How many inspection deficiencies does St. Margaret's Daughters Home have?

St. Margaret's Daughters Home has 38 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at St. Margaret's Daughters Home?

St. Margaret's Daughters Home has a one-star staffing rating from CMS with 0.24 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is St. Margaret's Daughters Home located?

St. Margaret's Daughters Home is located in NEW ORLEANS, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does St. Margaret's Daughters Home have?

St. Margaret's Daughters Home has 112 certified beds.

Who owns St. Margaret's Daughters Home?

St. Margaret's Daughters Home is a non profit - corporation facility and operates independently (not part of a chain).

How does St. Margaret's Daughters Home compare to other nursing homes?

St. Margaret's Daughters Home has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

St. Margaret's Daughters Home

Name: St. Margaret's Daughters Home
Address: 3525 BIENVILLE ST, NEW ORLEANS, LA, 70119, US
Telephone: (504) 279-6414
Rating: 1.0

3525 BIENVILLE ST, NEW ORLEANS, LA 70119 · (504) 279-6414

Non profit - Corporation 112 Beds Independent Data: November 2025

Trust Grade

40/100

#251 of 264 in LA

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Last Inspection: August 2024

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

Overview

St. Margaret's Daughters Home has a Trust Grade of D, which means it is below average and raises some concerns about the facility. It ranks #251 out of 264 in Louisiana, placing it in the bottom half of nursing homes in the state, and it is ranked #11 out of 11 in Orleans County, indicating that there are no better local options available. While the facility is improving, with issues decreasing from 13 in 2024 to 4 in 2025, it still faces significant challenges. Staffing is a strong point, with a turnover rate of 0%, which is much better than the state average, but the overall rating for staffing is still poor at 1 out of 5. There have been no fines, but there are concerning incidents, such as unsecured hazardous chemicals accessible to residents and pests found in the kitchen, which highlight ongoing safety and cleanliness issues.

Trust Score: D
In Louisiana: #251/264
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: Turnover data not reported for this facility.
Penalties: No fines on record. Clean compliance history, better than most Louisiana facilities.
Skilled Nurses: Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 38 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 13 issues

2025: 4 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

The Ugly 38 deficiencies on record

Aug 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record reviews, the facility failed to ensure a resident was assessed to ensure the resident could safely self-administer a medication prior to the resident self-administering medications for 1 (Resident #47) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings: Review of Resident #47's Minimum Data Set with an Assessment Reference Date of 07/02/2025 revealed, in part, a Brief Interview for Mental status score of 11, which indicated Resident #47 had moderate cognitive impairment. Review of Resident #47's Physician Orders as of 08/20/2025 revealed, in part, no orders for Resident #47 to self-administer his medications, and no order for Voltaren gel (a gel medication used for arthritis pain). Review of Resident #47's Care Plan with a target date of 10/09/2025 revealed, in part, Resident #47 was not care planned to self-administer medications or have medications at his bedside. Review of Resident #47's Electronic Medication Administration Record from 08/01/20225 to 08/31/2025 revealed, in part, documentation that Resident #47's medications were administered by facility staff.Observation on 08/18/2025 at 11:10AM revealed a tube of gel labeled as Voltaren gel was present on Resident #47's bedside table. Observation on 08/19/2025 at 12:19PM revealed a tube of gel labeled as Voltaren gel was present on Resident #47's bedside table. In an interview on 08/19/2025 at 12:22PM, S8Licensed Practical Nurse indicated Resident #47 should not have access to the medication Voltaren. In an interview on 08/19/2025 at 12:31PM, S8LPN indicated Resident #47 was not assessed and/or care planned to self-administer medications. In an interview on 08/20/2025 at 8:47AM, S2Director of Nursing indicated Resident #47 should not have had the medication Voltaren at his bedside because he wasn't assessed and care planned to self-administer medications .

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to:1. Ensure a resident's care plan was revised after a witnessed fall (Resident #72); and,2. Ensure a residents fall care plan interventions were implemented after a witnessed fall (Resident #72). This deficient practice was identified for 1 (Resident #72) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings:1.Review of the facility's Accidents/Incidents Policy, last revised on 06/17/2002, revealed, in part the charge nurse and/or the nursing supervisor will initiate a plan of care change that was professionally warranted to ensure a resident's welfare and safety prior to the end of the shift. Review of Resident #72's Electronic Medical Record revealed, in part, Resident #72 was admitted to the facility on [DATE] with a history of falling. Review of Resident #72's Incident and Accident Log, revealed, in part, Resident #72 had a witnessed fall with no injury on 08/17/2025. Review of Resident #72's care plan with a next review date of 11/10/2025 and last revision date of 05/19/2025 revealed, in part, Resident #72's care plan was not updated with new goals and/or interventions following Resident #72's fall on 08/17/2025. In an interview on 08/19/2025 at 1:30PM, S2Director of Nursing (DON) indicated Resident #72's care plan was not updated with fall interventions after a witnessed fall on 08/17/2025, and should have been. In an interview on 08/19/2025 at 2:30PM, S13Minimum Data Set (MDS) Nurse indicated the nurse supervisor/charge nurse on duty did not update Resident #72's care plan after Resident #72's fall prior to the end of the shift on 08/17/2025, and should have. 2. Review of Resident #72's Activities of Daily Living (ADL) care plan initiated and revised on 08/19/2025 revealed, in part, Resident #72 required maximal assistance and required the assistance of two person to transfer. Review of Resident #72's Incident and Accident Log dated 08/20/2025 revealed, in part, S14Certified Nursing Assistant (CNA) attempted to transfer Resident #72 from the bed to the wheelchair without assistance which resulted in a witnessed fall. In an interview on 08/20/2025 at 12:45PM, S2DON indicated Resident #72 was care planned to have two staff assist for transfers. S2DON further indicated Resident #72's fall care plan was not implemented when S14CNA attempted to transfer Resident #72 without assistance.

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to:1. Ensure hazardous chemicals were not accessible to residents (Resident #75's room, Hall c, Hall d, Room f); and, 2. Ensure a resident had sufficient supervision to prevent a fall (Resident #72). This deficient practice was identified for 5 (Resident #75's room, Hall c, Hall d, Room f) of 5 (Resident #75's room, Hall c, Hall d, Room f) locations observed containing unsecured chemicals during observations and for 1 (Resident #72) of 4 (Resident #5, Resident #47, Resident #72, Resident #105) sampled residents investigated for accidents. Findings:1. Observation on 08/18/2025 at 10:26AM revealed a spray bottle with an unknown purple chemical substance on the housekeeper’s cart located on Hall “c”. In an interview on 08/18/2025 at 10:28AM, S5Housekeeper indicated her housekeeper’s cart located on Hall “c” did contain a spray bottle which contained a purple floor cleaner. S5Housekeeper further indicated the floor cleaner was E31, a pH neutralizer cleaner. Observation on 08/18/2025 at 10:30AM revealed a bottle of plant food/fertilizer on a table in the Hall “c” dining room. In an interview on 08/18/2025 at 10:34AM, S6Licensed Practical Nurse (LPN) indicated the plant food/fertilizer should not have been accessible to residents in the Hall “c” dining room. Observation on 08/18/2025 at 10:48AM revealed Hall “d” cabinet next to Room “e” contained a spray bottle with an unknown green chemical substance. In an interview on 08/18/2025 at 10:50AM, S7Certified Nursing Assistant (CNA) indicated the spray bottle located in the Hall “d” cabinet contained a sanitizer. S7CNA further indicted the chemical should be secured and was not. Observation on 08/18/2025 at 11:09AM revealed, in part, the door to Room “f”, a general room for hair care, was propped open. Further observation of Room “f” revealed an cleaning chemicals contained in an unsecured cabinet, and an opened 64 ounce bottle of disinfectant used to clean salon/barbershop equipment/tools. In an interview on 08/18/2025 at 11:13AM, S3LPN indicated the door to Room “f” should always be locked while not in use to avoid resident access to sharps and chemicals. In an interview on 08/18/2025 at 11:30AM, S2Director of Nursing (DON) indicated all chemicals should be secured and not available to residents. Review of Resident #75’s care plan review dated 08/31/2025, revealed, in part, Resident #75 had sensory and perception alterations related to vision. Further review revealed an intervention for staff to remove possible environmental barriers to ensure safety. Further review revealed an intervention for the facility to perform safety risk evaluations as needed. In an interview on 08/18/2025 at 3:57PM, Resident #75 indicted she had two cans of aerosolized insecticide in the room. Observation on 08/18/2025 at 4:00PM revealed two cans of aerosolized insecticide the lower shelf of Resident #75’s room. Observation on 08/19/2025 at 2:44PM revealed S8Licensed Practical Nurse (LPN) picked up the two cans of aerosolized insecticide and placed them in the closet of Resident #75’s room. S8LPN further indicated she was unaware Resident #75 had two cans of aerosolized insecticide in Resident #75’s room. In an interview on 08/20/2025 at 12:30PM, S1Administrator indicated Resident #75 should not have had aerosolized insecticide in her room. 2. Review of the facility’s Accidents/Incidents Policy, last revised on 06/17/2002, revealed, in part the charge nurse and/or the nursing supervisor will initiate a plan of care change that was professionally warranted to ensure a resident’s welfare and safety prior to the end of the shift. Review of Resident #72’s Electronic Medical Record revealed, in part, Resident #72 was admitted to the facility on [DATE] with a history of falling. Review of Resident #72’s Incident and Accident Log, revealed, in part, Resident #72 had a witnessed fall with no injury on 08/17/2025. Review of Resident #72’s Activities of Daily Living (ADL) care plan initiated and revised on 08/19/2025 revealed, in part, Resident #72 required maximal assistance and required the assistance of two person to transfer. Review of Resident #72’s Incident and Accident Log dated 08/20/2025 revealed, in part, S14Certified Nursing Assistant (CNA) attempted to transfer Resident #72 from the bed to the wheelchair without assistance which resulted in a witnessed fall. In an interview on 08/20/2025 at 12:45PM, S2DON indicated Resident #72 was care planned to have two staff assist for transfers. S2DON further indicated Resident #72’s fall care plan was not implemented when S14CNA attempted to transfer Resident #72 without assistance.

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 F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record reviews, the facility failed to ensure the facility was free of pests. Findings:Observation on 08/18/2025 at 8:56AM revealed 4 black flying insects were present in the kitchen's dry storage room. In an interview on 08/18/2025 at 8:56AM, S11Dietary Manager (DM) confirmed the presence of the black flying insects in the facility's dry storage room and in the facility's kitchen. In an interview on 08/19/2025 at 11:13AM, S11DM confirmed that the facility's kitchen had an increased amount of black flying insects. Observation on 08/19/2025 at 11:20AM revealed 3 black flying insects were present in the kitchen's dry storage room. Observation on 08/19/2025 at 11:23AM revealed 3 black flying insects flying around the kitchen's shelving unit. Observation on 08/19/2025 at 11:24AM revealed a gallon bottle of distilled vinegar with the bottle's cap ajar. Further observation revealed at 4 black insects were floating in the liquid contained in the gallon bottle of distilled vinegar. In an interview on 08/19/2025 at 11:25AM, S11DM confirmed that there were insects floating in the gallon bottle of distilled vinegar. In an interview on 08/19/2025 at 12:12 PM, S2Director of Nursing (DON) was informed of findings in kitchen, including multiple black flying and dead insects. S2DON acknowledged insects should not have been present in the facility's kitchen. In an interview on 08/19/2025 at 12:15PM, S2DON confirmed she was aware that the black flying insects were in the facility, but that she was not aware the insects were in the facility's kitchen. In an interview on 08/20/2025 at 10:33AM, S1Administrator indicated that the black flying insects were periodically present in the facility. S1Administrator further indicated S11DM had not notified S1Administrator that the black flying insects had returned to the facility's kitchen. S1Administrator further indicated that it was part of S11DM's job to be aware of the state of the facility's kitchen. S1Administrator further indicated that S11DM should have notified pest control and facility administration as soon as the black flying insects had returned to the facility's kitchen. S1Administrator confirmed that the black insects should not have been present in the facility.

Dec 2024 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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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 follow a physician's order to perform a weekly skin assessment for a resident at risk for pressure ulcers for 1 (Resident #2) of 3 sampled residents reviewed. Findings: Review of the facility's undated Wound Prevention policy and procedure revealed, in part, weekly skin checks will be conducted by the licensed nurse and documented in the resident's Electronic Medical Record (EMR). Review of the facility's undated Skin Care (Decubitus Prevention and Wound Care) policy and procedure revealed, in part, a resident with a score greater than 12 on the Braden Scale with reverse numbering is considered at risk and is checked weekly by the nurse assigned to their care. Review of Resident #2's December 2024 physician orders revealed, in part, complete weekly skin assessment in the morning every Wednesday. Review of Resident #2's care plan with a review date of 02/02/2025 revealed, in part, a care plan for risk for pressure ulcers with approaches which included skin evaluations. Review of Resident #2's assessment report revealed, in part, no documented evidence, and the facility could not provide any documented evidence, a weekly skin assessment was performed on 12/11/2024 as ordered. Review of Resident #2's Braden Scale assessment dated [DATE] revealed, in part, a total score of 8.0 which indicated Resident #2 was at a very high risk of skin breakdown and/or developing a pressure ulcer. In an interview on 12/17/2024 at 1:15PM, S15Licensed Practical Nurse (LPN) indicated Resident #2 was at a high risk for skin breakdown and/or pressure ulcer development. S15LPN further confirmed Resident #2's 12/11/2024 skin assessment was not completed as ordered and should have been. In an interview on 12/17/2024 at 2:45PM, S2Director of Nursing (DON) confirmed Resident #2's skin assessment was not completed on 12/11/2024 as ordered and should have been.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure a Resident's medication administration record was accurately documented for 1 (Resident #R5) of 5 residents reviewed for medication administration documentation. Findings included: Review of the facility's undated Liberalized Medication policy and procedure revealed, in part, the date, time, dosage, and medication administered should be recorded in the resident's medical record by the individual administering the medication. Review of Resident #R5's December 2024 physician's orders revealed, in part, Ferrous Gluconate 324 milligrams (mg) one tablet by mouth daily with breakfast was to be administered to Resident #R5. Review of Resident #R5's Medication Administration History Report revealed, in part, S8Licensed Practical Nurse (LPN) documented she administered 324 mg of Ferrous Gluconate to Resident #R5 on the following dates: - 12/11/2024 at 9:24AM; - 12/12/2024 at 8:59AM; - 12/13/2024 at 8:41AM; - 12/14/2024 at 1:07PM; - 12/15/2024 at 9:20AM; and, - 12/16/2024 at 9:04AM. Further review revealed S14LPN documented she administered 324mg of Ferrous Gluconate to Resident #R5 on 12/10/2024 at 10:22AM. In an interview on 12/17/2024 at 8:57AM, S8LPN indicated the above mentioned medication administration history report for Resident #R5 was inaccurate because she did not administer 324mg of Ferrous Gluconate to Resident #R5 on the above dates. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) confirmed that the above mentioned medication administration history report for Resident #R5 was inaccurate.

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility document review it was determined that the facility failed to ensure the medication error rate was not greater than 5% by having a medication error rate of 6.66 % for 2 (Resident #3 and Resident #R5) of 7 residents observed during medication administration. Findings Included: Resident #3 Review of Resident #3's medical record revealed, in part, Resident #3 was admitted to the facility on [DATE] with a diagnosis of, in part, Iron Deficiency Anemia (low levels of iron in the blood). Review of Resident #3's Minimum Data Set with an Assessment Reference Date (ARD) of 09/18/2024 revealed, in part, Resident #3 had a brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #3 was cognitively intact. Review of Resident #3's December 2024 physician's orders revealed, in part, Ferrous Gluconate (a medication used to treat low levels of iron in the blood) oral tablet give one tablet once a day by mouth. Observation on 12/17/2024 at 8:15AM revealed S7Licensed Practical Nurse (LPN) attempted to administer one Ferrous Sulfate 325 milligrams (mg) tablet by mouth to Resident #3. In an interview on 12/17/2024 at 8:21AM, Resident #3 indicated she refused to take the iron pill S7LPN attempted to administer to her because she knew it was the incorrect medication. In an interview on 12/17/2024 at 08:24AM S7LPN indicated Resident #3 was ordered 240 mg of Ferrous Gluconate. S7LPN further indicated she attempted to administer 325 mg of Ferrous Sulfate to Resident #3 and should not have. In an interview on 12/17/2024 at 9:40AM, S16Pharmacist indicated Ferrous Sulfate should not be used in place of Ferrous Gluconate unless approved by a physician. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) indicated Resident #3's physician's order was for one tablet of Ferrous Gluconate 240 mg once a day by mouth. S2DON further indicated S7LPN should not have attempted to administer Resident #3 one tablet of Ferrous Sulfate 325 mg. Resident #R5 Review of Resident #R5's medical records revealed, in part, Resident #5 was admitted to the facility on [DATE] with diagnoses of, in part, Anemia, Cognitive Deficit, and Dementia. Review of Resident #R5's December 2024 physician's orders revealed, in part, Ferrous Gluconate 324 milligrams (mg) one tablet by mouth daily with breakfast. Observation on 12/17/2024 at 8:43AM revealed S8Licensed Practical Nurse (LPN) attempted to administer one Ferrous Gluconate 240 mg tablet by mouth to Resident #R5. In an interview on 12/17/2024 at 8:57AM, S8LPN indicated Resident #R5 was ordered to receive 324 mg of Ferrous Gluconate. S8LPN further indicated she attempted to administer Resident #R5 240 mg of Ferrous Gluconate, and should not have. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) indicated S7LPN should not have attempted to administer Resident #R5 the incorrect dose of Ferrous Gluconate.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure: 1. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care for 2 (Resident #R6 and Resident #R7) of 2 residents observed during incontinence care; and, 2. Clean laundry was kept separate from dirty and/or contaminated laundry for 1 (Laundry Room f) of 7 laundry rooms observed. Findings included: 1. Review of the facility's undated Handwashing policy and procedure revealed, in part, the purpose of handwashing is to prevent cross contamination and control infection. Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, decontaminate hands if moving from a contaminated body site to a clean body site during patient care. Resident #R6 Review of Resident #R6's Minimum Data Set with an Assessment Reference Date (ARD) of 11/06/2024 revealed, in part, Resident #R6 was always incontinent of bowel and bladder. Further review revealed Resident #R6 was dependent on staff for toileting hygiene. Observation on 12/18/2024 at 11:21AM revealed S12Certified Nursing Assistant (CNA) entered Resident #R6's room to perform incontinence care. S12CNA then removed Resident #R6's urine and feces soiled brief, cleaned Resident #R6's buttock's area of feces, and placed a clean brief on Resident #R6 without changing gloves or performing hand hygiene. S12CNA then disposed of Resident #R6's soiled brief into the trash, and then touched Resident #R6's pillow and bed linens with the same gloves used to perform incontinence care. In an interview on 12/18/2024 at 11:45AM, S12CNA confirmed she did not change gloves or perform hand hygiene prior to placing a clean adult brief on Resident #R12, and should have. In an interview on 12/18/2024 at 3:24PM, S2Director of Nursing (DON) confirmed S12CNA did not perform hand hygiene according to infection control standards, and should have. Resident #R7 Review of Resident #R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/2024 revealed, in part, Resident #R7 was incontinent of bowel and bladder, requiring maximum assistance with toileting, and had a Urinary Tract Infection. Observation on 12/18/2024 at 11:54PM revealed S13Certified Nursing Assistant (CNA) did not perform hand hygiene before putting on gloves to provide peri-care to Resident #R7. Further observation revealed S13CNA did not remove gloves, did not perform hand hygiene, and did not put on new gloves before she placed the clean brief on Resident #R7. Further observation revealed that S13CNA did not perform hand hygiene before she left Resident #R7's room. In an interview on 12/18/2024 at 3:22PM, S13CNA indicated she should have performed hand hygiene before she performed peri-care on Resident #R7, and that she should have changed gloves and performed hand hygiene after she completed peri-care on Resident #R7. In an interview on 12/18/2024 at 3:30PM, S2Director of Nursing (DON) indicated S13CNA should have performed hand hygiene before and after she performed Resident #R7's peri-care. S2DON further indicated S13CNA should have changed gloves, performed hand hygiene, and placed clean gloves on before she placed a clean brief on Resident #R7. 2. In an interview on 12/16/2024 at 11:15AM, S1Administrator confirmed the CNA staff collected, washed, and dried the resident's clothing in the facility's laundry area on each unit. Observation of laundry room f on 12/16/2024 at 12:24PM revealed five unlabeled plastic baskets of laundry on the floor next to each other. In an interview on 12/16/2024 at 12:30PM, S5Housekeeper indicated the above mentioned five baskets of laundry consisted of baskets of both clean and dirty laundry. S5Housekeeper further indicated the clean and dirty laundry should have been labeled, separated, and not left on the floor. In an interview on 12/16/2024 at 12:32PM, S10CNA indicated the baskets of laundry on the floor in the north third floor laundry room were unlabeled, and consisted of clean and dirty laundry. Observation of laundry room f on 12/16/2024 at 1:54PM, revealed visibly soiled linen balled up in the hand wash sink next to the washing machine. Further observation revealed, a pile of clean laundry sitting directly on the top surface of the dryer. In an interview on 12/16/2024 at 1:56PM, S11CNA indicated she placed the above mentioned dirty linen in the handwashing sink and should not have. In an interview on 12/16/2024 at 2:02PM, S4Licensed Practical Nurse (LPN) indicated dirty linen should not have been placed in the handwashing sink. Observation of laundry room f on 12/17/2024 at 9:04AM revealed an uncovered basket on the floor containing contaminated clothing. Further observation revealed cleaned laundry directly on top of the surface of the dryer.

CONCERN (F) 📢 Someone Reported This

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

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

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

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Based on record review, the facility failed to electronically submit payroll information for direct care staffing as required. Findings included: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2024 (July 1 - September 2024) revealed, in part, the facility failed to submit staffing data for Quarter 4. There was no documented evidence and the facility did not present any documented evidence the facility's PBJ Staffing Data for FY Quarter 4 2024 (July 1 - September 30) was submitted as required.

Aug 2024 7 deficiencies

CONCERN (D)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) had a performance review within the last 12 months for 1 (S5CNA) of 3 (S5CNA, S6CNA, and S7CNA) sampled CNAs reviewed for sufficient staff review. Findings: Review of S5CNA's personnel file revealed a date of hire of 10/17/2018. Further review revealed no documented evidence and the facility presented no documented evidence of a performance review having been completed for S5CNA within the last 12 months. In an interview on 08/27/2024 at 2:33 p.m., S3Chief Operating Officer indicated the facility did not have any documented evidence of a performance review had been completed for S5CNA.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to: 1. ensure expired food was not available for resident consumption, 2. ensure the facility's kitchen was maintained in a sanitary manner; and, 3. ensure staff checked and documented the temperature of the facility's steam tables and refrigerator/freezers. Findings: 1. Review of the facility's undated Food Storage Policy revealed, in part, the facility will ensure safe and appropriate food storage. Further review revealed appropriate foods will be covered, labeled, and dated as stored in the refrigerator or freezer. Observation on 08/26/2024 at 9:15 a.m. revealed the following: -1 opened bottle of garlic parmesan wing sauce available for use with expiration dates of 05/04/2024 and 08/21/2024 -1 opened container of solidified ground ginger available for use with an expiration date of 12/27/2022 -1 opened bottle of vanilla syrup available for use with an expiration date of 09/2023 -1 unopened bottle of cinnamon sauce available for use with an expiration date of 02/19/2023 -1 unopened gallon of regular milk available for use with an expiration date of 08/23/2024 In an interview on 08/26/2024 at 9:20 a.m., S12Dietary Manager acknowledged expired food should not have been available for use in the food pantry and kitchen. In an interview on 08/26/2024 at 9:30 a.m. S1Administrator acknowledged expired food in the food pantry and kitchen should not have been available for use. 2. Observation on 08/26/2024 at 9:15 a.m. revealed the following: -1 box of oranges that contained three fuzzy light green shriveled oranges available for resident consumption, -A brown liquid substance on floor in front of the 3 compartment steamer, -deep fryer with a caked on brown substance, -a liquid brown substance on the floor directly in front of the 2 compartment deep fryer, -steam table had cloudy yellow water in all three compartments, -2 tier serving cart located next to the 2 compartment deep fryer had splatter a brown liquid substance, -a wet white blanket on the floor next to the dishwasher, -3 compartment sink had dirty pots and pans with brown dried food substances and dried rice, -speed racks with brown greasy substances in all crevices where the sheet pan would sit, -1 Sheet pan with dark brown greasy substance on a waxy paper, -3 Saute skillets with thick black hard substances to their bottoms, and -the sink used for hand washing had a leak in the pipe causing water to leak onto the floor when in use. In an interview on 08/26/2024 at 9:10 a.m., S12Dietary Manager further indicated food should have been stored in the facility's kitchen in a sanitary manner. S12Dietary Manager further indicated the kitchen's equipment used to prepare food should have been kept clean. In an interview on 08/26/2024 at 9:30 a.m., S1Administrator indicated food should have been stored in the facility's kitchen in a sanitary manner. S12Dietary Manager further indicated the kitchen's equipment used to prepare food should have been kept clean. 3. Review of the facility's temperature log book did not reveal documented evidence, and the provider did not present any documented evidence the food temperatures for steam table a and temperatures for refrigerator/freezer a were checked in August 2024. Observation on 08/26/2024 at 12:00 p.m. revealed no documented evidence temperature checks were performed and documented for steam table a. Further observation revealed no documentation that temperature checks were performed and documented for refrigerator/freezer a. In an interview on 08/28/2024 at 12:10 p.m., S16Homemaker indicated she did not check food temperatures from steam table a prior to serving breakfast to residents. S16Homemaker also indicated she did not perform a temperature check on the refrigerator/freezer a. In an interview on 08/28/2024 at 12:16 a.m., S2DON acknowledged S16Homemaker should have obtained temperature checks of prepared food placed on steam table a prior to serving breakfast to residents. S2DON also indicated S15Homemaker should have obtained temperature checks refrigerator/freezer a and documented the results in the temperature log book. S2DON did not provided any documented evidence of temperature checks for steam table a and refrigerator/freezer a for August 2024. Review of the facility's temperature log book revealed no documented evidence, and the provider did not present any documented evidence, the food temperatures for steam table b and the temperatures for refrigerator/freezer b were checked since 06/27/2024. Observation on 08/28/2024 at 12:19 p.m. revealed, S15Homemaker putting food onto plates for residents' consumption. In an interview on 08/28/2024 at 12:20 p.m., S15Homemaker indicated she did not check the food temperatures on steam table b prior to serving food to residents on 08/28/2024 before serving breakfast and before serving lunch. S15Homemaker also indicated she did not check the temperatures on refrigerator/freezer b. In an interview on 08/28/2024 at 12:30 p.m., S1Administrator indicated S15Homemaker should have obtained temperatures of food prepared and placed on steam table b prior to serving food to residents. S1Administrator indicated temperature checks of food on the steam table should be completed prior to serving breakfast, lunch, and dinner to residents. S1Administrator also indicated, temperature checks of refrigerator/freezer b should be documented and maintained in the log book. The facility did not provide any documented evidence of temperature checks for the month of July and August for steam table b and refrigerator/freezer b.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to: 1. have documented evidence of maintaining the water management program for legionella; and, 2. have an accurate tracking and trending of all facility infections. Findings: 1. Review of the facility's Water Management Program dated 02/2024 revealed the facility shall facilitate principles of effective water management of, in part: Maintaining water temperatures outside the ideal range for Legionella growth (77-113°F); Preventing water stagnation; Ensuring adequate disinfection; and, Maintaining premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. In an interview on 08/27/204 at 11:51 a.m., S4Quality Director indicated the facility did not have documented evidence of monitoring and maintaining the water temperatures between 77-113 degrees Fahrenheit. S4Quality Director further stated the facility did not have any further documentation of monitoring of any of the components of the facility's Water Management Program. In an interview on 08/27/204 at 1:04 p.m., S2Director of Nursing (DON) indicated she had no further information to present on the above areas of deficient practice. In an interview on 08/27/2024 at 2:01 p.m., S1Administrator indicated the facility did not have any further information to present on the above mentioned deficient practice. 2. Review of the facility's Infection Log for May 2024 revealed the following, in part, Resident #80 had conjunctivitis on 05/07/2024; Resident #22 had an upper respiratory infection on 05/08/2024; and, Resident #31 had an infection listed as other on 05/06/2024. Review of the facility's Tracking and Trending facility Maps for May 2024 revealed no documented evidence and the facility presented no documented evidence the facility had plotted the above mentioned infections for identification of clusters/trends of infections. Review of the facility's Infection Log for June 2024 revealed the following, in part, Resident #29 had a urinary tract infection on 06/06/2024; Resident #19 had a lower respiratory infection on 06/04/2024, and a urinary tract infection on 06/12/2024; Resident #25 had a skin infection on 06/17/2024; Resident #22 had urinary tract infection on 06/13/2024; Resident #33 had an infection listed as other on 06/06/2024; Resident #81 had a urinary tract infection on 06/05/2024; and, Resident #8 had a urinary tract infection on 06/11/2024. Review of the facility's Tracking and Trending facility Maps for June 2024 revealed no documented evidence and the facility presented no documented evidence the facility had plotted the above mentioned infections for identification of clusters/trends of infections. Review of the facility's Infection Control Log for July 2024 revealed the following, in part, Resident #59 had a urinary tract infection on 07/30/2024; Resident #37 had a urinary tract infection on 07/22/2024; Resident #63 had a skin infection on 07/24/2024; Resident #20 had a skin infection on 07/02/2024, 07/04/2024, and 07/22/2024; Resident #33 had an infection listed as other on 07/15/2024; and, Resident #95 had a urinary tract infection on 07/17/2024. Review of the facility's Tracking and Trending facility Maps for July 2024 revealed no documented evidence and the facility presented no documented evidence the facility had plotted the above mentioned infections for identification of clusters/trends of infections. In an interview on 08/27/2024 at 12:28 p.m., S4Quality Director indicated the facility was not tracking and trending infections appropriately to identify trends in infection. In an interview on 08/27/2024 at 1:04 p.m., S2Director of Nursing indicated she had no further information to present on the above areas of deficient practice.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure the resident's medical record contained documentation of the education and refusal of vaccination for the influenza and pneumococcal for 4 (Resident #27, Resident #32, Resident #66, and Resident #83) of 5 (Resident #27, Resident #32, Resident #66, Resident #83, and Resident #90) sampled residents reviewed for immunizations. Findings: Review of the facility's spread sheet for vaccination revealed the following, in part: -Resident #27 had not received an influenza vaccination since 09/27/2020 with notation of refused; -Resident #32 had refused the pneumococcal vaccination; -Resident #66 had refused the influenza and pneumococcal vaccinations; and, -Resident #83 had refused the influenza and pneumococcal vaccination. Review of Resident #27, Resident #32, Resident #66, and Resident #83's records revealed no documented evidence of a refusal or consent had been signed for the above mentioned vaccinations. The facility presented the above mentioned Informed Consents for Resident #27, Resident #32, Resident #66, and Resident #83's above mentioned vaccinations which were signed on 08/27/2024, the date of the vaccination review. Further review revealed the education provided on the vaccinations was from the 2022 Centers for Disease Control pamphlets. In an interview on 08/27/2024 at 12:28 p.m., S4Quality Director indicated he had verbally asked the above mentioned residents in the past regarding vaccinations and documented on the facility's spread sheet if administered or refused, but did not have proof of the refusals or education prior to today, 08/27/2024. S4Quality Director further indicated the facility did not provide current literature for education on the vaccinations risks and benefits. In an interview on 08/27/2024 at 1:04 p.m., S2Director of Nursing (DON) indicated she had no further information to present on the above areas of deficient practice.

CONCERN (D)

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

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure Certified Nursing Assistants (CNA) received 12 hours of in-services annually for 3 (S5CNA, S6CNA, and S7CNA) of 3 (S5CNA, S6CNA, and S7CNA) sampled CNAs records reviewed. Findings: Review of S5CNA's personnel file revealed a date of hire of 10/17/2018. Further review revealed S5CNA's personnel file revealed no documented evidence and the facility was unable to present any documented evidence of 12 hours of in-services had been completed for S5CNA annually. Review of S6CNA's personnel file revealed a date of hire of 03/15/2019. Further review revealed S6CNA's personnel file revealed no documented evidence and the facility was unable to present any documented evidence of 12 hours of in-services had been completed for S6CNA annually. Review of S7CNA's personnel file revealed a date of hire of 11/10/2020. Further review revealed S7CNA's personnel file revealed no documented evidence and the facility was unable to present any documented evidence of 12 hours of in-services had been completed for S7CNA annually. In an interview on 08/27/2024 at 2:33 p.m., S3Chief Operating Officer indicated the facility did not have documentation of 12 hours of in-services annually for S5CNA, S6CNA, and S7CNA. S3Chief Operating Officer further indicated the facility had not monitored to ensure 12 hours were completed annually.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observations and interviews, the facility failed to: 1. Ensure a resident's room and equipment was kept clean for 2 (Resident #36 and Resident #66) of 7 (Resident #6, Resident #16, Resident #27, Resident #36, Resident #56, Resident #66, and Resident #90) and, 2. Ensure a resident's equipment was in good repair for 3 (Resident #6, Resident #27, and Resident #56) of 7 (Resident #6, Resident #16, Resident #27, Resident #36, Resident #56, Resident #66, and Resident #90) sampled residents reviewed for environment. Findings: 1. Resident #36 Observation on 08/26/2024 at 10:01 a.m., revealed large areas of a dried tan substance on the floor near Resident #36's tube feeding pole and on the base of Resident #36's tube feeding pole. Observation on 08/28/2024 at 3:05 p.m., revealed large areas of a dried tan substance on the floor near Resident #36's tube feeding pole and on the base of Resident #36's tube feeding pole. In an interview on 08/28/2024 at 3:05 p.m., S9Licensed Practical Nurse confirmed there were areas of a dried tan substance on Resident #36's floor and the base of Resident 36's tube feeding pole, and both should have been clean. Resident #66 Observation on 08/26/2024 at 9:45 a.m., revealed small and large pieces of food and splatters of dried liquids on the floor next to Resident #66's bed. Further observation revealed pieces of food and splatters of dried liquid on the right side of Resident #66's side rail and bed frame. Observation further revealed small pieces of food and a brown liquid along the edge of Resident #66's rolling bedside table. Observation on 08/27/2024 at 11:42 a.m. revealed small pieces of food and splatters of dried liquids on the floor next to Resident #66's bed. Further observation revealed pieces of food and splatters of dried liquid on the right side of Resident #66's side rail and bed frame. In an interview on 08/28/2024 at 2:35 p.m., S1Administrator confirmed Resident #66's room and equipment were dirty and staff should have kept Resident #66's room clean. 2. Resident #6 Observation on 08/27/2024 at 12:18 p.m. revealed the edges along the top surface of Resident #6's rolling bedside table were peeled and broken. Resident #27 Observation on 08/27/2024 at 12:20 p.m. revealed the edges and center of the top surface of Resident #27's rolling bedside table edges were peeled and broken. Resident #56 Observation on 08/27/2024 12:28 p.m. revealed the edges along the top surface of Resident #56's rolling bedside table were peeled and broken. In an interview on 08/27/2024 at 12:45 p.m., S1Administrator confirmed Resident #6's, Resident #27's, and Resident #56's rolling bedside tables were damaged and should have been replaced.

CONCERN (E)

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

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected multiple residents

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Based on record reviews and interview, the facility failed to ensure documentation was complete and accurate for resident's Physician Progress Notes for 2 (Resident #6 and Resident #11) of all sampled resident's records reviewed for accuracy. Findings: Resident #6 Review of Resident #6's Physician Progress Notes revealed, in part, S14Nurse Practitioner (NP) documented a physician progress note for Resident #6 on 01/16/2024, 03/16/2024, 04/16/2024, 05/16/2024, and 06/18/2024. Further review revealed Resident #6's chief complaint, physical exam, diagnosis, problem list, and plan were exactly the same in all of the above mentioned notes documented by S14NP. Further review revealed S14NP's Physician Progress Notes documented on 03/16/2024, 04/16/2024, 05/16/2024 and 06/18/2024 were photocopies of Resident #6's note documented on 01/16/2024 with the date changed and handwritten in. Resident #11 Review of Resident #11's Physician Progress Notes revealed, in part, S14NP documented a physician progress note for Resident #11 on 11/15/2023, 03/15/2024, 04/15/2024, 05/15/2024, and 06/10/2024. Further review revealed Resident #11's vital signs, chief complaint, physical exam, laboratory results, diagnosis, problem list, and plan were exactly the same in all of the above mentioned notes documented by S14NP. Further review revealed Resident #11's physician progress notes documented by S14NP dated 03/16/2024, 04/16/2024, 05/16/2024 and 06/10/2024 were photocopies of Resident #11's physician progress note dated 11/15/2023 with the date changed and handwritten in. In an interview on 08/29/2024 at 11:25 a.m., S14NP indicated she would often make copies of resident's previous physician progress notes and use those copies to document a resident's current assessment. S14NP acknowledged Resident #11's physician progress notes dated 03/15/2024, 04/15/2024, 05/15/2024, and 06/10/2024 were photocopied from Resident #11's physician progress note dated 01/16/2024. S14NP confirmed Resident #11's assessments which included vital signs and a physical exam would not have been exactly the same for her visits and the above mentioned physician progress notes were inaccurate. In an interview on 08/29/2024 at 12:23 p.m., S2Director of Nursing indicated S14NP should not have photocopied a resident's physician progress note, changed the date, and then used the photocopy for future assessments. In an interview on 08/29/2024 at 4:20 p.m., S1Administrator indicated it was not the facility's policy for physicians and/or nurse practitioners to photocopy a resident's previous progress note and change the date for use as subsequent progress notes. S1Administrator further indicated it was also not the facility's policy to have physicians and/or nurse practitioners document a previous assessment as current and accurate on a resident's progress note. In an interview on 08/29/2024 at 4:20 p.m., S3Chief Operating Officer indicated it was not the facility's policy for physicians and/or nurse practitioners to photocopy a resident's previous progress note and change the date for use as subsequent progress notes. S1Administrator further indicated it was also not the facility's policy to have physicians and/or nurse practitioners document a previous assessment as current and accurate on a resident's progress note.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's rights to be free from psychosocial abuse from S5Certified Nursing Assistant (CNA). This deficient practice was identified for 3 (Resident #1, Resident #2, Resident #3) of 3 sampled residents reviewed for abuse. Findings: Review of the facility's undated policy and procedure on Abuse Recognition, Reporting, and Investigation revealed, in part, residents of the facility are protected from any physical and mental mistreatment. Further review of the policy revealed verbal abuse was defined as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents regardless of their age, ability to comprehend, or disability. Review of the facility's required posted staffing schedule and hours dated 02/26/2024 revealed, in part, S5CNA was assigned to work 7:00 p.m. - 7:00 a.m. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses, in part, of generalized muscle weakness, heart failure and depression. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 revealed, in part, a Brief Interview of Mental Status (BIMS) of 13 which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 required assistance with bed mobility, transfers, and toileting. In an interview on 03/18/2024 at 12:09 p.m. S2CNA stated during morning rounds on 02/27/2024, she discovered Resident #1 visibly upset and crying. S2CNA indicated Resident #1 informed her that S5CNA told her she was in the nursing home because her family did not love her. In an interview on 03/19/2024 at 9:30 a.m. S3Licensed Practical Nurse (LPN) stated during morning report on 02/27/2024, S4LPN informed her that S5CNA was rude to several of the residents during the night. S3LPN further stated when she entered Resident #1's room to perform care, Resident #1 grabbed her hand and started crying. In an interview on 03/19/2024 at 3:40 p.m. S4LPN stated before ending her shift she entered Resident #1's room and observed her crying. S4LPN stated Resident #1 asked to speak to the Administrator and informed her she did not want S5CNA to come back into her room. Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses, in part, of Spinal Stenosis, Morbid Obesity and Pain. Review of Resident #1's quarterly MDS with an ARD of 01/24/2024 revealed, in part, Resident #2 had a BIMs of 11 which indicates moderate impairment, required assistance with bed mobility, transferring and toileting. In an interview on 03/18/2024 at 12:09 p.m., S2CNA indicated while passing breakfast trays, Resident #2 informed her that S5CNA disregarded her request to be careful with her knee during incontinence care. In an interview on 03/19/2024 at 9:30 a.m., S3LPN indicated Resident #2 reported that S5CNA was not careful when performing care and caused increased pain in her right knee. S3LPN stated this occurred on the night shift of 02/26/2024. In an interview on 03/19/2024 at 3:00 p.m., Resident #2 stated S5CNA came into her room during the night to perform incontinence care. Resident #2 indicated she explained to S5CNA that her right knee was hurting from arthritis and requested her to be careful with her knee while performing incontinence care. Resident #2 further indicated S5CNA disregarded her request told her there was nothing wrong with her leg and performed incontinence care as usual which aggravated her arthritis pain during incontinence care. Residen#2 indicated she told S5CNA God was watching her and S5CNA responded back that God was watching her too. Resident #2 stated she reported the incident to S2CNA and S3LPN. Resident #3 Resident #3 was admitted to the facility on [DATE] with diagnoses in part of Morbid Obesity, Bilateral Osteoarthritis of the knee, Osteoporosis, and Hemiplegia. Review of Resident #3's quarterly MDS with an ARD of 01/23/2024, revealed in part, a BIMS of 12 which indicated mild cognitive impairment. Further review revealed Resident #3 required extensive assistance with mobility and transfers. In an interview on 03/18/2024 at 12:09 p.m., S2CNA stated Resident #3 reported to her that S5CNA was rough when turning him in bed during the night of 02/26/2024. Resident #3 also indicated S5CNA told him he could turn himself and he indicated he told her he could not. In an interview on 03/19/2024 at 9:30 a.m., S3LPN stated Resident #3 reported to her on the morning of 02/27/2024 that S5CNA handled him rough when turning him therefore, he chose to wait until the day shift CNA came on to get out of bed. During a telephone interview on 03/20/2024 at 12:55 p.m., S1Administrator stated on the morning of 02/27/2024, she was immediately informed of Resident #1, Resident #2, and Resident #3's reports of abuse from S5CNA and began to interview residents on the unit and employees. S1Administrator also stated as a result of her findings, S5CNA was immediately terminated. S1Administator acknowledged abuse to residents by S5CNA should not have occurred.

Oct 2023 11 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation and interview the facility failed to respect a resident's right to have her fingernails untrimmed for 1 (Resident #88) of 4 (Resident #40, Resident #46, Resident #62, and Resident #88) sampled residents reviewed for Activities of Daily Living (ADL). Findings: Review of clinical record revealed, in part, a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/2023. This MDS indicated Resident #88 had a Brief Interview for Mental Status (BIMS) of 11 which suggests she was moderately impaired in cognition. Observation on 10/09/2023 at 10:50 a.m. revealed Resident #88 had clean fingernails that extended beyond the tip of her fingers on her left hand. In an interview on 10/09/2023 at 10:50 a.m., Resident #88 stated she preferred her fingernails to be as long as they were and did not want them cut. In an interview on 10/11/2023 at 11:55 a.m., Resident #88 stated, That nurse cut my nails. I did not want my nails cut. Observation on 10/11/2023 at 11:55 a.m. revealed Resident #88 opened her hand to extend her fingers to show that her nails were shorter than they had been on 10/09/2023. In an interview on 10/11/2023 at 12:00 p.m., S24RegisteredNurse (RN) stated she cut resident #88's fingernails even though Resident #88 did not want them cut. S24RN stated Resident #88 told her she did not want her nails cut. In an interview on 10/12/2023 at 11:45 a.m., Resident #88 stated she felt terrible about the nurse cutting her nails and she was very upset because she did not want her nails cut. In an interview on 10/12/2023 at 1:00 p.m., S1Administrator acknowledged that Resident #88 should not have had her nails cut if she did not want them cut.

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 F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner for 2 (Resident #208 and Resident #209) of 3 (Resident #208, Resident #209, and Resident #210) residents reviewed for beneficiary notification. Resident #208 Review of Resident #208's Beneficiary Notification Review revealed, in part, Resident #208's Medicare covered Part A services started on 05/26/2023 and her last Medicare Part A covered day was 07/13/2023. Review of Resident #208's NOMNC revealed, in part, Resident #208's last covered day of Medicare Part A services was 07/13/2023. Further review revealed Resident #208 signed the NOMNC on 07/13/2023 to acknowledge she received and understood the notice. Resident #209 Review of Resident #209's Beneficiary Notification Review revealed, in part, Resident #209's Medicare covered Part A services started on 08/03/2023 and her last Medicare Part A covered day was 09/27/2023. Review of Resident #209's NOMNC revealed, in part, Resident #209's last covered day of Medicare Part A services was 09/27/2023. Further review revealed Resident #209 signed the NOMNC on 09/26/2023 to acknowledge she received and understood the notice Review of the above mentioned NOMNC's revealed the facility did not issue Resident # 208's or Resident 209's NOMNC at least 2 days prior to the end of Medicare Part A coverage to allow them the right to appeal the discharge. In an interview on 10/12/2023 at 11:44 a.m., S25Social Worker stated she was responsible for issuing NOMNC's to the resident and/or resident representative when the facility initiated a Medicare Part A discharge. S25Social Worker confirmed she did not issue a NOMNC to Resident #208 or Resident #209 at least 2 days prior to their Medicare Part A discharge as required.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) was completed within 14 days of a resident beginning hospice services for 1 (Resident #39) of 2 (Resident #39 and Resident #43) sampled residents investigated for Hospice. Findings: Review of Resident #39's October 2023 Physician Orders revealed, in part, Resident #39 was admitted to Hospice for Chronic Obstructive Pulmonary Disease and Vascular Dementia on 04/24/2023. Review of Resident #39's medical record revealed a Significant Change in Status MDS assessment was not completed within 14 days after hospice admission on [DATE]. In an interview on 10/11/2023 at 12:45 p.m., S5MDS Nurse stated when a resident is admitted to Hospice Services, a Significant Change in Status MDS assessment should be completed 7-14 days after a resident was admitted to Hospice. S5MDS Nurse confirmed Resident #39 was admitted to Hospice services on 04/24/2023 and a Significant Change in Status MDS assessment was not completed.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #71) of 1 (Resident #71) sampled residents reviewed for requiring a PASARR Level II evaluation. Findings: Resident #71'a clinical record, reveled, in part, Resident #71 was admitted to the facility on [DATE]. Further review revealed, Resident #71 had a diagnosis of bipolar disorder (a serious mental illness that causes mood swings) with an onset date of 08/30/2023 and major depressive disorder (a serious mental illness that can cause persistent sadness) with an onset date of 08/22/2023. Further review revealed, no documentation that a Level II PASARR evaluation was completed for Resident #71. Review of Resident #71's Level I PASARR evaluation prior to admission revealed, in part, Resident #71 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses were selected to review. Review of Residents #71's clinical record on 10/11/2023 at 2:17 p.m., revealed no documented evidence and the facility did not present any documented evidence a Level II PASARR was completed on Resident #71. In an interview on 10/12/2023 at 08:19 a.m., S25Social Worker stated she was responsible to submit a Level II PASARR evaluation when a resident was newly diagnosed with a mental illness. S25Social Worker further stated the nursing staff did not communicate to her when Resident #71 was diagnosed with a serious mental illness after her admission to the facility. S25Social Worker confirmed Resident #71 did not have the required Level II PASARR screening. In an interview on 10/12/2023 at 9:33 a.m., S2Director of Nursing (DON) DON confirmed that Resident #71's Level II PASARR screening was not completed and agreed the facility had a break in their Level II PASARR evaluation process.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to: 1) Ensure a resident had a comprehensive care plan that addressed Activities of Daily Living (ADL) (Resident #46); 2) Ensure a resident had a comprehensive care plan that addressed self-administration of medication (Resident #71); and, 3) Ensure a resident had a comprehensive care plan that addressed a diagnosis of anxiety and depression (Resident #81). This deficient practice was identified for 3 (Resident #46, Resident #71, and Resident #81) in a total sample of 21 residents reviewed for care planning. Findings: Resident #46 Review of Resident #46's Medical Record revealed, in part, Resident #46 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, Hemiplegia, Hemiparesis and Moyamoya Disease. Review of Resident #46's Significant Change Minimum Data Set with an Assessment Reference Date of 8/07/2023 revealed, in part, Resident #46 decision making was severely impaired and was totally dependent for activities of daily living (ADL) to include bed mobility, dressing, eating, toilet use, personal hygiene and bathing. Review of Resident #46's Care Plan revealed, in part, no documented evidence of problems, goals or interventions addressing personal hygiene, dressing, toilet use or bathing. In an interview on 10/12/2023 at 9:46 a.m., S2Director of Nursing (DON) confirmed Resident #46's care plan with review date of 10/31/2023 did not include goals or interventions addressing Resident #46's personal hygiene, dressing, toileting or bathing needs and should have included them. Resident #71 Review of facility's policy for Self -Administration of Medications revealed, in part, the facility must provide patients with appropriate education and training on the safe and effective self-administration of their medications. Further review revealed the facility must periodically reassess a resident's ability to self-administer medications to ensure ongoing safety and appropriateness. Review of Resident #71's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/2023 revealed, in part, Resident #71 was admitted to the facility on [DATE] and her cognition was intact. Observation on 10/09/2023 at 12:52 p.m. revealed, in part, Resident #71 had a bottle of Laxative (a medication used to treat constipation) 25 milligram (mg) tablets on her rolling bed side table. In an interview on 10/09/2023 at 12:52 p.m., Resident #71 stated she self-administered the medication once a day. Record review of Resident #71 October 2023 Physician's Orders revealed, in part, an order with a start date of 09/20/2023 for Ex Lax (the brand name for laxatives) give 1 tablet nightly. Review of Resident #71's medical record revealed, in part, a handwritten verbal order from Resident #71's physician received on 09/29/2023 to allow Resident #71 to keep the laxatives at bedside and self-administer. In an interview on 10/11/2023 at 1:05 p.m., S28Licensed Practical Nurse stated she received the verbal order for Resident #71 to keep the laxative at bedside and self-administer the laxative but she did not update Resident #71 physician order set. Review of Resident #71's care plan revealed no evidence and the facility did not present any evidence Resident #71 had a care plan to address education and ongoing assessments of Resident #71's ability to self-administer the laxative. In an interview on 10/12/2023 at 8:14 a.m., S5Minimum Data Set (MDS) Nurse stated self-administration of a medication by a resident would require a care plan problem to include goals and interventions for staff to periodically assess for safe self-administration of the medication. S5MDS Nurse acknowledged she was not aware Resident #71 was self-administering a laxative daily; therefore, she did not implement a care plan problem or interventions to address medication self-administration. S5MDS Nurse confirmed Resident #71 should have had the daily self-administration of a laxative included in her care plan for monitoring. Resident #81 Review of Resident #81's Medical Record revealed, in part, Resident #81 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Anxiety Disorder and Depression. Review of Resident #81's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/2023 revealed, in part, Resident#81 experienced little interest or pleasure nearly every day in the look back period and had depressed feeling several days during the lookback period. Further review revealed Resident #81was administered an antianxiety medications for 7 of 7 days in the lookback period and an antidepressant medication for 7 of 7 days in the lookback period. Review of Resident #81's physician's order revealed, in part, an order dated 04/18/2023 for Zoloft (antidepressant medication) 50 milligram (mg) by mouth daily for depression and an order dated 4/18/2023 for Buspirone HCL(antianxiety medication) 7.5 milligram (mg) twice daily for anxiety. Review of Resident #81's Care Plan revealed, in part, no documented evidence of goals or interventions related to Resident #81's antianxiety or antidepressant medication usage. In an interview on 10/12/2023 at 1:00 p.m., S5Minimum Data Set Nurse acknowledged she was aware Resident #81 was on antianxiety and antidepressant and confirmed Resident #81's care plan with review date of 11/11/2023 did not include goals or interventions addressing antianxiety and antidepressants usage, and should have included them. In an interview on 10/12/2023 at 3:05 p.m., S2 Director of Nursing (DON) confirmed that Resident #81's care plan did not include goals and interventions addressing his use of antianxiety and antidepressants and the care plan should have.

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

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Based on observations, interviews, and record reviews, the facility failed to ensure nail care was provided for a dependent resident who required assistance with nail cleanliness for 1 (Resident #62) of 4 (Resident #40, Resident #46, Resident #62, and Resident #88) residents reviewed for activities of daily living (ADLs). Findings: Review of Resident #62's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/27/2023 revealed, in part, resident required total assistance from 2 people for personal hygiene and bathing. Review of Resident #62 October 2023 physician orders revealed, in part, an order to assess and trim fingernails every 7 days on Friday. Observation on 10/09/23 at 10:38 a.m. revealed a dark brown substance under the middle finger nail and ring finger nail of Resident #62's right hand. Further review revealed a dark brown substance under the nail of the middle finger nail of Resident #62's left hand. Observation on 10/10/2023 at 3:30 p.m. revealed a dark brown substance under the middle finger nail and ring finger nail of Resident #62's right hand. Further review revealed a dark brown substance under the nail of the middle finger nail of Resident #62's left hand. Observation on 10/11/2023 at 9:45 a.m. revealed a dark brown substance under the middle finger nail and ring finger nail of Resident #62's right hand. Further review revealed a dark brown substance under the nail of the middle finger nail of Resident #62's left hand. In an interview on 10/11/2023 at 10:00a.m., S29Certified Nursing Assistant stated Resident #62 required total assistance with his personal hygiene and bathing. She further stated Resident #62's nails should be cleaned when Resident #62 received a bath. In an interview on 10/11/2023 at 10:50 a.m., S30Licensed Practical Nurse confirmed the presence of a dark brown substance under the nails of Resident #62's fingers. She further stated Resident #62 should have his nails trimmed and cleaned during bathing.

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to post the required nurse staffing information on a daily basis. Findings: Observation on 10/10/2023 at 10:25 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 10/10/2023 at 2:20 p.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 10/11/2023 at 9:00 a.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 10/11/2023 at 1:00 p.m. revealed the facility's resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. In an interview on 10/11/2023 at 2:46 p.m., S1Administrator stated the facility's posting did not include the facility's daily census or the number of staff required for each shift and it should have included that information.

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview the facility failed to: 1. Ensure a residents had compression stockings applied per physician orders for 1 (Resident #32) of 1 (Resident #32) sampled resident reviewed for skin conditions- non pressure; and 2. Ensure a resident had a splint applied per physician orders for 1 (Resident #40) of 1 (Resident #40) sampled resident reviewed for limited range of motion. Findings: Resident #32 Review of Resident #32's October 2023 Physician Orders revealed an order for compression stockings to Resident #32's bilateral lower extremities (legs). Further review of Resident #32's order revealed the compression stockings were to be applied at 6 a.m. and removed at 6 p.m. to prevent swelling to Resident #32's lower extremities. Observation on 10/10/2023 at 10:00 a.m. revealed Resident #32 was up in her wheelchair without compression stockings present to Resident #32's lower extremities. Left lower extremity very edematous. Observation on 10/11/2023 at 12:20 p.m. revealed Resident #32 was up in her wheelchair without compression stockings present to Resident #32's lower extremities. Left lower extremity very edematous. Observation on 10/11/2023 at 2:00 p.m. revealed Resident #32 was up in her wheelchair without compression stockings present to Resident #32's lower extremities. Left lower extremity very edematous. Observation on 10/11/2023 at 8:40 a.m. revealed Resident #32 was up in her wheelchair without compression stockings present to Resident #32's lower extremities. Left lower extremity very edematous. In an interview on 10/11/2023 at 1:15p.m., S11 License Practical Nurse (LPN) acknowledged Resident #32 did not have compression stockings in place to bilateral lower extremities. S11LPN further stated she was aware Resident #32 should have compression stockings in place to both lower extremities. In an interview on 10/12/2023 at 1:40 p.m., S2Director of Nursing confirmed Resident #32 should have had compression stockings bilaterally to lower extremities. Resident#40 Review of Resident #40's October 2023 Physician's Orders revealed, in part, an order to apply a brace to Resident #40's left hand for 12 hours daily, with the brace to be applied to the resident's left hand at 8:00 a.m. and removed from the resident's hand at 8:00 p.m. Review of Resident #40's care plan revealed, in part, Resident #40 to wear a left hand splint up to 12 hours a day. Further review revealed the following approaches, in part, to teach correct application of brace; and assist with applying brace for scheduled wearing time. Further review revealed Resident #40's staff was to apply a left hand splint to reduce spasticity with an approach, in part, staff to apply the left hand splint from 8:00am through 8:00 pm to prevent contracture. Observation on 10/09/2023 at 11:24 a.m. revealed Resident #40 was lying in his bed with no splint on his left hand. Observation on 10/10/2023 at 11:03 a.m. revealed Resident #40's was lying in his bed with no splint present to his left hand. In an interview on 10/10/2023 at 11:03 a.m., Resident #40 stated his splint was in the corner of the room. Observation on 10/10/2023 at 3:45 p.m. revealed Resident #40 was lying in his bed with no splint present to his left hand. In an interview on 10/10/2023 at 3:45 p.m., Resident #40 stated no one put the splint on his left hand. Observation on 10/11/2023 at 11:28 a.m. revealed, Resident #40's was lying in his bed with no splint present to his left hand. In an interview on 10/11/2023 at 11:30 a.m., Resident #40 stated the splint on his left hand did not hurt and he wanted to wear the splint. In an interview on 10/11/2023 at 11:40 a.m., S26LicensedPracticalNurse (LPN) confirmed there was an order to apply a splint to Resident #40's left hand. In an interview on 10/11/2023 at 12:00 p.m., S24RegisteredNurse (RN) stated Resident #40 had a splint for his left hand and should be applied daily per physician orders. Observation on 10/12/2023 at 9:01 a.m. revealed Resident #40's left hand splint was positioned on his left forearm instead of his left hand. In an interview on 10/12/2023 at 9:01 a.m., Resident #40 stated the splint had been on since yesterday. In an interview on 10/12/2023 at 2:40 p.m., S3ChiefOperatingOfficer stated Resident #40 should have his splint applied per physician orders.

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 F0729 (Tag F0729)

Could have caused harm · This affected multiple residents

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Based on record reviews and interview, the facility failed to ensure State Registry verifications were completed prior to hire for 3 (S12Certified Nursing Assistant (CNA), S15CNA, and S18CNA) of 8 CNA personnel files reviewed for state registry verification reviews. Findings: Review of S12CNA's personnel file revealed a hire date of 02/17/2021. Further review of S12CNA's personnel file revealed no documentation of CNA Registry check. Review of S15CNA's personnel file revealed a hire date of 03/11/2020. Further review of S15CNA's personnel file revealed no documentation of CNA Registry check. Review of S18CNA's personnel file revealed a hire date of 07/21/2022. Further review of S18CNA's personnel file revealed no documentation of CNA Registry check. There was no documented evidence and the facility did not present any documented evidence of the CNA Registry check that was completed upon hire for S12CNA, S15CNA, and S18CNA. In an interview on 10/11/2023 at 2:46 p.m., S1Administrator stated the CNA registry check should have been completed upon hire for S12CNA, S15CNA, and S18CNA.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to: 1) Ensure leftover food was properly labeled in the main kitchen refrigerator; 2) Ensure food was not stored on the freezer floor; and, 3) Ensure food was properly labeled in the individual floors kitchen refrigerators. Findings: 1) Observation on 10/09/2023 at 9:30 a.m. of the walk in refrigerator in Kitchen A revealed, in part, -a container of potato casserole which was not labeled nor dated; -a container of brown gravy which was not labeled nor dated; -a pan of 12 biscuits covered with a clear wrap which was not labeled nor dated; and, -a container of mashed potatoes which was not covered nor labeled nor dated. In an interview on 10/09/2023 at 9:30 a.m., S8Dietary Manager acknowledged the food was not labeled or dated and should have been. 2) Observation on 10/09/2023 at 9:30 a.m. of Kitchen A freezer revealed an unopened case of juices which did not have a barrier/space between the floor and the case. In an interview on 10/09/2023 at 9:30 a.m., S8Dietary Manager confirmed an unopened case of juices was directly on the floor in the freezer and should have been stored elevated above the floor. 3) Observation on 10/10/2023 at 9:50 a.m. of Kitchen B refrigerator revealed the following, in part: -a container with a bag of brown liquid which was not labeled nor dated; -a black bowl of mashed potatoes covered with clear wrap which was not labeled nor dated; -a black bowl with white gravy which was not labeled nor dated; and, -a pan of macaroni which was not labeled nor dated. Observation on 10/10/2023 at 9:55 a.m. of a Kitchen B refrigerator and freezer revealed the following, in part: -a pitcher of orange liquid half-filled covered with clear wrap which was not labeled nor dated; -a second pitcher with yellow liquid half-filled covered with clear wrap which was not labeled nor dated; -a one gallon pitcher filled with red liquid which was not labeled nor dated a label or a date; -a squeeze bottle with thick white fluid labeled ranch which was not dated; and, -a squeeze bottle with yellow liquid labeled Italian which was not dated. In an interview on 10/10/2023 at 10:45 a.m., S8Dietary Manager stated the leftover food and liquids in the individual floor kitchens should have been labeled and dated. Observation on 10/10/2023 at 11:46 a.m. of Kitchen D refrigerator revealed, in part, a squeeze bottle with thick yellow liquid which was not labeled nor dated. Observation on 10/10/2023 at 11:52 a.m. of Kitchen C refrigerator revealed, in part: -a pitcher of orange liquid half-filled which was not labeled nor dated; -a second pitcher of orange liquid three fourths filled which was not labeled nor dated; -a third pitcher of orange liquid three-fourths filled which was not labeled nor dated; and, -a black container of oatmeal covered with clear wrap which was not labeled nor dated. In an interview on 10/10/2023 at 11:55 a.m., S9Homemaker confirmed the juices in the 3 pitchers and oatmeal in the black container in Kitchen C were not labeled nor dated.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observations and interviews the facility failed to ensure: 1. The resident's ice supply was maintained according to infection control practices for 1 (Ice Chest A) of 1 (Ice Chest A) observed for infection control practices; and 2. Staff were knowledgeable about the sanitation and/or disinfection procedures for the facility whirlpools for 3 (S19Certified Nursing Assistant, S20Certified Nursing Assistant, and S23Certified Nursing Assistant) of 4 (S15Certified Nursing Assistant, S19Certified Nursing Assistant, S20Certified Nursing Assistant, and S23Certified Nursing Assistant) certified nursing assistant staff interviewed for infection control practices. Findings: 1. Observation on 10/10/2023 at 10:21 a.m. revealed an uncontained ice scoop lying on the counter next to Ice Chest A. Observation on 10/11/2023 at 8:55 a.m. revealed an uncontained ice scoop lying on the counter next to Ice Chest A. Observation on 10/11/2023 at 11:42 a.m. revealed an uncontained ice scoop lying on the counter next to Ice Chest A. In an interview on 10/12/2023 at 9:34 a.m., S2Director of Nursing (DON) stated ice scoops should be stored and contained in the storage bag when not in use. S2DON further stated Ice Chest A's ice scoop should not have been lying on the counter uncontained. 2. Review of the facility's Buckeye Eco Odor Counteractant label revealed, in part, the solution was used to eliminate odor. In an interview on 10/12/2023 at 10:21 a.m., S20Certified Nursing Assistant (CNA) stated she used Buckeye Eco Odor Counteractant to clean the whirlpool before and after every use. Observation on 10/12/2023 at 10:22 a.m. revealed S20CNA sprayed Buckeye Eco Odor Counteractant onto the whirlpool surface, filled the whirlpool with water, turned on the whirlpool jets, and wiped the whirlpool surfaces with a washcloth. S20CNA allowed the water to sit in the whirlpool until 10:25 a.m. S20CNA then drained the whirlpool and rinsed the whirlpool's surface with water. Review of the facility's Buckeye Eco Neutral Disinfectant container label revealed, in part: 1. Spray 6-8 inches from the surface, and rub with a brush, cloth or sponge; 2. Let the solution remain on the surface for a minimum of 10 minutes; and, 3. Rinse or allow to air dry. In an interview on 10/12/2023 at 12:31 p.m., S19CNA stated she used the Buckeye Eco Neutral Disinfectant to clean the whirlpool after every use. S19CNA further stated she allowed the disinfectant to sit on the surface of the whirlpool for 3 minutes prior to rinsing. In an interview on 10/12/2023 at 12:38 p.m., S23CNA stated she used the Buckeye Eco Neutral Disinfectant to clean the whirlpool after each use. S23CNA further stated she allowed the disinfectant to remain on the surface for 1 minute before rinsing. In an interview on 10/12/2023 at 3:00 p.m., S3Chief Operating Officer (COO) stated the Buckeye Eco Odor Eliminator was an odor eliminator and should not have been used to disinfect the whirlpool. S3COO stated the Buckeye Eco Neutral Disinfectant (E23) should have been used to disinfect the whirlpool. In an interview on 10/12/2023 at 3:11 p.m., S4Chief Clinical Officer (CCO) stated Buckeye Eco Neutral Disinfectant should remain on the whirlpool surface for at least 10 minutes.

Apr 2023 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #4, and Resident #6) sampled residents observed during incontinence care in a total investigative sample of 6. Findings: Review of Resident #2's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) 03/31/2023 revealed, in part, Resident #2 had a BIMS (Brief Interview for Mental Status) of 15 (score of 13-15 indicated Resident #2 was cognitively intact). Observation on 04/18/2023 at 4:55 a.m., revealed S7Certified Nursing Assistant (CNA) entered Resident #2's room, left the door to the room open, and proceeded to remove Resident #2's bed linen, incontinence diaper and start incontinence care. S7CNA then had to leave the room to obtain additional incontinence products leaving Resident #2 uncovered with her genitalia exposed and the door open. S7CNA then re-entered the room and finished providing incontinence care with the door open with Resident #2's genitalia uncovered during the entire incontinence care process. In an interview on 04/18/2023 at 12:04 p.m., Resident #2 stated she did not like the idea that she was uncovered and exposed during incontinence care. In an interview on 04/18/2023 at 1:04 p.m., S1Administrator and S2Director of Nursing (DON) were made aware of the above findings. S1Administrator stated the door should always be closed during incontinent care for resident privacy.

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to: 1. Have documented evidence of a resident's grievance summary for 2 (Resident #1 and Resident #2) of 6 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5,Resident #6) and 1 (Confidential Interview #3) of 4 (Confidential Interview #1, Confidential Interview #2, Confidential Interview #3, and Confidential Interview #4) confidential interviews conducted; 2. Have documented evidence of the investigation summary and resolution of a grievance for 1 (Resident #3) of 6 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5,Resident #6). Findings: Review of the facility's Grievance Policy revealed, in part, all grievances and the resolutions will be documented in the facility's Grievance Log. Confidential Interview #3 In an interview on 04/18/2023 at 10:30 a.m., Confidential Interview #3 stated complaints have been voiced at care plan meetings regarding how long the resident had to wait for incontinence care. Confidential Interview #3 stated they do not feel like complaints get addressed appropriately and they never received a call back after complaints are vvoiced to notify them of the results of the investigation or what the resolution would be. Resident #1 Review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) dated 03/22/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 had no cognitive impairment. Further review revealed, Resident #1 was always incontinent of bowel and bladder and required total dependence of one person for toileting. Review of facility's Grievance Binder for January 2023- present revealed Resident #1 had no grievances documented. In an interview on 04/17/2023 at 11:31 a.m., Resident #1 stated she was not receiving a bath every Monday, Wednesday, and Friday and she was not being changed every 2 hours and as needed. Resident #1 stated the last time she had a bath was Tuesday on 04/11/2023. She stated she has reported the above stated issues to S1Adminstrator, S2Director of Nursing (DON), and S3Social Worker during her care conferences. Resident #1 further stated she has never been offered a chance to file a grievance. In an interview on 04/18/2023 at 9:19 a.m., S3Social Worker stated Resident #1's and Resident #1's family have reported complaints about care issues. S3Social Worker further stated a grievance was not documented. In an interview on 04/18/2023 at 12:34 p.m., S1Administrator stated the facility had an issue with appropriately documenting grievances once a complaint is received. S1Administrator further stated S3Social Worker was ultimately responsible to ensure a grievance was filed upon Resident #1 reporting issues. S1Administrator further stated the facility had no documented evidence to present which showed a grievance for Resident #1. Resident #2 In an interview on 04/18/2023 at 9:19 a.m., S3Social Worker (SW) was asked if she had ever received a grievance from Resident #2 or on behalf of Resident #2. S3SW stated at the last care conference attended last week Resident #2's responsible party brought up concerns about staff to resident ratios and care provided. S3SW stated she had informed S1Administrator regarding the issues but had not documented the grievance, any investigation, or resolution to the grievances. Resident #3 Review of Resident #3's Grievance Report with no date documented revealed complaints voiced regarding Resident #3's care were: 1. Missed appointments due to the resident not being up and ready in time for the appointment; 2. Hygiene care, diaper changes, and urinal dumping; and 3. Bath Schedule. Further review revealed no documentation of an investigation, action taken, resolution of the grievance, or name of person receiving and completing the grievance. In an interview on 04/18/2023 at 9:19 a.m., S3SW stated Resident #3 and Resident #3's responsible party had complaints about Resident #3 not making it to early appointments and difficulty with getting appropriate hygiene care. S3SW further stated the facility had no documentation of an investigation of the grievance or the resolution of the grievance. In an interview on 04/18/2023 at 9:19 a.m., S3SW stated as a facility, they had not been consistent with documenting an investigation, action taken, or the resolution of the grievance on the Grievance Report forms. S3SW the facility did not have documentation of what grievances were discussed or what actions were taken for the grievances from the morning standup meetings. S3SW further stated it was her responsibility to ensure grievances were documented, investigated, and a resolution was provided; however, she did not have any documentation evidence to produce which showed compliance with the regulation. In an interview on 04/18/2023 at 1:04 p.m., S1Administrator stated the facility had not been consistent with appropriately documenting grievances. S1Administrator further stated S3SW was responsible for documenting the investigation of the complaint, and S3SW would be responsible for documenting the investigation, resolution, and follow-up with the complainant. S1Administrator further stated the facility had no documented evidence to present which showed the investigation or resolution to Resident #2 or Resident #3 grievance and did not have documented evidence of the grievances filed by Resident #2's responsible party on the 02/23/2023 care plan meeting.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on record review and interview, the facility failed to ensure that Certified Nursing Assistants (CNA) completed annual competencies as required for 2 (S4Office Manager/Certified Nursing Assistant and S6Certified Nursing Assistant) of 3 (S4Office Manager/Certified Nursing Assistant, S6Certified Nursing Assistant, S7Certified Nursing Assistant) CNAs personnel records reviewed for competencies. Findings: Review of S4Office Manager/CNA's personnel file revealed, in part, the last documented skills and performance competency was completed on 10/17/2017. Review of S6CNA's personnel file revealed, in part, the last documented skills and performance competency was completed on 10/21/2021. In an interview on 4/18/2023 at 3:30 p.m., S2Director of Nursing stated the facility held an inservice with all staff, but there was no documentation of return demonstration or competency of the staff. In an interview on 4/18/2023 at 4:09 p.m., S1Administrator stated CNA competencies should be completed annually and they were not. The facility was unable to provide any documented evidence of competencies completed since the above mentioned dates.

CONCERN (E) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview, the facility failed to ensure dependent residents were provided incontinence care timely for 4 (Resident #1, Resident #2, Resident #3, and Resident #6) of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for incontinence care and 1 (Resident R1) of 4(Resident R1, Resident R2,Resident R3, and Resident R4) randomly selected residents observed during incontinence care. Findings: In an interview on 04/17/2023 at 4:02 p.m., Confidential Interview #4 (a cognitive resident) stated the last diaper change today was at 5:15a.m. In an interview on 04/18/2023 at 5:15 a.m., Confidential Interview #4 stated she had not been changed since they put her to bed yesterday. Confidential Interview #4 further stated she did not remember anyone coming to check on her during the night for any needs. Resident #1 Review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) dated 03/22/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 had no cognitive impairment. Further review revealed, Resident #1 was always incontinent of bowel and bladder and required total dependence of one person for toileting. Review of Resident #1's current Care Plan revealed Resident #1 was always incontinent. Further review revealed approaches that included, in part, assist with perineal cleansing as needed. Review of Resident #1's CNA (Certified Nursing Assistant) Activities of Daily Living (ADL) Tracking Tool for March 2023 revealed, in part, no documented evidence of incontinence care having been provided on the day shift (7a.m. to 3pm) 03/01/2023-03/06/2023,03/09/2023, and 03/11/2023-03/31/2023 or the evening shift (3p.m.-11p.m.) from 04/03/2023-04/31/2023. Review of Resident #1's CNA Activities of Daily Living (ADL) Tracking Tool for April 2023 revealed, in part, no documented evidence of incontinence care having been provided on the day shift (7a.m. to 3pm) 04/01/2023-04/16/2023 or the evening shift (3p.m.-11p.m.) from 04/01/2023-04/17/2023. Review of the facility Call light Logs revealed Resident #1's call light was activated on the following dates, in part, 04/17/2023 at 2:31 p.m. activated for 64 minutes. In an interview on 04/17/2023 at 11:31 a.m. Resident #1 stated she does not receive assistance from the CNAs with ADL care. Resident #1 further stated she does not get changed when she asks to be changed. Resident #1 further stated sometimes she has to wait over an hour to get assistance. In an interview on 04/17/2023 at 4:13 p.m. Resident #1 stated she activated her call light around 2:30 p.m. and she had not been changed. S4OM/CNA entered Resident #1's room and stated her CNA was on break. Observation on 04/17/2023 at 4:20 p.m. revealed S9Licensed Practical Nurse (LPN) and S4Office Manager (OM)/CNA entered Resident #1's room to provide incontinence care and Resident #1 was visibly soiled. In interview on 04/18/2023 at 6:59 a.m., S6CNA stated she cares for 19 residents and 11 of them are dependent residents. S6CNA further stated sometimes it does take her 2-3 hours to make rounds on each resident. In an interview on 04/18/2023 at 11:34 a.m. S5CNA stated ADL care for all of the residents has to be prioritized. S5CNA further stated sometimes residents do have to wait a long time for ADL to be provided. In an interview on 04/18/2023 at 12:34 p.m., S1Adminstrator stated the call light logs and ADL documentation are not routinely reviewed. S1Administrator stated ADL documentation has been an ongoing issue and it is not being supervised daily. In an interview on 04/18/2023 at 1:30 p.m., S2Director of Nursing (DON) stated facility has had an ongoing problem with providing and documenting activities of daily living (ADL) and they have not implemented a process to correct it. S1DON further stated a resident should wait no longer than 20 minutes before being provided care. Resident #2 Review of Resident #2's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/31/2023 revealed, in part, Resident #2 had a BIMS (Brief Interview for Mental Status) score of 15 (score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #2 required extensive assistance of one person for transfers and toilet use. Review of Resident #2's current Care Plan revealed Resident #2 required assistance with activities of daily living and was at risk for falls. Further review revealed approaches of, in part, remind the resident to ask staff for assistance with ambulation and assist the resident to the bathroom or commode as needed. Review of Resident #2's Record revealed no documented evidence and the facility presented no documented evidence of the facility having provided ADL assistance to Resident #2 for March 2023. Review of Resident #2's CNA-ADL Tracking Form for April 2023 revealed the document was blank other than the resident's name and Month of April 2023. The facility presented no documented evidence of ADL care having been provided to Resident #2 in April 2023. Observation on 04/18/2023 at 4:50 a.m., revealed S7CNA (Certified Nursing Assistant) was lying down on the couch next to Resident #3's room with her the hood to her sweatshirt over her head, and covered by a blanket. Further observation revealed a pager was noted on the day room table in front of the couch S7CNA was lying on. Observation revealed upon the surveyor walking up and introducing herself, S7CNA stood up and ran directly into Resident #2's room. Observation also revealed the only other staff on the unit were S12Licensed Practical Nurse (LPN) and S13Respiratory Therapist who were documenting resident care. Review of the facility Call light Logs revealed Resident #2's call light was activated on the following dates, in part, 04/18/2023 at 4:23 a.m. activated for a total of 28 minutes. Observation on 04/18/2023 at 4:50 a.m., revealed S7CNA (Certified Nursing Assistant) was lying down on the couch next to Resident #3's room with her the hood to her sweatshirt over her head, and covered by a blanket. Further observation revealed a pager was noted on the day room table in front of the couch S7CNA was lying on. Observation revealed upon the surveyor walking up and introducing herself, S7CNA stood up and ran directly into Resident #2's room. Observation also revealed the only other staff on the unit were S12Licensed Practical Nurse (LPN) and S13Respiratory Therapist who were documenting resident care. In an interview on 04/18/2023 at 5:55 a.m., S7CNA stated she should not have been lying down on the couch. In an interview on 04/18/2023 at 1:04 p.m., S1Administrator stated S7CNA should have been rounding at 4:50 a.m., should have been checking the pagers for resident calls, and definitely should not have been lying on the couch when residents required care. Resident #3 Review of Resident #3's MDS with an ARD of 03/15/2023 revealed, in part, Resident #3 had a BIMS of 15 (cognitively intact) and Resident #3 was totally dependent on two persons assistance for the following activities of daily living, in part: bed mobility, transfers, dressing, toilet use, and bathing. Further review revealed Resident #3 was always incontinent of bowel and bladder. Review of Resident #3's current Care Plan revealed Resident #3 was incontinent of bowel and bladder with approaches of, in part, provide incontinent pad of choice, and assist with perineal cleansing as needed. Review of Resident #3's Grievance Report, undated, revealed Resident #3 with had filed a grievance with complaints of, in part, hygiene care and diaper changes. Review of Resident #3's Record revealed no documented evidence and the facility presented no documented evidence of the facility having provided ADL assistance to Resident #3 for March 2023. Review of Resident #3's CNA-ADL Tracking Form for April 2023 revealed the document was blank other than the resident's name and Month of April 2023. The facility presented no documented evidence of ADL care having been provided to Resident #3 in April 2023. In an interview on 04/17/2023 at 12:04pm, Resident #3 stated the CNAs were short-handed and it was common to have to wait over 30 minutes after each incontinent episodes. Resident #6 Review of Resident #6's MDS with an ARD of 03/22/2023 revealed, in part, Resident #6 had a BIMS of 15 (cognitively intact), and Resident #6 was totally dependent on one person for the following activities of daily living: transfers, toilet use, personal hygiene, and bathing. Further review revealed Resident #6 was always incontinent of bowel and bladder. Review of Resident #6's current Care Plan revealed Resident #6 was incontinent with approaches of, in part, encourage resident to call for assistance with toileting Review of Resident #6's Record revealed no documented evidence and the facility presented no documented evidence of the facility having provided ADL assistance to Resident #6 for March 2023. Review of Resident #6's CNA-ADL Tracking Form for April 2023 revealed the document was blank other than the resident's name and Month of April 2023. The facility presented no documented evidence of ADL care having been provided to Resident #6 in April 2023. Observation on 04/18/2023 at 5:02 a.m., revealed S7CNA provided incontinent care to Resident #6. Observation further revealed Resident #6's diaper and under pad were both heavily soiled. Resident #6 then requested S7CNA place an incontinence pad inside of her diaper, in case she was up for long periods of time without incontinence care. In an interview on 04/17/2023 at 3:54 p.m., S14LPN stated it was one nurse, one CNA, and one respiratory therapist on the shift. S14LPN stated it was difficult for the CNA to provide all the care needed for the residents. S14LPN stated she often has to stop her tasks to provide incontinent care, so the residents do not have to wait as long. S14LPN further stated unfortunately the residents are sometimes are forced to wait because they do not have enough staff. In an interview 04/17/2023 at 3:58 p.m., S15CNA stated the residents will get agitated at times due to they have to wait due to only one CNA. In an interview on 04/18/2023 at 5:30 a.m., S13RT stated there was only one CNA on the shift and sometimes the residents have to wait for care. S13RT stated the staff tries to round on residents every 2 hours, but with the number of residents to staff it was difficult at times. In an interview on 04/18/2023 at 7:56 a.m., S1DON (Director of Nursing) stated facility had known they had an issue with providing and documenting activities of daily living (ADL). S1DON further stated they had not yet started the QAPI process in order to fix the deficient practice. In an interview on 04/18/2023 at 1:04 p.m., S1Administrator stated the facility had no documentation of ADLs having been completed for any of the above mentioned residents for March 2023. S1Adminsitrator stated the facility had issues with CNA not reporting on the halls timely and staff having to cover each other, leaving the hall short. S1Administrator and S2DON stated they will review the call light logs with complaints, but does not routinely pull the report to check on wait times. S1DON stated a reasonable wait time was no longer than 15-20 minutes.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview, the facility failed to: 1. Ensure the Certified Nursing Assistant (CNA) removed gloves and completed hand hygiene during incontinent care (S4Office Manager/CNA, S6CNA, and S7CNA); 2. Ensure the CNA did not place uncontained soiled items on the floor (S6CNA and S7CNA); and 3. Ensure the CNA did not carry soiled items uncontained to the soiled linen room without gloves (S7CNA). This deficient practice was identified for 3 (S4Office Manager, S6CNA, and S7CNA) of 4 (S4Office Manager, S6CNA, S7CNA, and S11CNA) staff observed during incontinent care. Findings: 1. Review of the facility's Hand Washing policy revealed, in part, it was the policy of the facility that all staff members will perform good hand washing techniques. Further review revealed, the purpose of the policy was to prevent cross contamination and control infection. Observation on 04/17/2023 at 4:20 p.m. revealed S9Licensed Practical Nurse (LPN) and S4Office Manager (OM)/CNA entered Resident #1's room to provide incontinence care. Observation further revealed S4OM/CNA donned clean gloves, opened Resident #1's soiled brief, and cleaned the top of Resident #1's genital area and down Resident #1's left and right groin area. Observation further revealed S4OM/CNA placed a new diaper on Resident #1, covered Resident #1 with her linens, and touched Resident #1's door handle to her bathroom and did not change gloves or perform hand hygiene. Observation on 04/18/2023 at 5:00 a.m. revealed S6CNA entered Resident R1's room to provide incontinence care. Observations further revealed S6CNA donned clean gloves, removed Resident R1's linen, and opened two visibly soiled briefs. Observation further revealed, S6CNA opened two drawers on Resident R1's dresser and removed clothing and one door on Resident R1's closet and removed socks and did not change gloves or perform hand hygiene. Observation further revealed, S6CNA cleaned the top of Resident R1's genital area and down Resident R1's left and right groin area, turned Resident R1 onto her left side, and used the same wipe to clean her buttock area. Observation revealed S6CNA then placed a clean brief and clean clothing on Resident R1 and transferred Resident R1 to her wheelchair and did not change gloves or perform hand hygiene. Observation on 04/18/2023 at 5:02 a.m., revealed S7CNA applied gloves prior to entering Resident #6's room to provide incontinence care. S7CNA entered Resident #6's room proceeded with gloved hands to open Resident #6's closet and pull out clothing items for the resident to pick from, then with the same gloved hands opened the top drawer of the bedside table and removed a can of disinfectant and sprayed the wheelchair cushion. S7CNA, with the same gloved hands, moved the bedside table to the side of the room and then cranked the bed into position. S7CNA proceeded with incontinence care without changing gloves and without performing hand hygiene. S7CNA then proceeded to dress Resident #6 and transferred the resident to the wheelchair with the same gloves she had worn during the incontinent care. Observation on 04/18/2023 at 5:17 a.m. revealed S6CNA entered Resident R2's room to provide incontinence care. Observation revealed S6CNA donned clean gloves, opened Resident R2's soiled diaper, and cleaned the top of Resident R2's genital area and down Resident R2's left and right groin area. Observation revealed S6CNA proceeded to clean Resident R2 and did not change gloves or complete hand hygiene. Observation further revealed S6CNA then continued to complete Resident R2's incontinent care area, placed a new clean brief on top of the soiled brief, turned Resident R2 on her side, removed the soiled brief, and replaced Resident R2's bed linen and did not change her gloves or perform hand hygiene. Observation on 04/18/2023 at 5:33 a.m. revealed S6CNA entered Resident R3's room to provide incontinence care after Resident R3 had a bowel movement. S6CNA donned gloves and cleaned R3's soiled groin area, turned Resident R3 to his right side, and cleaned his soiled buttocks. Observation further revealed S6CNA rolled up Resident R3's soiled brief, placed a clean brief on top of the soiled brief, and turned Resident R3 to his left side and did not change gloves or complete hand hygiene. Observation revealed S6CNA wiped her visibly soiled gloves with a wipe, removed the soiled brief from the bed, and secured Resident R3's clean brief. S6CNA then approached Resident R3's clean clothes basket, sifted through Resident R3's clothing, and removed a pair of pants and a shirt from the basket. S6CNA then opened a drawer on Resident R3's nightstand and removed a pair of socks. Observation revealed S6CNA then placed Resident R3's clothing on and placed Resident R3's wheelchair at bedside and did not change gloves or perform hand hygiene. Observation on 04/18/2023 at 6:45 a.m. revealed S6CNA entered Resident #1's room to provide incontinence care. Observation further revealed S6CNA donned clean gloves, opened Resident #1's soiled diaper, and cleaned the top of Resident #1's genital area and down Resident #1's left and right groin area. Observation revealed S6CNA proceeded to clean Resident #1 and did not change gloves or perform hand hygiene. S6CNA then continued to complete Resident #1's incontinence care area and removed Resident #1's soiled brief, placed a new clean brief on Resident #1, assisted Resident #1 with bed linen on top of her legs, and replaced Resident #1's bedside table without changing her gloves or performing hand hygiene. In an interview on 04/18/2023 at 6:59 a.m., S6CNA stated she should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident #1, Resident R1, Resident R2, and Resident R3 and before she touched personal items Resident R1, Resident R2 and Resident R3's room.] In an interview on 04/18/2023 at 12:34 p.m., S1Adminstrator stated S4OM/CNA and S6CNA should have changed their gloves and completed hand hygiene after incontinence care was provided to Resident #1, Resident R1, Resident R2, and Resident R3's and before they touched personal items in Resident R1, Resident R2 and Resident R3s room. In an interview on 04/18/2023 at 1:30 p.m., S2Director of Nursing(DON) stated S4OM/CNA and S6CNA should have changed their gloves and completed hand hygiene after incontinence care was provided to Resident #1, Resident R1, Resident R2, and Resident R3's and before they touched personal items in Resident R1, Resident R2 and Resident R3s room. 2. Observation on 04/18/2023 at 4:55 a.m., revealed S7CNA provided incontinence care to Resident #2 and removed the soiled diaper and soiled pad from under Resident #2, and proceeded to roll the soiled diaper in the soiled pad and threw the rolled items directly onto the floor of the resident's room. Observation on 04/18/2023 at 6:45 a.m. revealed S6CNA entered Resident #1's room to provide incontinence care. Observation revealed S6CNA completed Resident #1's incontinence care, removed Resident #1's visibly soiled brief, and placed it on the floor uncontained. In an interview on 04/18/2023 at 6:59 a.m., S6CNA stated she placed the brief on the floor in Resident #1's room and she should have placed it in a garbage can or in a bag. In an interview on 4/18/2023 at 12:34 p.m., S1Adminsitrator stated soiled briefs should be placed in a bag when removed from the resident and should not be placed on the floor. In an interview on 4/18/2023 at 1:30 p.m., S2DON stated soiled briefs should be placed in a bag for proper storage and not be placed on the floor. 3. Observation on 04/18/2023 at 5:40 a.m., S7CNA walked out of Resident #6's room with an uncontained soiled gown without gloves present and walked across the hallway to dirty linen room. In an interview on 04/18/2023 at 5:55am, S7CNA was informed of the above observations and stated she should not have placed uncontained items on the floor, and should have changed gloves and performed hand hygiene between dirty and clean procedures. In an interview on 04/18/2023 at 1:04 p.m., S1Administrator and S2Director of Nursing (DON) were informed of the findings during incontinence care for both Resident #2 and Resident #6. S1Administrator and S2DON stated the above findings were a breach in the facility's Infection Control program. S2DON confirmed staff should have changed gloves and performed hand hygiene between clean and dirty procedures and should not handle soiled items uncontained and ungloved.

Nov 2022 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on record reviews, interviews and observations the facility failed to cover the urinary catheter bag for 1 (Resident 156) of 21 sampled residents. This failed practice had the potential to affect any of the 5 residents with urinary catheters in the facility as documented on the Matrix for Providers, CMS-802. Findings: Review of Resident 156's record revealed, in part, an admit date of 10/26/2022 with diagnoses of Heart Failure, Hypertension, Acute kidney failure, and Chronic kidney disease. Review of Resident 156's Minimum Data Set with an Assessment Reference Date of 11/01/2022 revealed, in part, the following: Section C- Brief Interview for Mental Status score of 14 which indicates high cognitive status; Section G-Extensive assistance with 1 person assist for dressing, and total dependence with 1 person assist for toileting; Section H- Indwelling urinary catheter and always incontinent of bowel and bladder. An observation on 11/01/22 at 11:45 A.M., revealed Resident 156 sitting in his wheelchair in the rehabilitation therapy room. Resident 156's urinary catheter bag was attached to his wheelchair, uncovered draining clear, yellow fluid. An observation on 11/02/22 at 1:01 P.M., revealed Resident 156 sitting in his wheelchair, outside on the patio, with family. Resident 156's urinary catheter bag was attached to his wheelchair, uncovered, draining clear, yellow fluid. An observation on 11/03/2022 at 10:45 A.M., revealed Resident 156 in the therapy room. Resident 156's urinary catheter bag was attached to his wheelchair, uncovered, and draining yellow fluid. In an interview on 11/03/2022 at 10:45am S3DON stated urinary catheter bags should be covered at all times, and acknowledge Resident 156's urinary catheter bag should have been covered.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview the facility failed to ensure a dependent resident received nail care from staff. This deficient practice was identified for 1 (Resident 66) of 21 sampled residents. This deficient practice had the potential to affect any of the 59 dependent residents as identified on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: Review of Resident 66's record revealed, in part, an admit date of 09/28/2021 with a diagnoses of Cerebral Vascular Accident with Hemiplegia (Stroke with Paralysis or weakness to one side), and Type 2 Diabetes Mellitus (a disease with that results in too much sugar in the blood) with Neuropathy (weakness, numbness, or pain from nerve damage). Review of Resident 66's Minimum Data Set with an Assessment Reference Date of 09/27/2022 revealed, in part, the following: Section C- Brief Interview for Mental Status score of 15 which indicates high cognitive ability; and Section G- Personal Hygiene was total dependence with 1 person physical assistance. Review of Resident 66's Care Plan revealed, in part, Resident 66 required moderate to extensive assistance for all Activities of Daily Living. An observation on 11/01/22 at 9:25 A.M, revealed Resident 66 sitting in his wheelchair, and his finger nails were unkempt, long, and jagged. In an interview on 11/01/2022 at 9:25 A.M., Resident 66 stated he would like to have his finger nails trimmed. Resident 66 further stated the staff had not trimmed his nails in a long time. An observation on 11/02/2022 at 9:52 A.M., revealed Resident 66's finger nails long, jagged, and unkempt. An observation on 11/03/2022 at 10:10 A.M., revealed Resident 66's fingernails long, jagged, and unkempt. In an interview on 11/03/2022 at 10:40 A.M., S3DON stated Certified Nursing Assistants should complete nail care on resident shower days. After observing Resident 66's nails, she stated Resident 66's nails should not look the way they do and should have been groomed.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview, the facility failed to store medications in a locked cabinet as evidenced by having prescription medications left on the bedside table for 2 (Resident #66, Resident #91) of 21 sampled residents. This failed practice had the potential to affect any of the 103 residents in the facility according to the facility's Resident Census and Conditions of Residents form, CMS-672 Findings: Resident 66 Review of Resident 66's record revealed, in part, an admit date of 09/28/2021 with a diagnoses of Cerebral Vascular Accident with Hemiplegia (Stroke with Paralysis or weakness to one side), and Type 2 Diabetes Mellitus (a disease with that results in too much sugar in the blood) with Neuropathy (weakness, numbness, or pain from nerve damage). Review of Resident 66's November 2022 Physician Orders revealed, in part, clean wound on right knee with wound cleaners, apply Silvadine and cover with bordered foam every day. An Observation on 10/31/22 at 11:29 A.M., Resident 66's room revealed 1 tube of Silver Sulfadiazine cream on the bedside table. Resident's 66's name and room number was documented on the tube. An Observation on 11/01/22 at 09:25 A.M., of Resident 66's room revealed 1 tube of Silver Sulfadiazine cream on the bedside table. Resident's 66'name and room number on tube. An Observation on 11/02/22 at 9:52 A.M., of Resident 66's room revealed 1 tube of Silver Sulfadiazine cream on the bedside table. Resident's 66' name and room number on tube. An Observation on 11/03/22 at 9:37 A.M., of Resident 66's room revealed 1 tube of Silver Sulfadiazine cream on the bedside table. Resident's 66' name and room number on tube. In an interview on 11/03/2022 at 9:45 A.M., S7LPN stated she applied Resident 66's Silver Sulfadiazine cream as ordered daily. S7LPN stated that the tube of Silver Sulfadiazine cream should not have been left at his bedside. Resident 91 Review of Resident 91's record revealed, in part, original admit date of 02/26/2021 and a readmit date of 10/20/2022 with a diagnosis of Skin Yeast infection. Review of Resident 91's November 2022 Physician's orders revealed, in part, an order for Nystatin 100,000 units/gram cream. Apply cream to affected area twice a day for 4 weeks with a start date of 10/27/2022. An observation on 10/31/2022 at 1:09 P.M., revealed a tube of Nystatin Cream on Resident 91's bedside table. In an interview on 10/31/2022 at 1:09 P.M., Resident 91 stated the nurse applies Nystatin cream to his private area twice a day. An observation on 11/01/2022 at 11:25 A.M., revealed a tube of Nystatin Cream on Resident 91's bedside table. An observation on 11/02/2022 at 10:06 A.M., revealed on Resident 91's bedside table a tube of Nystatin cream. An observation on 11/02/2022 at 2:15 P.M. revealed a tube of Nystatin Cream on Resident 91's bedside table. An observation on 11/03/2022 at 10:45 A.M., revealed a tube of Nystatin Cream on Resident 91's bedside table. In an interview on 11/03/2022 at 10:45 A.M., S7LPN stated Nystatin Cream should not be left on Resident 91's bedside table. In an interview on 11/03/2022 at 10:50 A.M., S3DON stated medications should not be left unattended and in an unlocked area for any and all residents have access to.

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to identify water drainage from a portable air conditioning unit for 1 (room [ROOM NUMBER]A) room of the 103 resident rooms inspected. This failed practice had the potential to affect any of the resident using portable air conditioning units in the facility. Findings: An observation on 10/31/22 at 12:45 A.M., of room [ROOM NUMBER]A revealed a Portable air condition unit in use with leaking water observed on the side of the bed, under the bed and at the foot of the bed. An observation on 11/01/22 at 11:28 A.M., of room [ROOM NUMBER]A revealed a Portable air condition unit in use with leaking water observed on the side of Resident #60's bed, under the bed and at the foot of the bed. An observation on 11/02/2022 at 11:30 A.M. of room [ROOM NUMBER]A revealed a Portable air condition unit in use with leaking water observed on the side of Resident #60's bed, under the bed and at the foot of the bed. An observation on 11/03/2022 at 11:35 A.M., revealed a Portable air condition unit in use with leaking water observed on the side of Resident #60's bed, under the bed and at the foot of the bed. In an interview on 11/03/2022 at 11:40 A.M., S2Administrator acknowledge there should not be water on the floor in Resident 60's room as this was a safety hazard.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation interview the facility failed to maintain a sanitary environment in the kitchen to prevent the possibility of food contamination. This deficient practice had the potential to affect any of the 97 of the 103 residents who consumed meals prepared in the facility kitchen as documented on the facility's Census and Conditions of Resident's form (CMS-672). Findings: Observation on 10/31/2022 at 9:45am during the initial kitchen tour with S4Dietary Manager revealed the following: S10Cook was observed frying chicken without a covering over his beard; 2 pans of fried chicken on the counter was observed uncovered; 2 pans of raw chicken on the counter was observed uncovered; 12 packs of sugar free chocolate cake mix inside a cardboard box with expiration dates of 07/07/2020 on the packages; A box of lemons with 9 of the 30 lemons were covered in a green fuzzy substance; A 16 ounce container of ground ginger with an expiration date of 06/11/2019; An opened 32 ounce container of granulated peanuts was observed with an expiration date of 01/29/2021; An opened bag of granulated sugar with a white Styrofoam cup in the bag; Ice formed on the cooler's condenser, attached to the ceiling of the walk in cooler was melting onto the floor; Walk in cooler temperature was 43 degrees (should be less than 41 degrees Fahrenheit) Fahrenheit; and An opened and partially used pack of sliced cheese observed without an opened or expiration date; Review of a copy of the facility's Kitchen Check List revealed, in part, to assure all items were to be dated, labeled, covered and protected in the refrigerator; check the refrigerator temperature; assure a hair is covered and assure all foods are stored to prevent cross contamination. Review of the kitchens' temperature log revealed temperatures were checked daily with a documented out of range temperature for 10/31/2022 of 43 degrees Fahrenheit. Observation on 11/02/2022 at 11:20am revealed S11Cook was preparing pureed food for consumption without wearing gloves. Further observation revealed S10Cook without a beard covering. In an interview on 10/31/2022 at 10:22am, S4Dietary Manager acknowledged the pans of cooked and uncooked chicken should have been covered and the storage room, walk in cooler should not have expired foods or an out of range temperature. S4Dietary Manager also, acknowledged, S10Cook should have a beard covering on his face when preparing food. In an interview on 11/02/2022 at 12:12pm, S11Cook stated he should have worn gloves but forgot to put them on.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

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

Concerns

• 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade D (40/100). Below average facility with significant concerns.

Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is St. Margaret'S Daughters Home's CMS Rating?

CMS assigns St. Margaret's Daughters Home 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. Margaret'S Daughters Home Staffed?

CMS rates St. Margaret's Daughters Home's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.

What Have Inspectors Found at St. Margaret'S Daughters Home?

State health inspectors documented 38 deficiencies at St. Margaret's Daughters Home during 2022 to 2025. These included: 38 with potential for harm.

Who Owns and Operates St. Margaret'S Daughters Home?

St. Margaret's Daughters Home 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 112 certified beds and approximately 97 residents (about 87% occupancy), it is a mid-sized facility located in NEW ORLEANS, Louisiana.

How Does St. Margaret'S Daughters Home Compare to Other Louisiana Nursing Homes?

Compared to the 100 nursing homes in Louisiana, St. Margaret's Daughters Home's overall rating (1 stars) is below the state average of 2.4 and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting St. Margaret'S Daughters Home?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is St. Margaret'S Daughters Home Safe?

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

Do Nurses at St. Margaret'S Daughters Home Stick Around?

St. Margaret's Daughters Home has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was St. Margaret'S Daughters Home Ever Fined?

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

Is St. Margaret'S Daughters Home on Any Federal Watch List?

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

Facility Details

Beds: 112
Avg. Residents: 97
Occupancy: 86.9%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
38 Deficiencies: -10
Final Score: 40/100

Nearby Alternatives

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

View all in NEW ORLEANS →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 195437