Carroll Health and Rehab LLC
For profit - Individual
120 Beds
Independent
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
11/100
#189 of 264 in LA
Photo by Carroll Pointe Nursing & Rehabilitation
Photo by Carroll Pointe Nursing & Rehabilitation
Photo by Carroll Pointe Nursing & Rehabilitation
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Carroll Health and Rehab LLC received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #189 out of 264 facilities in Louisiana places it in the bottom half, while being #2 out of 2 in West Carroll County means there is only one other option available locally, which is better. The facility is showing signs of improvement, having decreased from 24 issues in 2024 to 22 in 2025. However, staffing remains a concern, with a low rating of 1 out of 5 stars and a high turnover rate of 61%, which is above the state average. Specific incidents include a resident who was able to leave the facility unmonitored and was found wandering on a nearby highway, highlighting serious safety risks. Additionally, the facility has struggled with maintaining adequate nursing staff, especially on weekends, which could impact the level of care residents receive.
- Trust Score
- F
- In Louisiana
- #189/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 14 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
11/100
Bottom 29%
Review needed
24 → 22 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 24 issues
2025: 22 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 61%
15pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is elevated (61%)
13 points above Louisiana average of 48%
The Ugly 49 deficiencies on record
2 life-threatening
Jul 2025
17 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on observation, record reviews and interviews the facility failed to have an adequate system in place to ensure residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on observation, record reviews and interviews the facility failed to have an adequate system in place to ensure residents at risk for elopement are supervised to prevent elopement from the facility for 1 (#73) of 3 (#8, #72, and #73) residents reviewed for elopement. The deficient practice resulted in an Immediate Jeopardy for Resident #73 on 07/21/2025. Resident #73 was last observed on 07/21/2025 at 9:51 p.m. Resident #73 was picked up by police on 07/22/2025 at 6:28 a.m. after being notified of Resident #73 pacing on the four-lane highway approximately 0.9 miles from the facility. The police returned Resident #73 to the facility on [DATE] at 6:52 a.m. without injury. Resident #73 exited the building through a window in his room. The deficient practice had the likelihood to cause more than minimal harm to any residents residing in the facility at risk for elopement. S1Manager and S3Director of Nursing (DON) were notified of the Immediate Jeopardy on 07/24/2025 at 7:54 p.m.The Immediate Jeopardy was removed on 07/25/2025 at 3:47 p.m. when it was determined the facility had implemented an acceptable Plan of Removal (POR) as confirmed through onsite interviews, record reviews and observations prior to the survey exit.
Findings:
Review of the facility’s Elopement/Missing Resident Policy undated revealed in part:
Purpose: Ensure a safe and secure environment for all residents.
Procedure:
1. All newly admitted residents will be screened for the potential of wandering and/or elopement, including past history and current cognitive status. Observation of the resident’s behavior that may indicate the potential for wandering and/or elopement will continue for the initial 14 days in the facility. Such potential will be included in the baseline care plan for that resident within the initial 48 hours following admission. If identified after that 48-hour period, interventions to ensure the resident’s safety will be added to the baseline care plan and included in the initial comprehensive plan of care.
4. Appropriate facility staff will monitor resident whereabouts including the monitoring of responses/reactions to events/ activity in surroundings at the time wandering and report unusual behaviors to the supervisor immediately.
Review of the medical record for Resident #73 revealed an admission date of 07/15/2025. Resident #73 had diagnoses including vascular dementia, hemiplegia, cerebrovascular accident, heart failure, and mild cognitive impairment.
Review of the Elopement Risk Evaluation dated 07/15/2025 revealed Resident #73 was at risk for elopement with a score of 2.0 and had a BIMS score of 6 which indicated Resident #73 had severe cognitive impairment for daily decision making. Further review of the assessment revealed Resident #73 had a history of elopement or an attempted elopement while at home and a history of attempting to leave the facility without informing staff.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment for daily decision making.
Review of the physician’s orders revealed no documented evidence of any orders regarding elopement prior to the incident on 07/21/2025.
Review of the interim care plan revealed no documented evidence of an elopement risk focused area noted in the care plan.
Review of the Sheriff’s Department Offense/Incident Report dated 07/22/2025 revealed the Sheriff’s department received a call on 07/22/2025 at 6:22 a.m. regarding a male pacing on the highway carrying a book and almost got hit by two vehicles. The Sheriff’s department arrived at the scene at 6:28 a.m. and Resident #73 was returned to the nursing facility on 07/22/2025 at 6:52 a.m.
Review of the Incident/Accident report dated 07/22/2025 at 6:50 a.m. written by S17Licensed Practical Nurse (LPN) revealed a local emergency department called and asked if we had a resident named ______. S17LPN went and checked the room and the curtain was pulled and the window was opened. The Sheriff’s department found Resident #73 at a store. A Certified Nursing Assistant (CNA) made rounds and he wasn't in his bed at 11:00 p.m. and the CNA thought he was in the hospital. The Sherriff’s department brought him back at 7:15 a.m., Resident #73 did not have any injuries.
On 07/24/2025 at 12:10 p.m. observation and interview of Resident #73 revealed he was sitting on the side of the bed and he had an orange band on his right wrist. Resident #73 was unable to verbalize where he currently was, but did state that he climbed out of the window the other night trying to get back home. Resident #73 denied injuring himself when he climbed out of the window.
On 07/24/2025 at 12:30 p.m. review of the video surveillance dated 07/21/2025 at 9:51 p.m. revealed S19CNA went into Resident #73’s room and came out of the room with a trash bag.
On 07/24/2025 at 2:32 p.m. interview with S3DON confirmed she did not reinservice all staff after Resident #73 eloped from the facility on 07/21/2025.
On 07/24/2025 at 2:45 p.m. a phone interview with S18Certified Nursing Assistant (CNA) revealed she was working 11:00 p.m. – 7:00 a.m. shift the night of 07/21/2025 when Resident #73 eloped from the facility. S18CNA revealed she went to check on Resident #73 at approximately 11:45 p.m., he wasn’t in the room and she assumed he was in the bathroom. S18CNA further revealed at approximately 2:00 a.m. she went to check on Resident #73, he wasn’t in the room and she assumed he was in the hospital. S18CNA confirmed she did not notify the nurse when she was unable to locate Resident #73. S18CNA revealed she was not aware that Resident #73 was at risk for elopement prior to the incident.
On 07/24/2025 at 4:45 p.m. a phone interview with S19CNA revealed he worked on 07/21/2025 from 3:00 p.m. – 11:00 p.m. with Resident #73. Further interview with S19CNA revealed he provided incontinent care to Resident #73 on 07/21/2025 at approximately 9:30 p.m. S19CNA confirmed he was not aware that Resident #73 was at risk for elopement, and he was unsure if Resident #73 was wearing an orange wrist band to indicate at risk for elopement on 07/21/2025.
On 07/24/2025 at 5:45 p.m. interview with S3DON revealed she performed the elopement risk assessment on 07/15/2025 for Resident #73. S3DON confirmed she informed the day shift nurse on 07/15/2025 of Resident #73’s risk for elopement but she did not inform any other staff members.
On 07/25/2025 at 10:35 a.m. a phone interview with S17LPN revealed she worked the 11:00 p.m. to 7:00 a.m. shift on 07/21/2025. She revealed she gave his night time medications at approximately 9:00 p.m. S17LPN further revealed on 07/22/2025 at approximately 6:30 a.m. she received a call from the Sherriff’s department and was informed they had Resident #73. Resident #73 was brought back to the nursing facility by the Sheriff’s department, he was assessed and no injuries were noted.
On 07/28/2025 at 9:30 a.m. interview with S3DON confirmed when Resident #73 was assessed to be at risk for elopement on 07/15/2025 and a care plan was not developed for Resident #73’s at risk for elopement upon admission.
On 07/28/2025 at 1:45 p.m. interview with S3DON revealed prior to the incident on 07/21/2025 with Resident #73, the facility did not have a plan in place to make sure the staff were informed of the residents that were at risk for wandering.
The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit.
The facility's POR submitted on 07/25/2025:
Actions the facility will take-
07/22/2025 DON or Designee will screen all new admits or readmits for potential wandering and/or elopement, including history and current cognitive status and continue with ongoing elopement risk assessments.
07/22/2025 hourly observations for Resident #73 was initiated. 07/25/2025 hourly observations for all high risk for elopement residents were initiated.
07/22/2025 ensured all high risk for elopement residents had on orange wristbands.
07/22/2025 Maintenance Director secured all windows.
07/22/2025 DON or Designee will be responsible for updating the elopement binders for all high-risk new admissions and readmissions for elopement. To be placed at each nurses station with face sheets continuously.
07/22/2025 elopement policy updated to include: any elopement risk resident will wear an orange wrist band as an identifier.
07/25/2025 Charge nurses will meet with all staff (CNAs, nurses, any other direct/indirect care staff) at beginning of each shift to communicate high risk elopement residents.
Education/Training Plan -
07/22/2025 DON and ADON inserviced nurses to complete hourly observations of high risk elopement residents and document on monitoring tool – completed inservice on 07/25/2025.
07/22/2025 DON inserviced MDS nurse to update care plan to reflect elopement risk residents. Inservice was completed on 07/24/2025 by DON and ADON to all staff on elopement risk and orange wristbands. Education also added to the new hire orientation process.
Monitoring of Implemented Actions -
07/22/2025 DON or Designee will observe and document high risk elopement residents’ behaviors for initial 14 days in facility after new admission or readmission.
07/22/2025 inserviced staff began using the hourly observations monitoring tool for Resident #73.
07/24/2025 DON or Designee will monitor the completion of the hourly observations of high risk residents and the documentation on monitoring tool is complete 5 days a week times 2 weeks, then 3 days a week times 2 weeks, then randomly thereafter until compliance is met.
07/24/2025 inserviced staff began using the hourly observations monitoring tool for all high risk elopement residents.
07/25/2025 Maintenance Director will monitor windows to 3 random rooms a day times 5 days for 4 weeks, then randomly until compliance is met. All findings will be reported to Quality Assurance (QA) committee weekly.
07/25/2025 hourly monitor tool binder on high risk elopement residents to be completed for the initial 14 days after new admission or readmission.
07/25/2025 DON or Designee will monitor orange wristbands to ensure it is intact and to be changed as needed if soiled or dislodged on high risk residents 5 days a week times 2 weeks, then 3 days a week times 2 weeks, then randomly thereafter until compliance is met.
07/25/2025 DON or Designee will complete elopement drills 3 times a week, 1 per shift times 2 weeks until compliance is met. All findings will be reported to the QA committee weekly.
Date facility asserts the likelihood for serious harm to any recipient no longer exists: 07/25/2025.
II. Based on observations, record reviews, and interviews, the facility failed to ensure the resident's environment remained as free of accident hazards as is possible by failing to ensure bedrails were properly secured for 3 (#2, #6, #50) of 4 (#2, #6, #50, #65) residents reviewed for bedrails.
Findings:
Review of the undated facility policy for Bedrails revealed the following, in part:
Purpose: Ensure correct installation, use and maintenance of bedrails.
Procedure: This facility will attempt to use appropriate alternatives prior to installing a side or bedrail.
If a bed or side rail is used, this facility must ensure correct installation, use and maintenance of bedrails, including but not limited to the following elements:
1) Assess the resident for risk of entrapment from bedrails prior to installation and ensure that the bed's dimensions are appropriate for the resident's size and weight.
4) Follow the manufacturers' recommendations and specifications for installing and maintaining bedrails.
When installing and using bedrails, the facility should:
-Ensure that the bed's dimensions are appropriate for the resident.
-Confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed.
-Install bedrails using the manufacturer's instructions to ensure a proper fit.
-Inspect and regularly check the mattress and bed rails for areas of possible entrapment.
Resident #6
Review of Resident #6's medical record revealed an admission date of 01/27/2024 with diagnoses of chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder.
Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed a BIMS of 14, which indicated no cognitive impairment. Further review of the MDS revealed Resident #6 had no impairment on both sides of upper and lower extremities.
On 07/21/2025 at 9:20 a.m., 07/22/2025 at 9:25 a.m., and 07/23/2025 at 9:50 a.m., observations revealed Resident #6 was in bed and had quarter bedrails in place on both sides of her upper bed. The quarter bedrails were loose and were not secured properly to her bed.
On 07/23/2025 at 1:10 p.m., S3DON and S4Director of Maintenance observed Resident #6’s right bedrail and confirmed the bedrail was loose and needed to be repaired.
Resident #50
Review of Resident #50's medical record revealed an admission date of 04/22/2025 with diagnoses of acute kidney failure, adult failure to thrive, and cirrhosis of the liver.
Review of Resident #50's MDS assessment dated [DATE] revealed a BIMS of 12 which indicated he was moderately cognitively impaired. Further review of the MDS revealed Resident #50 had no impairment on both sides of upper and lower extremities.
On 07/21/2025 at 1:04 p.m., 07/22/2025 at 2:28 p.m., and 07/23/2025 at 9:45 a.m., observations revealed Resident #50 was in bed and had a raised quarter rail in place on the right side of his upper bed. The quarter bedrail was loose and was not secured properly to his bed.
On 07/23/2025 at 1:10 p.m., S4Director of Maintenance and S3DON observed Resident #50’s right quarter bedrail and confirmed the bedrail was loose and needed to be repaired.
Resident #2
Review of the medical record for Resident #2 revealed an admission date of 12/19/2023 with diagnoses including unspecified open wound of lower back and pelvis without penetration into retroperitoneum, paraplegia, unspecified, bipolar disorder, unspecified, anxiety disorder, unspecified, and acquired absence of left leg below knee.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 15, which indicated intact cognition for daily decision making.
On 07/21/2025 at 9:18 a.m., 07/22/2025 at 9:32 a.m., and 07/23/2025 at 8:45 a.m. observations of Resident #2’s bed revealed a metal half bedrail attached to the upper left side of the resident’s bed. Further observation of the bedrail revealed the rail was loose and not secured properly to the bed.
On 07/23/2025 at 1:10 p.m., S4Director of Maintenance and S3DON observed Resident #2's bedrail and confirmed the bedrail was loose and needed to be repaired.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to be administered in a manner that enabled its resources to be used...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #73) of 3 (#8, #72 and #73) sampled residents reviewed for elopement. S3Director of Nursing (DON) failed to 1) notify staff that Resident #73 was assessed to be at risk for elopement and 2) initiate the interim care plan with appropriate interventions to prevent elopement after S3DON assessed Resident #73 to be at risk for elopement.The deficient practice resulted in an Immediate Jeopardy for Resident #73 on 07/21/2025. Resident #73 was last observed on 07/21/2025 at 9:51 p.m. Resident #73 was picked up by police on 07/22/2025 at 6:28 a.m. after being notified of Resident #73 pacing on the four lane highway approximately 0.9 miles from the facility. The police returned Resident #73 to the facility on [DATE] at 6:52 a.m. without injury. Resident #73 exited the building through a window in his room. The deficient practice had the likelihood to cause more than minimal harm to any residents residing in the facility at risk for elopement. S1Manager and S3Director of Nursing (DON) were notified of the Immediate Jeopardy on 07/24/2025 at 7:54 p.m.The Immediate Jeopardy was removed on 07/25/2025 at 3:47 p.m. when it was determined the facility had implemented an acceptable Plan of Removal (POR) as confirmed through onsite interviews and observations prior to the survey exit. Findings, Cross Reference F689: On 07/24/2025 at 5:45 p.m. interview with S3DON revealed she completed the Elopement Risk Evaluation on 07/15/2025 for Resident #73. S3DON confirmed she informed the day shift nurse on 07/15/2025 that Resident #73 was at risk for elopement but did not inform any other staff members. On 07/25/2025 at 1:10 p.m. a phone interview with S2Corporate Registered Nurse (RN) revealed when S3DON assessed Resident #73 to be at risk for elopement she should have placed the resident closer to the nurses' station, communicated with the staff to inform them that Resident #73 was at risk for elopement. Further interview with S2Corpoarate RN revealed S3DON should have updated the elopement binder and should have made sure the care plan included Resident #73's elopement risk assessment. On 07/28/2025 at 2:15 p.m. a phone interview with S2Corporate RN revealed S3DON was responsible for staff training regarding elopement. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. The facility's POR submitted on 07/25/2025: Action the facility will take- 07/22/2025 Maintenance Director secured all windows.07/22/2025 DON or Designee updated elopement risk binders and placed at each nurses station.07/22/2025 Minimum Data Set (MDS) nurse updated Resident #73 care plan to reflect high risk for elopement and completed 100% audit of residents' elopement care plan to ensure compliance.07/22/2025 Body assessment conducted immediately on Resident #73 upon arrival to facility by DON and Social Worker.07/22/2025 elopement policy updated to include: any elopement risk resident will wear an orange wrist band as an identifier. Education/Training Plan-07/24/2025 Inservices were initiated and completed by DON or Designee to all staff on elopement risk and orange wristbands. Education also added to new hire orientation process.DON and Administrator inserviced by corporate compliance consultant on elopement assessment, safety, and how to train staff completed on 07/24/2025. Educational Review from Corporate Compliance:DON or designee will verify on admission or readmissions if a resident is at high risk for elopement. DON or designee will communicate to MDS nurse high risk residents and care plan will be updated.DON or designee will communicate with the Nurse Manager for the residents with high risk of elopement.Nurse Manager or designee will place orange wrist band on resident.Nurse Manage will communicate with Certified Nursing Assistant (CNAs) of high risk elopement residents. Assistant Director of Nursing (ADON) or designee will update elopement binder at each nurses station as needed. Nurse Manager or designee will observe resident behaviors for 14 days after readmission/new admission. The facility must have written policies and procedures that include training new and existing nursing home staff and in-service training on wandering or elopement type behaviors.The facility's policies should clearly define the mechanisms and procedures for assessing or identifying, monitoring, and managing residents at risk for elopement that can help to minimize the risk of a resident leaving a safe area without the facility's awareness and or supervision.All new admissions, readmissions, and those residents with changes in condition that can present as wandering, exit seeking behavior or statements, improved mobility, mental status changes and other changes should be assessed/re-assessed for elopement risk.Residents identified to be an elopement risk should have interventions in their comprehensive plan of care to address the potential for elopement.Facilities are responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address this risk.The facility must implement care plan interventions to monitor a resident with a known history of elopement attempts which, can result in the resident leaving the building unsupervised, putting the resident at risk for serious injury or death.This is to ensure the facility provides adequate supervision and necessary devices to each resident to prevent elopement. This includes identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring effectiveness and modifying interventions when necessary. Monitoring of Implemented Actions-Corporate Compliance Nurse or Designee will be responsible for the oversight and monitoring of DON and Administrator with weekly scheduled conference calls for compliance starting 07/25/2025 weekly times 4 weeks. Will report to Ownership and Compliance Officer all negative findings and continue reporting to ensure continued compliance for the next 4 weeks until compliance is met. DON or Designee to audit all admissions and readmissions for accurate elopement risk assessments starting 07/25/2025 for 4 weeks. All findings will be reported to Quality Assurance (QA) Committee weekly until compliance is met. Date facility asserts the likelihood for serious harm to any recipient no longer exists: 07/25/2025.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure residents have the right to be free from chemical restraint...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure residents have the right to be free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms by having residents with orders for psychotropic medications greater than 14 days for 2 (#5 and #23) of 5 (#1, #5, #6, #12 and #23) residents reviewed for unnecessary medications. Findings: Resident #5
Review of the medical record for Resident #5 revealed an admission date of 06/13/2025. Resident #5 had diagnoses that included chronic obstructive pulmonary disease, peripheral vascular disease, hypertension, major depressive disorder, and dementia without behavioral disturbance.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #5 was cognitively intact for daily decision making.
Review of the July 2025 physician’s orders revealed an order for Klonopin 1 milligram (mg) to be given by mouth every 8 hours as needed for anxiety.
Review of the Gradual Dose Reduction (GDR) letter dated 07/07/2025 revealed the request by the pharmacist to provide a specific duration and stop date for the as needed Klonopin.
On 07/23/2025 at 11:15 a.m., an interview with S3Director of Nursing (DON) confirmed that the physician did not address the stop date for the as needed medication as requested by the pharmacist. S3DON further confirmed that the medication had been ordered for greater than 14 days.
Resident #23
Review of the medical record for Resident #23 revealed an admission date of 08/19/2024. Resident #23 had diagnoses that included edema, heart failure, depressive disorder, and anxiety.
Review of the MDS assessment dated [DATE] revealed that Resident #23 had intact cognition for daily decision making with a BIMS score of 14.
Review of the July 2025 physician orders revealed an order dated 08/28/2024 for Klonopin 0.5 mg as needed for alcoholism.
Review of the GDR letter dated 05/01/2025 revealed the request by the pharmacist to provide a specific duration and stop date for the Klonopin 0.5 mg as needed. Further review revealed that the physician did not address the recommendation for the psychotropic medication.
On 07/23/2025 at 11:15 a.m., an interview with S3DON confirmed that the physician did not address the stop date for the as needed medication as requested by the pharmacist. S3DON further confirmed that the medication had been ordered for greater than 14 days.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-cente...
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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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#40) of 1 resident reviewed for contractures and 2 (#72, #73) of 3 (#8, #72, #73) residents reviewed for elopement. Findings: Resident 73
Review of the record for Resident #73 revealed an admission date of 07/15/2025 with diagnoses of vascular dementia, hemiplegia, cerebrovascular accident, heart failure, and mild cognitive impairment.
Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment for daily decision making.
Review of the Elopement Risk Evaluation dated 07/15/2025 revealed Resident #73 was at risk for elopement.
Review of the record revealed no documented evidence of a care plan developed upon admission to address the elopement risk for Resident #73.
On 07/28/2025 at 9:30 a.m. interview with S3Director of Nursing (DON) confirmed there was not an elopement care plan developed for Resident #73 upon admission.
Resident 72
Review of the medical record for resident #72 revealed an admission date of 07/02/2025. Resident #72 had diagnoses which included hyperlipidemia, rhabdomyolysis, hypertension, dementia and depression.
Review of the admission MDS assessment dated [DATE] revealed Resident #72 had a BIMS score of 3, which indicated severe cognitive impairment for daily decision making.
Review of the Elopement Risk Evaluation dated 07/02/2025 revealed Resident #72 was at risk for elopement.
Review of the record revealed no documented evidence of a care plan developed upon admission to address the elopement risk for Resident #72.
On 07/28/2025 at 9:15 a.m. interview with S3DON confirmed there was not an elopement care plan developed for Resident #72 upon admission.
Resident 40
Record review revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included paraplegia incomplete, polyosteoarthritis and idiopathic neuropathy.
Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment.
On 07/21/2025 at 10:24 a.m., observation revealed Resident #40 had bilateral contractures to both hands. Resident #40 reported she has requested splints and they put wash cloths in her hands a few times but not on a regular basis.
On 07/23/2025 9:23 a.m., an interview with S7Therapy Director revealed Resident #40 had braces for both hands but she was noncompliant with wearing them, so she ordered new braces for both hands.
Record review revealed there was no active care plan related to Resident #40`s contracted hands.
On 07/23/2025 10:18 a.m., an interview with S3DON confirmed there was not an active care plan related to Resident #40`s bilateral hand contractures.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents received care consistent with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that residents received care consistent with professional standards of practice to prevent pressure ulcers for 1 (#11) of 3 (#11, #47, #50) residents reviewed for pressure ulcers.Findings:Review of the facility`s policy (undated) related to Skin and Wound Management revealed the following in part: Pressure Ulcers/Skin Breakdown - Clinical Protocol Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). Record review revealed Resident #11 was admitted on [DATE] with diagnoses which included dementia, epilepsy, abnormal posture, melanoma of scalp, and age related disability. Record review of Resident #11's skin assessment using the Braden Score System dated 06/27/2025 revealed a score of 18 which indicated he was at risk for developing pressure ulcers. Review of the active care plan for July 2025 revealed Resident #11 used a wheelchair for ambulation. Further review of the care plan revealed he was at risk for skin impairment and had an intervention to place a cushion to the seat of his wheelchair. On 07/21/2025 at 10:06 a.m., Resident #11 was observed sleeping in bed with his clothes on and his wheelchair was at his bedside in the locked position. Further observation revealed the wheelchair did not have a pressure reducing device in the seat. Velcro was observed in the wheelchair seat and appeared to be where a cushion should be applied. On 07/22/2025 at 9:05 a.m. and 07/23/2025 at 9:31a.m., observations revealed Resident #11 was observed sleeping in bed. Further observation revealed his wheelchair was observed at the bedside with no pressure relieving device in the seat of the chair. On 07/22/2025 10:19 a.m., an observation of Resident #11 was conducted in his room with S3Director of Nursing (DON). S3DON confirmed Resident #11 did not have a pressure relieving device in his chair. S3DON confirmed Resident #11 once had a cushion in his chair and needed one placed back in it.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that a resident received appropriate treatm...
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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 ensure that a resident received appropriate treatment and services to prevent urinary tract infections for 1 (#75) of 2 (#4 & #75) residents reviewed for urinary catheter. Findings:Review of the facility's Urinary Catheter Care Policy dated September 2014 revealed in part:Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Control2.b. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the record for Resident #75 revealed an admission dated of 01/08/2019 with diagnoses that included diabetes mellitus, heart disease, urinary retention, and dementia.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10 which indicated that Resident #75 had moderate cognitive impairment for daily decision making. On 07/21/2025 at 11:40 a.m. and 07/22/2025 at 9:05 a.m., observations of Resident #75 revealed the resident's catheter bag was observed lying on the floor in a plastic bag and the catheter tubing was lying directly on the floor. On 07/21/2025 at 11:45 a.m., interview with S20Licensed Practical Nurse (LPN) revealed the catheter bag and tubing should not have been on the floor and the catheter bag should not be stored in a trash bag. On 07/23/2025 at 9:20 a.m., an observation of Resident #75 with S3Director of Nursing (DON) revealed the indwelling catheter tubing was lying directly on the floor. S3DON confirmed that the tubing should not be on the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor lab results for a resident receiving anti-seizure medication for 1 (#12) of 5 (#1, #5, #6, #12, #23) residents reviewed for unnecessary medications.Findings: Review of the record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage without loss of consciousness, initial encounter; other seizures; altered mental status and encephalopathy.On 07/22/2025 at 10:00 a.m., a review of Resident #12's current care plan revealed the facility should obtain lab/diagnostic work as ordered and report results to physician.On 07/22/2025 at 10:15 a.m., a review of Resident #12's active physician orders revealed an order for Valproic Acid oral solution 15 milliliters (ml) by mouth every morning ordered 04/10/2025 and Valproic Acid oral solution 20 ml by mouth every evening for seizures ordered 04/09/2025. Further review revealed a physician's order dated 05/01/2025 for a Depakote (Valproic Acid) level to be drawn every month.On 07/23/2025 at 11:05 a.m., a record review revealed no documented Depakote lab results in Resident #12's chart.On 07/23/2025 at 11:45 a.m., an interview with S3Director of Nursing confirmed Resident #12 did not have Depakote levels drawn while in facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to properl...
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Based on observations and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to properly store the ice scoop utilized in serving ice to residents in a sanitary manner.Findings: On 07/21/2025 at 8:15 a.m., an observation of the facility's kitchen revealed that an ice scoop was being stored inside an ice chest that contained ice for resident use.On 07/21/2025 at 8:22 a.m., an observation with S8Dietary Supervisor confirmed the ice scoop was being stored in the ice chest containing resident ice.On 07/23/2025 at 11:45 a.m., S3Director of Nursing (DON) was informed of dietary staff storing an ice scoop in the ice chest for resident use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly with all required members present.Findings: Review of the...
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Based on record review and interview the facility failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly with all required members present.Findings: Review of the QAA committee meetings revealed quarterly meetings with required staff present were recorded on 08/08/2024, 11/21/2024, and 04/24/2025. On 07/23/2025 at 4:20 p.m., an interview/observation with S2Corporate Registered Nurse (RN) confirmed records of the quarterly meetings with required staff present were recorded on 08/08/2024, 11/21/2024, and 04/24/2025. On 07/23/2025 at 4:20 p.m., an interview with S3Director of Nursing confirmed four quarterly QAA committee meetings with all required staff present had not been completed in the past year.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing to ensure that Enhanced Barrier Precautions (EBP) were implemented as ordered for 1 (#47) of 3 (#11, #47, #50) residents reviewed for pressure ulcers.Findings:Review of the undated EBP policy revealed, in part:Purpose: Prevent the spread of novel or targeted multi-drug resistant organisms (MDROs)EBP expand the use of personal protective equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.EBP apply to:Wounds and/or indwelling medical devices (i.e., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. On 07/21/2025 at 9:36 a.m. and 07/22/2025 at 9:02 a.m., observations of Resident #47's room revealed no EBP signage posted.Review of the medical record for Resident #47 revealed an admission date of 04/21/2025 with diagnoses that included end stage renal disease, hypothyroidism, hypertension, and unstageable pressure ulcer of left heel.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13 which indicated that Resident #47 is cognitively intact for daily decision making.Review of the July 2025 physician's orders revealed an order for EBP dated 06/26/2025.On 07/23/2025 at 9:15 a.m., S3Director of Nursing (DON) confirmed that EBP signage should have been posted on Resident #47's door. S3DON also confirmed that the signage was not posted at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on record reviews and interview, the facility failed to provide in-services, at least 12 hours in a year, sufficient to ensure the continued competence of Certified Nursing Assistants (CNA) for ...
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Based on record reviews and interview, the facility failed to provide in-services, at least 12 hours in a year, sufficient to ensure the continued competence of Certified Nursing Assistants (CNA) for 3 (S12CNA, S14CNA, S15CNA) of 5 (S11CNA, S12CNA, S13CNA, S14CNA, S15CNA) CNAs reviewed for in-service training. Findings:Review of the personnel record for S12CNA revealed a hire date of 07/02/2021. Further review of the personnel file revealed no documented evidence of 12 hours of annual training. Review of the personnel record for S14CNA revealed a hire date of 04/19/2023. Further review of the personnel file revealed no documented evidence of 12 hours of annual training. Review of the personnel record for S15CNA revealed a hire date of 05/30/2012. Further review of the personnel file revealed no documented evidence of 12 hours of annual training. On 07/22/2025 at 4:40 p.m., an interview with S3Director of Nursing (DON) confirmed that the required annual in-service training had not been provided to S12CNA, S14CNA and S15CNA.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure that individual financial records are available to the resident through quarterly statements for 1 (#6) of 1 (#6) residents reviewed...
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Based on interview and record review, the facility failed to ensure that individual financial records are available to the resident through quarterly statements for 1 (#6) of 1 (#6) residents reviewed for personal funds out of a total sample of 37 residents. Findings:Review of the facility's Resident Funds policy (undated) revealed in part:Purpose: Ensure than an individual record is established for each resident on which only those transactions involving his/her personal funds are recorded and maintained. Procedure:3. The individual financial record must be available to the resident through quarterly statements and upon request. Review of the medical record for Resident #6 revealed a Brief Interview of Mental Status score of 14 which indicated that the resident is cognitively intact.On 07/23/2025 at 1:30 p.m., a phone interview with S5Business Office Manager (BOM) related to the management of resident finances was conducted. During the interview, S5BOM was asked to confirm the delivery method of quarterly statements. S5BOM stated that quarterly statements are mailed by way of the postal service. On 07/23/2025 at 3:06 p.m., an interview was conducted with Resident #6 related to the availability of quarterly statements. Resident #6 voiced that she had not received her most recent quarterly statement. On 07/23/2025 at 3:10 p.m., an interview was conducted with S6Social Services Director (SSD) related to the delivery of resident mail. S6SSD voiced that she does not recall if quarterly statements were delivered.On 07/23/2025 at 3:40 p.m., an interview was conducted with an anonymous source who stated that quarterly statements are not being received by residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#1, #2, #22, #43) of 6 (#1, #2, #6, #22, #40, #43) sampled residents reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were maintained in good repair.Findings:
Resident #1
Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below knee, Type 2 diabetes, and epilepsy. Further review revealed an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 used a wheelchair for ambulation and required supervision/touch assistance for most activities of daily living.
On 07/21/2025 at 9:50 a.m., Resident #1 was in his wheelchair in the hall. An observation of his wheelchair revealed the left wheelchair arm padding was cracked and needed to be repaired. Further observation revealed the wheelchair wheels had a build-up of dirt and grime.
On 07/22/2025 at 3:46 p.m., Resident #1 was in bed in his room and his wheelchair was next to his bed. Further observation revealed the left wheelchair armrest padding and the wheelchair seat was cracked and were in need of repair. Also, it was noted that the wheelchair wheels had a build-up of dirt and grime.
On 07/23/2025 at 1:10 PM, an observation of Resident #1’s wheelchair was conducted with S3Director of Nursing (DON) and S4Director of Maintenance. They confirmed that Resident #1's left armrest padding and seat of his wheelchair was cracked and needed to be repaired. S3DON and S4Director of Maintenance also confirmed the wheelchair needed to be cleaned.
Resident #22
Review of the record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Alzheimer’s disease, schizophrenia, and major depressive disorder. Further review revealed a Quarterly MDS assessment dated [DATE] revealed that Resident #22 used a wheelchair for ambulation and required moderate assistance for most activities of daily living.
On 07/21/2025 at 9:33 a.m. and 07/22/2025 at 9:12 a.m., observations revealed Resident #22 was in her wheelchair. Observations of her wheelchair revealed the right wheelchair arm padding was cracked and needed to be repaired.
On 07/23/2025 at 1:10 PM, an observation of Resident #22’s wheelchair was conducted with S3DON and S4Director of Maintenance. They confirmed that Resident #22's right wheelchair armrest padding was cracked and needed to be repaired.
Resident #2
Review of the record for Resident #2 admitted to the facility on [DATE] with diagnoses including unspecified open wound of lower back and pelvis without penetration into retroperitoneum, paraplegia, bipolar disorder, anxiety disorder, and acquired absence of left leg below knee.
On 07/21/2025 at 9:18 a.m., 07/22/2025 at 9:32 a.m., and 07/23/2025 at 8:45 a.m., observations of Resident #2’s wheelchair revealed the wheelchair arm padding to be cracked and torn.
On 07/23/2025 at 1:10 p.m., an observation conducted with S3DON and S4Director of Maintenance confirmed that Resident #2's wheelchair armrest padding was cracked, torn, and in need of repair
Resident # 43
Review of the record revealed Resident #43 admitted to the facility on [DATE] with diagnoses including alcohol abuse with other alcohol-induced disorder; essential (primary) hypertension; cerebrovascular disease, aphasia and other seizures.
Review of quarterly Minimal Data Set (MDS) assessment dated [DATE] section GG revealed that Resident # 43 is ambulatory by walker and wheelchair.
On 07/22/2025 at 8:35 a.m., 07/22/2025 at 1:05 p.m., and 07/23/2025 at 8:10 a.m., observations of Resident #43’s wheelchair revealed the wheelchair arm padding to be cracked and torn.
On 07/23/2025 1:10 p.m., an observation conducted with S3DON and S4Director of Maintenance confirmed that Resident #2's wheelchair armrest padding was cracked, torn, and in need of repair.
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 F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to 1) ensure a physician's order for bed rails was ob...
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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 physician's order for bed rails was obtained for residents, 2) assess residents for risk of entrapment from bed rails prior to the installation of bed rails, and 3) ensure care plans reflected the use of bed rails for 4 (#2, #6, #50, #65) of 4 residents reviewed for bedrails. Findings:
Review of the undated facility policy for Bedrails revealed the following, in part:
1.) Assess the resident for risk of entrapment from bedrails prior to installation and ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility will assess the resident's need for bedrails and all factors involved, including alternatives. Alternatives to bedrails will always be attempted before consideration of bedrail application. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident’s assessed needs.
What assessed medical needs would be addressed by the use of bedrails; the resident's benefits from the use of bed rails and the likelihood of these benefits; the resident's risks from the use of bedrails and how these risks will be mitigated and alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate.
Resident #6
Review of Resident #6's medical record revealed an admission date of 01/27/2024 with diagnoses of chronic obstructive pulmonary disease, major depressive disorder, and anxiety disorder.
Review of Resident #6's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Further review of the MDS revealed Resident #6 had no impairment on both sides of upper and lower extremities.
Further review of Resident #6’s medical record revealed there was no documentation of the following regarding the use of bilateral quarter bedrails: physician’s order, entrapment assessment prior to the installation of the bedrails, and care plan for the use of the quarter bedrails.
On 07/21/2025 at 9:20 a.m., 07/22/2025 at 9:25 a.m., and 07/23/2025 at 9:50 a.m., observations revealed resident #6 was in bed and had bilateral quarter bedrails in place on both sides of her upper bed.
On 07/23/2025 at 9:30 a.m., an interview with S3Director of Nursing (DON) confirmed the facility failed to have the following documentation regarding Resident #6’s quarter bedrail: physician order, risk for entrapment, and the care plan was not developed.
Resident #50
Review of Resident #50's medical record revealed an admission date of 04/22/2025 with diagnoses of acute kidney failure, adult failure to thrive, and cirrhosis of the liver.
Review of Resident #50's MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated he was moderately cognitively impaired. Further review of the MDS revealed Resident #50 had no impairment on both sides of upper and lower extremities.
Further review of Resident #50’s medical record revealed there was no documentation of the following regarding the use of a bilateral quarter bedrail: physician’s order, entrapment assessment prior to the installation of the bedrails, and care plan for the use of the quarter bedrail.
On 07/21/2025 at 1:04 p.m., 07/22/2025 at 2:28 p.m., and 07/23/2025 at 9:45 a.m., observations revealed resident #50 was in bed and had a raised quarter rail in place on the right side of his upper bed.
On 07/23/2025 at 9:30 a.m., an interview with S3DON confirmed the facility failed to have the following documentation regarding Resident #50's quarter bedrail: physician order, risk for entrapment, and a care plan was not developed.
Resident #2
Review of the record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including unspecified open wound of lower back and pelvis without penetration into retroperitoneum; paraplegia, bipolar disorder, anxiety disorder and acquired absence of left leg below knee.
Review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment.
On 07/21/2025 at 9:18 a.m., 07/22/2025 at 9:32 a.m., and 07/23/2025 at 8:45 a.m., observations of Resident #2’s bed revealed a metal 1/2 bedrail attached to upper left side of resident’s bed.
On 07/22/2025 at 11:00 a.m., record review revealed the following: no order for bedrail use, no care plan for bedrail, and no bedrail entrapment assessment.
On 07/23/2025 9:30 a.m., an interview with S3DON confirmed the facility did not have the following: a physician’s order for side rail use, an entrapment risk assessment completed, or a care plan for side rail usage.
Resident #65
Review of Resident #65’s medical record revealed an admission date 07/16/2024. Resident #65 had diagnoses including diabetes mellitus, morbid obesity, heart disease, osteoarthritis, and muscle weakness.
Review of Resident #65’s Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS of 13, which indicated intact cognition for daily decision making.
Review of Resident #65’s medical record revealed there was no documentation of the following regarding the use of bilateral quarter bed rails: physician’s order, entrapment assessment prior to the installation of the bedrails, and a care plan for the use of the quarter bed rails.
On 07/21/2025 at 1:12 p.m. and 07/23/2025 at 9:00 a.m., observations revealed Resident #65 was in bed and had quarter bedrails in place on both sides of her upper bed.
On 07/23/2025 at 9:30 a.m., an interview with S3DON confirmed the facility failed to have the following documentation regarding Resident # 65’s quarter bedrails: physician order, risk for entrapment, and a care plan was not developed for the use of bed rails.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation of medication administration, record review, and interview, the facility failed to ensure the medication error rate was not 5% or greater. The facility had a 19.35% medication err...
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Based on observation of medication administration, record review, and interview, the facility failed to ensure the medication error rate was not 5% or greater. The facility had a 19.35% medication error rate with 6 medication errors for 2 (#26, #29) of 5 (#26, #29, #46, #49, #57) residents observed for medication administration. The facility had 6 medication administration errors out of 31 opportunities. The facility's current census was 65 residents. Findings:Review of the facility's Administering Medications Policy revised December 2012 revealed the following, in part: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretations and Implementation: 3. Medications must be administered within one (1) hour of their prescribed time frame. Resident #26 An interview with S10Licensed Practical Nurse (LPN) on 07/23/2025 at 10:15 a.m., revealed she had not started to give medications for the residents on her hall, which was the hall where resident #26 resided. On 07/23/2025 at 10:40 a.m., an observation during medication administration pass with S10LPN revealed she administered the following medications for Resident #26: Norvasc (anti-hypertensive) 5 milligrams (mg) by mouth (po) 1 every day; Colace (laxative)100mg 1 po every day; Ferrous Sulfate (Iron) 325mg 1 po every day; Levaquin (antibiotic) 500mg 1 po every day; and Xarelto (blood thinner)10mg 1 po every day. Review of the Resident #26's July 2025 physician orders revealed the following orders: Norvasc 5mg po 1 every day; Colace 100mg 1 po every day; Iron Oral Tablet 325mg 1 po every day; Levaquin 500mg 1 po every day; and Xarelto 10mg 1 po every day. Review of Resident #26's July Medication Administration Record (MAR) revealed the above medications were to be administered at 9:00 a.m. On 07/23/2025 at 10:50 a.m., an interview with S10LPN confirmed the above morning medications for Resident #26 were due today at 9:00 a.m. and she was late giving them since the medications were given at 10:40 a.m. On 07/23/2025 at 11:00 a.m. S3Director of Nursing (DON) confirmed that resident #26's above medications were not given on time during the morning medication pass on 07/23/2025. Resident #29 On 07/23/2025 at 8:04 a.m., an observation during medication administration pass with S9LPN revealed she failed to administer Resident #29's Thiamine Hydrochloride (Vitamin B-1) 100 mg one po every day. Review of the July 2025 physician orders for Resident #29 revealed an order dated 04/25/2025 for Thiamine Hydrochloride 100mg one po every day. Review of Resident #29's July 2025 MAR revealed the Thiamine Hydrochloride was scheduled to be administered at 9:00 a.m. On 07/23/2025 4:10 p.m., S9LPN confirmed she failed to administer Resident #29's Thiamine Hydrochloride 100mg po every day at 9:00 AM during the above medication pass. S9LPN revealed she thought the medication was not available earlier. S3DON, S9LPN, and the surveyor observed the Thiamine Hydrochloride on the S9LPN's medication cart. S9LPN confirmed she was unaware it was on her medication cart during morning medication pass.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both ...
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Based on record review and interview the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. Findings:Review of the facility assessment revealed the last facility assessment was done on 06/25/2024. On 07/23/2025 at 9:40 a.m. interview with S3Director of Nursing (DON), S2Corporate Registered Nurse (RN) and S1Manager confirmed the last facility assessment was noted on 06/25/2024.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The fac...
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Based on record review and interview, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility had: 1) excessively low weekend staff during Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025 and 2) insufficient staff on: 06/08/2025, 06/14/2025, 06/22/2025, and 06/28/2025.Findings:Review of the facility's Payroll-Based Journal (PB&J) Staffing Report revealed the facility triggered excessively low weekend staff for Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025.Review of the facility's January 2025 weekend personnel staffing pattern revealed insufficient staff for the following dates: 01/04/2025, 01/05/2025, 01/11/2025, 01/12/2025, 01/18/2025, 01/19/2025, 01/25/2025, and 01/26/2025.Review of the facility's February 2025 weekend personnel staffing pattern revealed insufficient staff for the following dates: 02/01/2025, 02/02/2025, 02/08/2025, 02/09/2025, 02/15/2025, 02/16/2025, 02/22/2025, and 02/23/2025. Review of the facility's March 2025 weekend personnel staffing pattern revealed insufficient staff for the following dates: 03/01/2025, 03/02/2025, 03/08/2025, 03/09/2025, 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025 and 03/30/2025.Review of the personnel staffing pattern dated 06/01/2025 - 06/14/2025 revealed insufficient staff on 06/08/2025 and 06/14/2025.Review of the personnel staffing pattern dated 06/15/2025 - 06/28/2025 revealed insufficient staff on 06/22/2025 and 06/28/2025. On 07/23/2025 at 8:50 a.m. interview with S3Director of Nursing (DON) confirmed the facility had low staffing for the dates listed above and did not meet the required hours.
Apr 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to prevent the deve...
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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 provide a sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 (#2, #5, #6, and #7) of 4 residents reviewed for infection control. S7Certified Nursing Assistant (CNA) failed to clean the whirlpool according to manufacturer's guidelines. Residents #2, #5, #6, and #7 received whirlpool baths three times a week while having open wounds to their body. Residents #2, #5, #6 and #7 were currently receiving antibiotics related to wound infections.
Findings:
Review of the whirlpool manufacturer`s guidelines for cleaning whirlpool revealed the following in part:
Clean and disinfect the tub and swivel lift after every bath with cleaner/disinfectant.
1. Raise the swivel lift completely and rotate or swing the chair back into the tub.
2. Close and lock the door.
3. Press the tub fill button and turn the temperature control knob all the way to the left to its warmest level to heat the disinfectant solution.
4. Remove any visible tissue, residue, or fluids from the tub by pressing the shower button and rinsing the inside of the tub surfaces with the shower sprayer.
5. Press the fill button again to turn off the water. Allow the tub to drain, and place the drain plug over the drain.
6. Press and hold the disinfect jets button located on the left side of the tub. Release the button after you see solution coming out of all the air jets and you have 1 to 1 ½ gallons of disinfectant solution in the foot well of the tub.
7. Using the long-handled brush thoroughly scrub all interior surfaces of the tub, and Swivel Lift with the solution that remains in the foot well of the tub. Let disinfectant stay on the surface for 10 minutes.
8. Remove the plug from the drain.
9. Rinse the Swivel Lift and the tub's interior surfaces thoroughly with the shower sprayer.
10. Press and hold the Rinse jets button located on the left side of the control panel until clear water runs from all the air jets. Then release the Rinse jets button.
11. Finish rinsing the swivel lift bathing system and the interior surfaces of the tub with the shower sprayer.
12. Start the air blower by pushing the Aqua-Aire Button. Allow it to run for 30 seconds. This pushes the rinse water out of the air injection system. If this was the last bath of the day, allow the blower to run for 2 minutes to dry out the system.
13. Stop the Aqua-Aire blower by again pushing the Aqua-Aire button.
14. Visibly check the tub and reservoir (if applicable) was effectively cleaned during disinfecting procedure. If not, repeat the procedure.
15. If there is a delay of one or more hours before the next bath, we recommend using a towel to wipe off all excess water. This will keep your whirlpool looking great for years to come.
Review of the facility's policy and procedure (undated) related to whirlpool use revealed the policy and procedure did not follow the manufacturer's guidelines.
Resident #2
Review of the record for resident #2 revealed an admission date of 01/28/2025 with diagnoses including venous insufficiency (chronic) (peripheral), systolic congestive heart failure, cellulitis of unspecified part of limb, chronic obstructive pulmonary disease, chronic kidney disease, morbid obesity, sleep apnea, cerebral infarction, hyperlipidemia, hypertension, nicotine dependence, and history of falling.
Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment. Further review of the MDS revealed resident required moderate to maximal assistance with activities of daily living.
An observation/interview on 04/09/2025 at 10:00 a.m. was conducted with resident #2 while the resident was observed in the hall awaiting his whirlpool. Observation revealed resident #2 had a dressing to his left lower leg. Interview with resident #2 revealed he received a whirlpool bath 3 times per week on Monday, Wednesday, and Friday since he was admitted to the facility and he had an open wound to his left lower leg.
An interview on 04/09/2025 at 11:30 a.m. with S6Wound Care (Licensed Practical Nurse) LPN/Infection Preventionist revealed resident #2 had a wound to his left lower leg and went to the whirlpool 3 times per week. S6Wound Care LPN/Infection Preventionist confirmed resident #2 had a culture to his left lower leg and the results on 03/30/2025 revealed resident #2 had staphylococcus in his wound.
Review of resident #2's Skin Only Evaluations revealed the resident had an open venous ulcer to his left lower leg.
Review of the culture results for resident #2's left lower leg dated 03/30/2025 revealed the following results - #1 Enterococcus raffinosus- heavy growth, #2 - Staphyloccus aureus- heavy growth, Methicillin resistant (MRSA), and #3 multiple negative rods present, none predominant, indicative of a heavily colonized/contaminated specimen site - heavy growth.
Review of resident #2's Physician's Orders revealed an order dated 03/31/2025 for Doxycycline Hyclate oral tablet 100 milligrams (mg) 1 tablet by mouth (po) 2 times a day related to cellulitis of unspecified part of limb for 7 days.
On 04/09/2025 at 11:20 a.m. an interview with S7CNA was conducted in the whirlpool room as she cleaned the whirlpool between residents. S7CNA confirmed resident #2 had used the whirlpool the week of 04/07/2025, and confirmed resident #2 had an open wound to his body. S7CNA confirmed resident #2 was on the whirlpool schedule to receive whirlpool baths on Monday, Wednesday, and Friday for the month of April.
Resident #5
Review of the record for resident #5 revealed an admission date of 12/19/2023 with diagnoses including unspecified open wound of lower back and pelvis without penetration into retroperitoneum, paraplegia, bipolar disorder, neuromuscular dysfunction, anxiety disorder, chronic combined systolic and diastolic heart failure, acquired absence of left leg below knee, pressure ulcer of other site stage 3, and peripheral vascular disease.
Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Further review of the MDS revealed resident required assistance with activities of daily living.
An observation/interview was conducted with resident #5 on 04/09/2025 at 10:00 a.m. while he was sitting in the hall awaiting his whirlpool. Observation revealed resident #5 had a dressing to his right lower leg. An interview with resident #5 revealed he received a whirlpool bath on Monday, Wednesday, and Friday weekly. Resident #5 reported he had open wounds to his right lower leg. Resident #5 reported he had a culture at the end of March 2025 and was started on antibiotics for an infected wound after they received wound culture results. Resident #5 further reported he did not stop going to whirlpool even after he was placed on antibiotics for a wound infection, but continued to go to the whirlpool 3 times per week on Monday, Wednesday, and Friday.
An interview on 04/09/2025 at 11:30 a.m. with S6Wound Care LPN/Infection Preventionist revealed resident #5 had a wound to his right lower leg and went to the whirlpool 3 times per week on Monday, Wednesday, and Friday.
Review of resident #5's culture results to right leg wound revealed that Pseudomonas aeruginosa, Vancomycin-resistant Enterococcus (Enterococcus faecalis), and multiple negative rods were present on the results dated 03/30/2025.
Review of Progress notes revealed resident #5 was ordered 2 antibiotics (Ciprofloxacin HCL and Penicillin) on 03/25/2025 by the nurse practitioner due to an infected wound to his right lower extremity.
Review of resident #5's Physician's Orders revealed an order dated 03/25/2025 for Ciprofloxacin Hydrochloride (HCL) tablet 500 mg give 1 tablet by mouth 2 times a day for wound infection to lower extremity for 10 days and Penicillin V Potassium oral tablet 500 mg give 1 tablet by mouth 4 times a day for wound infection to lower extremity for 10 days.
On 04/09/2025 at 11:20 a.m. an interview with S7CNA was conducted in the whirlpool room as she cleaned the whirlpool between residents. S7CNA confirmed resident #5 had used the whirlpool the week of 04/07/2025 and confirmed resident #5 had an open wound to his body. S7CNA confirmed resident #5 was on the whirlpool schedule to receive whirlpool baths on Monday, Wednesday, and Friday for the month of April.
Resident #6
Review of the record for resident #6 revealed an admission date of 04/02/2025 with diagnoses that included fractured clavicle, person injured in collision between other specified motor vehicles, lacerated kidney, and fractured lumbar vertebra.
Review of the Skin Only Evaluations dated 04/02/2025 revealed resident #6 had an open abscess to her left elbow.
Review of the active physician orders for April 2025 revealed the following:
Clindamycin 300 milligrams Give 1 capsule by mouth every 8 hours for skin infection to left elbow for 7 days. Start date 04/07/2025.
Review of whirlpool bath schedule revealed resident #6 was to receive a whirlpool baths every week on Monday, Wednesday, and Friday.
On 04/09/2025 at 09:05a.m., resident #6 was observed in hallway outside of the whirlpool. Resident #6 was found to be alert and oriented while talking to other residents. A bandage was observed to her left elbow. Resident #6 was waiting to get a whirlpool bath.
On 04/09/2025 at 2:20 p.m., an interview with S6Wound LPN/Infection Preventionist confirmed resident #6 had been started on Clindamycin on 04/07/2025 as prophylactic treatment related to the wound infection.
On 04/09/2025 at 11:20 a.m. an interview with S7CNA was conducted in the whirlpool room as she cleaned the whirlpool between residents. S7CNA confirmed resident #6 had used the whirlpool the week of 04/07/2025 and confirmed resident #6 had an open wound to her body. S7CNA confirmed resident #6 was on the whirlpool schedule to receive whirlpool baths on Monday, Wednesday, and Friday for the month of April.
Resident #7
Review of the record for resident #7 revealed an admission date of 05/17/2022. Resident #7 had diagnoses that included an abrasion to the left great toe.
Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated she was cognitively intact.
Review of the active Physician orders for April 2025 revealed the following:
Clindamycin Capsule 300 milligrams: Give 1 capsule by mouth every 8 hours for infection to left great toe for 10 Days - Started 04/07/2025.
Review of whirlpool bath schedule revealed resident #7 was to receive a whirlpool bath every week on Monday, Wednesday, and Friday.
On 04/09/2025 at 10:15 a.m., resident #7 was observed in hallway outside of the whirlpool. Resident #7 was found to be alert and oriented while talking to other residents. Resident #7 was waiting to get a whirlpool bath.
On 04/09/2025 at 2:20p.m., an interview with S6Wound LPN/Infection Preventionist confirmed resident #7 had been started on Clindamycin on 04/07/2025 as a prophylactic treatment related to a wound infection to the left great toe.
On 04/09/2025 at 11:20 a.m. an interview with S7CNA was conducted in the whirlpool room as she cleaned the whirlpool between residents. S7CNA confirmed resident #7 had used the whirlpool the week of 04/07/2025 and confirmed resident #7 had an open wound to her body. S7CNA confirmed resident #7 was on the whirlpool schedule to receive whirlpool baths on Monday, Wednesday, and Friday for the month of April.
Observation on 04/09/2025 at 11:20 a.m. revealed S7CNA cleaning the whirlpool between residents. Further observation revealed the swivel lift chair was outside of the whirlpool during the cleaning process. S7CNA reported the whirlpool had a button to push that would release a disinfectant to clean the whirlpool jets after each resident use but there was nothing coming out of the jets when she pushed the button to clean the jet system. She demonstrated by pushing the cleaning button and nothing came through the jets. S7CNA reported she did not know where the disinfectant reservoir was located to clean the jets on the whirlpool. S7CNA did not acknowledge that she reported the disinfectant not coming through the jets to her supervisor. S7CNA cleaned the inner surface of the tub with a disinfectant cleaner in a spray bottle. She sprayed the entire inner surface of the whirlpool. She planned to allow the cleaning solution to stay on the surface for 5 minutes before rinsing out the tub and preparing for the next resident. S7CNA reported she could spray the disinfectant cleaner into the jets but was not observed doing so in the cleaning process. S7CNA confirmed she was not able to clean the inner jet system. A brush was not observed being used in the cleaning process. The swivel lift chair remained outside of the whirlpool during the cleaning process and was not mentioned or cleaned during the process.
On 04/10/2025 at 8:35 a.m., an interview with S5Maintenance Supervisor confirmed there was a disinfectant reservoir behind a locked panel in the front of the whirlpool that disinfected the jet system. S5Maintenance Supervisor confirmed the disinfectant reservoir was found to be empty that morning. S5Maintenance Supervisor confirmed he had not been checking the whirlpool disinfectant reservoir since he began working at the facility on 01/08/2025 as maintenance supervisor.
On 04/10/2025 at 11:04 a.m., an interview with S2DON revealed she was acting as the CNA Supervisor. S2DON reported she had not monitored the cleaning of the whirlpool since she became DON/CNA supervisor on 02/12/2025. S2DON confirmed resident #2, resident #5, resident #6, and resident #7 should not have been using the whirlpool with open wounds. S2DON confirmed the current facility policy and procedure for cleaning the whirlpool did not follow manufacturer guidelines to prevent the spread of infections. S2DON confirmed S7CNA did not clean the whirlpool per the manufacturer's guidelines.
Jan 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to immediately consult the resident's physician when a resident had ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to immediately consult the resident's physician when a resident had a change in condition or started a new treatment for 1 (#1) of 3 (#1, #3, and #4) residents reviewed for accidents. The deficient practice was evidenced by the nurse failing to notify the physician in a timely manner after she observed blisters on resident #1's skin.
Findings:
Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses which included in part, acquired absence of right leg below knee, Type 1 diabetes with diabetic neuropathy, and hypertensive chronic kidney disease.
Review of the significant change in status assessment dated [DATE] revealed resident #10 had a brief interview for mental status score of 15 which indicated the resident was cognitively intact with his daily decision making skills. Further review of the assessment revealed that resident #1 was independent with his ability to eat.
Review of the medical record revealed a physician's order dated 01/11/2025 for Silvadene External Cream 1% (Silver Sulfadiazine) apply to right thigh topically one time a day related to patient's other non-compliance with medication regimen; Burn to right thigh-apply Silvadene and cover with Bordered gauze or wrap with Kerlix daily and as needed until healed.
Review of the Incidents By Incident Type Report revealed that resident #1 had a documented skin impairment incident on 01/11/2025 at 3:00 a.m. Review of the incident description revealed: resident called night nurse to room and said he burned himself with some noodles, looked at right thigh and noticed blisters. Review of the resident description revealed the following documentation: I warmed up my noodles and I had just made it to the door and I spilled the noodles over my leg. I called the Certified Nursing Assistant (CNA) and she cleaned off the noodles from my leg. I got in bed and was getting changed by another CNA and she noticed that I had a blister on my leg. I told her I wasted noodles on my leg. I called for the nurse and I showed it to her.
On 01/23/2025 at approximately 2:15 p.m., an interview with resident #1 revealed that he had self-propelled himself to the activity room where he heated up a cup of noodles. Resident #1 further revealed that when he got back to his room door, he had gotten distracted and spilled the cup of noodles on himself. He revealed that the juice from the noodles had gotten on the left thigh a little bit, but more so on his right thigh. Resident #1 could not recall the exact time, but approximately an hour later, his CNAs came to change his brief and noticed that the areas on his thigh were burned. He further revealed that the CNAs had told his nurse (Referring to S3Licensed Practical Nurse (LPN) and she had come to his room to look at his skin.
On 01/23/2025 at 4:11 p.m., a telephone interview with S3LPN revealed that during her shift on 01/11/2025 at approximately 3:00 a.m., she was notified by one of the CNAs that resident #1 had spilled some noodles on his leg. S3LPN further revealed that she (S3LPN) had assessed resident #1 and observed 2-3 water blisters, ½ to 1 inch blister length to the resident's right knee. S3LPN revealed that she had notified the oncoming nurse (S5LPN) during morning report. She confirmed that she (S3LPN) did not notify the physician of resident #1 having blisters on his skin.
On 01/23/2025 at 4:32 p.m., S4Registered Nurse (RN) revealed that resident #1 had told her that he had spilled noodle juice on himself, just as he was leaving out of the facility to go to dialysis. She revealed the date was on 01/11/2025 at approximately 11:00 a.m. She further revealed that resident #1 had asked her if she would look at his leg when he got back and that he had a little burn. S4RN revealed that she assessed the resident's leg after he returned back to the facility and observed a burned area that looked to be a large blister with ½ of the blistered area that had burst and the other ½ with the layer of skin gone on the resident's right thigh. S4RN revealed she then contacted the physician and received an order for Silvadene cream 1% to be applied to resident #1's burned skin every day until healed.
On 01/27/2025 at approximately 2:40 p.m. S1Administrator was notified of the above findings.
On 01/29/2025 at 10:15 a.m., an interview with S5LPN revealed she had worked the 7:00 a.m. to 7:00 p.m. shift on 01/11/2025. She further revealed that she did not recall S3LPN reporting to her that resident #1 had burned himself that a.m. S5LPN confirmed that she did not become aware of the burn until S4RN was informed of resident #1 with a burn to his skin on 01/11/2025 at approximately 11:00 a.m.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure each resident received adequate supervision...
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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 ensure each resident received adequate supervision to prevent accidents for 1 (#7) of 1 (#7) residents observed smoking in an unsafe manner. The deficient practice was evidenced by resident #7 tossing his lit cigarette butt on the concrete when left unsupervised outside in the smoking area.
Findings:
Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses including dementia and nicotine dependence.
Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed that resident #1 had a Brief Interview for Mental Status score of 05 which indicated the resident had severe cognitive impairment with his daily decision making skills.
Review of the care plan revealed that resident #7 was a smoker. Further review revealed the approaches included that resident #7 required supervision while smoking.
On 01/28/2025 at approximately 12:18 p.m., an observation revealed resident #7 smoking a cigarette in the designated outside smoking area, unsupervised. When he had finished smoking, resident #7 tossed the remainder of the lit cigarette butt onto the concrete instead of using the fire safety ashtray that was located directly in front of him.
On 01/28/2025 at 12:34 p.m., S1Administrator was notified of the observation regarding resident #7 smoking unsupervised and tossing his lit cigarette butt onto the concrete when finished. S1Administrator confirmed that resident #7 needed to be re-evaluated for safe smoking.
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
Smoking Policies
(Tag F0926)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure policies were being followed for 1 (#10) of 7 (#5, #7, #8,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure policies were being followed for 1 (#10) of 7 (#5, #7, #8, #9, #10, #11, and #12) residents reviewed for smoking. The deficient practice was evidenced by the facility not having documented evidence of a Safe Smoking Evaluation completed quarterly for resident #7.
Findings:
Smoking/Tobacco Usage Waiver Smoking Policy (Undated):
Review of the policy revealed it is the policy of the nursing facility to enforce a smoke-free environment within the facility for both residents and staff to ensure the rights, safety, and well-being of all residents and staff. Review of the smoking procedure included, but was not limited to: Residents who smoke will be assessed on admission, quarterly, and when there is a significant change in the resident's ability to handle their smoking products.
Findings:
Review of the medical record revealed that resident #10 was admitted to the facility on [DATE].
Review of the physician's progress notes dated 12/07/2024 revealed resident #10 had a documented diagnosis of chronic schizophrenia.
Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed resident #10 had a documented Brief Interview for Mental Status score of 15 which indicated that resident #10 was cognitively intact with his daily decision making skills.
Review of resident #10's medical record revealed a Safe Smoking Evaluation sheet. The words non- smoker had been hand -written at the top of ride side of the sheet and resident #10's name was hand-written at the left lower portion of the sheet. Further review revealed there had been no other information entered on the Safe Smoking Evaluation sheet and it was not dated.
Review of resident #10's medical record further revealed a second Safe Smoking Evaluation sheet dated 01/09/2024 indicating the resident was a deemed as a safe smoker. On 01/28/2025 at 1:03 p.m., an interview with S6Social Services revealed that date of 01/09/2024 was incorrect and should have been 01/09/2025. Upon further review, there was no documented evidence of a Safe Smoking Evaluation being completed quarterly for resident #10.
On 01/28/2025 at 2:50 p.m., S1Administrator was notified of the above findings. S1Administrator confirmed there was no documented evidence of a Safe Smoking Evaluation being completed for resident #10 on a quarterly basis.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to maintain an infection prevention and control progra...
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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 maintain an infection prevention and control program designed to provide a sanitary environment and to help prevent cross contamination for 1 (#1) of 1 (#1) residents observed for wound care. The deficient practice was evidenced by the Wound Care Nurse (WCN) contaminating a cream used to treat a resident's burn and by storing a contaminated bottle of Dermal Wound Cleanser (DWC) inside of the wound care cart.
Findings:
Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses which included in part, acquired absence of right leg below knee, Type 1 diabetes with diabetic neuropathy, and hypertensive chronic kidney disease.
Review of the medical record revealed a physician's order dated 01/11/2025 for Silvadene External Cream 1% (Silver Sulfadiazine) apply to right thigh topically one time a day related to patient's other non-compliance with medication regimen; Burn to right thigh-apply Silvadene and cover with Bordered gauze or wrap with Kerlix daily and as needed until healed.
On 01/27/2025 at 3:15 p.m., an observation revealed S2WCN preparing for resident #1's wound care procedure. During the preparation, S2WCN opened a jar of Silvadene Cream 1% (a cream used to treat burns). S2WCN retrieved a small medication cup from inside of the wound care cart with her bare hand and dipped the cup down and into the Silvadene Cream using a scooping motion. Both the inside and outside of the medication cup was in direct contact with the topical cream.
S2WCN was further observed placing a bottle of DWC on top of and indirect contact with resident #1's over-the-bed table. S2WCN did not sanitize the table prior to placing the cleanser on the table top. After the wound care procedure was completed, S2WCN gathered up her supplies and returned to the wound care cart. She placed the bottle of DWC on top of the cart then shortly afterwards, she returned the bottle to the inside of the bottom drawer next to other wound care supplies. S2WCN did not sanitize the bottle of DWC prior to setting the bottle down on the top of the wound care cart and prior to returning it back inside of the cart. S2WCN revealed that the Silvadene Cream was not specific to just resident #1, but was available for any resident who may require the cream. S2WCN was notified of the findings and she confirmed that she had not used proper infection control techniques to help prevent possible cross contamination.
On 01/27/2025 at 3:45 p.m., S1Administrator was notified of the above findings.
Nov 2024
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the residents' environment remained as free of accident haza...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the residents' environment remained as free of accident hazards as is possible for 1 (#5) of 3 (#1, #5 and #8) residents reviewed for accident hazards. The facility failed to complete an Accident and Incident Report per the facility's policy and the facility failed to perform a thorough investigation after resident #1 was found to have illegal drugs in his possession.
Findings:
Review of the facility's Accident and Incident Documentation and Investigation Resident Incident policy undated revealed:
Policy: Accidents and/or incidents involving resident care will be investigated and documented on the Risk Assessment section of Point Click Care (PCC) system. An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident. Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents.
Review of the medical record for resident #5 revealed an admission date of 09/16/2024 with diagnoses of end stage renal disease, reflux, hyperlipidemia, epilepsy, type 2 diabetes mellitus, schizoaffective disorder and hypertension.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated resident #5 was cognitively intact for daily decision making. Further review of the MDS revealed the resident had no range of motion impairment of the upper extremities, had impairment on one side of the lower extremity and used a wheelchair for locomotion.
Review of the nurses notes dated 10/14/2024 at 6:37 a.m. revealed resident #5 was out in the smoking area when another resident came and got the nurse stating he (referring to resident #5) was not acting right. S7Licensed Practical Nurse (LPN) assessed the resident his eyes were very dilated and glossy and he was not making any sense when attempting to answer questions and he had a very strong marijuana odor. The physician was notified of the resident's condition with orders to send to the emergency department for evaluation. S7LPN notified Emergency Medical System (EMS), administrative staff and the responsible party as well as calling in a report to the hospital. This nurse received instructions to go through resident #5's personal belongings due to the fact he admitted to EMS that he smoked weed and took a pill. This nurse along with three coworkers as witnesses went through a bag that resident #5 had and he had what appeared to be marijuana in a pill bottle as well as marijuana rolled in a cigar tube half smoked. This nurse along with a fellow nurse took the substance and placed it in a double bag and locked it up in the narcotic box.
Review of the nurses notes signed by S3Registered Nurse (RN) dated 10/14/2024 at 1:05 p.m. revealed disposed of marijuana and witnessed by S5Licensed Practical Nurse (LPN). Further review of nurses' notes revealed the marijuana was flushed down the toilet.
Review of the hospital notes dated 10/13/2024 at 9:09 p.m. revealed the patient stated he only smoked marijuana.
On 11/06/2024 at 1:20 p.m. S1Administrator revealed she was notified by S3RN of the incident with resident #5. S1Administrator confirmed the facility did not complete an Accident and Incident Report and a thorough investigation was not performed to determine where and how the resident obtained the marijuana.
On 11/06/2024 at 2:00 p.m. an interview with resident #5 revealed he denied having or bringing any illegal drugs into the facility.
On 11/12/2024 at 11:53 a.m., during a phone interview with S7LPN, S7LPN revealed she worked on 10/13/2024 from 7:00 p.m. - 7:00 a.m. when resident #5 started acting funny and they found marijuana in a bag in his room. The physician was notified and resident #5 was sent to the emergency department as ordered.
On 11/12/2024 at 12:10 p.m. interview with S3Registered Nurse (RN) revealed on 10/13/2024 S7LPN called to inform him of resident #5 was acting funny and he was sent to the emergency department and he told the EMS that he had smoked marijuana. S3RN revealed he notified S1Admnistrator and she instructed him to tell S7LPN to search resident #5's room. S3RN revealed S7LPN and another nurse found marijuana in resident #5's room and S7LPN double bagged the marijuana and locked it in the narcotic box. S3RN revealed on 10/14/2024 he and S4LPN disposed of the marijuana by flushing it down the toilet as directed by the Administrator.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, policy review, and interviews, the facility failed to implement policies and procedures f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, policy review, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 1 (#2) of 3 (#1, #2, and #6) residents reviewed for enhanced barrier precautions.
Findings:
Review of the facility's Enhanced Barrier Precautions (EBP) policy dated 04/01/2024 revealed
Definition and Scope
Enhanced Barrier Precautions are infection control interventions designed to reduce transmission of multidrug-resistant organisms (MDROs).
Example of Use
EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices)
Review of resident #2's medical record revealed an admission date of 10/28/2024 with diagnoses including type 2 diabetes mellitus, chronic kidney disease, abdominal pain, severe sepsis, bacterial peritonitis, abscess of vulva, peripheral vascular disease, schizophrenia, bipolar disorder, and end stage renal disease.
Review of the resident #2's current physician's orders revealed an order dated 10/29/2024 to clean right labia with dermal wound cleanser (DWC), pat dry with 4 by 4 gauze, apply Dakin's wet to dry dressing change 2 times a day (bid) and as needed (prn) soilage/dislodgement.
Review of the 5 day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 indicating cognitively intact. Further review of the MDS revealed the resident required substantial to maximal assistance with activities of daily living.
Observations on 11/04/2024 at 11:20 a.m., 11/06/2024 at 8:30 a.m., and 11/06/2024 at 3:45 p.m. revealed no enhanced barrier precaution sign on resident #2's door.
An interview on 11/12/2024 at 10:00 a.m. with S3Registered Nurse (RN) revealed he is the infection preventionist. S3RN revealed when residents are to be placed on enhanced barrier precautions he posts the sign on the door and he verbally notifies staff of residents that are on EBP.
An interview on 11/12/2024 at 12:30 p.m. with S2Director of Nursing (DON) confirmed that resident #2 required EBP and did not have an EBP sign posted on her door on 11/04/2024 and 11/06/2024.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by having environmental concerns throughout the i...
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Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by having environmental concerns throughout the inside and outside of the building. This deficient practice had the potential to affect 51 residents that resided in the building.
Findings:
On 11/04/2024 at 8:45 a.m. observation of the kitchen revealed the ceiling contained acoustic suspended tiles. The ceiling tiles were observed to have old water stains, the tiles by the ceiling vents were sagging, and 2 holes in the ceiling approximately 4 inches by 4 inches were observed.
On 11/12/2024 at 11:40 a.m., an interview with S5Dietary Manager confirmed the ceiling tiles in the kitchen were stained with water damage, sagging, had 2 holes in the ceiling, and the ceiling needed to be repaired.
On 11/4/2024 at 2:30 p.m. observation of the hallway floors throughout the facility revealed the floors had a buildup of dirt and grime and needed to be cleaned.
On 11/04/2024 at 4:00 p.m. S1Administrator was notified of the hallway floors throughout the facility had a buildup of dirt and grime and needed to be cleaned.
On 11/04/2024 at 12:40 p.m. observation of the whirlpool room revealed the window was open and the screen was not attached, a box fan was observed sitting in the opened window.
On 11/04/2024 at 12:45 p.m. S1Administrator went to the whirlpool room with the surveyor. S2Administrator confirmed the staff should not have been putting the box fan in the window without a screen attached.
On 11/06/2024 at 10:15 a.m. observations of the outside of the facility revealed 2 mop buckets, 3 gray barrels, 1 old mattress on the ground by the dumpster, an old mattress was leaning against the outside of the building, and a bed frame was directly on the ground. Further observations revealed pieces of sheet rock, a shower chair, a Christmas tree, a broken glass picture frame, pieces of a shower, and rusted pipes were observed on the ground.
On 11/06/2024 at 10:45 a.m. observations of the laundry room revealed rotten wood was observed on the outside bottom part of the building. Observations of the inside of the laundry room behind the clean sink and eye wash station revealed rotten wood, and the floor was wet behind the washer and contained a black substance.
On 11/06/2024 at 10:45 a.m. S6Laundry Worker confirmed behind the clean sink and eye wash station revealed rotten wood, and the floor was wet behind the washer and contained a black substance.
On 11/06/2024 at 1:15 p.m. S1Administrator was informed of the environmental issues outside of the building and in the laundry area.
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 F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2
Review of resident #2's medical record revealed an admission date of 10/28/2024 with diagnoses including type 2 diab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2
Review of resident #2's medical record revealed an admission date of 10/28/2024 with diagnoses including type 2 diabetes mellitus, chronic kidney disease, abdominal pain, severe sepsis, bacterial peritonitis, abscess of vulva, peripheral vascular disease, schizophrenia, bipolar disorder, and end stage renal disease.
Review of the resident #2's current Physician's Orders revealed the following an order dated 10/29/2024 to clean right labia with dermal wound cleanser (DSW), pat dry with 4x4 gauze, apply Dakin's wet to dry dressing change 2 times a day (bid) and as needed (prn) soilage/dislodgement.
Review of the 5 day Medicare MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognitively intact. Further review of the MDS revealed resident requires substantial to maximal assistance with activities of daily living.
Review of resident #2's November TAR revealed the nurses failed to document wound care to right labia 6 times.
Review of the November 2024 nurses notes revealed no documentation regarding refusal of wound care by resident #2.
Confirmation on 11/12/2024 at 12:30 p.m. with S2DON confirmed the nurses failed to document resident #2's wound care to right labia 6 times on the November 2024 TAR. S2DON further confirmed there were no documentation in the November nurses notes of resident #2 refusing wound care.
Resident #3
Review of the record for resident #3 revealed an admission date of 06/27/2024 with diagnoses including chronic respiratory failure with hypoxia, other sequelae of cerebral infarction, chronic obstructive pulmonary disease, type 2 diabetes mellitus, epilepsy, other seizures, pressure ulcer of sacral region stage 4, left hemiparesis, tracheostomy status, wheezing, gastroesophageal reflux disease, secondary hypertension, and other seizures.
Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Further review of the MDS revealed resident #3 was dependent on staff with 1 to 2 physical assist for all activities of daily living.
Review of resident #3's Physician's Orders revealed the following orders:
06/27/2024 suction type: oral and trach frequency and why: per shift and as needed 2 times a day, trach suction every (q) shift and as needed (prn) q 4 hours as needed, 2 times a day, tracheostomy- change ties when soiled and as needed 2 times a day, change suction tip: yanker and suction catheter 2 times a day, change suction tubing 2 times a day, and
08/20/2024-tracheostomy- assess skin around stoma site and under ties during trach care1 time a day
09/16/2024 Gentamycin Sulfate solution use 80 milligrams (mg) intravenous (IV) every (q) 24 hours (hrs), and
09/17/2024- Imipenem-Cilastatin IV solution reconstituted 500 milligrams (mg) - use 500 mg intravenous (IV) every (q) 6 hours for 7 days.
Review of the September 2024 Medication Administration Record (MAR) revealed the following:
Change suction tip: Yanker and suction catheter 2 times a day- not documented 10 times, and
Gentamycin Sulfate solution use 80 mg IV q 24 hrs (9:00 p.m.)- not documented 3 times on 09/20/2024, 09/21/20224, and 09/22/2024, and
Imipenem-Cilastatin IV solution reconstituted 500 mg- use 500 mg intravenous (IV) every (q) 6 hours for 7 days - not documented 9 times.
Review of the September 2024 TAR revealed the following:
Tracheostomy- assess skin around stoma site and under ties during trach care 1 time a day- not documented 9 times
Suction type: oral and trach frequency and why: per shift and as needed 2 times a day (9:00 a.m./9:00 p.m.)- not documented 7 times
Trach care every day and as needed every day shift (7:00 a.m.)- not documented 9 times.
Review of the October 2024 TAR revealed the following:
Tracheostomy- assess skin around stoma site and under ties during trach care 1 time a day- not documented 10/01/2024, 10/04/2024, and 10/05/2024 (3 times); and
Trach care every day and as needed every day shift (7:00 a.m.)- not documented 10/01/2024, 10/04/2024, and 10/05/2024 (3 times).
Review of resident #3's September 2024 and October 2024 MAR and TAR revealed no documented evidence of tracheostomy suctioning from 09/28/2024-09/30/2024, and 10/01/2024-10/05/2024.
Review of the resident's current care plan revealed tracheotomy related to hypoxia/respiratory failure and interventions included change suction set up weekly per orders, change suction tip, yanker and suction catheter per facility protocol, document sputum color and amount 2 times per day (bid) per orders, ensure trach ties and secured at all times, monitor/document restlessness, agitation, confusion, increased heart rate (tachycardia), and bradycardia, monitor/document level of consciousness, mental status, and lethargy prn, monitor respiratory rate, depth, and quality, check and document q shift/as ordered, provide good oral daily and prn, provide means of communication and procedural information, reassure that help is available immediately, provide paper and pencil if needed, work with resident to develop communication system that will work in an emergency, reassure resident to decrease anxiety, suction as necessary, tracheotomy care q shift q day, assess skin around stoma site q day, use universal precautions as appropriate.
An interview on 11/12/2024 at 12:05 p.m. with S8Registered Nurse (RN) confirmed no documentation of suctioning on resident #3 for 7 times in September and 10 times in October, trach care not documented 9 times in September and 3 times in October, Imipenem Cilastatin not documented 9 times in September, Gentamycin not documented 3 times in September, and assessing skin around stoma site (tracheostomy) - not documented 9 times in September and not documented 3 times in October.
Based on record reviews and interviews, the facility failed to ensure that nursing staff were able to demonstrate competencies and skills necessary to care for residents needs for 4 (#1, #2, #3, and #6) of 4 residents. The facility failed to have documentation of wound care, tracheostomy care, and medication administration.
Findings:
Review of Medication Administration General Guidelines policy and procedure dated 07/2024 revealed the following, in part:
Procedure:
9. Only licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's Medication Administration Record (MAR)/electronic MAR or Treatment Administration Record (TAR)/electronic TAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.
Resident #1
Review of the medical record for resident #1 revealed an admission date of 12/19/2023 with diagnoses including paraplegia, bipolar disorder, neuromuscular dysfunction of the bladder, congestive heart failure, colostomy, and absence of left leg below knee.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating resident #1 was cognitively intact for daily decision making.
Review of the care plan dated 09/12/2024 revealed resident #1 had a stage 3 to the right lateral and right distal leg. The interventions were to administer medications as ordered, administer treatments as ordered and monitor for effectiveness, and to perform treatment to right distal and right lateral leg per orders.
Review of the physician orders revealed an order dated 09/12/2024 to clean right proximal and right distal lower extremity with Hibiclens, pat dry with 4x4 gauze, apply Medihoney to wound bed, cover with border gauze, wrap with roll gauze, and secure with tape. Change dressing as needed if soiled or dislodged, one time a day for wound care.
Review of the Treatment Administration Record (TAR) for October 2024 revealed no documented evidence of the dressings changed daily on 10/15/2024, 10/16/2024, 10/23/2024 and 11/02/2024 as ordered.
On 11/12/2024 at 8:55 a.m., an interview with S2Director of Nursing (DON) confirmed the wound care was not documented as done for resident #1 on 10/15/2024, 10/16/2024, 10/23/2024 and 11/02/2024.
Resident #6
Review of the medical record for resident #6 revealed an admission date of 03/18/2024 with diagnoses including pressure ulcer to the sacral area, diabetes mellitus, malignant neoplasm of the colon, dementia, and an ileostomy.
Review of the quarterly MDS assessment dated [DATE] revealed resident #6 scored a 15 on the BIMS indicating resident #6 was cognitively intact for daily decision making.
Review of the care plan for resident #6 revealed he had a stage 4 pressure ulcer to sacral region (present upon admission). Interventions were to administer treatments as ordered and monitor effectiveness.
Review of the physician orders revealed an order dated 09/12/2024 to cleanse the stage 4 sacral pressure ulcer with normal saline, pat dry with 4x4 gauze, apply collagen powder to the wound bed, and cover with a sterile border gauze change as needed and every Monday, Wednesday and Friday.
Review of the Treatment Administration Record (TAR) for October 2024 revealed no documented evidence of the dressings changed as ordered on 10/16/2024, 10/18/2024 and 10/25/2024.
On 11/12/2024 at 8:55 a.m., an interview with S2DON confirmed the wound care was not documented as done for resident #6 on 10/16/2024, 10/18/2024 and 10/25/2024.
Oct 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure a resident with wounds or history of wounds received necessary treatment and services, consistent with professional standards of pr...
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Based on record reviews and interviews the facility failed to ensure a resident with wounds or history of wounds received necessary treatment and services, consistent with professional standards of practice to promote healing, to prevent infection, and to prevent wounds for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure weekly skin assessments were performed.
Findings:
Review of the provider's policy entitled Preventive Skin Care with a revision date of 07/2024 revealed in part: That it is the practice of this facility to provide routine preventive skin care. This policy will serve as a guide to facility staff with regard to clinically acceptable techniques to be applied for skin care prevention. Procedures include: complete a weekly skin evaluation on all residents; evaluate interventions that may be implemented based upon the resident's Risk Evaluation and develop an individualized care plan for preventive skin care based upon evaluation.
Review of the provider's policy entitled Weekly Skin Audit dated 07/2024 revealed in-part: a skin audit will be documented on residents weekly. Any identified skin conditions will be documented and treatment initiated. Responsibility: Director of Nursing Services/Licensed Nurses/Medical Records
Procedure:
1. Every resident will have a head to toe skin evaluation performed and documented on a weekly basis. The evaluation will be documented electronically in the medical record.
2. Any skin abnormalities identified during this review can be documented in the Interdisciplinary Notes.
3. Physician and family will be notified of any abnormalities.
4. Treatment will be initiated per the physician's order.
5. The Unit Manager/Charge Nurse will review weekly skin audits. This review indicates appropriate follow-up
Resident #1
Review of the record for resident #1 revealed an admission date of 12/19/2023. Resident #1's diagnoses included but not limited to the following: unspecified open wound of lower back and pelvis without penetration into retro-peritoneum, stage 3 pressure ulcer right lateral leg, paraplegia, neuromuscular dysfunction of bladder, congestive heart failure, colostomy, absence of left leg below knee, and sepsis. Further review of resident #1's medical record failed to reveal weekly skin assessments had been performed.
Resident #2
Review of resident #2's medical record revealed an admit date of 02/29/2015. Resident #2's diagnoses included but not limited to the following: dementia, schizophrenia, diabetes mellitus, and stage 2 pressure ulcer of sacral region. Further review of resident #2's medical record failed to reveal weekly skin assessments had been performed.
Resident #3
Review of resident #3's medical record revealed an admit date of 03/18/2024. Resident #3's diagnoses included but not limited to the following: muscle wasting and atrophy, type 2 diabetes, colostomy, stage 4 pressure ulcer of sacral region. Further review resident #3's medical record failed to reveal weekly skin assessments had been performed
During an interview on 10/09/2024 at 10:30 a.m., S2InterimDirector of Nursing/Wound Care Nurse confirmed resident #1 had not had a weekly skin assessment performed since she has begun as wound care nurse beginning 09/16/2024.
During an interview on 10/09/2024 at 12:55 p.m., S3Registered Nurse (RN) reported he was resident #1's nurse and confirmed he had not performed any weekly skin assessments on resident #1.
During an interview on 10/09/2024 at 1:15 p.m., S2InterimDirector of Nursing/Wound Care Nurse reported a new wound could deteriorate fast if it was not treated. S2Interim Director of Nursing/Wound Care Nurse acknowledged weekly skin assessments were not being completed on any of the residents in the facility and should have been.
During an interview on 10/09/2024 at 3:20 p.m., S1Administrator confirmed that the facility had not performed weekly skin assessments on residents.
Sept 2024
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to protect the residents' right to be free from verbal and mental ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to protect the residents' right to be free from verbal and mental abuse for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents.
Findings:
Review of the facility's Abuse Prevention Policy dated 07/2024 revealed in-part:
Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardian, surrogates, friends, or any other individual.
Definitions:
a) Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the depravation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Abuse may be resident-to-resident, staff-to- resident, family-to-resident, or visitor-to-resident.
b) Verbal abuse: The use of oral, written, or gestured communication or sounds that willfully includes disparaging terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.
e) Mental abuse: The use of verbal and nonverbal conduct which causes or has caused the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation including staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s).
Resident #4
Record review revealed resident #4 was admitted to the facility on [DATE] with diagnoses that included type 1 diabetes mellitus with foot ulcer, diabetic neuropathy, end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, insomnia, depression, atherosclerotic heart disease of native coronary artery disease without angina, hypertension, muscle weakness (generalized) unspecified lack of coordination, abnormal posture, unsteadiness on feet, unspecified abnormalities of gait and mobility, constipation, gastroesophageal reflux disease with esophagitis, and acquired absence of right leg below knee.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident #4 was cognitively intact for daily decision making. Further review revealed resident #4 required substantial/maximal assistance with toileting, transfers, showering and required moderate assistance with personal hygiene and dressing. Resident #4 was occasionally incontinent of bowel and bladder. Resident #4 was unable to walk and used the manual wheel chair for ambulation.
Resident #1
Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included paraplegia, four stage 4 pressure ulcers, unspecified anemia, decreased white blood count, other thrombocytopenia, pain in unspecified joint, neuromuscular dysfunction of bladder, hypomagnesemia, and major depressive disorder.
Review of End of Therapy MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated cognitively intact for daily decision making. Further review revealed resident #1 was independent with bed mobility, independent with transfers - required set up help only, independent with eating - required set up help only, and independent with toilet use - required set up help only.
Review of the care plan for resident #1 revealed: have the potential to be verbally aggressive toward other residents related to poor impulse control. The goal: will demonstrate effective coping skills through the review date. Interventions include the following: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Ask resident to report to nursing staff any problems with other residents before calling parish authorities to report conflict. Assess and anticipate resident's understanding of situation. Allow time for the resident to express self and feelings towards the situation. Give the resident as many choices as possible about care and activities. Provide positive feedback for good behavior. Remove/redirect resident from escalating conversations with staff and other residents, use calming techniques to reduce agitation. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated.
Review of progress note dated 08/25/2024 at 12:45 a.m. revealed resident #1 entered dining area where resident #4 was on gaming monitor wearing ear phones. Resident #1 turned music on high volume on television set. Resident #4 asked resident #1 to turn down music before S9 Licensed Practical Nurse (LPN) entered dining room area. Resident #1 started cursing resident #4. When S9LPN entered the dining room area, she asked both residents to lower their voices and explained other residents were sleeping. Resident #1 trying to goad resident #4 into a physical altercation stating he was P*ssy and not about that life. Resident #4 tried to leave dining room area as resident #1 continued to curse and scream at resident #4. S9LPN then explained to resident #1 there was a way to resolve an issue without cussing other residents or trying to escalate the situation until there is a physical altercation. And if there was no resolve but screaming and cursing I would have no other option than to alert the authorities. Resident #1 voice understanding and remained in the dining room.
On 09/16/2024 at 8:05 a.m., an interview with S2Director of Nursing (DON) revealed resident #1 was discharged from the facility on 09/12/2024 and he was not expected to return to the facility.
During an interview on 09/16/2024 at 10:30 a.m., resident #4 reported on 08/25/2024 sometime after midnight he was playing on the computer that was in the hallway by the nurse's station when resident #1 came up the hallway playing loud rap music on his cell phone. Resident #4 revealed he asked the nurse if she could ask him to turn the music down. Resident #4 reported resident #1 asked him if he was wanting to fight. Resident #4 reported he did not reply to resident #1, went to the main dining room area, started playing a game on the computer and put his head his head phones on. Resident #4 reported not long after that, resident #1 came in the main dining room and turned the music on high volume through the smart television. Resident #4 asked resident #1 if he could turn the music down. Resident #4 revealed resident #1 responded by saying what does it matter you have head phones on. Resident #4 reported resident #1 started yelling at him and called him a p*ssy *ss n*gger. Resident #4 reported resident #1 verbally threatened to whoop his *ss, but did not touch him. Resident #4 reported this to S9LPN. S9LPN intervened and asked resident #1 to turn the volume down because it was late and other residents were trying to sleep. Resident #4 revealed S9LPN threatened to call the police if we did not stop yelling at each other. Resident #4 revealed S9LPN instructed for us to stay apart from one another. Resident #4 reported resident #1 continued to yell and curse at him as he left out of the dining room area. Resident #4 reported resident #1 remained in the dining room listening to his music.
Further interview with resident #4 revealed one day last weekend (09/07/2024 or 09/08/2024) around 3:30 p.m., he was waiting on S11Certified Nursing Aide (CNA) to return to his room to clean him up and change his brief. Resident #4 revealed S11CNA had gone to go get supplies and was coming back to assist him. Resident #4 reported resident #1 came to the door of his room and told him that he stunk and smelled like poo poo. Resident #4 revealed resident #1 told him you done sh*t yourself and you should be cleaning your own booty. Resident #4 reported resident #1 called him sh*tty boy. Resident #4 reported he notified S11CNA about what resident #1 had told him when she returned to his room to provide incontinent care and change his brief. Resident #4 reported he had not told anyone else about this incident with resident #1 until 09/10/2024 when he informed S5Social Worker.
Surveyor asked resident #4 how these two incidents with resident #1 made him feel. Resident #4 reported it made uncomfortable and mad that resident #1 would call him those names, harass him, and pick at him about his condition. Resident #4 reported he was not scared of resident #1.
On 09/16/2024 at 11:45 a.m., an interview with S10LPN revealed she worked the night shift on 08/25/2024 and resident #1 was listening to loud rap music on his cell phone in the hallway. S10LPN reported resident #4 was playing on the computer that was located on the hallway by the nurse's station. S10LPN reported she asked resident #1 to turn his music down because there were residents who were asleep. S10LPN reported resident #4 left the computer and went to the main dining room area. S10LPN reported she went to the main dining room a few minutes later to check on resident #4 and observed resident #1 yelling and cursing at resident #4 and threatening to whoop his *ss. S10LPN reported she heard resident #1 call resident #4 a b*tch *ss n*gger, and that he was always complaining like a little b*tch. S10LPN reported S9LPN was already in the dining room and had to intervene to calm them both down. S10LPN reported she immediately called and notified S2DON of the incident.
Surveyor asked S10LPN if she was aware of any other occurrences were resident #1 had been verbally abusive to resident #4. S10LPN reported she could not remember the exact day but it was on a Saturday or Sunday (09/7/2024 or 09/08/2024) around 3:30 p.m. S11CNA informed S10LPN that resident #4 reported resident #1 came to his door of his room and told him that he stinks, look at you sh*tting yourself like a little baby, and even my little child knows to go to the bathroom. S10LPN reported she did not document conversation but revealed she informed S3Registered Nurse (RN).
During a telephone interview on 09/16/2024 at 3:18 p.m., S9LPN reported on 08/25/2024 around 12:45 a.m. she was at the nurse's station that is located by the dining room. S9LPN reported resident #4 was already the dining room playing a game on the computer with his head phones on and resident #1 came in dining room and turned the music on very loud on the smart television in the dining room. S9LPN reported she immediately went to ask resident #1 to turn down the volume on the television because it was too loud and residents were trying to sleep. S9LPN reported as she enter the dining room, resident #4 was asking resident #1 to turn down the volume. S9LPN reported resident #1 started yelling and cursing resident #4. S9LPN reported resident #1 called resident #4 a p*ssy *ss n*gger and was taunting resident #4 and threatening to whoop his *ss. S9LPN reported she intervened and made sure they stayed separated. S9LPN reported she told both of them if they could not stop yelling and calm down, she would have to call the police. S9LPN reported resident #4 left the main dining room and resident #1 stayed in the dining room listening to his music at an acceptable volume.
On 09/16/2024 at 10:30 a.m., an interview with S5Social Worker revealed resident #4 came to her office on 09/10/2024 around 2:00 p.m. S5Social Worker revealed resident #4 was reporting that resident #1 was wheeling up to his room, pushing his door open without knocking, harassing him with curse words, and making fun of him that he smells like poop and about his condition. Resident #4 further complained about resident #1 playing loud disruptive music, bowing up to him and saying bad things to him. Resident #1 makes verbal threats by saying he will beat his *ss and the cops. S5Social Worker reported she immediately notified S1Administrator on 09/10/2024 around 2:20 p.m. after talking with resident #4 and initiating a grievance related to resident #4's alleged allegations of how resident #1 was treating him. S5Social Worker further reported she and S1Administrator met with resident #1 personally on 09/10/2024 at 4:30 p.m. to investigate the alleged allegations reported by resident #4. S5Social Worker reported resident #1 did not deny the alleged allegations and reported he was trying to be nice to resident #4.
On 09/17/2024 at 1:30 p.m., an interview with S1Administrator confirmed resident #1 caused verbal abuse and mental abuse to resident #4 on the two separate occasions.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the provider failed to: 1) ensure an alleged violation involving verbal and mental abuse ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the provider failed to: 1) ensure an alleged violation involving verbal and mental abuse witnessed by staff was reported immediately to the Administrator and Director of Nursing and 2) ensure all allegations of verbal abuse/mental abuse were reported immediately, but no later than 2 hours after the allegation was made to State Survey Agency in accordance with State Laws for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled residents.
Findings:
Review of the facility's current Abuse Prevention Policy dated 7/2024 revealed in-part:
Policy: The Facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardian, surrogates, friends, or any other individual.
Definitions:
a)
Abuse: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the depravation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Abuse may be resident-to-resident, staff-to- resident, family-to-resident, or visitor-to-resident.
b)
Verbal abuse: The use of oral, written, or gestured communication or sounds that willfully includes disparaging terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.
e)
Mental abuse: The use of verbal and nonverbal conduct which causes or has caused the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation including staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s).
Identification:
2. The Executive Director and Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Executive Director and Director of Nursing Services must be called at home or must be paged and informed of such incident.
Reporting:
Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or results in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and other state officials (including State Survey Agency, Adult Protection Services (APS), and local law enforcement as required). Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident.
Record review revealed resident #4 was admitted to the facility on [DATE] with diagnoses that included type 1 diabetes mellitus with foot ulcer, diabetic neuropathy, end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, insomnia, depression, atherosclerotic heart disease of native coronary artery disease without angina, hypertension, muscle weakness (generalized) unspecified lack of coordination, abnormal posture, unsteadiness on feet, unspecified abnormalities of gait and mobility, constipation, gastroesophageal reflux disease with esophagitis, and acquired absence of right leg below knee.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident #4 was cognitively intact for daily decision making. Further review revealed resident #4 required substantial/maximal assistance with toileting, transfers, showering and required moderate assistance with personal hygiene and dressing. Resident #4 was occasionally incontinent of bowel and bladder. Resident #4 was unable to walk and used the manual wheel chair for ambulation.
During an interview on 09/16/2024 at 10:30 a.m., resident #4 reported on 08/25/2024 sometime after midnight he was playing on the computer that was in the hallway by the nurse's station when resident #1 came up the hallway playing loud rap music on his cell phone. Resident #4 revealed he asked the nurse if she could ask him to turn the music down. Resident #4 reported resident #1 asked him if he was wanting to fight. Resident #4 reported he did not reply to resident #1, went to the main dining room area, started playing a game on the computer and put his head his head phones on. Resident #4 reported not long after that, resident #1 came in the main dining room and turned the music on high volume through the smart television. Resident #4 asked resident #1 if he could turn the music down. Resident #4 revealed resident #1 responded by saying what does it matter you have head phones on. Resident #4 reported resident #1 started yelling at him and called him a p*ssy *ss n*gger. Resident #4 reported resident #1 verbally threatened to whoop his *ss, but did not touch him. Resident #4 reported this to S9Licensed Practical Nurse (LPN). S9LPN intervened and asked resident #1 to turn the volume down because it was late and other residents were trying to sleep. Resident #4 revealed S9LPN threatened to call the police if we did not stop yelling at each other. Resident #4 revealed S9LPN instructed for us to stay apart from one another. Resident #4 reported resident #1 continued to yell and curse at him as he left out of the dining room area. Resident #4 reported resident #1 remained in the dining room listening to his music.
Further interview with resident #4 revealed one day last weekend (09/07/2024 or 09/08/2024) around 3:30 p.m., he was waiting on S11Certified Nursing Aide (CNA) to return to his room to clean him up and change his brief. Resident #4 revealed S11CNA had gone to go get supplies and was coming back to assist him. Resident #4 reported resident #1 came to the door of his room and told him that he stunk and smelled like poo poo. Resident #4 revealed resident #1 told him you done sh*t yourself and you should be cleaning your own booty. Resident #4 reported resident #1 called him sh*tty boy. Resident #4 reported he notified S11CNA about what resident #1 had told him when she returned to his room to provide incontinent care and change his brief. Resident #4 reported he had not told anyone else about this incident with resident #1 until 09/10/2024 when he informed S5Social Worker.
On 09/16/2024 at 11:45 a.m., an interview with S10LPN revealed she worked the night shift on 08/25/2024 and resident #1 was listening to loud rap music on his cell phone in the hallway. S10LPN reported resident #4 was playing on the computer that was located on the hallway by the nurse's station. S10LPN reported she asked resident #1 to turn his music down because there were residents who were asleep. S10LPN reported resident #4 left the computer and went to the main dining room area. S10LPN reported she went to the main dining room a few minutes later to check on resident #4 and observed resident #1 yelling and cursing at resident #4 and threatening to whoop his *ss. S10LPN reported she heard resident #1 call resident #4 a b*tch *ss n*gger, and that he was always complaining like a little b*tch. S10LPN reported S9LPN was already in the dining room and had to intervene to calm them both down. S10LPN reported she immediately called and notified S2Director of Nursing (DON) of the incident.
On 09/16/2024 at 10:30 a.m., an interview with S5Social Worker revealed resident #4 came to her office on 09/10/2024 around 2:00 p.m. S5Social Worker revealed resident #4 was reporting that resident #1 was wheeling up to his room, pushing his door open without knocking, harassing him with curse words, and making fun of him that he smells like poop and about his condition. Resident #4 further complained about resident #1 playing loud disruptive music, bowing up to him and saying bad things to him. Resident #1 makes verbal threats by saying he will beat his *ss and the cops. S5Social Worker reported she immediately notified S1Administrator on 09/10/2024 around 2:20 p.m. after talking with resident #4 and initiating a grievance related to resident #4's alleged allegations of how resident #1 was treating him.
On 09/16/2024 at 1:00 p.m., an interview with S2DON confirmed she was notified on 08/25/2024 by S10LPN of the incident between resident #1 and resident #4. S2DON further reported she was not informed of the incident between resident #1 and resident #4 that occurred over the weekend (09/07/2024 or 09/08/2024). S2 DON confirmed S11CNA and S10LPN had not notified her of the incident between resident #1 and resident #4.
On 09/17/2024 at 1:30 p.m., an interview with S1Aministrator reported she had not been notified of the incident between resident #1 and resident #4 that occur over the weekend (09/07/2024 or 09/08/2024) until S5Social Worker informed her on 09/10/2024. S1Administrator further revealed she had not been notified of the incident between resident #1 and resident #4 that occurred on 08/25/2024. S1Administrator confirmed staff should have notified her and S2DON promptly after the incidents occurred. S1Admininstrator revealed the verbal and mental abuse of resident #4 by resident #1 on 08/25/2024 and over the weekend (09/07/2024 or 09/08/2024) was not reported to the state agency and should have been.
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 F0836
(Tag F0836)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to be incompliance with all applicable Federal, State, and Local Laws, regulations, and codes by S1Administrator response time from residence ...
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Based on interview and record review, the facility failed to be incompliance with all applicable Federal, State, and Local Laws, regulations, and codes by S1Administrator response time from residence to facility being over one hour.
Findings:
During an interview on 09/10/2024 at 10:35 a.m., S1Administrator revealed she lived 1.5 hours away from the facility.
Review of S1Administrator's employee file revealed her residence listed was at least a 1.5 hour drive to the facility.
During an interview on 09/17/2024 at 1:30 p.m., S1Administrator confirmed that her response time from her residence to the facility was over one hour.
Jun 2024
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment within 14 days after the resident was discharged from the facility for 3 (#10, #31 and #40) of 3 residents reviewed for assessments.
Findings:
Review of the medical record for resident #10 revealed the resident was admitted to the facility on [DATE] and discharged on 03/24/2024.
Review of the medical record for resident #31 revealed the resident was readmitted to the facility on [DATE] and discharged on 03/01/2024.
Review of the medical record for resident #40 revealed the resident was admitted to the facility on [DATE] and discharged on 01/13/2024.
On 06/25/2024 at 2:45 p.m., interview with S5Minimum Data Set (MDS) Coordinator confirmed the discharge MDS assessments were not performed and transmitted in a timely manner for residents #10, #31 and #40.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #34
Record review revealed resident #34 was admitted to the facility on [DATE] with diagnoses that included chronic sy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #34
Record review revealed resident #34 was admitted to the facility on [DATE] with diagnoses that included chronic systolic congestive heart failure.
Review of resident #34's most recent Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental status score of 15 which indicated he was cognitively intact.
On 06/24/2024 an 11:30 a.m., an observation of resident #34's room revealed a nebulizer machine was sitting on top of the desk. The nebulizer mask and tubing were uncovered and not dated. Resident #34 reported he receives breathing treatments 4 times a day as needed.
On 06/25/2024 at 8:30 a.m., an observation of resident #34's room revealed the nebulizer mask and tubing were uncovered and not dated. Resident #34 reported the last time he received a breathing treatment was a couple of days ago.
Review of the facility's undated Small Volume Nebulizer Policy revealed in part, the following:
Policy: Nebulizer Therapy will be utilized to administer medications per physician orders.
Procedure:
14. Replace small volume Nebulizer approximately weekly or when visibly soiled. Change set-up weekly.
15. Store in a labeled plastic bag.
Review of resident #34's June 2024 physician orders revealed an order dated 05/22/2024 for Ipratropium-Albuterol 0.5-3 (2.5) milligram (mg)/3 milliliter (ml) inhale 1 vial per nebulizer q 6 hours when necessary (prn).
Review of May 2024 Medication Administration Record (MAR) revealed documentation that resident #34 received Ipratropium-Albuterol breathing treatments as ordered on the following dates: 05/22/2024, 05/23/2024, and 05/31/2024.
Review of the June 2024 MAR revealed documentation that resident #34 received Ipratropium-Albuterol breathing treatment as ordered on 06/01/2024 and 06/25/2024.
On 06/25/2024 at 2:12 p.m., an observation conducted with S2Director of Nursing (DON) in resident #34's room revealed the nebulizer mask and tubing were not stored in a plastic bag and was laying across the dresser. S2DON confirmed the nebulizer mask and tubing should be replaced weekly and stored in plastic bag when not in use.
Based on record reviews, observations, and interviews, the facility failed to ensure residents who received respiratory care are provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#20 & #34) of 2 residents reviewed for respiratory care. The facility failed to ensure: 1.) resident #20 was administered oxygen via nasal cannula per the physician orders and 2.) resident #34's nebulizer mask and tubing was stored in a plastic bag when not in use.
Findings:
Review of the record for resident #20 revealed an admit date of 11/27/2023 with the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and vascular dementia.
Review of the June 2024 Medication Administration Record (MAR) for resident #20 revealed an order for continuous oxygen (O2) therapy at the following rate: oxygen at 2 liters/minute continuous by nasal cannula.
Review of the undated policy for oxygen therapy revealed in part that oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. For a nasal cannula it is to be used for an oxygen flow of 1-4 liters per minute (lpm).
Procedure: 1. Oxygen therapy is to be provided under the direction of a written physician's order. A physician's order for O2 therapy is to contain the liter flow per minute by mask or cannula and time frame.
Observation on 06/24/2024 at 9:37 a.m. revealed resident #20 was in the activity/dining room sitting in a wheelchair. O2 per nasal cannula concentrator was set on 5.5 liters per minute.
Observation of resident #20 on 06/24/2024 at 1:30 p.m. revealed resident #20 was asleep in her room on the sofa. Observation revealed resident #20 was receiving oxygen per nasal cannula at 5.5 liters per minute.
Observation of resident #20 on 06/25/2024 at 6:30 a.m. revealed resident #20 was asleep in the bed. Further observation revealed resident #20 was receiving oxygen per nasal cannula at 5.5 liters per minute.
Observation of resident #20 on 06/25/2024 at 11:25 a.m. revealed resident #20 was in the day room awaiting the lunch meal. Further observation revealed resident #20 was receiving oxygen per nasal cannula at 5.5 liters per minute.
On 06/25/2024 at 1:00 p.m., S6Assistant Director of Nursing (ADON)/wound care nurse observed and confirmed that resident #20's oxygen was being administered at 5.5 liters per minute by oxygen concentrator. At this time S6ADON/wound care nurse placed the oxygen concentrator at 2 liters per minute per nasal cannula. S6ADON/wound care nurse stated that resident #20 had a recent respiratory exacerbation and the oxygen flow had been increased but that the oxygen rate should have been brought back down per the physician orders. S6ADON/wound care nurse confirmed that resident #20 was unable to readjust the flow of oxygen independently.
An interview on 06/26/2024 at 3:20 p.m., with S2 Director of Nursing (DON) confirmed that the oxygen concentrator should not have been set on 5.5 liters per minute for resident #20.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected 1 resident
Based on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) initially upon hire and monthly ther...
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Based on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) initially upon hire and monthly thereafter for 5 (S20CNA, S21CNA, S22CNA, S23CNA and S24CNA), and the facility also failed to ensure the CNA registry was verified upon hire for 1 (S20CNA) for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) personnel files reviewed.
Findings:
Review of S20CNA's personnel file revealed a hire date of 03/26/2024. Further review of S20CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S20CNA upon hire or monthly thereafter. There was no documented evidence of the CNA registry check obtained upon hire for S20CNA.
Review of S21CNA's personnel file revealed a hire date of 07/02/2021. Further review of S21CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S21CNA upon hire or monthly thereafter.
Review of S22CNA's personnel file revealed a hire date of 07/28/2023. Further review of S22CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S22CNA upon hire or monthly thereafter.
Review of S23CNA's personnel file revealed a hire date of 10/05/2023. Further review of S23CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S23CNA upon hire or monthly thereafter.
Review of S24CNA's personnel file revealed a hire date of 01/01/2021. Further review of S24CNA's personnel file revealed there was no documented evidence of a State Adverse Actions check for S24CNA upon hire or monthly thereafter.
On 06/25/2024 at 2:20 p.m., an interview with S3Regional Human Resources confirmed there was no documentation of the adverse actions search being completed upon hire or monthly for the above CNAs.
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 F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents received services in the facility with reasonabl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs for 5 (#15, #17, #18, #26, #29 and #43) of 5 sampled residents and had the potential to affect all 44 residents that reside in the facility.
Findings:
Resident #17
Record review revealed resident #17's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment.
On 06/24/2024 at 9:15 a.m., an interview with resident #17 revealed sometimes the facility runs out of wipes when they are providing care.
Resident #26
Record review revealed resident #26's MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated no cognitive impairment.
On 06/24/2024 at 9:43 a.m., an interview with resident #26 revealed sometimes the facility does not have enough wipes to provide care.
Resident #29
Record review revealed resident #29 was admitted on [DATE]. Further review revealed resident #29's admission MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated the resident had moderately impaired cognition.
Observation on 06/24/2024 at 10:30 a.m. revealed there was no toilet paper or paper towels in resident #29's bathroom. At this time, resident #29 reported that he has not had paper towels since he was admitted there.
Observation on 06/25/2024 at 12:35 p.m. revealed there were no paper towels in resident #29's bathroom.
Observation on 06/26/2024 at 1:40 p.m. revealed there were no paper towels in resident #29's bathroom. At this time, resident #29 reported that he had asked for paper towels, but hasn't received them yet.
During the Resident Council meeting on 06/24/2024 at 2:30 p.m., residents #15, #18 and #43 voiced complaints of the facility not having enough toilet paper and wipes.
On 06/25/2024 at 9:10 a.m., an interview with S20Certified Nursing Assistant (CNA) revealed several weeks ago she was having issues with not having the right size of briefs or pull-ups for the residents. S20CNA reported they had a limited supply of large and extra-large briefs. Also, sometimes they did not have enough wipes.
On 06/26/2024 at 9:50 a.m., an interview with S17CNA revealed there has been a shortage of wipes and briefs, especially extra-large size. S17CNA also reported some residents have complained to her about not having enough toilet paper.
On 06/26/2024 at 3:05 p.m., an interview with S6Assistant Director of Nursing (ADON)/Wound Care Nurse revealed she's responsible for ordering patient care supplies. She reported about a month ago, the facility changed medical supply vendors and this caused a delay in some of their supplies being delivered, especially wipes, briefs, and pull-ups. S6ADON/Wound Care Nurse confirmed there was a limited supply of these items for a short period of time.
On 06/26/2024 at 2:40 p.m., S1Administrator was informed of the above concerns with the facility having a limited supply of the above patient care items.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment. The deficient practice affected 9 (#8, #11, #15, #17, #23, #26, #27, #29 & #4...
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Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment. The deficient practice affected 9 (#8, #11, #15, #17, #23, #26, #27, #29 & #49) of 9 sampled residents and had the potential to affect all 44 residents that resided in the facility.
Findings:
On 06/24/2024 at 9:15 a.m., 06/25/2024 at 9:28 a.m., and 06/26/2024 at 8:46 a.m., observations of resident #17's bathroom revealed a black substance in the toilet.
On 06/24/2024 at 9:37 a.m., 06/25/2024 at 9:30 a.m., and 06/26/2024 at 8:50 a.m., observations of resident #23's bathroom revealed a black substance in the toilet and a foul odor noted.
On 06/24/2024 at 9:43 a.m., 06/25/2024 at 9:32 a.m., and 06/26/24 at 8:55 a.m., observations of resident #26's bathroom revealed a black substance in the toilet.
On 06/24/2024 at 10:30 a.m., an observation of resident #29's room revealed there was a urine odor noted. Further observation on 06/25/2024 at 12:35 p.m. revealed resident #29's door had spills and splatters on it and dirt and grime was on the closet drawers and around the floor and base boards. Resident #29's bathroom had a urine odor and there was a black substance on the toilet seat and in the toilet.
On 06/24/2024 at 1:51 p.m., an interview with resident #15 revealed that staff were not cleaning his room properly.
On 06/25/2024 at 12:40 p.m., an observation of resident #11's room revealed his door was dirty and there was dirt and grime around the floor and baseboards. Observation of resident #11's bathroom revealed a black substance in the toilet.
On 06/25/2024 at 12:45 p.m., observation of the hall where residents #11, #27, #29, and #49 resided revealed spills and splatters on the floor and on the walls down the hallway.
On 06/25/2024 at 12:47 p.m., an observation of resident #8's room revealed the door was dirty. Observation of resident #8's bathroom revealed a build-up of old soap on the wall under the soap dispenser, black substance in the toilet, and the sink also needed cleaning.
On 06/25/2024 at 12:50 p.m., an observation of resident #49's room revealed the door was dirty and there was dirt and grime on the floor and baseboards. Observation of resident #49's bathroom revealed there was a build-up of old soap on the wall under the soap dispenser, a black substance in the toilet, and the sink needed cleaning.
On 06/25/2024 12:55 p.m., an observation of resident #27's room revealed the floors were dirty. Observation of the bathroom revealed a black substance in the toilet and the sink needed cleaning.
An interview with S1Administrator on 06/26/2024 at 2:45 p.m. confirmed the facility was in need of a thorough cleaning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement policies and procedures for ensuring the reporting of a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to the stage agency and one or more law enforcement entities for 1 (#34) of 1 (#34) residents reviewed for misappropriation of resident property.
Findings:
Review of the facilities Abuse Prevention Policy and Procedure (policy was not dated) revealed in-part:
Misappropriation of Resident Property: The deliberate misplacement, exploitations, or wrongful temporary or permanent use of a resident's personal belongings or money without the resident's consent.
Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of a crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of a crime or allegation of abuse, neglect, or misappropriation of resident property is to be reported to at least one law enforcement agency.
Review of resident #34's most recent Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental status score 15 which represented he was cognitively intact.
On 06/24/204 at 11:25 a.m. an interview with resident #34 revealed he had a $100 bill stolen from his wallet in his room on 06/13/2024. Resident #34 reported he originally had $1,000 dollars in his wallet. He revealed he had eight $100.00 dollar bills and ten $20 dollar bills. Resident #34 reported he normally keeps his wallet in the back pack on the back of his wheel chair, but he left it sitting on the dresser in his room and left his room and went down the hallway toward the nurse's station. Surveyor asked Resident # 34 why he left his wallet on the dresser instead of keeping it with him in his back pack like he said he normally does. Resident #34 reported he was trying to see if anyone would steal his money.
Resident #34 reported S9Houskeeping/Laundry Supervisor had passed him as he headed down the hallway. Resident #34 reported he headed back to his room after a few minutes and saw S9Houskeeping/Laundry Supervisor exit his room. Resident #34 reported she seemed surprised when he asked her what she was doing in his room. Resident #34 reported S9Houskeeping/Laundry Supervisor told him she was looking for him. Resident #34 reported S9Houskeeping/Supervisor had just saw him when she passed him in the hallway. Resident #34 reported he went and checked his wallet and he had only 7 $100 dollar bills and there should have been 8 $100 dollar bills.
Resident #34 reported he went to S1Administrator and informed her that he had something important he needed to tell her but wanted to wait until Monday and set up a meeting because S7Previous DON (Director of Nursing) was not present.
Resident #34 reported he met with S1Admininstrator and S7Previous DON on 06/17/2024 around 4:00 p.m. and informed them of what had occurred on Thursday evening 06/13/2024.
On 06/25/2024 at 8:20 a.m. an interview with S1Administraor revealed resident #34 informed her and S7Previous DON (Director of Nursing) on 06/17/2024 around 4:00 p.m. that he had $100 dollar bill stolen from his wallet on 06/13/2024 by S9Housekeeping/Laundry Supervisor.
On 06/26/2024 at 2:45 p.m. an interview with S1Administrator revealed she reported the allegation of misappropriation of resident property to the state agency on 06/25/2024 at 9:50 a.m., but she did not notify the allegation to the local law enforcement entity. S1Administrator confirmed she should have reported the allegation of misappropriation of resident property to the state agency and to local law enforcement agency within 24 hours of becoming aware of the misappropriation of property allegation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure all alleged violations of misappropriation of resident prope...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure all alleged violations of misappropriation of resident property are thoroughly investigated in a timely manner for 1 (#34) of 1 (#34) resident reviewed for personal property.
Findings:
Review of the facilities undated Abuse Prevention Policy and Procedure revealed in-part:
Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.
Definitions:
Misappropriation of Resident Property: The deliberate misplacement, exploitations, or wrongful temporary or permanent use of a resident's personal belongings or money without the resident's consent.
Investigation: The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection. The Executive Director, or designee, shall report any allegations of abuse, neglect, or misappropriation of resident property as well report any reasonable suspicion of a crime in accordance with Section 1150B of the Social Security Act to the Department of Health as required.
Protection:
1. Any allegation of abuse, neglect, misappropriation or exploitation against any employee must result in his/her immediate suspension to protect the resident.
2. Suspected or substantiated cases of resident abuse, neglect, misappropriation of property, or mistreatment shall be thoroughly investigated, documented, and reported to the physician, families, and/or representative, and as required by state guidelines.
Record review revealed resident #34 was admitted to the facility on [DATE] with diagnoses that include post procedural complications of skin, after care following surgery for neoplasm, disruption of wound unspecified sequela, hypothyroidism, Crohn's disease unspecified without complications, chronic systolic congestive heart failure, other chronic pain, Tourette's disorder, primary generalized osteoarthritis, generalized muscle weakness, other reduced mobility, abnormal posture, rheumatoid arthritis, and lack of coordination.
Review of resident #34's most recent Minimum Data Set assessment dated [DATE] revealed Brief Interview of Mental status score 15 which represented he was cognitively intact.
On 06/24/2024 at 11:25 a.m. an interview with resident #34 revealed he had a $100 bill stolen from his wallet in his room on 06/13/2024. Resident #34 reported he originally had $1,000 dollars in his wallet. He revealed he had eight $100.00 dollar bills and ten $20 dollar bills. Resident #34 reported he normally keeps his wallet in the back pack on the back of his wheel chair, but he left it sitting on the dresser in his room and left his room and went down Hall A toward the nurse's station. Surveyor asked resident # 34 why he left his wallet on the dresser instead of keeping it with him in his back pack like he said he normally does. Resident #34 reported he was trying to see if anyone would steal his money.
Resident #34 reported S9Houskeeping/Laundry Supervisor had passed him as headed down the hallway. Resident #34 reported he headed back to his room after a few minutes and saw S9Houskeeping/Laundry Supervisor exit his room. Resident #34 reported she seemed surprised when he asked her what she was doing in his room. Resident #34 reported S9Houskeeping/Laundry Supervisor told him she was looking for him. Resident #34 reported S9Houskeeping/Supervisor had just saw him when she passed him on Hall A. Resident #34 reported he went and checked his wallet and he had only 7 $100 dollar bills and there should have been 8 $100 dollar bills.
Resident #34 reported he went to S1Administrator and informed her that he had something important he needed to tell her but wanted to wait until Monday and set up a meeting because S7Previous DON (Director of Nursing) was not present.
Resident #34 reported he met with S1Admininstrator and S7Previous DON on 06/17/2024 around 4:00 p.m. and informed them of what had occurred on Thursday evening 06/13/2024. Resident #34 reported he did not have proof who stole his $100 dollar bill, but told them he thought it was S9Houskeeping/Laundry Supervisor.
Review of the facilities grievance/complaint report dated 06/18/2024 revealed Resident #34 said he left wallet out with money in his room. Resident #34 saw S9Houskeeping/Laundry Supervisor come out of his room. Resident #34 reported S9Houskeeping/Laundry Supervisor took $100 and was surprised when he showed up. Resident #34 said he set her up. Resident #34 reported he had $800 then $700.
S1 Administrator obtained statements, provided resident with lock box, reasoned with resident not to set up staff. On 06/23/2024 grievance was unable to be verified by S1Administrator. S1Administrator informed resident #34 there was no proof of how much money he had in his wallet. Resident was provided with lock box.
Review of S9Houskeeping/Laundry Supervisor written statement dated 06/21/2024 revealed she did not work Hall A and did not go into resident #34's room.
Review S11Activity Director written statement dated 06/21/2024 revealed on
On Thursday, 06/13/2024, I took resident #34 to Walmart to get some items. As I am aware of S9Houskeeping/Laundry Supervisor was not assigned to Hall A. S11Activity Director did not see S9Houskeeping/Laundry Supervisor enter resident #34's room at any time.
Review of S13Houskeeper's written statement dated June 06/21/2024 revealed S9Houskeeping/Laundry Supervisor do no work on Hall A. Never saw S9Houskeeping/Laundry Supervisor go into resident #34's room.
Review of S12Licensed Practical Nurse (LPN) written statement dated 06/21/2024 at 4:31 p.m. revealed I do not recall the date nor the exact time but it was close to 3 p.m. resident #34 self-propelled in wheel chair up Hall A and stated S12LPN do you have change. Asked resident #34 what he needed change for resident #34 presented a $100 bill. Gave resident (5) $20 bills and counted them out to the resident. Resident #34 wanted change for another $100 dollar bill. Resident told me to reach in his backpack front zipper and give him his wallet. Resident #34 gave me a $100 dollar bill. S12LPN gave him (5) more $20 bills and counted them to him as well. Resident #34 expressed his gratitude and propelled back to his room by himself.
Review S14Laundy written statement (that was not dated) revealed she only goes in resident #34's room when dealing with his clean or dirty clothes. I (S14Laundry) try to make sure he is in there before I go. I have never seen his wallet or where he keeps it. As for the 13th of this month, I don't remember if I had to wash anything for him.
Resident #34 does not have a roommate.
Resident #34 does not have video surveillance cameras inside his room.
On 06/25/2024 at 08:20 a.m. an interview conducted with S1Administrator revealed S9Housekeeping/Laundry Supervisor was not suspended pending the outcome of the investigation. S1Administrator revealed she had contacted a technician to have him come show me how to access and view the facility's video surveillance. S1Administrator reported the technician came to the facility yesterday evening and showed her how to access the facilities video camera footage yesterday evening. S1Admininstrator reported the monitor in her office did not work, but the monitor in the office in the back of the facility worked. S1Administrator reported she was able to view the video camera footage on Hall A from Thursday 06/13/2024 and observed S9Housekeeping/Laundry Supervisor enter Resident #34's room on 06/13/2024 at 3:30 p.m. with nothing in her hands. S1Admininstrator reported S13Housekeeper was on Hall A and had entered another room across the hall from resident #34's room.
S1Admininstraor reported S9Houskeeping/Supervisor exited Resident #34's room at 3:31 p.m. with nothing in her hands and walked up Hall A toward the nurses' station.
S1Administrator had saved the video recording to her computer. Surveyor was able to watch the video camera footage that was dated and time stamped it revealed S9Houskeeping/Laundry Supervisor had entered resident #34's room on 06/13/2024 at 3:30 p.m. with nothing in her hands and exited his room at 3:31 p.m. with nothing in her hands.
S1Administrator reported that S9Housekeeping/Laundry Supervisor had reported she had not gone into resident #34's room and had provided a written statement that she had not gone into his room on 06/13/2024. S1Aministrator reported that she could not prove S9Houskeeping/Laundry Supervisor stole resident #34's $100 dollar bill, because she had no proof of how much money he had in his wallet. S1Admininstrator reported after talking with S3Regional Human Resources they were going to fire S9Housekeeping/Laundry Supervisor this morning for lying during the investigation interview and on her witness statement.
Surveyor asked S1Administrator why it took so long to obtain the staff witness statements and to have a technician to come out and check on the video surveillance system and show her how to operate it. S1Administrator reported she got busy on 06/18/2024 when Director of Nursing and Assistant Director of Nursing both quit.
On 06/25/2024 at 8:40 a.m. an interview with S9Housekeeping/Laundry Supervisor revealed she has been working at the facility for 24 years. Surveyor asked S9Housekeeping/Laundry Supervisor if she stole $100 dollar bill from resident #34 on 06/13/2024. S9Housekeeping/Laundry Supervisor denied stealing any money from resident #34. S9Housekeeping/Laundry Supervisor revealed she was not assigned Hall A where resident #34 resides. S9Housekeeping/Laundry Supervisor denied going into resident #34's room. S9Housekeeping/Laundry Supervisor revealed she had received training on abuse and neglect.
On 06/26/22024 at 2:45 p.m. an interview with S1Administrator confirmed she should have suspended S9Housekeeping/Laundry Supervisor pending the outcome of the investigation on 06/17/2024 after being informed of resident #34's allegation of stolen property. S1Administrator further confirmed she should not have taken so long to obtain the employee statements and review the facilities video surveillance camera footage.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
Record review revealed resident #17 had diagnoses of chronic kidney disease, type 1 diabetes mellitus, and chronic ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
Record review revealed resident #17 had diagnoses of chronic kidney disease, type 1 diabetes mellitus, and chronic ischemic heart disease. Further review revealed a 05/15/2024 Minimum Data Set (MDS) with a Brief Interview for Mental Status (BIMS) score of 14, which indicated resident #17 had no cognitive impairment. Review of the MDS further revealed that resident #17 required set up for personal hygiene care.
On 06/24/2024 at 9:15 a.m. and 06/25/2024 at 9:28 a.m., observations of resident #17's fingernails revealed they were long, a dark substance was noted underneath nails, and some fingernails were jagged.
Review of resident #17's June 2024 Physician Orders revealed and order dated 09/12/2021 for nail care every week and as needed.
Review of resident #17's current care plan revealed she was unable to perform activities of daily living without assistance. Further review revealed an intervention to provide nail care weekly.
On 06/25/2024 at 3:35 p.m., S10Registered Nurse (RN) and surveyor observed resident #17's fingernails. Resident #17's fingernails were long, a dark substance was noted underneath nails, and some fingernails were jagged. S10RN confirmed resident #17's fingernails were long and needed to be groomed.
Resident #23
Record review revealed resident #23 had diagnoses of Alzheimer's disease, cognitive communication deficit, and schizophrenia. Further review revealed a 04/04/2024 MDS assessment with a BIMS score of 8, which indicated resident #23 had moderate cognitive impairment. Further review of the MDS revealed that resident #23 required set up assistance for personal hygiene care.
On 06/24/2024 at 9:37 a.m. and 06/25/24 09:30 a.m., observations of resident #23's fingernails revealed they were long, a dark substance was noted underneath nails, and some fingernails were jagged.
On 06/25/2024 at 3:40 p.m., S10RN and surveyor observed resident #23's fingernails. Resident #23's fingernails were long, a dark substance was noted underneath nails, and some fingernails were jagged. S10RN confirmed resident #23's fingernails were long and needed to be groomed.
Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for 3 (#6, #17 #23) of 4 (#6, #11, #17, #23) sampled residents for Activities of Daily Living as evidenced by, 1) failing to ensure resident's clothing was clean and free of food debris and 2) failing to ensure resident's fingernails and toenails were trimmed and clean.
Findings:
Resident #6
Review of the record for resident #6 revealed a date of admission of 07/23/2015 with following diagnoses: chronic obstructive pulmonary disease, type 2 diabetes, cerebral disease, and dysphagia.
Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #6 had a brief interview for mental status score of 2. A score of 00-07 indicated that resident #6 was severely impaired with daily decision making skills. Review of functional abilities and goals for eating revealed setup or clean-up assistance, oral hygiene was supervision, and personal hygiene was substantial/maximal assistance.
Review of June 2024 physician orders for resident #6 revealed nail care every week and PRN (As needed).
An observation of resident #6 on 06/24/24 at 9:58 a.m., revealed the resident to be unshaven, his finger nails were long with grime and dirt in nailbed, and food particles were on the resident's clothing.
An observation of resident #6 on 06/24/2024 at 4:19 p.m., revealed the resident completed his supper meal in the main dining room. Resident #6 had food and debris all over his clothing, wheelchair, floor, and table. Further observation of resident #6 revealed him self-propelling in his wheel chair from main dining room to bedroom. There were multiple staff in hallway observing resident #6 and no assistance was provided.
An observation of resident #6 on 06/25/2024 at 11:43 a.m., revealed resident with food debris all over front of his shirt and pajama pants. No assistance was provided from the staff.
An Interview on 06/26/2024 at 11:00a.m., with S10Registered Nurse (RN), confirmed that staff should ensure all residents ADL's were maintained. Further interview with S10RN confirmed that resident #6 required assistance with ADL's and that he should not go around the facility with food debris on his clothing and his nails should have been trimmed and kept clean.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on record reviews and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified ...
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Based on record reviews and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 5 (S20Certified Nursing Assistant (CNA), S21CNA, S22CNA, S23CNA, and S24CNA) personnel records reviewed.
Findings:
Review of the personnel record for S20CNA revealed a hire date of 03/26/2024. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S20CNA.
Review of the personnel record for S21CNA revealed a hire date of 07/02/2021. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S21CNA.
Review of the personnel record for S22CNA revealed a hire date of 07/28/2023. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S22CNA.
Review of the personnel record for S23CNA revealed a hire date of 10/05/2023. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S23CNA.
Review of the personnel record for S24CNA revealed a hire date of 01/01/2021. Further review of the personnel record revealed no documented evidence of skills checks or competency evaluations for S24CNA.
On 06/25/2024 at 2:20 p.m., an interview with S3Regional Human Resources confirmed there was no documentation of competency evaluations and skills checks completed for the CNAs listed above.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation of the medication pass, review of physician orders and interview, the facility failed to ensure that it is free from a medication error rate of 5% or greater by having 4 errors ou...
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Based on observation of the medication pass, review of physician orders and interview, the facility failed to ensure that it is free from a medication error rate of 5% or greater by having 4 errors out of 33 opportunities for a medication error rate of 12.12%. (Residents #41, #13)
Findings:
Resident 41
Observation of the medication pass for resident #41 on 06/25/2024 at 8:27 a.m. revealed that S15Licensed Practical Nurse (LPN) administered 6 oral medications and 1 eye medication.
Review of the June 2024 physician orders for resident #41 revealed the high blood pressure medication Losartan 25 milligrams (mg) administer 1 tablet every day by mouth at 9:00 a.m. Observation of the medication pass revealed Losartan 25 mg was not observed to be administered to resident #41.
Interview with S10Registered Nurse (RN) on 06/26/2024 at 11:00 a.m. confirmed that the medication Losartan 25mg, 1 tablet every day should have been administered to resident #41.
Observation of the medication pass for resident #41 on 06/25/2024 at 8:27 a.m. revealed that the eye medication, Carboxymethyl Cellulose Sodium ophthalmic solution 0.5% was not administered and was not available.
Review of the June 2024 physician orders for resident #41 revealed an order for Carboxymethyl Cellulose Sodium, 1 drop in both eyes one time a day at 9:00AM (for dry eye syndrome of unspecified lacrimal gland).
Interview on 06/25/2024 at 3:30 p.m. with S15LPN confirmed that the eye medication Carboxymethyl Cellulose Sodium was not available and was not administered to resident #41.
Resident #13
Observation of the medication pass for resident #13 on 06/25/2024 at 8:38 a.m. revealed S16LPN administered 6 oral medications which included Vitamin D3, 50,000 IU (International Unit) 1 tablet.
Review of the June 2024 physician orders for resident #13 revealed the following order: Vitamin D3 50,000 IU, 1 tablet weekly. Review of the medication administration record for resident #13 revealed staff had been administering this medication on a daily basis instead of weekly as ordered.
Interview with S10RN on 08/26/2024 at 11:00 a.m. revealed that Vitamin D3 50,000 units is ordered once weekly and is scheduled to be administered on Wednesdays. S10RN confirmed that the Vitamin D3 should not have been administered on a daily basis.
Observation of the medication pass for resident #13 on 06/25/2024 at 8:38 a.m. revealed S16LPN administered 6 oral medications which included the antipsychotic medication Seroquel 25mg 1 tablet.
Review of the June 2024 physician orders for resident #13 revealed the following order: Seroquel 25mg, 1 tablet at bedtime.
On 06/26/2024 at 11:00 a.m., an interview with S10RN confirmed that the medication Seroquel 25mg was ordered for bedtime and should not have been given in the morning. S10RN further confirmed that S16LPN administered Seroquel on 06/26/2024 during morning medication pass.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to prepare and distribute food in accordance with professional standards for food service safety by failing to ensure food was defrosted prope...
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Based on observations and interviews, the facility failed to prepare and distribute food in accordance with professional standards for food service safety by failing to ensure food was defrosted properly. This deficient practice had the potential to affect 44 residents who received meals served from the kitchen.
Findings:
Review of the facility Policy for Safely Thawing Food (no date noted) revealed in part:
How to Thaw Food Safely:
3). Thawing in cold water - fill a bowl with cold water and leave the tap water running over the food as it thaws. This does require a lot of water, but it will keep the surface temperature of your food from growing bacteria too rapidly. If you can, keep your food in its original container or in a plastic bag to protect your kitchen sink and counter from germs.
On 6/25/2024 at 6:50 a.m. during a follow-up visit to the kitchen, an observation revealed a large amount of chicken breasts submerged in water in the kitchen sink and there was no running cold water noted. Further observation revealed the chicken breasts were not placed in a container in the sink, but were placed directly in the sink.
On 6/25/2024 at 10:30 a.m., an interview with S19Dietary Manager confirmed staff failed to defrost the chicken breast properly and according to their policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on review of the Quality Assessment and Assurance (QAA) record and interview, the facility failed to have documented evidence of having a QAA meeting at least quarterly for the year 2024.
Findi...
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Based on review of the Quality Assessment and Assurance (QAA) record and interview, the facility failed to have documented evidence of having a QAA meeting at least quarterly for the year 2024.
Findings:
Review of the QAA binder revealed no documented evidence of the facility having a QAA meeting for the first quarter of 2024 to address facility issues.
On 06/26/2024 at 5:50 p.m., an interview with S1Administrator confirmed there was no documented evidence of a QAA meeting for the first quarter of 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, policy review and interviews the facility failed to implement policies and procedures for enhanced barrier precautions for 5 (#24, #25, #26, #45, #255) of 5 (#24, #25, #26, #45, ...
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Based on observation, policy review and interviews the facility failed to implement policies and procedures for enhanced barrier precautions for 5 (#24, #25, #26, #45, #255) of 5 (#24, #25, #26, #45, #255) residents reviewed for enhanced barrier precautions.
Findings:
Review of the provider's undated Enhanced Barrier Precautions Policy revealed the following in-part:
Policy: Enhanced Barrier Precautions are indicated for residents with infections or colonization with a Center for Disease Control (CDC) and Prevention -targeted Multi Drug-Resistant Organisms (MDRO) when contact precautions do not apply or for residents with wounds and/or indwelling medical devices without secretions/excretions that are unable to be covered/contained & are not known to be infected/colonized with any MDRO during high-contact resident care activities as these residents are at an increased risk of being infected.
Definition:
1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of MDROs in nursing homes. Enhanced Barrier Precautions involve gown and glove used during high-contact resident care activities for residents known to be colonized with MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices).
2. Enhanced Barrier Precautions only require use of gown/gloves when performing high contact activities:
a. Dressing
b. Bathing/showering
c. Transferring (in room, shower/tub rooms, and therapy gyms)
d. AM/PM Care
e. Changing linens
f. Changing briefs or assisting with toileting
g. Device care or use: central lines, urinary catheter, feeding tube, tracheostomy, or ventilator
h. Wound care: any skin opening requiring a dressing
3. Duration: Enhanced Barrier Precautions are intended to remain in effect for the duration of the resident stay or until wound is closed/medical device removed.
On 06/24/2024 at 9:30 a.m. an interview with S2Director of Nursing (DON) and S1Administrator revealed they do not have any residents on isolation at this time.
On 06/24/2024 at 10:00 a.m. observations during tour of the facility revealed there were no resident's on enhanced barrier precautions.
Record review revealed the following:
Resident #24 had a wound and a colostomy.
Resident #25 had a wound.
Resident #26 had a wound.
Resident #45 had a wound and a colostomy.
Resident # 255 had a wound and a colostomy.
On 06/25/24 01:00 p.m. an interview with S8Clinic Operations Consultant confirmed Resident #24, Resident #25, Resident #26, Resident #45, and Resident #255 should have been on enhanced barrier precautions according to the facilities Enhanced Barrier Precaution Policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview and review of the facility's Infection Control Records, the facility failed to designate an individual/individuals as the Infection Preventionist, who is responsible for the facilit...
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Based on interview and review of the facility's Infection Control Records, the facility failed to designate an individual/individuals as the Infection Preventionist, who is responsible for the facility's infection prevention and control program.
Findings:
Review of the facility's Infection Control Records revealed there was no documented evidence that the facility had designated a staff member as the Infection Control Preventionist.
On 06/25/2024 at 1:10 p.m., an interview with S1Administrator confirmed they do not currently have a staff member designated as the Infection Preventionist for the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observations, record review, and interviews, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected...
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Based on observations, record review, and interviews, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 11 (#9, #11, #15, #18, #24, #27, #29, #33, #43, #47, and #49) of 11 sampled residents and had the potential to affect all 44 residents that resided in the facility.
Findings:
Review of the Pest Control Policy dated May 2008 revealed the following, in part:
1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
Observation of the hall where residents #11, #27, #29, and #49 reside on 06/24/2024 at 11:00 a.m. with S1Administrator revealed flies in the hallway. Interview with S1Administrator at this time revealed the facility has a problem with flies.
Observations on 06/25/2024 at 8:25 a.m. and 06/26/2024 at 1:40 p.m. of the hall where residents #11, #27, #29, and #49 reside revealed flies in the hallway.
Observation on 06/24/2024 at 10:30 a.m. of resident #29's room revealed a urine smell in the room and multiple flies in the room. Observation 06/25/2024 at 8:22 a.m. revealed resident #29's breakfast tray was on his bedside table and there were multiple flies in his room. Observation on 06/26/2024 at 1:40 p.m. revealed there were multiple flies in resident #29's room.
During an interview with resident #11 on 06/24/2024 at 1:00 p.m., resident #11 reported that the facility has a problem with flies. He reported that he uses his fly swatter in his room. Observation on 06/25/2024 at 12:40 p.m. revealed there were multiple flies in resident #11's room.
During an interview with resident #49 on 06/24/2024 at 12:30 p.m., resident #49 reported that the facility has a problem with flies. He reported that he has a fly swatter in his room.
Observation on 06/24/2024 at 9:44 a.m. revealed there was a fly in resident #27's room.
During the Resident Council meeting on 06/24/2024 at 2:30 p.m., residents #9, #15, #18, #24, #33, #43, #47 voiced complaints of issues with flies throughout the building.
An interview with S1Administrator on 06/26/2024 at 2:45 p.m. confirmed the facility continues to have an issue with flies.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on record reviews and interview, the facility failed to provide in-service training for nurse aides to ensure competency for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) of 5 personnel records...
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Based on record reviews and interview, the facility failed to provide in-service training for nurse aides to ensure competency for 5 (S20CNA, S21CNA, S22CNA, S23CNA, and S24CNA) of 5 personnel records reviewed. The facility failed to ensure: 1.) S20CNA, S21CNA, S22CNA, and S23CNA received training in resident abuse, 2) S20CNA, S23CNA, and S24CNA received training in dementia management and 3) S21CNA and S24CNA who were employed greater than one year received 12 hours of inservice training yearly.
Findings:
Review of the personnel record for S20CNA revealed a hire date of 03/26/2024. Further review of the record revealed no documented evidence of dementia management training and resident abuse prevention training.
Review of the personnel record for S21CNA revealed a hire date of 07/06/2021. Further review of the record revealed no documented evidence of 12 hours per year of in-service training to include resident abuse prevention training.
Review of the personnel record for S22CNA revealed a hire date of 07/28/2023. Further review of the record revealed no documented evidence of resident abuse prevention training.
Review of the personnel record for S23CNA revealed a hire date of 10/05/2023. Further review of the record revealed no documented evidence of dementia management training and resident abuse prevention training.
Review of the personnel record for S24CNA revealed a hire date of 01/01/2021. Further review of the record revealed no documented evidence of 12 hours per year of in-service training to include dementia management training.
On 06/25/2024 at 2:20 p.m., an interview with S3Regional Human Resources confirmed there was no documentation of annual training, dementia management training and resident abuse prevention training for the employees listed above.
Jul 2023
3 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure that a resident maintains acceptable paramete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to ensure that a resident maintains acceptable parameters of nutritional status for 1 (#31) of 1 (#31) resident reviewed for nutrition. The facility failed to notify the Registered Dietician regarding a resident's significant weight loss. Findings:
Review of resident #31's medical record revealed diagnoses including Parkinson's disease, severe dementia with behavioral disturbance, major depressive disorder, and delusional disorder.
Review of resident #31's Quarterly Minimum Data Set, dated [DATE] Quarterly Minimum Data Set revealed a Brief Interview for Mental Status score of 0, which indicated severe cognitive impairment. Further review revealed she was totally dependent on staff for all activities of daily living with 1-2 person assistance. She was also totally dependent on staff with 1 person assistance for eating.
Review of resident #31's Malnutrition Risk assessment dated [DATE] revealed she was assessed to be at a high risk for malnutrition.
On 07/24/2023 at 12:10 p.m., an observation revealed resident #31 was in a gerichair in her room. She was confused and had rambling speech. She required total assistance with her meal and a Certified Nursing Assistant (CNA) was feeding her a pureed diet.
On 07/26/2023 at 11:20 a.m., an interview with S5CNA revealed resident #31 has to be fed by staff for all meals. She reported the resident ate slowly and you have to be patient with her. S5CNA reported resident #31 mostly had a fair appetite and some days were better than others.
Review of resident #31's nurses' notes revealed from 07/01/2023 to 07/23/2023 staff documented the following: resident would not open mouth, would bite spoon and straw, required total care per staff, and she was confused. Further review revealed on 07/24/2023 CNA reported resident wouldn't open mouth all the way during feeding and she stated it was difficult to feed her some days.
Review of resident #31's medical record revealed the following weights were documented in pounds (lbs.) for resident #31:
01/2023 - 136.5
02/2023 - 137
03/06/2023 - 115.5
03/13/2023 - 116
03/20/2023 - 135.5 (Dietary Weight Record); 116.1 (Weekly Weight Flowchart) - discrepancy in weights recorded on 03/20/2023
03/27/2023 - 115.7
04/03/2023 - 135.5 and 116 (Weekly Weight Flowchart) - 2 different weights recorded 04/10/2023 - 116.5
04/17/2023 - 116.5
05/2023 - no weight documented
06/15/2023 - 107
07/01/2023 - 108
Review of the above weights revealed on 04/17/2023, the resident weighed 116.5 lbs. and on 07/01/2023, the resident weighed 108 lbs. which is a -7.30 % loss. Also, there was an inconsistency in resident #31's weight documentation from January 2023 - April 2023 which made it difficult to determine the resident's actual weight loss during this time frame.
Review of resident #31's labs revealed on 03/14/2023 her Albumin was 2.7 (normal range 3.4-5.0).
Review of resident #31's care plan revealed on 03/03/2022, the facility identified she was at a high risk for malnutrition. Further review revealed an intervention to notify the Registered Dietitian (RD) of any weight change of 5% in 1 month or 10% in 6 months.
Review of the Dietary Manager Progress Notes revealed S4Dietary Manager reviewed the resident's nutritional status on 03/20/2023, 06/15/2023, and 07/24/2023. Further review revealed on 06/15/2023, the resident's current weight was 107 lbs. and weight loss was noted. There was no documentation the RD was notified of resident #31's weight loss.
Review of the medical record for resident #31 revealed on 04/20/2023, supplements were ordered for the resident; however, there was no documentation from January 2023-July 2023 that her weight loss was assessed by a RD per her plan of care.
On 07/26/2023 at 11:30 a.m., an interview with S4Dietary Manager (DM) confirmed resident #31 had weight loss and there was no RD assessment for resident #31 from January 2023-July 2023. S4DM confirmed resident #31 should have been assessed by the RD for her weight loss.
On 07/26/2023 at 8:35 a.m., an interview with S2Director of Nursing (DON) confirmed documentation for resident #31's weights were inconsistent and there was no RD assessment for resident #31 from January 2023-July 2023. She also confirmed the RD should have been notified regarding resident #31's significant weight loss.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#14 and #17) of 6 (#10, 14, 17, 21, 22 and 31) residents r...
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Based on record reviews and interviews the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#14 and #17) of 6 (#10, 14, 17, 21, 22 and 31) residents reviewed for unnecessary medications. The facility failed to obtain lab work for residents #14 and #17 as ordered by the physician.
Findings:
Resident #17
Review of the medical record for resident #17 revealed an admission date of 03/02/2020 with diagnoses including acute osteomyelitis, diabetes mellitus, arthritis, venous insufficiency, hypokalemia, heart disease, edema, magnesium deficiency, obesity, hyperlipidemia, and anxiety.
Review of the physician orders dated 09/14/2021 revealed an order to obtain a Complete Blood Count (CBC) and chem 14 every 6 months in May and November.
Review of the nurses notes dated 05/16/2023 revealed the nurse attempted to draw labs times two attempts and unable. The Nurse Practitioner was notified and an order was obtained to draw the labs on 05/18/2023.
Review of the lab results or nurses noted revealed no documented evidence of the CBC or chem 14 obtained or attempted to draw as ordered.
On 07/26/2023 at 8:50 a.m., an interview with S2Director of Nursing (DON) revealed the there was no documented evidence of the labs attempted or obtained as ordered on 05/18/2023.
Resident #14
Review of the July 2023 physician orders for resident #14 revealed his medication regimen included Synthroid for hypothyroidism and Crestor for hyperlipidemia. Review of the physician orders also revealed resident #14 was to have a lipid panel and TSH (Thyroid Stimulating Hormone) level collected annually.
Review of the lab results revealed there was no evidence the lab was obtained.
On 07/26/2023 at 8:30 a.m., interview with S2DON confirmed the resident did not have lab drawn for Lipid and TSH levels as ordered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on review of the Quality Assessment and Assurance (QAA) record and interview the facility failed to have documented evidence of having QAA meeting as least quarterly for the year 2023.
Findings...
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Based on review of the Quality Assessment and Assurance (QAA) record and interview the facility failed to have documented evidence of having QAA meeting as least quarterly for the year 2023.
Findings:
Review of the QAA binder revealed no documented evidence of the facility having a QAA meeting for the first quarter of 2023 to address facility issues.
On 07/26/2023 at 11:45 a.m., interview with S3Corporate Nurse revealed the facility did not have documented evidence of QAA meetings done quarterly.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s). Review inspection reports carefully.
- • 49 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • Grade F (11/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 11/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Carroll Health And Rehab Llc's CMS Rating?
CMS assigns Carroll Health and Rehab LLC 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 Carroll Health And Rehab Llc Staffed?
CMS rates Carroll Health and Rehab LLC's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Carroll Health And Rehab Llc?
State health inspectors documented 49 deficiencies at Carroll Health and Rehab LLC during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 47 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Carroll Health And Rehab Llc?
Carroll Health and Rehab LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 62 residents (about 52% occupancy), it is a mid-sized facility located in Oak Grove, Louisiana.
How Does Carroll Health And Rehab Llc Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, Carroll Health and Rehab LLC's overall rating (1 stars) is below the state average of 2.4, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Carroll Health And Rehab Llc?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can 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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Carroll Health And Rehab Llc Safe?
Based on CMS inspection data, Carroll Health and Rehab LLC has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Carroll Health And Rehab Llc Stick Around?
Staff turnover at Carroll Health and Rehab LLC is high. At 61%, the facility is 15 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Carroll Health And Rehab Llc Ever Fined?
Carroll Health and Rehab LLC 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 Carroll Health And Rehab Llc on Any Federal Watch List?
Carroll Health and Rehab LLC 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.