care plan was not revised as required related to the above mentioned falls and ADL declines.
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 F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on record reviews, observation, and interviews, the facility failed failed to ensure staff was available at all times to provide care and services to meet the resident's needs by failing to ensu...
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Based on record reviews, observation, and interviews, the facility failed failed to ensure staff was available at all times to provide care and services to meet the resident's needs by failing to ensure staff was not sleeping while on duty.
This deficient practice was identified for 1 staff member S6Certified Nursing Assistant (CNA) observed for 1 of 3 days during the survey.
Findings:
Review of facility's Employee Code of Conduct revealed, in part, sleeping while on duty was a violation that would constitute cause for immediate termination.
Review of S6CNA's personnel record revealed, in part, S6CNA signed the Employee Code of Conduct on 07/08/2024 which indicated he understood and would abide by the rules of conduct while on or off duty on the facility premises.
Review of facility's Daily Nursing Staff Schedule dated 07/29/2024 revealed, in part, S6CNA was assigned to provide services to residents on the day shift from 7:00 a.m. to 7:00 p.m. on floor x. Further review revealed S6CNA was assigned to provide care and services to 7 residents during this time frame.
Observation on 07/29/2024 at 2:27 p.m. revealed S6CNA was sitting slouched over in a chair with his eyes closed in the hallway on floor x. S6CNA stayed asleep in this position while Administrative staff was asked to come to the unit to observe.
Observation on 07/29/2024 at 2:42 p.m. revealed S2Director of Nursing (DON) arrived to floor x and woke up S6CNA. Further observation revealed, S2DON stated to S6CNA, this is unacceptable and S6CNA then replied, I'm sorry.
In an interview on 07/29/2024 at 4:10 p.m., S6CNA indicated he was asleep in the chair in the hallway on floor x earlier today and should not have been.
In an interview on 07/31/2024 at 4:58 p.m., S1Administrator indicated that S6CNA was working on floor x from 7:00 a.m. through 7:00 p.m. on 07/29/2024 and confirmed S6CNA should not have been asleep while on duty.
Apr 2024
2 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0728
(Tag F0728)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure staff working as nurse aides met minimum sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure staff working as nurse aides met minimum state-approved competency and training requirements for 8 (S4Direct Service Worker [DSW], S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15Front Desk Receptionist [FDR]) of 13 (S3DSW, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S9DSW, S10DSW, S11DSW, S12DSW, S13Certified Nursing Assistant [CNA], S14CNA, and S15FDR) personnel files reviewed.
On [DATE], at approximately 7:17 a.m., an Immediate Jeopardy occurred when the facility allowed S4DSW, S11DSW, and S12DSW to work independently with residents as nurse aides without having met the minimum state-approved competency and training requirements. Review of the facility's CNA Break and Lunch Schedule Sheets revealed, in part on [DATE] through [DATE], S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15FDR were assigned to work independently as nurse aides to provide direct care to residents without having met the minimum state-approved competency and training requirements. The Immediate Jeopardy continued on [DATE] through [DATE] when the survey team observed, S4DSW, S6DSW, and S15FDR working as nurse aides independently throughout the facility without having met the minimum state-approved competency and training requirements.
S1Administrator was notified of the Immediate Jeopardy on [DATE] at 2:08 p.m.
The Immediate Jeopardy was removed on [DATE] at 4:12 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit.
This deficient practice had the likelihood to cause more than minimum harm to all 79 residents in the facility due to uncertified staff providing direct care independently for residents as nurse aides without having met the minimum state-approved competency and training requirements.
Findings:
Review of the facility's undated policy and procedure titled, Nursing Services, revealed in part, the facility was to assure that there was sufficient qualified nursing staff available at all times to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being.
Review of the facility's Certified Nursing Assistant Job Description with a revision date of 08/2013 revealed in part, the job qualification for a CNA included to have successfully completed the stated certification course.
Review of the facility's Staff List revealed, in part, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, and S11DSW were classified as CNAs in training. Review revealed, S12DSW was classified as a CNA supervisor in training. Further review revealed, in part, S15FDR was classified as a front desk receptionist.
S4DSW
Review of S4DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Further review revealed, there was no documented evidence and the facility did not present any documented evidence that S4DSW had a current CNA certification.
Review of the CNA registry database on [DATE] revealed, no data present for S4DSW.
Review of S4DSW's time card dated [DATE] through [DATE] revealed, S4DSW worked on [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], and [DATE]. Further review revealed, S16HumanResources approved S4DSW's above mentioned hours worked.
Review of the facility's CNA Break and Lunch Schedule Sheets from the time period of [DATE] through [DATE] revealed, S4DSW was assigned as a CNA on [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], and [DATE] to work independently on Floor A, Floor B, and Floor C to provide direct care to residents.
Observation on [DATE] at 11:16 a.m., S4DSW was present on Floor A working as a nurse aide.
Observation on [DATE] at 12:50 p.m., revealed S4DSW passing ice to residents on Floor A.
In an interview on [DATE] at 1:32 p.m., S4DSW stated she had been working at the facility for a little over a year. S4DSW confirmed she was hired with the job description of a CNA. S4DSW confirmed she worked as a CNA independently and did not require direct supervision when providing direct care to residents on Floor A, Floor B, and Floor C. S4DSW stated she completed a CNA certification course in [DATE], but had not taken the state approved certification test. S4DSW further confirmed she was performing CNA duties in the facility prior to being enrolled in the CNA course.
In an interview on [DATE] at 11:17 a.m., S20Licensed Practical Nurse (LPN) confirmed she was the day shift nurse on Floor A and she did not directly supervise the staff when they provided direct care to the residents.
S5DSW
Review of S5DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Further review revealed, there was no documented evidence and the facility did not present any documented evidence of S5DSW had a current CNA certification.
Review of the CNA registry database revealed on [DATE], no data present for S5DSW.
Review of S5DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S5DSW was assigned as a CNA to work independently on Floor C and Floor D to provide direct care to residents on [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE]. Further review revealed, S16HumanResources approved S5DSW's above mentioned hours worked.
S6DSW
Review of S6DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Review revealed, a signed Certified Nursing Assistant Job Description by S6DSW on [DATE]. Further review revealed, there was no documented evidence, and the facility did not present any documented evidence, of S6DSW had a current CNA certification.
Review of the CNA registry database on [DATE] revealed no data present for S6DSW.
Review of S6DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S6DSW was assigned as a CNA to work independently on Floor C to provide direct care to residents on [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], and [DATE] through [DATE]. Further review revealed, S16HumanResources approved S6DSW's above mentioned hours worked.
In an interview on [DATE] at 1:26 p.m., S6DSW stated she had been employed since [DATE] and she was hired with the job description of a CNA. S6DSW stated since her hire date she had worked independently as a CNA providing direct care to residents on Floor C and did not have direct supervision. S6DSW stated she completed a CNA certification course in [DATE]. S6DSW confirmed she was not currently scheduled for or in a CNA class and she was not scheduled for a CNA class. S6DSW further confirmed she had not taken the state-approved certification test and successfully passed.
In an interview on [DATE] at 10:55 a.m., S19LPN confirmed S6DSW was a full time nurse aide on Floor C. S19LPN further stated she did not directly supervise S6DSW when she provided direct care to residents.
S7DSW
Review of S7DSW's personnel file revealed a hire date of [DATE]. Further review of S7DSW's personnel file revealed there was no documented evidence, and the facility did not present any documented evidence, of a certificate of completion of a state-approved nursing aide training course.
Review of the CNA registry database on [DATE] revealed, S7DSW was certified from [DATE] through [DATE]. Further review revealed S7DSW's current status was not certified.
Review of S7DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S7DSW was assigned as a CNA to work independently on Floor A, Floor C, and Floor D to provide direct care to residents on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE]. Further review revealed, S16HumanResources approved S7DSW's above mentioned hours worked.
In a telephone interview on [DATE] at 1:44 p.m., S7DSW confirmed she was hired on [DATE] with the job description of a CNA and she currently worked as needed 3 to 4 days a week. S7DSW stated since her hire date, she had worked independently as a CNA providing direct care to residents on Floor A, Floor B, Floor C, and Floor D and did not have direct supervision. S7DSW stated she completed a CNA certification course in 2012. S7DSW confirmed she was not currently scheduled for or in a CNA class and her past certification had expired.
S8DSW
Review of S8DSW's personnel file revealed, in part, a hire date of [DATE]. Further review of S8DSW's personnel file revealed there was no documented evidence, and the facility did not present any documented evidence, of a certificate of completion from a state-approved nursing aide training course.
Review of the CNA registry database on [DATE] revealed no data present for S8DSW.
Review of S8DSW's time card dated [DATE] through [DATE] revealed, S8DSW worked on [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], and [DATE] through [DATE]. Further review revealed, S16HumanResources approved S8DSW's above mentioned hours worked.
Review of the facility's CNA Break and Lunch Schedule Sheets [DATE] through [DATE] revealed, S8DSW was assigned on [DATE], [DATE], and [DATE] to work independently on Floor A and Floor B to provide direct care to residents.
Observation on [DATE] at 11:55 a.m. revealed S8DSW on the hall way on Floor A working independently as a nurse aide.
In an interview on [DATE] at 1:23 p.m., S8DSW stated she had been employed since [DATE] and she was hired with the job description of a CNA. S8DSW stated since her hire date she had worked independently as a CNA providing direct care to residents on Floor C and did not have direct supervision. S8DSW confirmed she had never completed nor was she currently scheduled for or in a CNA certification course. S8DSW further stated she was not scheduled for nor had she ever taken the state-approved certification test and successfully passed.
S11DSW
Review of S11DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Further review revealed, there was no documented evidence, and the facility did not present any documented evidence, S11DSW had a current CNA certification.
Review of the CNA registry database on [DATE] revealed no data present for S11DSW.
Review of S11DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S11DSW was assigned as a CNA to work independently on Floor A, Floor B, and Floor D to provide direct care to residents on [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], and [DATE] through [DATE]. Further review revealed, S16HumanResources approved S11DSW's above mentioned hours worked.
S12DSW
Review of S12DSW's personnel file revealed, in part, a hire date of [DATE]. Review revealed a certified nursing assistant course certificate with a completion date of [DATE]. Review revealed, a signed Certified Nursing Assistant Job Description by S12DSW on [DATE]. Further review revealed, there was no documented evidence, and the facility did not present any documented evidence, S12DSW had a current CNA certification.
Review of the CNA registry database on [DATE] revealed no data present for S12DSW.
Review of S12DSW's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S12DSW was assigned as a CNA to work independently on Floor A to provide direct care to residents on [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], and [DATE]. Further review revealed, S16HumanResources approved S12DSW's above mentioned hours worked.
S15FDR
Review of S15FDR's personnel file revealed, in part, a hire date of [DATE]. Further review of the personnel file revealed there was no documented evidence and the facility did not present any documented evidence of a completion certificate of a state-approved nursing aide training course.
Review of the CNA registry database revealed no data present for S15Front Desk Receptionist.
Review of S15FDR's time card and the CNA Break and Lunch Schedule Sheets, dated [DATE] through [DATE] revealed, S15FDR was assigned as a CNA to work independently on Floor B, Floor C, and Floor D to provide direct care to residents on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], and [DATE]. Further review revealed, S16HumanResources approved S15FDR's above mentioned hours worked.
Observation on [DATE] at 11:11 a.m. revealed S15FDR working independently on Floor B as a nurse aide.
In an interview [DATE] at 11:13 a.m., S21LPN, confirmed she was the full time nurse on the Floor B and she did not directly supervise the nurse aides when they provided direct care to residents.
In an interview on [DATE] at 10:43 a.m. S16Human Resources Manager stated she was unaware the facility could not hire DSWs to provide direct care to residents. S16Human Resources confirmed the above mentioned staff were not certified and were working as nurse aides without having met the minimum state-approved competency and training requirements.
In an interview on [DATE] at 4:00 p.m., S2Director of Nursing (DON) stated she was unaware the above mentioned staff were not certified nursing assistants because she assumed the facility only hired certified staff. S2DON further stated all staff working on the floor should have a certification or license prior to providing direct care to residents.
In an interview on [DATE] at 10:50 a.m., S1Administator stated she was aware the above mentioned staff were working as nurse aides without having met the minimum state-approved competency and training requirements. S1Administrator further confirmed due to the above mentioned actions of the facility, all 79 residents had the likelihood of experiencing serious injury or harm from [DATE] through [DATE] while the above mentioned uncertified staff were providing direct care to residents without supervision without having met the minimum state-approved competency and training requirements.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to ensure staff wo...
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Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to ensure staff working as nurse aides met minimum state-approved competency and training requirements for 8 (S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15FDR) of 13 (S3DSW, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S9DSW, S10DSW, S11DSW, S12DSW, S13CNA, S14CNA, and S15FDR) personnel files reviewed.
This lack of administrative oversight resulted in an Immediate Jeopardy situation on 02/09/2024, at approximately 7:17 a.m., when the facility's administration allowed S4DSW, S11DSW, and S12DSW to work independently as nurse aides without having met the minimum state-approved competency and training requirements. Review of the facility's CNA Break and Lunch Schedule Sheets revealed, in part for the time period of 02/09/2024 through 03/30/2024 revealed, in part, S4DSW, S5DSW, S6DSW, S7DSW, S8DSW, S11DSW, S12DSW, and S15Front Desk Receptionist were assigned to work independently as nurse aides to provide direct care to residents without having met the minimum state-approved competency and training requirements. The Immediate Jeopardy continued on 04/01/2024 through 04/03/2024 when the survey team observed, S4DSW, S6DSW, and S15Front Desk Receptionist working as nurse aides independently with residents throughout the facility without having met the minimum state-approved competency and training requirements.
S1Administrator was notified of the Immediate Jeopardy on 04/03/2024 at 2:08 p.m.
The Immediate Jeopardy was removed on 04/04/2024 at 5:46 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit.
Findings:
Cross Reference F728.
Review of S5DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S5DSW was assigned as a CNA to work independently on Floor C and Floor D to provide direct care to residents on 02/12/2024 through 02/14/2024, 02/17/2024, 02/19/2024 through 02/22/2024, 02/27/2024, 03/01/2024 through 03/03/2024, 03/05/2024, 03/08/2024, 03/10/2024, 03/11/2024 through 03/13/2024, 03/16/2024 through 03/19/2024, 03/21/2024, 03/22/2024, 03/24/2024 through 03/27/2024, 03/30/2024 through 04/02/2024. Further review revealed, S16HumanResources approved S5DSW's above mentioned hours worked.
Review of S6DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S6DSW was assigned as a CNA to work independently on Floor C to provide direct care to residents on 02/09/2024 through 02/14/2024, 02/16/2024, 02/19/2024, 02/20/2024, 02/27/2024, 02/28/2024, 03/04/2024 through 03/06/2024, 03/09/2024 through 03/16/2024, 03/19/2024, 03/23/2024, 03/25/2024 through 03/29/2024, and 03/31/2024 through 04/02/2024. Further review revealed, S16HumanResources approved S6DSW's above mentioned hours worked.
Review of S7DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S7DSW was assigned as a CNA to work independently on Floor A, Floor C, and Floor D to provide direct care to residents on 02/24/2024, 02/25/2024, 03/10/2024, 03/12/2024, 03/15/2024, 03/19/2024, 03/20/2024, 03/28/2024 through 03/30/2024. Further review revealed, S16HumanResources approved S7DSW's above mentioned hours worked.
Review of S8DSW's time card dated 03/03/2024 through 04/03/2024 revealed, S8DSW worked on 03/07/2024, 03/08/2024, 03/11/2024 through 03/13/2024, 03/16/2024 through 03/18/2024, 03/21/2024, 03/22/2024, 03/25/2024 through 03/27/2024, and 03/30/2024 through 04/03/2024. Further review revealed, S16HumanResources approved S8DSW's above mentioned hours worked.
Review of S11DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S11DSW was assigned as a CNA to work independently on Floor A, Floor B, and Floor D to provide direct care to residents on 02/09/2024, 02/10/2024, 02/21/2024 through 02/27/2024, 03/02/2024, 03/05/2024 through 03/11/2024, 03/14/2024, 03/16/2024 through 03/19/2024, 03/22/2024, 03/24/2024, and 03/26/2024 through 03/31/2024. Further review revealed, S16HumanResources approved S11DSW's above mentioned hours worked.
Review of S12DSW's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S12DSW was assigned as a CNA to work independently on Floor A to provide direct care to residents on 02/09/2024, 02/10/2024, 02/13/2024 through 02/18/2024, 02/20/2024 through 02/23/2024, 02/26/2024 through 02/29/2024, 03/02/2024, 03/03/2024, 03/05/2024 through 03/10/2024, 03/12/2024 through 03/16/2024, 03/19/2024 through 03/23/2024, 03/26/2024 through 03/30/2024, and 04/02/2024. Further review revealed, S16HumanResources approved S12DSW's above mentioned hours worked.
Review of S15FDR's time card and the CNA Break and Lunch Schedule Sheets, dated 02/04/2024 through 04/03/2024 revealed, S15FDR was assigned as a CNA to work independently on Floor B, Floor C, and Floor D to provide direct care to residents on 02/13/2024, 02/15/2024, 02/17/2024, 02/18/2024, 02/20/2024, 02/22/2024, 02/27/2024, 02/29/2024, 03/02/2024 through 03/04/2024, 03/07/2024, 03/08/2024, 03/12/2024, 03/13/2024, 03/16/2024, 03/17/2024, 03/20/2024 through 03/22/2024, 03/25/2024 through 03/27/2024, 04/02/2023, and 04/03/2024. Further review revealed, S16HumanResources approved S15FDR's above mentioned hours worked.
In an interview on 04/03/2024 at 10:43 a.m. S16Human Resources Manager stated she was unaware the facility could not hire DSWs to provide direct care to residents. S16Human Resources confirmed the above mentioned staff were not certified and were working as nurse aides without having met the minimum state-approved competency and training requirements.
In an interview on 04/03/2024 at 4:00 p.m., S2Director of Nursing (DON) stated she was unaware that all staff were not certified nursing assistants because she assumed the facility only hired certified staff. S2DON further stated all staff working on the floor should have a certification or license prior to providing direct care to residents.
In an interview on 04/03/2024 at 10:50 a.m., S1Administator stated she was aware the above mentioned staff were working as nurse aides without having met the minimum state-approved competency and training requirements. S1Administrator further confirmed due actions of the facility, all 79 residents had the likelihood of experiencing serious injury or harm from 02/09/2024 through 04/03/2024 while the uncertified staff were providing direct care to residents without supervision without having met the minimum state-approved competency and training requirements.
In an interview on 04/03/2024 at 4:37 p.m., S17CCO stated he was unaware S1Administrator was allowing uncertified staff to work in the facility as nurse aides and provided direct care to residents without having met the minimum state-approved competency and training requirements. S17CCO further stated the staff should not have been allowed to work as nurse aides and provide direct care independently to residents. S17CCO stated S1Administrator, S2DON, and S16Human Resource Manager were educated on the requirements for compliance to ensure no unlicensed assistive personnel were allowed to provide direct care to residents by the S18COO.
Feb 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to develop policies and procedures to investigate injuries of unknown origin for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewe...
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Based on record review and interview the facility failed to develop policies and procedures to investigate injuries of unknown origin for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for abuse.
Findings:
Review of the facility's Resident Abuse, and Abuse Recognition, Reporting, and Investigation policies and procedures revealed no documented evidence and the facility presented no documented evidence of the facility having developed policies and procedures on how to identify, investigate, and reporting requirements for injuries of unknown origin.
In an interview on 02/08/2024 at 2:29 p.m., S1Administrator stated the facility did not have a policy and procedure on how to identify, investigate, and reporting requirements for injuries of unknown origin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to report a bruise with an unknown origin within 2 hours of the bruise having been identified for 1 (Resident #42) of 1 (Resident #42) sampled...
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Based on record review and interview, the facility failed to report a bruise with an unknown origin within 2 hours of the bruise having been identified for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for abuse.
Findings:
Review of Resident #42's Nurse's Notes dated 01/30/2024 revealed Resident #42 was noted to have a bruise under Resident #42's right breast. Further review revealed no documented assessment of the bruise nor any documented evidence of a potential cause for the bruise under Resident #42's right breast.
Review of Resident #42's Wound Care Notes dated 01/30/2024 revealed no documented evidence of an assessment of the bruise under Resident #42's right breast or potential cause of the bruise.
In an interview on 02/06/2024 at 1:54 p.m., S35Licensed Practical Nurse (LPN) stated on 01/30/2024 she noted a bruise under Resident #42's right breast which was approximately the size of a nickel and was purple in color. S35LPN further stated the staff prior to my shift had not reported any new skin conditions and/or bruising. S35LPN stated she reported Resident #42's bruise to S1Administrator. S35LPN further stated she was not aware of the cause of the bruise.
In an interview on 02/07/2024 at 10:45 a.m., S32LPN stated she had not noticed any bruising nor had any of the staff who reported bruising to Resident #42's right breast on her shifts prior to 01/30/2024.
In an interview on 02/07/2024 at 11:59 a.m., S36CNA stated she had gotten Resident #42 up for the day on 01/30/2024. S36CNA stated she did not observe any bruising on Resident #42.
In an interview on 02/08/2024 at 10:58 a.m., S8Wound Care Nurse stated she was not aware of a bruise under Resident #42's right breast and therefore did not assess under Resident #42's breast on 01/30/2024.
In an interview on 02/08/2024 at 11:17 a.m., S2Director of Nursing (DON) stated she assessed Resident #42 with S8Wound Care Nurse on 01/30/2024. S2DON stated she was not notified of the bruise under Resident #42's breast and due to Resident #42 being agitated we were not able to complete a full body audit nor were we able to assess under Resident #42's breast. S2DON further stated if she would have been made aware of the bruise under Resident #42's breast she would have assessed and investigated the cause of the bruise and reported to the administrator if the cause of the injury was unable to be determined.
In an interview on 02/08/2024 at 11:53 a.m., S1Administrator stated she was made aware of Resident #42's bruise to the breast from S35LPN. S1Administrator stated S2DON and S8Wound Care Nurse had assessed Resident #42 on 01/30/2024; however, Resident #42 was agitated and did not allow a full body audit at that time. S1Administrator further stated she did not ensure an assessment of the bruise under Resident #42's breast had been completed and therefore the facility had no documented evidence of the origin of Resident #42's bruise. S1Administrator stated due to lack of investigation and assessment of the bruise the facility did not report or identify if the bruise was a potential injury of unknown origin and did not report the bruise to the state as an injury of unknown origin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to have evidence that injuries of unknown origin were thoroughly investigated for 1 (Resident #42) of 1 (Resident #42) sampled residents review...
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Based on record review and interview the facility failed to have evidence that injuries of unknown origin were thoroughly investigated for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for abuse.
Findings:
Review of Resident #42's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status (BIMS) score of 0 (score of 0-7 indicated the resident had a severe cognitive impairment). Further review revealed Resident #42 had altered level of consciousness with behavioral fluctuations.
Review of Resident #42's nurse's notes dated 01/30/2024 at 6:25 a.m. revealed Resident #42 was noted to have scratches to her chest, scratches to her abdomen, and a bruise underneath her right breast. Further review revealed the nurse asked the Certified Nursing Assistant (CNA) what happened, and the CNA replied Resident #42 was being combative. Review revealed the nurse then asked the CNA what happened to Resident #42's arm, chest, abdomen and right breast and the CNA stated the scratches to Resident #42's arm, chest, and abdomen had been there.
Review of S24CNA's Written Statement dated 01/30/2024 revealed S24CNA noticed Resident #42 scratching her right shoulder on 01/28/2024 and had redirected Resident #42's hand. Review revealed the scratching was self-inflicted. Further review revealed on 01/29/2024 as S24CNA was bathing Resident #42, S35Licensed Practical Nurse (LPN) noticed Resident #42 had several more scratches all over her body. Review revealed S24CNA documented the scratches were new and self-inflicted within Resident #42's range of motion over her body.
Review of Resident #42's Wound Care Notes dated 01/30/2024 at 10:15 a.m. revealed a resident assessment at Resident #42's bedside in reference to generalized scratches to Resident #42's body. Review revealed scratches were noted to neck, arms, and abdomen. Further review revealed upon assessment with S8Wound Care Nurse and S2Director of Nursing (DON), Resident #42 was combative. Further review revealed Resident #42's scratches were ruled out to be self-inflicted behavior. Review revealed skin was intact to affected areas on Resident #42's body which displayed intact scars.
In an interview on 02/06/2024 at 1:54 p.m., S35LPN stated entered Resident #42's room on 01/30/2024 and noted scratches to Resident #42's chest, neck, and abdomen, and a bruise under Resident #42's right breast. S35LPN stated the staff on the prior shift had not reported any scratches or bruising. S35LPN stated Resident #42 had several superficial scratches with redness and a nickel sized purple bruise under her right breast. S35LPN further stated she reported the above information to S1Administrator.
In an interview on 02/07/2024 at 10:45 a.m., S32LPN stated she had not noticed any bruising or scratching on Resident #42 prior to 01/30/2024. S32LPN further stated if she would have been notified by the staff and/or noticed any bruising or scratches she would have reported this information to administration. S32LPN stated she had not been interviewed nor had administration requested she write a statement regarding Resident #42's skin condition.
In an interview on 02/07/2024 at 11:59 a.m., S36CNA stated she provided activity of daily living (ADL) care to Resident #42 on the date in question, 01/30/2024. S36CNA stated she didn't see any scratches or bruising on Resident #42. S36CNA further stated the staff had not interviewed her or requested she write a statement regarding Resident #42's skin condition.
In an interview on 02/08/2024 at 10:58 a.m., S8Wound Care Nurse stated on 01/30/2024 she was asked to assess scratches on Resident #42. S8Wound Care Nurse stated she and S2DON assessed scratches to Resident #42's collar bone, abdomen, and arms with Resident #42's skin being intact. S8Wound Care Nurse stated they did not complete a full body audit and did not assess under Resident #42's right or left breast and was not informed of a bruise under the resident's breast.
In an interview on 02/08/2024 at 11:17 a.m., S2DON stated she was notified by S35LPN that S24CNA was attempting to provide care and noticed scratches to the resident's shoulder. S2DON stated she and S8Wound Care Nurse went to assess Resident #42's scratches but due to the resident being agitated were only able to assess the top of her chest and abdomen. S2DON stated she and S8Wound Care Nurse were not notified of a bruise. The surveyor reviewed inconsistencies with S2DON between the nurse's notes documenting S24CNA informing her the scratches had been present, and S24CNA's statement of the scratches being new self-inflicted scratches. S2DON stated she was not aware of S24CNA's written statement and had not reviewed either documents. S2DON stated she did not remember interviewing staff from previous shifts regarding the scratches and bruise, nor did she request any statements to be written. S2DON further stated had she been aware of the bruise she would have investigated the bruise for an injury of unknown origin and/or abuse.
In an interview on 02/08/2024 at 11:53 a.m., S1Administrator stated S35LPN had notified her of the scratches and a bruise on 01/30/2024 and had sent her the pictures of the injuries. S1Administrator stated the facility did not keep a copy of the pictures of the scratches or bruise, but she believed the bruise was to either on the side of the left or the right breast. S1Administrator stated she had spoken with S35LPN and S24CNA, and had S2DON and S8Wound Care Nurse assess Resident #42. S1Administrator stated she let S2DON and S8Wound Care Nurse take care of the investigation from that point. S1Administrator stated she thought she mentioned the above issues to S32LPN, but did not remember interviewing any other LPNs and/or CNAs or requesting any statements. S1Administrator stated since she was aware of the bruising from the nurse she should have assured the bruising was assessed for an injury of unknown origin. S1Administrator stated the facility did not notice the conflicting information in the nurse's note and the statement written by S24CNA; did not investigate the inconsistencies; and should have investigated Resident #42's bruise to the right breast. S1Administrator stated due to the lack of assessment and information, the facility did not thoroughly investigate nor report an allegation of injury of unknown origin.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure:
1. Louisiana Physician Orders for Scope of Treatment (LaPos...
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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:
1. Louisiana Physician Orders for Scope of Treatment (LaPost) was placed on residents records per the care plan for 2 (Resident #42 and Resident #63) of 2 (Resident #42 and Resident #63) sampled residents reviewed for Advanced Directives; and
2. A Resident with a significant weight loss was care planned for nutritional interventions for 1 (Resident #18) of 2 (Resident #18 and Resident #36) sampled residents reviewed for nutrition.
Findings:
1. Resident #42
Review of Resident #42's record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses, in part, cerebral vascular accident (CVA). Further review revealed there was no documented evidence of advanced directives.
Review of Resident #42's Physician Progress Notes dated [DATE] revealed, in part, Resident #42 was a full code (Cardio Pulmonary Resuscitation (CPR) was to be initiated if found without breathing or a pulse).
Review of Resident #42's Care Plan with a goal date of [DATE] revealed, in part, Resident #42 code status was a full code. Further review revealed approaches, in part, code status and signed LAPOST will be placed in Resident #42's record.
In an interview on [DATE] at 10:45 a.m., S32Licensed Practical Nurse (LPN) stated the code status is kept in the resident's record, usually right in the front of the record on a yellow page. S32LPN reviewed Resident #42's record and confirmed the LaPost was not present on Resident #42's record.
In an interview on [DATE] at 11:17 a.m., S2Director of Nursing stated if a resident was unresponsive.
In an interview on [DATE] at 11:53 a.m., S1Administrator stated Resident #42's LaPost was not available in Resident #42's record and should have been available in Resident #42's record.
Resident #63
Review of Resident #63's record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses in part, Altered Mental Status, Schizophrenia Disorder, and Neuro Cognitive Disorder. Further review revealed there was no documented evidence of advanced directives.
Review of Resident #63's Physician Progress Notes dated [DATE] revealed, in part, Resident #63 was a full code (Cardio Pulmonary Resuscitation (CPR) was to be initiated if found without breathing or a pulse).
Review of Resident #63's Care Plan revealed with goal date of [DATE] revealed Resident #63 was a full code. Further review revealed approaches of, in part, code status and signed LAPOST will be placed in Resident # 63's record.
In an interview on [DATE] at 12:37 p.m., S34Licensed Practical Nurse (LPN) stated the code status is kept in the resident's record, and the LaPost should be located in the front of the resident's chart. Further review revealed S34LPN reviewed Resident #63's record and confirmed the LaPost was not present in Resident #63's medical record.
In an interview on [DATE] at 3:00 p.m., S2DON acknowledged she was unable to locate a LaPost on Resident #63's chart. S2DON also acknowledged the LaPost should be placed in the front of the Resident's chart to identify Resident #63's code status.
2. Resident #18
Review of Resident #18's record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses in part, Altered Mental Status, Schizophrenia Disorder and Neuro Cognitive Disorder. Further review revealed the facility had no documented evidence that Resident #18's significant weight loss.
Review of the Physician orders dated February 2024 revealed in part: Resident #18 was currently on monthly weight, regular diet with pureed meats, thin liquids, encourage at least 8 ounces (oz.) of medication (med) pass with meals, Ondansetron 4 milligrams (mgs) 1tablet by mouth every 8 hours and as needed for nausea and vomiting.
Further review of the facilities weights revealed the following monthly weights in pounds indicating a 14.80 percentage (%) weight loss over a period of 6 months;
[DATE] 106.60,
[DATE] 102.00,
[DATE] 92.80,
[DATE] 99.20,
[DATE] 96.40, and
[DATE] 91.80.
In an interview on [DATE] at 2:00 p.m., S2DON stated a weight management meeting was held [DATE] with dietary recommendations. S2DON acknowledged Resident # 18's care plan was not updated based on the dietary recommendations and the Physician orders for Resident #18's weight loss and nutritional status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to obtain the resident's most recent plan of care, certification of terminal illness, and documentation of services provided for 1 (Resident #...
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Based on record review and interview, the facility failed to obtain the resident's most recent plan of care, certification of terminal illness, and documentation of services provided for 1 (Resident #26) of 1 (Resident #26) sampled residents reviewed for hospice.
Findings:
Review of the facility's contract with the local hospice agency revealed, in part, the hospice agency shall develop the plan of care specifying information pertinent to the resident's treatment. The plan will be reviewed by the hospice agency on a minimum of every two weeks and updated as necessary by the hospice agency.
Review of Resident #26's hospice binder revealed Resident #26 was admitted to hospice on 01/19/2024. Further review of Resident #26's hospice binder revealed no documented evidence of Resident #26's certification of terminal illness, hospice plan of care, nor any documents for services provided.
In an interview on 02/07/2024 at 4:00 p.m., S33Licensed Practical Nurse (LPN) stated she was aware Resident #26 was receiving hospice services, however S33LPN was not aware of all the hospice disciplines which provided services to Resident #26 nor how often the hospice staff were expected to provide services. S33LPN stated she was not aware if the hospice agency provided communication regarding Resident #26's care, and confirmed the hospice record did not contain a care plan for Resident #26.
In an interview on 02/07/2024 at 4:21 p.m., S3Chief Clinical Officer (CCO) stated to his knowledge the plan of care would be completed upon admission and with any changes in care. S3CCO stated the hospice agency was its own entity; and therefore, the facility did not monitor their compliance with providing the care plan, the facility would contact the hospice agency as needed. S3CCO further stated the facility did not have copies of Resident #26's hospice care plan, discipline notes, nor certification of terminal illness in Resident #26's hospice binder.
In an interview on 02/08/2024 at 11:16 a.m., S2Director of Nursing (DON) stated the hospice care plan and documents should have been in Resident #26's hospice binder. S2DON further stated the facility did not have the above named documents available.
In an interview on 02/08/2024 at 11:40 a.m., S1Administrator stated the facility did not have the above mentioned documents as required, and she failed to understand the facility's role in ensuring residents receive coordinated care with the hospice agency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) resident assessments were transmitted and accepted by the Centers for Medicare and Medicaid Services (CMS) wi...
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Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) resident assessments were transmitted and accepted by the Centers for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment being completed for 4 (Resident #12, Resident #52, Resident #62, and Resident #278) of 4 (Resident #12, Resident #52, Resident #62, and Resident #278) sampled residents reviewed for Resident Assessment.
Findings:
Resident #12
Review of Resident #12's Quarterly MDS with an ARD of 11/08/2023 revealed, in part, a completion date of 11/27/2023.
Review of the facility's Final Validation Report for Resident #12's MDS with an ARD of 11/08/2023 revealed the MDS was rejected.
There was no documented evidence and the facility presented no documented evidence the facility had transmitted an approvable MDS for Resident #12's ARD of 11/08/2023 from completion of the MDS on 11/27/2023 until the start of the survey on 02/05/2024.
Resident #52
Review of Resident #52's Quarterly MDS with an ARD of 11/08/2023 revealed, in part, a completion date of 11/22/2023.
Review of the facility's Final Validation Report for Resident #52's MDS with an ARD of 11/08/2023 revealed the MDS was rejected.
There was no documented evidence and the facility presented no documented evidence the facility had transmitted an approvable MDS for Resident #52's ARD of 11/08/2023 from completion of the MDS on 11/22/2023 until the start of the survey on 02/05/2024.
Resident #62
Review of Resident #62's Quarterly MDS with an ARD of 11/08/2023 revealed, in part, a completion date of 11/27/2023.
Review of the facility's Final Validation Report for Resident #62's MDS with an ARD of 11/08/2023 revealed the MDS was rejected.
There was no documented evidence and the facility presented no documented evidence the facility had transmitted an approvable MDS for Resident #62's ARD of 11/08/2023 from completion of the MDS on 11/27/2023 until the start of the survey on 02/05/2024.
Resident #278
Review of Resident #278's admission 5 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2023 revealed, in part, a completion date of 11/21/2023.
Review of the facility's Final Validation Report for Resident #278's MDS with an ARD of 11/07/2023 revealed the MDS was rejected.
There was no documented evidence and the facility presented no documented evidence the facility had transmitted an approvable MDS for Resident #279's ARD of 11/07/2023 from completion of the MDS on 11/21/2023 until survey date of 02/05/2024.
In an interview on 02/06/2024 at 10:13 a.m., S3Chief Clinical Officer stated the facility was aware Resident #12, Resident #52, and Resident #62's MDS's for the above mentioned ARD dates were rejected. S3Chief Clinical Officer further stated the facility had not transmitted an accepted MDS for Resident #12, Resident #52, Resident and Resident #62's MDS for the above mentioned ARD dates prior to the start of the survey on 02/05/2024.
In an interview on 02/08/2024 at 11:51 a.m., S7Quality Control stated the facility was aware Resident #12, Resident #52, Resident #62, and Resident #278's MDS for the above mentioned ARD dates were rejected.
In an interview on 02/08/2024 at 2:16 p.m.,S3Chief Clinical Officer stated the facility had not transmitted an accepted MDS for Resident #12, Resident #52, Resident #62, and Resident #278's MDS for the above mentioned ARD dates prior to the start of the survey on 02/05/2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure water accessible to residents did not exceed 120 degrees Fahrenheit for 9 (Bathroom A, Bathroom B, Bathroom D, Bathroom E, Bathroom F,...
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Based on observation and interview, the facility failed to ensure water accessible to residents did not exceed 120 degrees Fahrenheit for 9 (Bathroom A, Bathroom B, Bathroom D, Bathroom E, Bathroom F, Bathroom H, Bathroom I, Bathroom J, and Bathroom L) of 12 (Bathroom A, Bathroom B, Bathroom C, Bathroom D, Bathroom E, Bathroom F, Bathroom G, Bathroom H, Bathroom I, Bathroom J, Bathroom K, and Bathroom L) bathrooms observed for water temperature.
Findings:
Observations on 02/05/2024 between 10:10 a.m. and 10:30 a.m. of resident rooms on Hall W and Hall X revealed bathroom sink water temperatures were hot to touch, and surveyors were unable to maintain their hand in the flow of water for more than 5 seconds due to high temperature.
In an interview on 02/05/2024 at 12:20 p.m., S6Facilities Manager stated he thought the maximum safe temperature was 120 degrees Fahrenheit, but was not sure.
Observations on 02/05/2024 between 1:10 p.m. and 1:25 p.m. revealed S6Facilities Manager obtained water temperatures (in degrees Fahrenheit) as followed:
1:10 p.m. 123.3 degrees in Bathroom A;
1:11 p.m. 122.1 degrees in Bathroom B;
1:15 p.m. 121.8 degrees in Bathroom D;
1:16 p.m. 122.8 degrees in Bathroom E;
1:17 p.m. 122.7 degrees in Bathroom F;
1:20 p.m. 122.8 degrees in Bathroom H;
1:21 p.m. 120.2 degrees in Bathroom I;
1:23 p.m. 121.6 degrees in Bathroom J; and
1:25 p.m. 122.1 degrees in Bathroom L.
In an interview on 02/05/2024 at 1:30 p.m., S6Facilities Manager stated the water temperatures in resident bathrooms should not be above 120 degrees Fahrenheit.
In an interview on 02/06/2024 at 8:43 a.m., S1Administrator acknowledged the water temperatures in Bathroom A, Bathroom B, Bathroom D, Bathroom E, Bathroom F, Bathroom H, Bathroom I, Bathroom J, and Bathroom L should not have been above 120 degrees Fahrenheit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) had completed annual competencies as required for 3 (S17CNA, S23CNA, S24CNA) of 5 (S9CNASupervio...
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Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) had completed annual competencies as required for 3 (S17CNA, S23CNA, S24CNA) of 5 (S9CNASuperviosr, S17CNA, S23CNA, S24CNA, and S27CNA) CNAs personnel records reviewed for competencies.
Findings:
Review of S17CNA's personnel file revealed, the last annual competency documented was 07/28/2022. Further review revealed no documented evidence and the facility presented no documented evidence of the facility had completed competencies on S17CNA since the CNA was re-hired on 12/19/2022.
Review of S23CNA's personnel file revealed, in part, a hire date of 10/17/2019 with a re-hire date of 09/19/2023. Further review revealed, the last competency documented was 02/14/2022.
Review of S24CNA's personnel file revealed, in part, a hire date of 06/11/2023 with a re-hire date of 12/15/2023. Review revealed, S24CNA's competency was without a completion date and an overall evaluation of S24CNA's competency of skills to be provided to residents.
In an interview on 02/07/2023 at 1:00 p.m., S13Human Resources (HR) stated she was a new employee and was unsure if the above mentioned CNA competencies had been completed.
In an interview on 02/08/2024 at 2:30 p.m., S1Adminstrator confirmed S17CNA and S23CNA, did not have competencies completed and all direct care staff should have up to date competencies completed prior to performing direct care to residents. S1Adminstrator further confirmed S24CNA's competency was not completed and it should have been.
There was no documented evidence and the facility did not present any documented evidence of competencies being completed upon hire, re-hire, and 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
Based on record reviews and interviews, the facility failed to complete an annual performance review for every certified nurse aide (CNA) at least once every 12 months for 1 (S17CNA) of 5 (S9CNASuperv...
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Based on record reviews and interviews, the facility failed to complete an annual performance review for every certified nurse aide (CNA) at least once every 12 months for 1 (S17CNA) of 5 (S9CNASupervisor, S17CNA, S23CNA, S24CNA, and S27CNA) CNA personnel records reviewed.
Findings:
Review of S17CNA's personnel record revealed, in part, a hire date of 11/06/2020 with a re-hire date of 12/19/2022. Further review revealed no documented evidence and the facility presented no documented evidence the facility had completed an annual performance review for S17CNA since the CNA was re-hired on 12/19/2022.
In an interview on 02/08/2024 at 3:26 p.m., S1Administrator confirmed S17CNA did not have an annual performance review completed in the last 12 months.
There was no documented evidence and the facility did not present any documented evidence of an annual performance review being completed for S17CNA.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review, observation, and interview the facility failed to:
1. Ensure staff performed hand hygiene during dining observation for 3 (Hall W, Hall X, and Hall Z) of 4 (Hall W, Hall X, Hal...
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Based on record review, observation, and interview the facility failed to:
1. Ensure staff performed hand hygiene during dining observation for 3 (Hall W, Hall X, and Hall Z) of 4 (Hall W, Hall X, Hall Y, and Hall Z) sampled halls observed during dining observations;
2. Ensure the Certified Nursing Assistant (CNA) removed their gloves and completed hand hygiene during incontinence care for 1 (S9CNA Supervisor) of 1 staff observed during incontinence care; and,
3. Ensure a system of surveillance was in place for water management to prevent Legionella.
Findings:
Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene policy and most recently reviewed on 02/08/2024 revealed, in part, staff should perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, and before and after assisting a resident with meals.
Review of the facility's policy and procedure title, Employee Education on Performing Hand Hygiene most recently reviewed on 02/08/2024 revealed, in part, hand hygiene should be performed immediately before touching a resident, after touching a resident or resident's environment, and after glove removal.
1. Observation of Hall W on 02/05/2024 at 1:19 p.m. revealed S30Certified Nursing Assistant (CNA) acquired a lunch food tray on Hall W's food cart for Resident #44 without performing hand hygiene, entered Resident #44's room, set up Resident #44's food tray, then exited Resident #44's room, and did not perform hand hygiene.
Observation of Hall W on 02/05/2024 at 1:33 p.m. of Hall W revealed S29CNA did not perform hand hygiene before feeding lunch to Resident #18.
Observation of Hall X on 02/05/2024 at 1:49 p.m. revealed S17CNA assisted Resident #11 from the dining room couch to his wheelchair, then proceeded to set up Resident #11's food tray without having performed hand hygiene prior to touching Resident #11's food tray. Further observation revealed S17CNA acquired Resident #5's food tray from Hall X's food cart, and did not perform hand hygiene. S17CNA then delivered the hall food tray and did not perform hand hygiene prior to delivering and providing setup assistance for Resident #128's food tray. Further observation revealed S17CNA then assisted feeding Resident #128.
Observation of Hall Z on 02/08/2024 at 8:56 a.m. revealed S28CNA acquired a breakfast food tray on Hall Z's food cart for Resident #3 without performing hand hygiene, entered Resident #3's room, set up Resident #3's food tray, touched Resident #3 on the leg, and exited Resident #3's room without having performed hand hygiene.
Observation of Hall Z on 02/08/2024 at 8:59 a.m. revealed S28CNA acquired a breakfast food tray on Hall Z's food cart for Resident #20 without preforming hand hygiene, entered Resident #20's room, set up Resident #20's food tray, and exited Resident #20's room without having performed hand hygiene.
Observation of Hall Z on 02/08/2024 at 9:03 a.m. revealed S28CNA acquired a breakfast food tray on Hall Z's food cart for Resident #50 without performing hand hygiene, entered Resident #50's room, set up Resident #50's food tray, and exited Resident #50's room without having performed hand hygiene.
Observation of Hall Z on 02/08/2024 at 9:04 a.m. revealed S31Homemaker acquired a breakfast food tray on Hall Z's food cart for Resident #55 without having performed hand hygiene, entered Resident #55's room, set up Resident #55's food tray, adjusted Resident #55's pillow, and exited Resident #55's room without having performed hand hygiene.
Observation of Hall Z on 02/08/2024 at 9:06 a.m. revealed S26CNA acquired a breakfast food tray on Hall Z's food cart for Resident #379 without performing hand hygiene, entered Resident #379's room, set up Resident #379's food tray, and exited Resident #379's room without having performed hand hygiene.
In an interview on 02/08/2024 at 11:00 a.m., S28CNA stated she should have used hand hygiene before delivery of the food tray, after resident food tray setup, upon exiting the resident's room, and before acquiring another resident's food tray.
In an interview on 02/08/2024 at 11:50 a.m., S4Vice President (VP) stated hand hygiene should have been performed before food tray delivery, after resident set up, upon exiting a resident's room, and before food tray delivery to other residents.
In an interview on 02/07/2024 at 4:05 p.m., S1Administrator stated hand hygiene should be performed during dining services, between staff coming in contact with each resident's food tray, and prior to coming in contact with another resident.
In an interview on 02/08/2024 at 2:00 p.m., S7Quality Control, who was the facility's infection preventionist, stated hand hygiene should be performed during dining services, between staff coming in contact with each resident's food tray, and prior to coming in contact with another resident.
In an interview on 02/08/2024 at 2:25 p.m., S2Director of Nursing stated hand hygiene should be performed during dining services, between staff coming in contact with each resident's food tray, and prior to coming into contact with another resident.
2. Observation on 02/07/2024 at 10:48 a.m., revealed S9CNA Supervisor applied gloves prior to entering Resident #20's room to provide incontinence care. S9CNA Supervisor entered Resident #20's room, and proceeded to glove hands without performing hand hygiene. S9CNA Supervisor removed Resident #20's brief, cleaned the top of Resident #20's Genital area, then cleaned Resident #20's left and right groin area, and turned Resident #20 onto her right side. S9CNA Supervisor then cleaned Resident #20's visibly soiled buttock, removed the visibly soiled brief, and discarded into the trash can. Further observation, revealed S9CNA Supervisor then placed a clean brief on Resident #20 without having changed her gloves nor having performed hand hygiene.
In an interview on 02/07/2024 at 4:00 p.m., S9CNA Supervisor confirmed she did not perform hand hygiene during incontinence care for Resident #20 in the above mentioned observation. S9CNA Supervisor further confirmed she should have changed her gloves after she removed Resident #20's soiled brief prior to placing a new brief and she did not.
In an interview on 02/07/2024 at 4:05 p.m., S1Administrator stated S9CNA Supervisor should have performed hand hygiene and changed gloves in between removing soiled linen or briefs and placing a clean brief on a resident.
In an interview on 02/08/2024 at 2:00 p.m., S7Quality Control stated S9CNA Supervisor should have performed hand hygiene and changed gloves prior to placing a new brief on Resident #20.
3.
Review of the facility's Water Management Program policy revealed, in part the facility's protocol to facilitate effective water management included maintenance of water temperatures at outside of the ideal range for Legionella growth, preventing water stagnation, ensure adequate disinfection, maintaining premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm.
In an interview on 02/08/2024 at 10:00 a.m., S6Facilities Manager stated the facility does not have the water management program surveillance on-site because it is managed by the company who owns the building. S6Facilties Manager further stated he would have to obtain the information because he did not have it in his possession.
In an interview on 02/08/2024 at 3:00 p.m., S3Chief Clinical Officer stated the facility was unable to present any documented evidence the above mentioned protocol had been completed.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure all complaint surveys since the last annual survey were available for resident review.
Findings:
In an interview on 02...
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Based on observation, record review, and interview, the facility failed to ensure all complaint surveys since the last annual survey were available for resident review.
Findings:
In an interview on 02/06/2024 at 9:26 a.m., Resident #15 stated the state survey results located at the front entrance did not contain the most current survey results and she had to request to see the last complaint survey. Resident #15 further stated the last survey she had seen was from 2022.
Observation on 02/06/2024 at 10:10 a.m. in the front entrance revealed a dark blue binder, labeled survey results binder, on the bottom shelf of the table.
Review of the survey results binder revealed the last survey posted in the binder was dated 03/16/2023. Further review revealed no documented evidence and the facility presented no documented evidence of the survey results from the 07/12/2023 complaint survey having been available for review.
In an interview on 02/06/2024 10:30 a.m., S1Administrator confirmed the binder mentioned above was the survey results binder for the residents to access. S1Administrator further stated the binder did not contain the survey results from the complaint survey with an exit date of 07/12/2023, and therefore was not accessible to residents without having to request to view the results.
Jul 2023
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to Protect a resident from physical abuse for 2 Residents (Resident #4...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to Protect a resident from physical abuse for 2 Residents (Resident #4 and Resident #5) of 7(Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled residents.
This deficient practice resulted in an actual harm on 03/09/2023 for Resident #5 when Resident #3 hit Resident #5 with the arm of his wheelchair several times. Resident #5 was transferred to the hospital for emergency medical evaluation which revealed a laceration to Resident #5's scalp (the skin covering the head excluding the face). Resident #5 subsequently received surgical intervention to repair the laceration to the scalp. Resident #5 required wound care upon his discharged back to the facility on [DATE].
This deficient practice resulted in an actual harm on 05/31/2023 for Resident #4 when Resident #3 threw an object which hit Resident #4 in the face and left arm. Resident #4 received medical attention by the nursing staff and was transferred to the hospital for emergency medical evaluation which revealed a laceration to Resident #4's left cheek, a nasal fracture, a small laceration to the nose, and a contusion to the left upper arm. Resident #4 subsequently received surgical intervention to repair the laceration to the cheek. Resident #4 required wound monitoring upon discharged back to the facility on [DATE].
Based on the facility investigation, physical abuse was substantiated 03/09/2023 and on 05/31/2023.
The incident on 03/09/2023 resulted in an actual harm with the potential for more than minimal harm for Resident #5.
The incident on 05/31/2023 resulted in actual harm with the potential for more than minimal harm for Resident #4.
Findings:
Review of the facility's Abuse, Neglect and Exploitation policy revealed, in part; the purpose of the policy was to ensure the protection of residents and for the prevention of abuse and neglect.
Definitions
Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
Resident #5
Review of Resident #5's record revealed, in part, Resident #5 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses, in part, unspecified dementia with behavioral disturbances.
Review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderated cognitive impairment.
Review of facility's incident investigation report revealed, in part, Resident #5 was hit on the head with the arm of a wheelchair by Resident #3 on 03/09/2023. Further review revealed Resident #5 was transferred to the hospital for evaluation and treatment. Review revealed S1Administrator interviewed Resident #3 and he stated Resident #5 was in my bed so I hit him.
Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, Resident #5 had an incident of physical abuse which occurred on 03/09/2023.
In an interview on 07/12/2023 at 2:57 p.m., S1Administrator confirmed the incident between Resident #3 and Resident #5 was resident to resident physical abuse.
Review of Resident #5's nurse's notes dated 03/09/2023 at 6:48 p.m., revealed, in part, Resident #5 was returned to his unit (Floor 6) by S3Certified Nursing Assistant (S3CNA). S3CNA stated Resident #5 was on another unit (Floor 7) in a similar room (Room b) was located directly above his room on (Floor 6) Room a in the bed. Resident #3 was upset because Resident #5 was in his bed and requested for Resident #5 to get out of his bed. Resident #3 hit Resident #5 on the back of the head with the arm of his wheelchair. Resident #5 had blood noted on the back of the head and neck. Resident #5 had a laceration noted to the back of the head. Resident #5's Physician was notified and he was transferred to the hospital for an evaluation.
Review of Resident #3's nurse's note dated 03/09/2023 revealed, in part, Resident #3 became upset when Resident #5 was in his room and yelled. S3CNA went to Resident #3's room to assist Resident #5 out of the bed into his wheelchair. Resident #5 was hit on the back of the head several times with the arm of a wheelchair by Resident #3 as he was escorted out of the room by S3CNA. Resident #3 was redirected and educated on violence. Resident #3 remained upset.
Review of Resident #5's hospital record dated 03/09/2023 revealed, in part, he evaluated in the emergency department and diagnosis of laceration to scalp.
Review of Resident #5's nurse's note dated 03/10/2023 at 11:00 a.m., revealed, in part, Resident #5 presents with four staples to scalp to back of head related to incident.
In an interview on 07/10/2023 at 11:11 a.m., S2Registered Nurse (RN) stated she was the nurse for Resident #3 on 03/09/2023. S2RN stated on 03/09/2023 Resident #3 came to get her because he said a man was in his bed. S2RN stated she accompanied Resident #3 back to his room where she observed Resident #5 was in Resident #3's bed. S2RN stated she instructed Resident #5 to get out of Resident #3's bed and he did not comply. S2RN stated she escorted Resident #3 out of the room with her to get S3CNA to assist Resident #5 out of Resident #3's bed. S2RN stated she left Resident #3 in the hallway while she and S3CNA went back into Resident #3's room to assist Resident #5 out of Resident #3's bed. S2RN stated she left S3CNA in the room to assist Resident #5 into the wheelchair. S2RN stated S3CNA told her that Resident #5 was hit in the back of the head with the wheelchair arm. S2RN stated she assessed Resident #5 after he was hit on the head. S2RN stated Resident #5 had a laceration to his scalp from being hit on the back of the head with the wheelchair arm. S2RN stated Resident #5 was transferred to the emergency room.
In an interview on 07/10/2023 at 11:39 a.m., S3CNA stated on 03/09/2023 he heard Resident #3 cursing and upset because Resident #5 was in his room. S3CNA stated Resident #3 hit Resident #5 over eight times with the arm of his wheelchair while he escorted Resident #5 in a wheelchair out of Resident #3's room.
Resident #4
Review of Resident #4's record revealed, in part, Resident #4 was admitted to the facility on [DATE] with diagnoses, in part; Bipolar Disorder, Schizoaffective Disorder, difficulty in walking, Epilepsy, and Asthma.
Review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition.
Review of facility's incident investigation report dated 06/05/2023 revealed, in part, Resident #4 was hit on the head and arm by an object thrown by Resident #3 on 05/31/2023. Further review revealed Resident #4 was transferred to the hospital for evaluation and treatment. Review revealed S1Administrator interviewed Resident #3 and he stated Resident #4 entered his room so he threw something at her.
Review of the facility's Statewide Incident Management System (SIMS) report revealed, in part, Resident #4 had an incident of physical abuse that occurred on 05/31/2023. Review of the facility's final report revealed the abuse was substantiated.
In an interview on 07/12/2023 at 2:57 p.m., S1Administrator confirmed the incident between Resident #3 and Resident #4 was resident to resident physical abuse.
Review of Resident #4's nurse's notes dated 05/31/2023 at 2:30 p.m., revealed, in part, Resident #4 walked into Resident #3's room and was struck in the face with an unknown object which caused a laceration to left side of face and nose , and small laceration to left arm. A pressure dressing to face, and 911 was called. Physician and Resident Representative notified and resident sent to ER by Emergency Medical Services (EMS), S5DON and S1Administrator notified.
Review of Resident #3's nurse's note dated 05/31/2023 at 2:39 p.m. revealed, in part, Resident #3 sitting in room when another resident walked in. Resident #3 stated he asked her to leave, but she did not so he struck her with an unknown object. Resident responsible Party notified and MD notified. MD gave orders to send to local ER for psychiatry evaluation and treatment. Sent to ER by EMS, and [NAME] and Administrator notified.
Review of Resident #4's hospital record dated 05/31/2023 revealed, in part, was evaluated in the emergency department and diagnosis of laceration to left cheek, nasal fracture, and contusion to left bicep. Resident #4's left cheek sutured.
Review of Resident #4's nurse's note dated 05/31/2023 at 8:30 p.m. revealed, in part, Resident #4 returned from evaluation and treatment from hospital. Resident #4 refused to listen to her staff. Arrived back about 7:00p.m. with a bandage above the neck on the left side. Family, doctor, Administrator, and DON notified of her return.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a facility-initiated involuntary discharge was performe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a facility-initiated involuntary discharge was performed as required for 1 (Resident #3) of 7(Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled residents.
Findings:
Review of Resident # 3's record revealed an initial admit date of 06/16/2020 with readmission date of 02/14/2022. Resident#3 had diagnoses of, in part: Schizophrenia: Bipolar; Anxiety; Depression; Cerebrovascular Accident CVA); Left Hemiparesis; Post Traumatic Stress Disorder (PTSD); Anoxic Brain Damage, Unspecified Dementia and Suicidal Ideation.
Review of Resident#3's NOTICE OF INVOLUNTARY discharge date d 06/08/2023 presented by the facility and the Ombudsman contained an intent to discharge Resident#3 as soon as possible, as a result a result of Resident#3's aggressive behavior which is a danger to the health and safety of other residents as documented in your attacking and beating two other residents .You will be discharged to your present location which is a local behavioral hospital.
Review of the Facilities Accident/Incident Log from 10/01/2022 to 07/10/2023 revealed Resident#3 had 2 documented incidents defined as resident to resident incidents dated 03/09/2023 and 05/31/2023. Further record review revealed both incidents occurred in Resident#3's room when Resident #3 physically hit Resident#5 with the arm of his wheelchair on 03/09/2023, and Resident#3 threw an object at Resident#4 on 05/31/2023. The reports revealed Resident #5 had mistakenly gotten into Resident#3's bed, and Resident #4 had wandered into Resident#3's room.
Record review revealed the incident on 03/09/2023 resulted in Resident#3's admission to a local behavioral hospital for evaluation and treatment on 03/10/2023. Resident#3's care plan was not revised and there was no evidence interventions were implemented to prevent future incidents.
Record review revealed the incident on 05/31/2023 resulted in Resident #3's admission to a behavioral hospital. At this time Resident #3 remains in the behavioral hospital. Review of Resident #3's Nurses note dated 05/31/2023 at 5:00 p.m. revealed Resident would not return to the nursing facility.
In an interview on 7/07/2023 at 12:06p.m., the Social Worker (SW) for the Facility which received Resident#3 stated as far as she knew the facility was not aware the resident was not returning to the nursing home on admission. SW stated she was not aware of the Involuntary Discharge until 06/09/2023 when Resident#3 asked her to read the letter which was just hand delivered by staff from the nursing home. SW stated at a later date she became aware the receiving facility was notified on 06/07/2023.
In a telephone interview on 07/10/2023 at 11:37a.m., S3Certified Nursing Assistant (S3CNA) stated the facility attempted have a sitter at the door on the 7th floor to increase supervision. S3CNA stated having a sitter would require a 3rd CNA to work on the floor. When asked if the intervention helped, S3CNA stated no because he worked most of his shifts by himself. S3CNA stated Resident#3 was intelligent and nice. S3CNA stated Resident#3's behavior was manageable, and he would let the staff know if he was having mental issues. S3CNA stated Resident #3 asked Resident#5 a few times to get out of his bed before he got upset.
In an interview on 7/11/2023 at 2:16p.m., S4Licensed Practical Nurse (S4LPN) stated Resident#3 respected the staff and was helpful and intelligent. S4LPN stated he would let staff know if other residents were having problems like they appeared to falling. S4LPN stated Resident#3 is not an instigator, but reacts when someone is in his space and they don't respond to him asking them to leave.
In an interview on 7/11/2023 at 2:45p.m., S1Administrator stated the only documentation of contact with the receiving facility was her daily calendar which showed which showed an entry of 12:00p.m. on 06/07/2023. S1Administrator stated the admission team contacted the behavioral hospital on [DATE] by phone to inform the facility would not allow Resident #3 to return. When asked, S1Administrator stated the receiving facility was not notified of their intent to not allow Resident #3 to return prior to sending the resident to their facility. S1Administrator also stated there was no discharge summary or documentation by a physician or nurse practitioner of Resident#3's removal because his behavior was a risk to the safety and health of the other residents in the facility.
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 F0576
(Tag F0576)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to:
1. Ensure residents had privacy to open packages/mail; and,
2. To deliver packages to residents on the weekend and in a timely manner.
Thi...
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Based on record review and interview, the facility failed to:
1. Ensure residents had privacy to open packages/mail; and,
2. To deliver packages to residents on the weekend and in a timely manner.
This failure has the potential to affect the 76 residents who reside in the facility.
Findings:
Review of the Nursing Home Resident [NAME] of Rights reads, in part, 2. The right to private uncensored communication. 7. The right to privacy in treatment and caring for personal needs and to be secure in storing and using personal possessions.
Review of the Resident Council Meeting Minutes signed by S1Administrator for 06/20/2023 at 1:00 p.m. revealed, in part, residents' had issues with receiving their mail daily and staff members having to witness them opening their mail and/or packages. Further review revealed the facility's response to the issues included the facility must witness when packages and/or mail are opened.
In an interview on 07/11/2023 at 10:21 a.m., Resident #1 stated all her packages have been sent to the Administrator office until a staff member can monitor her opening them. Resident #1 stated she has waited up to three weeks to receive a package because they facility takes her packages. Resident #1 stated she should be able to receive her mail and packages without having to be monitored by facility staff. Resident #1 stated her packages have been brought to her opened and other packages have been opened by the facility and re-taped then brought to her. Resident #1 stated she has to open all of her packages in the presence of a staff member. Resident #1 stated she has informed the administrator multiple times that she wanted to have privacy when she opens her packages and / or mail and she has been told no.
In an interview on 07/11/2023 at 3:06 p.m., S1Administrator stated mail/packages are not delivered to the facility because a change of address was requested by entity they are leasing the space from. S1Administrator stated the entity they lease the space from did not want residents packages/mail delivered to the building they are housed in. S1Administrator stated residents mail/packages are delivered to an affiliate nursing home and transported daily to this facility. S1Administrator stated when packages are received in the facility they are given to residents and they are to open the package in front of staff. S1Administrator acknowledged that residents have not been receiving packages on the weekend because staff members have been instructed that residents have to open packages in the presence of a staff member. S1Administrator stated she has talked to staff about opening packages received on the weekends but acknowledged that residents have waited until Monday to receive packages received at the facility on the weekend.
Mar 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews, the facility failed to ensure:
1.Expired medications were not available for administration to residents for 1 of 2 Med rooms reviewed for medicat...
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Based on observations, record review, and interviews, the facility failed to ensure:
1.Expired medications were not available for administration to residents for 1 of 2 Med rooms reviewed for medication storage; and,
2.Nurses signed off on off on the narcotic count sheet at the beginning and end of each shift.
This deficient practice had the potential to affect any of the 20 residents who resided on the Floor W of the facility.
Findings:
Observation on 03/15/2023 at 12:03 p.m., Medication Storage Room Floor X revealed the following: A bottle of Century 21 Slow Release Iron expiration with an expiration date of 09/2022; a box of Magnesium tablets 500mg with an expiration date of 08/2022; and a bottle of Milk of Magnesia with an expiration date of 10/2022.
Review on 03/15/2023 at 12:30 p.m. Of the Narcotic Controlled Count Sheet for Floor W revealed signatures for nurses witnessing narcotic counts were missing on the following dates:
January 29,2023, February 19,2023, February 21, 2023, February 25, 2023, February 27, 2023, March 13,2023, and March 14, 2023
In an interview on 03/15/2023 at 12:03 p.m., S5 Licensed Practical Nurse (LPN) stated the nurses are responsible to ensure there are no expired medications available for resident use and confirmed the above documented medications were expired.
In an interview on 03/15/2023 at 12:30 p.m., S4 Licensed Practical Nurse (LPN) stated the nurses are responsible for counting and signing the Narcotic Controlled Count Sheet with the oncoming nurse and off going nurse for each shift.
In an interview on 03/15/2023 at 1:00 p.m., S2 Director of Nursing (DON) stated the nurses are responsible for checking for expired medications and nurses are responsible for counting and signing the Narcotic Controlled Count Sheet for all shifts with oncoming and off-going nurse for each shift worked.
In an interview on 03/15/2023 at 12:03 p.m., S5 Licensed Practical Nurse (LPN) stated the nurses are responsible to ensure there are no expired medications available for resident use and confirmed the above documented medications were expired.
In an interview on 03/15/2023 at 12:30 p.m., S4 Licensed Practical Nurse (LPN) stated the nurses are responsible for counting and signing the Narcotic Controlled Count Sheet with the oncoming nurse and off going nurse for each shift.
In an interview on 03/15/2023 at 1:00 p.m., S2 Director of Nursing (DON) stated the nurses are responsible for checking for expired medications and nurses are responsible for counting and signing the Narcotic Controlled Count Sheet for all shifts with oncoming and off-going nurse for each shift worked.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to assess and complete Quarterly Minimum Data set in a timely manner on a resident for 7 (#2, #21, #31, #36, #50, #55, and #58) of 13 (#2, #5, ...
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Based on record review and interview the facility failed to assess and complete Quarterly Minimum Data set in a timely manner on a resident for 7 (#2, #21, #31, #36, #50, #55, and #58) of 13 (#2, #5, #21, #28, #31, #36, #51, #54, #55, #58, #63 and #64) residents reviewed for Resident Assessment. This deficient practice had the potential to affect any of the 76 residents who reside in the facility as identified on the Facility Census and Condition of Residents form.
Findings:
Review of Resident #2's MDS assessments revealed a quarterly assessment completed and transmitted with an ARD/target date (Assessment Reference Date) of 12/01/2023. Further review Revealed Resident #2 did not have another assessment scheduled till 3/16/2023.
Further review of Resident #2 MDS Quarterly assessment with ARD (Assessment Reference Date) of 12/01/2023 revealed Section Z, RN completion date signed late on 12/30/2023
Review of Resident #21's MDS assessments revealed a admission assessment completed and transmitted with ARD (Assessment Reference Date) of 10/27/2023. Further review revealed Resident #21 did not have another OBRA assessment scheduled until 3/7/2023.
Review of Resident #31 MDS Quarterly assessment with ARD (Assessment Reference Date) of 11/21/2022 revealed all of Section B, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, were blank or not assessed. Further review or MDS Quarterly assessment revealed Section Z, RN completion date signed late with date on 12/30/2022.
Review of Resident # 36 MDS Quarterly assessment with ARD (Assessment Reference Date) of 12/12/2023 revealed Section Z RN completion date, signed late with date on 12/30/2022.
Review of Resident #50 MDS Quarterly assessment with ARD (Assessment Reference Date) of 12/23/2023 revealed Section Z, RN completion Date, signed late with date on 1/12/2023
Review of Resident # 55 MDS Quarterly assessment with ARD (Assessment Reference Date) of 12/30/23 revealed Section Z, RN completion date signed late with date on 1/16/22023
Review of Resident #58 MDS Quarterly assessment with ARD (Assessment Reference Date) of 12/5/2023 revealed Section Z, RN completion date signed late with date on 12/30/2023.
Interview on 3/16/2023 9:40 a.m. S3 MDS indicated she did not know what the errors meant on the Validation report. She scheduled Annual assessment per timeline from previous comprehensive assessment but was not aware that needed to be scheduled within 92 days of previous Quarterly MDS. She stated she has been doing MDS in facility since November 2022 and was trained by Polaris 10/31/2022-11/11/2022 in their MDSC Shadow training. S3 MDS acknowledged the missed assessments and the late RN signature date.
Interview on 3/16/2023 9:50 a.m. S2 Director of Nursing indicated she was the RN coordinator for past 5 days. She did indicate she knew the timelines for when Z0500 RN completion date on MDS must be complete. S2 DON acknowledge RN completion dates were late on assessments. S2 DON acknowledge RN completion dates were late on assessments
Dec 2022
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to report the final results of the investigation involving an allegation of staff to resident abuse to the State survey agency within 5 working...
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Based on record review and interview the facility failed to report the final results of the investigation involving an allegation of staff to resident abuse to the State survey agency within 5 working days of the incident. The deficient practice had the potential to affect any of the 74 residents who reside in the facility as identified on the resident census listing.
Findings:
Review of the facility's investigation report revealed, in part, the initial Statewide Incident Management System (SIMS) report dated 7/22/2022 had no follow-up or final report.
In an interview on 12/07/2022 at 11:40 am, S1Administrator stated the SIMS report was sent on 07/22/2022 and the investigation was started and completed with findings of unsubstantiated evidence that the behavior of the accused was not malicious or willful. S1Administrator acknowledged the facility made a mistake by not giving the final information timely to the state office by submitting the follow-up/ final report of the investigation within 5 working days after the initial SIMS report was sent and the investigation completed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 4 life-threatening violation(s), 1 harm violation(s), $389,001 in fines. Review inspection reports carefully.
- • 45 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $389,001 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is St Jude'S Health & Wellness Center's CMS Rating?
CMS assigns ST JUDE'S HEALTH & WELLNESS CENTER 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 Jude'S Health & Wellness Center Staffed?
CMS rates ST JUDE'S HEALTH & WELLNESS CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 69%, which is 23 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at St Jude'S Health & Wellness Center?
State health inspectors documented 45 deficiencies at ST JUDE'S HEALTH & WELLNESS CENTER during 2022 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 39 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates St Jude'S Health & Wellness Center?
ST JUDE'S HEALTH & WELLNESS CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 116 certified beds and approximately 80 residents (about 69% occupancy), it is a mid-sized facility located in NEW ORLEANS, Louisiana.
How Does St Jude'S Health & Wellness Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, ST JUDE'S HEALTH & WELLNESS CENTER's overall rating (1 stars) is below the state average of 2.4, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting St Jude'S Health & Wellness Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can 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 Immediate Jeopardy citations and the facility's high staff turnover rate.
Is St Jude'S Health & Wellness Center Safe?
Based on CMS inspection data, ST JUDE'S HEALTH & WELLNESS CENTER has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at St Jude'S Health & Wellness Center Stick Around?
Staff turnover at ST JUDE'S HEALTH & WELLNESS CENTER is high. At 69%, the facility is 23 percentage points above the Louisiana average of 46%. 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 Jude'S Health & Wellness Center Ever Fined?
ST JUDE'S HEALTH & WELLNESS CENTER has been fined $389,001 across 8 penalty actions. This is 10.5x the Louisiana average of $36,969. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is St Jude'S Health & Wellness Center on Any Federal Watch List?
ST JUDE'S HEALTH & WELLNESS CENTER 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.