TIOGA COMMUNITY CARE CENTER
Non profit - Corporation
154 Beds
COMMCARE CORPORATION
Data: November 2025
Trust Grade
20/100
#108 of 264 in LA
Photo by Tioga Community Care Center
Photo by Tioga Community Care Center
Photo by Tioga Community Care Center
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Tioga Community Care Center in Pineville, Louisiana, has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranked #108 out of 264 facilities in Louisiana, they fall into the top half, but their position is overshadowed by a concerning trend of worsening issues, increasing from 4 in 2024 to 9 in 2025. Staffing is a concern with a turnover rate of 60%, which is higher than the state average, although RN coverage is average. Additionally, the facility has faced $113,886 in fines, suggesting ongoing compliance problems. Specific incidents include a report of staff verbal abuse towards a resident and failures in providing adequate respiratory care, which collectively raise serious concerns about the safety and well-being of residents.
- Trust Score
- F
- In Louisiana
- #108/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $113,886 in fines. Higher than 55% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Top 40%
Review needed
4 → 9 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 9 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Above Louisiana average (2.4)
Meets federal standards, typical of most facilities
Staff Turnover: 60%
14pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $113,886
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: COMMCARE CORPORATION
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Louisiana average of 48%
The Ugly 23 deficiencies on record
1 actual harm
Jul 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 2 (#30 and #77) of 5 (#6, #30, #55, #77, ...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 2 (#30 and #77) of 5 (#6, #30, #55, #77, and #79) sampled residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction (GDR).
Findings:
Review of a facility policy on 07/23/2025 at 9:34 a.m. titled, “Psychotropic and Antipsychotic Medications and Non-Pharmacological Intervention” with an effective date of 01/2025 revealed in part…Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Residents should only receive psychotropic medications when other non-pharmacological interventions have been attempted and/or have been documented as being clinically contraindicated. Gradual Dose Reductions: Residents must only remain on psychotropic medications when gradual dose reduction and behavioral interventions (non-pharmacological interventions) have been attempted and/or deemed clinically contraindicated.
Resident #30
Review of Resident #30’s medical record revealed an admission date of 03/06/2024 with diagnoses that included in part… Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Chronic Diastolic (Congestive) Heart Failure, Atrial Fibrillation, and Depression.
Review of Resident #30’s current physician orders revealed an order for Trazodone HCl Tablet 50 mg by mouth at bedtime related to depression with a start date of 05/19/2025.
Review of Resident #30’s Quarterly MDS with an ARD of 06/11/2025 revealed the resident received antidepressants and had a BIMS of 13, which indicated intact cognition.
Review of Resident #30’s “Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction” form completed on 03/28/2025 revealed the pharmacy consultant requested a gradual dose reduction for Trazodone HCL 50mg tablet. The report read in part…Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented. Further review of the document revealed, the physician did not document if a dose reduction was appropriate or a clinical rationale for the psychotropic medication.
In an interview and record review on 07/22/2025 at 3:16 p.m., S7 ADON revealed Resident #30 currently received Trazodone HCL 50mg tablet at bedtime related to depression. S7 ADON confirmed the GDR written on 03/28/2025 for Resident #30 did not have documentation regarding if the dose reduction was appropriate or a documented clinical rationale, but should have.
Resident #77
Review of Resident #77’s medical record revealed an admit date of 11/12/2024 with diagnoses that included in part…Type 2 Diabetes Mellitus without complications, Alzheimer’s Disease, UTI, Dysphagia, Unspecified Dementia-mild with mood disturbance, Major Depressive Disorder, Essential Hypertension, Hyperlipidemia, Constipation, Vitamin D deficiency, and other Seizures.
Review of Resident #77’s Quarterly MDS with an ARD of 02/01/2024 revealed a BIMS of 14, which indicated intact cognition. Further review of MDS revealed Resident #77 had no behaviors. Resident #77 received an antipsychotic and an antidepressant medication.
Review of Resident #77’s care plan with a start date of 11/12/2024 revealed in part she was care planned for impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's Dementia and Potential for behavior problem related to dementia, mild with mood disturbances, attention seeking behaviors, gets upset when unable to complete sentences…
Review of Resident #77’s Physician’s orders revealed the following:
Aripiprazole tablet 2 mg by mouth one time a day
Sertraline HCL Oral tablet 100 mg by mouth one time a day
Review of the Pharmaceutical Consultant Report that was sent to NP on 05/26/2025 revealed the following: The Pharmacy Consultant Note to Physician read: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented either on this form or within the clinical record in order to be considered “clinically contraindicated” as to why the reduction is not desired at this time.
Review of the 05/26/2025 GDR revealed no documentation was noted for the questions of: Is a dose reduction appropriate, and is the dose a minimal effective dose. Further review revealed the NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. The facility NP documented “continue current plan of care.”
Review of the Pharmaceutical Consultant Report that was sent to NP on 11/24/2024 revealed the following: The pharmacy consultant Note to Physician read: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented either on this form or within the clinical record in order to be considered “clinically contraindicated” as to why the reduction is not desired at this time.
Upon reviewing the 11/24/2024 GDR, it was checked “no” for question of was a dose reduction appropriate and checked “yes” to Minimal Effective Dose. Facility NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated.
Review of the Pharmaceutical Consultant Report that was sent to NP on 11/12/2024 revealed the following: The pharmacy consultant Note to Physician read: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must be documented either on this form or within the clinical record in order to be considered “clinically contraindicated” as to why the reduction is not desired at this time.
Upon reviewing the 11/12/2024 GDR, no documentation was noted for the questions of is a dose reduction appropriate and is the dose a Minimal Effective Dose. NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. The facility NP documented “no changes.”
Review of Resident #77’s 05/30/2025 Psychiatric NP progress notes revealed in part…No changes. Diagnoses were Dementia, mild without behaviors and Major Depression. No clinical rationale was provided for not attempting a GDR.
Review of Resident #77’s MD progress notes from 06/02/2025 and 07/02/2025 revealed no rationales for continued medication therapy of Aripiprazole and Sertraline HCL.
Review of Resident #77’s NP progress notes from 05/14/2025 and 07/14/2025 revealed no rationales for continued medication therapy of Aripiprazole and Sertraline HCL.
Interview with S6 DON on 07/23/2025 at approximately 3:00 p.m., acknowledged Resident #77 had no GDR attempted and no physician rationale listed on GDR requests or medical record as required. S6 DON stated Resident #77 had been on both of these medications since she was admitted to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews, the facility failed to implement the care plan for 2 (#5 and #13) of 31 sampled residents. The facility failed to: 1. Place an assist rail to the ...
Read full inspector narrative →
Based on observations, record review, and interviews, the facility failed to implement the care plan for 2 (#5 and #13) of 31 sampled residents. The facility failed to: 1. Place an assist rail to the left side of Resident #5's bed, ensuring the resident could reposition himself as needed to maintain bed mobility as indicated on the patient-centered care plan; and2. Use ear protectors on Resident #13's nasal cannula as indicated in the resident's care plan.
Findings:
Review of a facility policy on 07/23/2025 at 9:34 a.m. titled, “Care Plans, Comprehensive Person-Centered” with a revision date of 03/2022 revealed the following part…A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. G. Receive the services and/or items included in the plan of care.
Resident #13
Review of Resident #13’s medical record revealed an admission date of 07/09/2024, with diagnoses that included in part…Parkinson’s Disease, Type II Diabetes Mellitus with other Specified Complication, Emphysema, and Schizophrenia.
Review of Resident #13’s admission MDS with an ARD of 07/14/2025 revealed a BIMS of 7, which indicated severe cognitive impairment. Resident #13 required total dependence with showering, bathing, and dressing and required partial/moderate assistance with personal hygiene.
Review of Resident #13’s current physician orders revealed orders for the following in part… -Oxygen at 2 liters per nasal cannula PRN O2 saturation less than 92% as needed for shortness of breath with a start date of 07/21/2025. -Treatment #13: Pressure, medical device related, stage 1, front right ear-cleanse with wound cleanser and 4X4 gauze, pat dry, apply Betadine, leave open to air (OTA) with an order date of 07/21/2025.
Review of Resident #13’s care plan with an initiated date of 07/09/2025 revealed the following part…Problem: (date initiated 07/21/2025) I have a pressure ulcer related to oxygen tubing- Treatment #13: 07/21/2025 pressure, medical device related injury (MDRI), stage 1, front right ear. Approaches: (date initiated 07/21/2025) Nasal cannula ear cushions.
Review of Resident #13’s nursing progress notes revealed in part…Resident #13 received oxygen therapies via nasal cannula on 07/19/2025, 07/20/2025, 07/21/2025, and 07/22/2025.
Observation on 07/21/2025 at 7:15 a.m. revealed Resident #13 with oxygen therapy in progress. Resident #13 was observed with redness behind bilateral ears and no ear protectors/cushions were observed to the nasal cannula.
Observation on 07/22/2025 at 1:45 p.m. revealed Resident #13 with oxygen therapy in progress. Resident #13 was observed with redness behind bilateral ears and no ear protectors/cushions were observed to the nasal cannula.
In an interview on 07/22/2025 at 2:15 p.m., S17 LPN revealed Resident #13 had oxygen therapy in progress. S17 LPN confirmed Resident #13 had no ear cushions applied to his nasal cannula and he had redness behind bilateral ears. S17 LPN confirmed Resident #13 should have had bilateral ear cushions applied to his oxygen tubing, but did not.
In an interview on 07/22/2025 at 2:45 p.m., S4 RN Wound Care revealed she was aware of the redness behind Resident #13’s bilateral ears and verified that the right ear had a medical device acquired injury (stage 1 pressure injury). S4 RN Wound Care confirmed that she care-planned for Resident #13 to have ear cushions applied to his oxygen tubing, but the ear cushions were not in place.
Findings:
Resident #5
Review of Resident #5’s medical record revealed an admit date of 05/20/2025 with diagnoses including Intraspinal Abscess and Granuloma, Cutaneous Abscess of Back, PVD, COPD, A-Fib, Pressure Ulcers, and Edema.
On 07/21/2025 at 6:35 a.m., Resident #5 was observed lying on his back with the head of the bed elevated with an assist rail on the right side of the bed and a trapeze bar above the bed. The resident stated he can reposition himself. He also stated that the staff does not come routinely or every two hours to help reposition him. The resident stated that he can use the assist rail on the right side and the trapeze above the bed and had requested an assist rail for the left side of the bed. The resident demonstrated that the trapeze is loose, and he states that he has been told the left assist rail had been ordered.
Review of Resident #5’s current care plan revealed a problem section for “ADL self-care performance deficit” initiated on 08/1/2022 and revised on 6/24/2025. Interventions revealed: “Bed Mobility: I require total dependent x 2, trapeze to assist with bed mobility and bilateral side rails.” This task has an initiated date of 08/01/2022 and a revision date of 05/08/2025.
In an interview on 07/22/2025 at 10:34 a.m., S2 MDS confirmed Resident #5’s bed should have two assist rails. S2 MDS stated that the request was sent to maintenance on 07/09/2025. S2 MDS stated S8 MDS, texted the maintenance supervisor, S9 Maintenance, to install an additional assist rail on the left side of Resident #5’s bed.
On 07/22/2025 at 11:02 a.m., S9 Maintenance was asked if he knew about Resident #5’s bed needing a left side rail. S9 Maintenance stated he was told about the assist rail need “a couple of days ago.” S9 Maintenance was asked if he could produce the order for a new left side rail for the resident’s bed. S9 Maintenance stated that there would not be an order because he would just take the assist rail from another bed frame that was not in use currently. S9 Maintenance was asked why he hadn’t done this yet, he stated that he “forgot about it.”
In an interview on 07/22/2025 at 3:50 p.m., S6 DON and S7 ADON both confirmed that Resident #5’s care plan had two assist rails specified and the resident should have had two assist rails on each side of bed and did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain go...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 2 (#61 and #77) of 3 (#11, #61, and #77) residents reviewed for ADL care. The facility failed to ensure oral care was provided for Resident #61; and Bath/Shower was provided for Resident #77. Findings:Review of the facility's policy dated 03/2018 titled Activities of Daily Living, Supporting read in part Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal/oral health.
Resident #61
Review of Resident #61's medical record revealed an admission date of 01/31/2020 with diagnoses that included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Spinal Stenosis, Dysphagia, and Disturbance of Salivary Secretions
Review of Resident #61’s Quarterly MDS with ARD of 06/18/2025 revealed a BIMS of 03, indicating severely impaired cognition. Resident #61 required substantial/max assistance with oral hygiene and dependent on staff for personal hygiene.
Review of Resident #61's care plan with a review date of 10/01/2025 read in part
Problem: have an ADL self-care performance deficit.
Approach: I require extensive assistance by (1) staff with personal hygiene and oral care.
Problem: I have potential for oral/dental health problems related to poor hygiene/condition.
Approach: I will be provided mouth care as per ADL personal hygiene.
Observation on 07/21/2025 at 8:01 a.m. revealed Resident #61’s was observed lying in bed awake but unable to answer questions when asked. Resident #61 was observed with a large amount of brown and yellow build up to teeth, lips, and gums.
Interview on 07/21/2025 at 1:08 p.m. with S13 CNA revealed that she provided oral care this morning but resident has a lot of buildup in his mouth. S13 CNA stated that Resident #61 does not refuse oral care.
Observation on 07/22/2025 at 9:40 a.m. revealed Resident #61 continued with a large amount of dried, stuck on brown and yellow build up on teeth.
Observation on 07/22/2025 at 1:30 p.m. revealed Resident #61 continued with large amount of dried, yellow and brown build up on teeth.
Observation on 07/22/2025 at 1:35 p.m. of S14 CNA providing oral care with S2 DON present. S14 CNA removed a significant amount of yellow/brown buildup from teeth with mouth swabs and water, while some buildup still remained. S14 CNA stated it was dried and she didn't want to rub too hard and make Resident #61’s gums bleed. S14 CNA stated she will attempt with a wash cloth.
In an interview on 07/22/2025 at 1:45 p.m., S2 DON confirmed that oral care for Resident #61 did not appear to have been provided after observation of oral care, but should had been done. S2 DON stated that she will be initiating an in service on oral care.
Resident #77
Review of Resident #77’s medical record revealed an admit date of 11/12/2024 ….with diagnoses that included in part…Type 2 Diabetes Mellitus without complications, Alzheimer’s Disease, UTI, Dysphagia, Unspecified dementia-mild with mood disturbance, Major depressive disorder, Essential hypertension, Hyperlipidemia, Constipation, Vitamin D deficiency, Other seizures.
Review of Resident #77’s Quarterly MDS with an ARD of 05/07/2025 revealed a BIMS of 14, which indicated intact cognition. Further review of MDS revealed Resident #77 required partial/moderate assistance with bathing, supervision or touching assistance with toileting, set-up or clean-up assistance with transfers and bed mobility, and resident was independent with eating.
Review of Resident #77’s care plan with a start date of 11/12/2024 revealed she was care planned for assistance with adls and required limited assist of 1 person with bathing.
Review of the CNA tasks revealed no documentation of bathing Resident #77 since 07/15/2025.
In an interview with Resident #77 on 07/22/2025 at 9:10 a.m., she stated she had not received a bath or bed bath in 7 days. She stated she had not been offered a bath. Observed there were no toiletries in resident’s room.
In an interview on 07/22/2025 at 9:45 a.m., S15 CNA stated Resident #77 cannot go to whirlpool because she was on isolation and stated she was independent and can do everything herself.
In an interview on 07/22/2025 at 9:45 a.m., S16 CNA stated non skilled residents get bed baths every other day and Resident #77 was independent.
In an interview on 07/22/2025 at 3:15 p.m., S7 ADON acknowledged there wasn’t any documentation of Resident #77 getting a bath in over a week. S7 ADON stated when she asked CNA about bathing Resident #77, the CNA stated, “She’s in isolation.” S7 ADON stated she had to explain to CNAs that residents in isolation still require baths, just like COVID patients did. S7 ADON acknowledged that Resident #77 had not been bathed in a week.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide care and services that met professional standa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality. The sampled residents were 31. The facility failed to: 1. Ensure proper physician orders were obtained for Resident #13's oxygen requirements.2. Ensure proper physician orders were obtained for Resident #36's rescue inhaler.3. Ensure Resident #36's rescue inhaler was stored in a safe and secure manner. Findings: Review of an undated facility policy on 07/23/2025 at 9:34 a.m. titled, Oxygen Administration revealed the following in part.The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or the facility protocol for oxygen administration. Review of a facility policy on 07/23/2025 at 9:34 a.m. titled, Storage of Medications with a revision date of 11/2020 revealed the following in part.The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications. Resident #13Review of Resident #13's medical record revealed an admission date of 07/09/2024, with diagnoses that included in part.Parkinson's Disease, Type II Diabetes Mellitus with other Specified Complication, Emphysema, and Schizophrenia. Review of Resident #13's admission MDS with an ARD of 07/14/2025 revealed a BIMS of 7, which indicated severe cognitive impairment. Resident #13 required total dependence with showering, bathing, and dressing and required partial/moderate assistance with personal hygiene.Review of Resident #13's current physician orders revealed orders for the following in part. -Oxygen at 2 liters per nasal cannula PRN O2 saturation less than 92% as needed for shortness of breath with a start date of 07/21/2025. -Resident #13 had no other current physician orders for oxygen therapy. Review of Resident #13's nursing progress notes revealed in part.Resident #13 received oxygen therapies on 07/20/2025: 4 liters nasal cannula; and 07/21/2025: 4 Liters nasal cannula. Observation on 07/21/2025 at 7:15 a.m. revealed Resident #13 with continuous oxygen therapy in progress. Observed oxygen settings at 4 liters via oxygen concentrator. Observation on 07/22/2025 at 1:45 p.m. revealed Resident #13 with continuous oxygen therapy in progress. Observed oxygen setting at 4 liters via oxygen concentrator. In an interview on 07/22/2025 at 2:15 p.m., S17 LPN revealed Resident #13 had continuous oxygen therapy in progress. S17 LPN confirmed Resident #13's oxygen settings were set at 4 liters via oxygen concentrator. In an interview and record review on 07/22/2025 at 3:16 p.m., S7 ADON revealed Resident #13's current physician's orders reflected an order for oxygen at 2 liters per nasal cannula as needed for shortness of breath or oxygen saturation less than 92%. S7 ADON confirmed there were no current physician orders for Resident #13 to have a continuous flow of 4 liters of oxygen via concentrator. S7 ADON confirmed the nurse should have obtained the required oxygen orders prior to applying a continuous flow of 4 liters of oxygen for Resident #13, but did not. Resident #36Review of Resident #36's medical record revealed an admission date of 07/08/2024, with diagnoses that included in part. Systolic (Congestive) Heart Failure, Non-St Elevation (Nstemi) Myocardial Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction, And Chronic Obstructive Pulmonary Disease. Review of Resident #36's admission MDS with an ARD of 07/15/2025 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #36's current physician orders (as of 07/21/2025) revealed no orders for any inhalers. Review of Resident #36's care plan with an initiated date of 07/10/2025 revealed in part.Problem: I have COPD. Approaches: I will receive aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. In an interview on 07/21/2025 at 8:14 a.m., with Resident #36 revealed that she uses her rescue inhaler daily every day since she admitted to the facility on [DATE]. Resident #36 stated the nurses know and do not help her with administering her inhaler. An inhaler was observed on the resident's bedside dresser at the time of interview. In an interview on 07/22/2025 at 3:02 p.m., with Resident #36 revealed she gave herself the rescue inhaler today. Resident #36 stated the doctor gave her orders to take the inhaler every day and she kept it at her bedside. Observation revealed an inhaler on the resident's bedside dresser. In an interview and record review on 07/22/2025 at 3:06 p.m., S17 LPN revealed she did see an inhaler on Resident #36's bedside dresser today. S17 LPN confirmed Resident #36 did not have current physician orders for a rescue inhaler. S17 LPN confirmed that there should had been physician orders obtained for Resident #36's rescue inhaler and the inhaler should had been stored/locked in the medication box, but was not. In an interview and record review on 07/22/2025 at 3:16 p.m., S7 ADON revealed the facility does not allow any residents to self-administer medications during their stay. S7 ADON confirmed Resident #36 did not have current physician orders for a rescue inhaler. S7 ADON confirmed that the inhaler should had been reconciled upon admission to the facility and correct doctor orders obtained for the inhaler, but was not. S7 ADON confirmed Resident #36's inhaler should not be stored at the bedside when not in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#55, and #87) of 5 (#13, #22, #38 #55, and #87) residen...
Read full inspector narrative →
Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (#55, and #87) of 5 (#13, #22, #38 #55, and #87) residents reviewed for respiratory care. The facility failed to:1.Store nebulizer mask appropriately for Resident #55; and2. Ensure oxygen was given or set at prescribed rate for Resident #87.Findings:Resident #87
Review of the facility’s undated policy entitled “Oxygen Administration” revealed, in part…staff is to verify there is a physician’s order for oxygen administration and provide oxygen at the prescribed flow rate.
Review of Resident #87’s medical record revealed an admission date of 04/03/2023 with diagnoses including Chronic Obstructive Pulmonary Disease and Shortness of Breath.
Review of Resident #87’s Quarterly MDS with an ARD of 04/30/2025 revealed a BIMS Score of 15, indicating intact cognition.
Review of Resident #87’s physician’s orders revealed oxygen at 2 LPM per NC was ordered on 03/28/2025.
Observation of Resident #87 on 07/21/2025 at 11:00 a.m. revealed the resident’s oxygen flowmeter was set between 2.5 and 3 LPM.
Observation of Resident #87 on 07/22/2025 at 9:32 a.m. revealed the resident’s oxygen flowmeter was set between 2.5 and 3 LPM.
Observation of Resident #87 on 07/22/2025 at 11:10 a.m. accompanied by S1LPN revealed the resident’s oxygen flowmeter was set between 2.5 and 3 LPM. S1LPN confirmed Resident #87’s oxygen flowmeter should have been set at 2 LPM, but was not.
Review of the Facility undated policy titled “Administering Medications Through a Small Volume Nebulizer” read in part….Steps in procedure: When equipment is completely dry, store in a plastic bag with the residents name and the date on it.
Resident #55
Review of Resident #55's medical record revealed an admit date of 09/03/2021 with diagnoses that included: Unspecified Sequelae of Unspecified Cerebrovascular Disease, Atherosclerotic Heart Disease, Schizoaffective Disorder, Bipolar Type, Dysphagia, Epilepsy, Unspecified Dementia, and Heart Failure.
Review of Resident #55’s 07/2025 Physician Orders read in part….06/23/2025 Albuterol Solution 2.5 mg/3ml inhale orally via nebulizer every 6 hours as needed for shortness of breath.
Review of Resident #55’s Care plan with a review date of 10/14/2025 read in part… I have potential for altered respiratory status related to allergic rhinitis and potential for shortness of breath. Interventions: Nebulizer as ordered, change nebulizer mask and tubing as ordered, and monitor oxygen saturation as ordered.
In an observation on 07/21/2025 at 1:09 p.m., Resident #55’s Nebulizer mask was observed sitting on the dresser, on top of nebulizer machine, not bagged and open to air.
In an observation on 07/22/2025 at 9:24 a.m., Resident #55’s Nebulizer mask was observed sitting on the dresser, on top of nebulizer machine, not bagged and open to air.
Interview on 07/22/2025 at 1:14 p.m. with S11 LPN confirmed that the nebulizer mask was left open to air, but should not 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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to:Ensure food, dish w...
Read full inspector narrative →
Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to:Ensure food, dish washer, refrigerator, and freezer temperatures were performed and recorded appropriately; and Ensure food was properly stored in the kitchen. This deficient practice had the potential to affect the 93 residents that received meals prepared in the kitchen. Findings:Review of the facility's undated policy titled, Prevention of Food Borne Illness read in part.Holding: Assure holding temperatures are maintained as needed for hot/cold foods. Measures temperatures using a calibrated thermometer and check temperatures at 2 hours intervals. Review of the facility's 10/2017 policy titled, Food Receiving and Storage read in part.Policy statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy interpretation: 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( received and/or open date). Review of the facility's 12/2014 policy titled, Refrigerators and Freezers read in part.Policy statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitations, and will observe food expiration guidelines. Policy Interpretations: 3. Food service supervisors or designated employees will check and record refrigerator and freezer temperature daily with first opening and at closing in the evening. Review of the facility's 04/10/2014 policy titled, Dishwasher Use and Maintenance Household and Neighborhood and Log read in part.Dishwasher Log: 1. Run/record at least (1) dishwasher check before using machine at each mealtime. 4. Do not use dish washer until the temperature and chemical checks are within the required range. In an observation on 07/21/2025 at 6:15 a.m. of the walk-in freezer revealed 2 opened boxes of home style yeast roll dough open to air. Interview on 07/21/2025 at 10:15 a.m. S12 [NAME] confirmed all the above findings. Review of the facility's Daily Temperature Log revealed the following:No refrigerators x 2, freezer, or dishwasher temperatures were completed for 07/03/2025 07/04/2025, 07/05/2025, 07/06/2025, 07/08/2025, 07/09/2025, 07/10/2025, 07/11/2025, 07/12/2025, 07/13/2025, and 07/14/2025. No food temperatures were completed for dinner meal services on 07/11/2025 and 07/15/2025. Interview on 07/22/2025 at 10:50 a.m. with S12 [NAME] confirmed the all the above findings and stated the temperature checks were not completed appropriately, but should have been. S12 [NAME] stated she had not been monitoring the temperature logs to ensure they were completed appropriately by the dietary staff, but should have.
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
Read full inspector narrative →
Deficiency Text Not Available
Feb 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was free from staff to resident verbal abuse for 1 (Resident #4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) sampled re...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure a resident was free from staff to resident verbal abuse for 1 (Resident #4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) sampled residents investigated for abuse. Resident #4, a cognitive residents, experienced mental anguish and psyshosocial harm as a result of the verbal abuse by staff.
This deficient practice resulted in an actual harm on 02/11/2025 at 10:00 a.m., when S3 CNA told Resident #4, Shut the F*** up and F*** this Sh**! during ADL care (showering). Resident #4 stated this caused him mental anguish and psychosocial harm/emotional distress, as he felt disrespected, insulted, and pissed off that S3 CNA cursed and spoke to him in that way. Resident #4 reported the incident to staff and told them he did not want S3 CNA in his room again.
Findings:
Review of the facility's policy on 02/26/2025 at 4:03 p.m. titled, Abuse Components Plan, Elder Justice Act and Affordable Care Act, with an effective date of 10/24/2022, read in part .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.
Review of the facility's employee Relias Training course on 02/26/2025 at 4:03 p.m. titled, Abuse, Neglect, and Exploitation dated 00/00/2022 read in part .Mental Abuse can be verbal or non-verbal .Mental Abuse includes: Humiliating .Verbal Abuse is a type of Mental Abuse. It includes: Mocking or ridiculing, yelling, threatening to withhold contact from others, and scolding .these actions are Verbal Abuse even if the resident does not understand what the person says.
Review of Resident #4's medical record revealed an admission date of 10/30/2018, with diagnoses that included in part .Myotonic Muscular Dystrophy, Abdominal, Anxiety Disorder, Chronic Inflammatory Demyelinating Polyneuritis, Muscular Dystrophy, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Anxiety Disorder.
Review of Resident #4's Quarterly and State Optional MDS with an ARD of 01/01/2025, revealed a BIMS score of 14, which indicated cognition was intact. Resident #4 required total dependence with two person physical assistance with bed mobility, toilet use, and transfers.
Review of Resident #4's care plan with a start date of 01/24/2025, revealed the following the part . -Problem: I have an ADL-self-care performance deficit, wheelchair bound with diagnosis of Muscular Dystrophy. Interventions included bathing/showering - I am totally dependent on one staff to provide bath/shower, with a start date of 11/01/2018. -Problem: Potential for Depression. Interventions included - may see LCSW of choice with a start date of 11/03/2023, and psych visits as needed/scheduled with a start date of 08/31/2021.
Review of a Visitation/Progress Note completed by S9 Social Worker on 02/20/2025, revealed the following in part .Resident #4 mentioned that he had not been feeling good recently. He expressed that he's been having rough days and did not feel good after recent events .reports an incident with a staff member who said ugly things and she got fired .I didn't want her to get fired but she did it to herself.
Review of a facility report completed by S1 Administrator titled, Grievance: Other dated 02/11/2025 at 10:15 a.m., revealed the following in part .Grievance dated 02/11/2025 for Resident #4: Resident Description: Nurse Aide Supervisor reported to DON and Administrator that resident just complained that a particular nurse aide did not know how to do her job, and that he wanted her wrote up for telling him to Shut the F*** up. Notes: 02/11/2025: Resident has a BIMS of 14, cognitively intact. Administrator and DON met with resident to discuss incident. Resident verified identity of aide and witnesses. Resident stated that aide did not cover the bed sheets and they were getting wet after his shower. Resident stated that he wanted her written up because she told him to shut the F*** up when he said she did not know how to do her job.
Review of a written statement completed by S6 CNA on 02/11/2025, revealed the following in part .I, S6 CNA, was helping S3 CNA do Resident #4, getting him out of the shower, and Resident #4 said that you don't know your job. S3 CNA said Shut the F*** up, I know my job.
Review of a written statement completed by S8 Treatment Nurse on 02/11/2025, revealed the following in part .While I was doing treatments down Hall X, S3 CNA requested my assistance in Resident #4's room. Verbal conflict with resident to aide continued the entire time of patient care, resident repeatedly called out S4 CNA Supervisor's name.
Review of a written statement completed by S3 CNA on 02/11/2025, revealed the following in part .I was showering Resident #4. Once he was done he told me I needed to cover the sheets because they was going to get wet. I already did that, and I explained that to him. He proceeded to say I didn't. I told him once again I did and this is not my first time taking care of him. I know how to do my job. He then told me I don't. I'm retarded, I'm dumb and slow. I told him I wasn't and that was not nice. I stepped out and asked S8 Treatment Nurse to assist for a witness because he (Resident #4) asked for S4 CNA Supervisor.
In an interview on 02/26/2025 at 10:12 a.m., S4 CNA Supervisor revealed in part .recently (about 2 weeks ago-could not remember the exact date) there was a situation where a CNA was terminated for verbal abuse. The verbal abuse was from the CNA to a resident. S4 CNA Supervisor could not remember the details of the verbal abuse incident or the CNA and Resident involved because she was out of the facility at that time. S4 CNA Supervisor stated that S2 DON and S5 ADON investigated the verbal abuse incident.
In an interview on 02/26/2025 at 10:35 a.m., S2 DON revealed she was not aware of any verbal abuse situations, or SIMS reports in the last two weeks - four weeks. S2 DON stated there were no verbal abuse allegations reported or investigated. S2 DON stated that she was alerted by S4 CNA Supervisor via telephone and was told of a situation. S2 DON stated she and S1 Administrator interviewed S3 CNA in the administrative office. S3 CNA stated Resident #4 was having an episode and S3 CNA fussed at him because he wanted the bedding changed. S2 DON stated S1 Administrator sent S3 CNA home on suspension pending the investigation. S2 DON said she and S1 Administrator then interviewed Resident #4, and he stated that S3 CNA said F*** you, during his shower. S2 DON stated she and S1 Administrator terminated S3 CNA via telephone for unprofessional interaction with a resident. S2 DON stated they did not classify this as verbal abuse, and did not report the incident. S2 DON stated they filed it as a facility Other Grievance. S2 DON stated she could not remember the actual date and time of the event because there was no abuse incident report.
In an interview on 02/26/2025 at 11:20 a.m., Resident #4 revealed he remembered the incident with S3 CNA very well. Resident #4 stated it happened on 02/11/2025 before 10:00 a.m., when S3 CNA told him, F*** you and F*** this S***! during his shower on that day. Resident #4 revealed that S3 CNA had an attitude and was mad the entire time of the shower because she did not want to shower him. Resident #4 revealed that he felt disrespected, insulted, and pissed off that S3 CNA cursed and spoke to him in that way. Resident #4 stated that he hollered out for S4 CNA supervisor during that time, but S4 CNA Supervisor did not come. Resident #4 stated that he did not know S3 CNA very well and she should have never spoken to him like that. Resident #4 stated that S6 CNA and S8 Treatment Nurse were in the room assisting S3 CNA during the incident. Resident #4 stated that this had never happened to him from any other staff members, and was the first time. Resident #4 revealed that he was upset that it even happened to him. He stated that S3 CNA left his room after he was put back to bed and the situation was over. Resident #4 stated that S5 ADON, S2 DON, and S1 Administrator came to his room to talk to him later that day. Resident #4 stated that he was told by S1 Administrator that S3 CNA was sent home on suspension.
In a telephone interview on 02/26/2025 at 12:37 p.m., S6 CNA revealed that she witnessed the situation with Resident #4 on 02/11/2025 at about 10:00 a.m. S6 CNA stated S3 CNA asked her on Hall X to assist with showering Resident #4. S6 CNA stated she went into the resident's shower stall and Resident #4 was upset about his neck placement, and he told S3 CNA to adjust his neck. S6 CNA confirmed that at this time, S3 CNA stated to the resident, Shut the F*** up, F*** this shit, and I know how to do my job! S6 CNA stated she immediately left the resident's room and told the closest CNA on the hall, which was S7 CNA. S6 CNA stated that S7 CNA then phoned S4 CNA Supervisor and reported what S3 CNA said to Resident #4.
In an interview on 02/26/2025 at 12:40 p.m., S7 CNA revealed that on 02/11/2025 at about 10:00 a.m., she was alerted by S6 CNA that S3 CNA cursed out Resident #4 during his shower. S7 CNA immediately called S4 CNA Supervisor and reported the situation. S7 CNA revealed that she cared for Resident #4 the rest of the day, and he was still upset about the situation that occurred earlier in the day. S4 CNA stated that Resident #4 kept telling her to not let S3 CNA back in his room.
In a telephone interview on 02/26/2025 at 1:30 p.m., S8 Treatment Nurse revealed that she was present on 02/11/2025 at about 10:00 a.m. when the situation happened with Resident #4. S8 Treatment Nurse stated that she did assist S3 CNA briefly with supervising Resident #4 in the shower and then dressing. S8 Treatment Nurse stated she remembered Resident #4 hollering out for S4 CNA Supervisor. S8 Treatment Nurse stated that Resident #4 was very upset at this point. S8 Treatment Nurse stated she did not hear any cursing from S3 CNA during her interactions; however, S8 Treatment Nurse was not present in the shower and bedroom the entire time.
In a telephone interview on 02/26/2025 at 1:45 p.m., S9 Social Worker revealed in part .she visited with Resident #4 on 02/20/2025, during her routine rounds, and he brought to her attention a recent incident that occurred with a CNA who cursed at him and that she was fired.
In an interview on 02/26/2025 at 2:00 p.m., S2 DON revealed in part .she was alerted by S4 CNA Supervisor via telephone at about 10:00 a.m. on 02/11/2025 .she revealed that during her investigation of the incident, Resident #4 complained about wet linens, how S3 CNA could not do her job, and how S3 CNA cursed at him. S2 DON stated that Resident #4 had a louder tone and voice during this interview. S2 DON stated she could not remember if she contacted S10 NP, but she must have, because she got the order for psychosocial monitoring every shift for Resident #4. S2 DON stated she did not consider cursing a resident as verbal abuse; however, she considered it as an unprofessional interaction. S2 DON confirmed that she does not expect staff to curse at residents, and the incident with S3 CNA and Resident #4 should not have happened.
In an interview on 02/26/2025 at 2:16 p.m., S1 Administrator revealed in part .he was alerted on 02/11/2025 in the morning by S2 DON of the situation with Resident #4. S1 Administrator stated he, S2 DON, and S5 ADON started an investigation. S1 Administrator stated during an interview with Resident #4, he (Resident #4) was mad, and told S1 Administrator that S3 CNA cursed him saying, F*** you, and F*** this S***! during his shower. S1 Administrator stated he, S2 DON, and S5 ADON obtained S3 CNA's statement, and then sent her home on suspension. S1 Administrator stated this was not verbal abuse, and referred to a facility form dated 00/00/2018 and stated, Because the resident did not have psychosocial harm, it was not verbal abuse, and not a reportable event. S1 Administrator stated he telephoned S9 Social Worker on 02/11/2025, who said she was going to visit Resident #4 on her next rounds (02/20/2025). S1 Administrator stated that S9 Social Worker determined there was no psychosocial harm when she saw Resident #4 on 02/20/2025, 9 days after the incident. S1 Administrator revealed that no in-servicing of staff was completed post event and he did not notify S10 NP nor S11 MD. S1 Administrator denied this event being verbal abuse or a reportable event. S1 Administrator confirmed the incident did occur and confirmed S6 CNA witnessed S3 CNA tell Resident #4 to Shut the F*** up.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure an incident of abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency ...
Read full inspector narrative →
Based on record review and interview, the facility failed to ensure an incident of abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency in accordance with state law for 1 (#4) of 9 (#1, #2, #3, #4, R1, R2, R3, R4, and R5) residents reviewed for abuse The provider failed to report staff to resident verbal abuse for Resident #4.
Findings:
On 02/26/2025, a review of the facility's policy titled Abuse Components Plan, Elder Justice Act and Affordable Care Act with an effective date of 10/24/2022 read in part .Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .
Reporting:
All alleged violations involving abuse, neglect, exploitation, mistreatment .will be reported by the Administrator or designee, to the following persons or agencies as required to provide notification:
a.
LDH online tracking system, Statewide Incident Tracking System (SIMS).
b.
An alleged violation involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of property/funds, and/or any other reportable incident will be reported immediately, but no later than:
a.
Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury; or
b.
Twenty four (24) hours if the alleged violation does not involve abuse .
Review of Resident #4's medical record revealed an admit date of 02/16/2017 with diagnoses that included in part .Anxiety and Major Depressive Disorder.
Review of Resident #4's Quarterly MDS with an ARD of 01/01/2025 revealed a BIMS score of 14, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #4 was dependent with eating, showering/bathing, rolling left or right, sitting to lying, lying to sitting on side of bed, and chair/bed to chair transferring.
Review of a grievance dated 02/11/2025 revealed .
Resident Description: Nurse Aide Supervisor reported to DON and Administrator that resident just complained that a particular nurse aide (S3 CNA) did not know how to do her job and that he wanted her wrote up for telling him to Shut the f___ up.
In an interview on 02/26/2025 at 11:20 a.m., Resident #4 stated S3 CNA cursed at him. Resident #4 reported S3 CNA had an attitude because she had to give him a shower. Resident #4 stated he told her she was getting his sheets wet and she started cursing him. Resident #4 reported S3 CNA told him to Shut the f___ up and F___ this sh__. Resident #4 stated this made him feel mad and disrespected. Resident #4 stated he told administration he didn't want her in his room anymore.
In an interview on 02/26/2025 at 2:20 p.m., S1 Administrator confirmed S3 CNA cursed Resident #4 and confirmed it was witnessed by another CNA. S1 Administrator reported he did not report this incident to the State Agency because he did not feel it met the definition of abuse because Resident #4 did not show evidence of psychological harm. S1 Administrator reported the incident was not abuse, but an unprofessional interaction with a resident by staff. S1 Administrator confirmed the incident was never reported to the State Agency and a SIMS was never completed.
Aug 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure Resident #1's Responsible Party (RP) was informed of changes in the resident's condition for 1 (Resident #1) of 3 (Resident #1, Resid...
Read full inspector narrative →
Based on interview and record review the facility failed to ensure Resident #1's Responsible Party (RP) was informed of changes in the resident's condition for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings:
Review of the facility's policy titled Change in a Resident's Condition or Status read in part . Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status in a timely manner.
Review of Resident #1's clinical record revealed an admission date of 02/28/2020 with diagnoses that included Alzheimer's disease with late onset, Generalized Anxiety Disorder (GAD), Major Depressive Disorder, Recurrent, Insomnia and Dementia, unspecified severity with other behavioral disturbance.
Review of Resident #1's Annual MDS Assessment with an ARD of 07/03/2024 revealed a BIMS score of 3 indicating severe cognitive impairment. Resident #1 received antianxiety and antidepressant medications.
Review of Resident #1's Quarterly MDS with an ARD of 05/29/2024 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #1 received antidepressant medications.
Review of Resident #1's Care Plan with a target date of 06/20/2024 revealed a problem initiated on 04/17/2024 when Resident #1 was prescribed anti-anxiety meds related to Anxiety disorder with interventions that included in part . to monitor/record/report prn if exhibited adverse reactions to anti-anxiety therapy.
Review of Resident #1's Physician's Orders read in part .
04/17/2024 - Trazodone HCl oral tablet give 12.5mg by mouth 2 times a day for anxiety and depression.
Start date 04/17/2024. Discontinued 04/24/2024.
04/24/2024 - Trazodone HCl oral tablet give 25mg by mouth 2 times a day for anxiety and depression. Start date 04/24/2024. Discontinued 05/22/2024.
05/22/2024 - Trazodone HCl oral tablet give 50mg by mouth 2 times a day for anxiety and depression. Start date 05/22/2024.
05/31/2024 - Xanax oral tablet 0.25mg 1 tablet by mouth BID for GAD. Start dated 05/31/2024. 06/13/2024 - Xanax oral tablet 0.25 mg 1 tablet by mouth every p.m. for GAD. Start dated 06/13/2024.
Review of Resident #1's Progress or Nurses Notes revealed no documentation of the above medication changes and no documentation that Resident #1's RP was notified of medication changes.
Telephone interview on 08/13/2024 at 3:50 p.m. with S3 LPN revealed she had cared for Resident #1. S3 LPN revealed she had spoken with Resident #1's daughter a couple of times when she would visit about some of her care and behaviors but could not recall what and when she had documented.
Interview on 08/14/2024 at 10:20 a.m. with S2 ADON verified that the nurses should have informed Resident #1's RP of medication changes but did not.
Interview on 08/14/2024 at 10:40 a.m. with S1 DON revealed there was no evidence that Resident #1's RP had been notified of medication changes. S1 DON confirmed Resident #1's RP should have been notified of changes in her medication regimen and had not been.
May 2024
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to implement the person-centered care plan for 1 (#81) of 3 (#76, #81, & #87) residents reviewed for pain management by failing to order and a...
Read full inspector narrative →
Based on record review and interview, the facility failed to implement the person-centered care plan for 1 (#81) of 3 (#76, #81, & #87) residents reviewed for pain management by failing to order and administer Lidocaine patches for pain, as recommended by the resident's orthopedic doctor.
Findings:
Review of Resident #81's medical record revealed an admit date of 04/28/2023 with diagnoses that included in part .Lumbago with Sciatica, Muscle Weakness, and Left Arm Pain.
Review of Resident #81's MDS with an ARD of 05/01/2024 revealed a BIMS score of 14, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #81 used a walker to ambulate and her primary medical condition was listed as Lumbago with Sciatica, right side. Review of the MDS revealed the resident received prn pain medications.
Review of Resident #81's current physician's orders revealed the following:
05/13/2024: Appointment with Orthopedist 05/23/2024 Right iliolumbar ligament and right sacroiliac joint injections
05/13/2024: Acetaminophen 325 mg -give 2 tablets po q 4 hours as needed for general discomfort
04/23/2024: Norco Oral Tablet 5-325 mg po q 12 hours prn pain
05/06/2024: Tizanidine HCL 2 mg give 1-2 tablets po at hs
Review of Resident #81's care plan with a target completion date of 05/16/2024 revealed she was care planned for I am on pain medication related to Scoliosis, Cervicalgia, Osteoporosis, and Lumbago with Sciatica, right side. Interventions included: I will be free of any discomfort or adverse side effects from pain medication through the review date; Administer my analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; Monitor/document/report as needed If I exhibit adverse reactions to analgesic therapy.
Review of the nurses' notes for Resident #81 revealed the following:
05/13/2024 at 12:19 p.m.: Resident returned from appointment with (Orthopedist), per wheelchair via facility's transportation. Resident returned in stable condition. Lidocaine patches recommended to affected area 12 hours on 12 hours off. Schedule for right iliolumbar ligament and right sacroiliac joint injections under fluoroscopy on 05/23/2024. By S2 LPN.
In an interview on 05/20/2024 at 9:32 a.m., Resident #81 stated her back was hurting and asked if I could find out about her getting some pain medicine for it. Resident #81 stated she only received Tylenol for the pain and stated it doesn't work.
In an interview on 05/21/2024 at 8:45 a.m., Resident #81 stated her back hurts this morning. Resident #81 stated she was hoping to get some relief when she goes to the Orthopedist on Thursday to get her injections.
In an interview on 05/21/2024 at 9:57 a.m , Resident #81 confirmed at her appointment on 05/13/2024 the Orthopedist did recommend Lidocaine patches but stated the nurses haven't put any patches on her yet. Resident #81 stated she wanted to try the patches.
In an interview on 05/21/2024 at 10:39 a.m., S2 LPN stated Resident #81 went to the doctor and returned with a progress note that recommended Lidocaine patches. S2 LPN stated she called the Orthopedist's office to get an order for the patches and left a message, but they never called her back. S2 LPN confirmed she never followed up with the doctor by trying to call them back.
Review of the progress note dated 05/13/2024 on 05/21/2024 at 10:42 a.m. with S1 ADON revealed the Orthopedist recommended Lidocaine patches to affected area, 12 hours on and 12 hours off. S1 ADON stated S2 LPN should have called the facility's Medical Director or Resident #81's Nurse Practitioner to see if they wanted to carry out this order, but did not.
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 interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's last 4 quarter...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's last 4 quarterly committee meetings.
Findings:
Review of the facility's quarterly Quality Assessment and Assurance (QAA) committee sign in sheets conducted on April 11, 2024, January 18, 2024, October 3, 2023, and July 13, 2023 revealed staff in attendance was the facility's Medical Director, Administrator, Director of Nurses, and the Infection Preventionist.
During an interview on 5/22/2024 at 12:10 p.m., S3 Administrator indicated that he was not aware of the other members required attendance in the Quarterly QAPI meetings.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #3) of 3 (Resident #1, Resident #2, ...
Read full inspector narrative →
Based on interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. The facility failed to ensure Resident #3's physician order was transcribed and a urinalysis was collected as ordered by the physician.
Findings:
Review of the clinical record for Resident #3 revealed an admit date of 11/22/2022 with diagnoses that included Fibromyalgia, Cerebral Infarction, Osteoarthritis, Atherosclerotic Heart Disease, Essential Hypertension, Type 2 Diabetes Mellitus, and Unspecified Dementia.
Review of Resident #3's Quarterly MDS with an ARD of 02/14/2024 revealed a BIMS of 10, which indicated moderately impaired cognition.
Review of Resident #3's Nurses Notes written on 03/04/2024 at 1:07 p.m. by S1 LPN read in part . Resident complains of pain and burning during urination. Nurse practitioner notified with new order to obtain a urinalysis.
Review of Resident #3's March 2024 Physician's orders revealed no order for a urinalysis on 03/04/2024.
An interview on 03/05/2024 at 12:14 p.m. with Resident #3 revealed the last time a urine sample was collected by a staff member had been a few weeks ago, and she denied that a staff member had attempted to collect a urine sample on her in the last few days.
An interview on 03/06/2024 at 9:36 a.m. with S1 LPN revealed on 03/04/2024 Resident #3 had just finished a round of Macrobid (antibiotic) for a urinary tract infection on the day prior, but continued to complain of burning and pain with urination. S1 LPN stated she called the nurse practitioner and received a verbal order for a repeat urinalysis. S1 LPN stated she filled out the lab slip and went to collect urine from Resident #3, but she was in the wheelchair and was not ready to get back in bed. S1 LPN stated she notified the oncoming nurse, S2 LPN, that urine needed to be collected from Resident #3. S1 LPN confirmed she forgot to input the urinalysis order in Resident #3's electronic physician orders to be collected.
An interview with S2 LPN on 03/06/2024 at 11:34 a.m. revealed she was notified on 03/04/2024 by S1 LPN that a urinalysis was ordered for Resident #3 and that she was unable to collect the urine. S2 LPN stated on 03/04/2024 the 2:00 p.m. to 10:00 p.m. shift she tried to collect the urinalysis for Resident #3 using a straight catheter, but was unable to collect any urine at the time. S2 LPN stated she did not document that she attempted to collect the urine in a nurse's note, but should have. S2 LPN stated she did not remember notifying the oncoming nurse that a urine sample needed to be collected for Resident #3. S2 LPN stated on 03/05/2024 at 4:30 p.m. she contacted the nurse practitioner notifying her that Resident #3's urinalysis had not been collected and that Resident #3 continued with pain with urination and began with itching to perineal area. S2 LPN revealed the nurse practitioner stated to collect Resident #3's urine today and start Diflucan (antifungal) for 2 days. S2 LPN revealed she collected urine from Resident #3 and it was sent to the lab on 03/06/2024.
An interview on 03/06/2024 at 10:42 a.m. with S3 DON confirmed a urinalysis was ordered for Resident #3 on 03/04/2024, but was not transcribed into Resident #3's Physician orders, or collected in a timely manner, and should have been.
Nov 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents who received showers or whirlpools in a facility spa room.
Find...
Read full inspector narrative →
Based on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents who received showers or whirlpools in a facility spa room.
Findings:
Observation on 11/14/2023 at 8:29 a.m. of the Spa Room on Hall W revealed 4 dirty, wet towels scattered on the floor around the whirlpool tub. There was a wet, dirty towel noted on the floor in the shower area. There were 2 hangers, trash and used gloves laying on the floor. One of the shower curtains was noted with only the top netted part hanging, the remainder of the curtain was missing or in torn strips hanging from the netted part. The sink was noted to be dirty and the trash cans were full and overflowing with trash. The small cabinet in the room was opened with supplies scattered throughout.
Interview on 11/14/2023 at 8:30 a.m. with S3 CNA revealed Spa Room on Hall W was used on a daily basis for resident showers and baths. S3 CNA stated it did not take but a minute to clean the area and she did not understand why it looked like it did.
Interview on 11/14/2023 at 8:32 a.m. with S2 LPN confirmed the above information. She stated the spa room should be cleaned after each use.
Interview on 11/14/2023 at 10:00 a.m. with S4 Housekeeping Supervisor revealed that she had been hired as the housekeeping supervisor in 11/2023 and was previously the CNA supervisor. S4 Housekeeping Supervisor stated she was made aware of the condition of the Spa Room on Hall W and stated it should not be in that shape.
May 2023
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who were unable to carry out ADLs...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide incontinent care to dependent residents for 1 (Resident #28) of 1 residents sampled for ADL's.
Findings:
Review of the clinical record revealed Resident #28 admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side; Muscle wasting and atrophy; and Type II Diabetes Mellitus.
Review of Resident #28's Quarterly MDS Assessment with ARD of 02/15/2023 revealed Resident #28 had mild cognitive impairment, did not reject care, and required the extensive assistance of 2 persons for toileting.
Review of Resident #28's CPOC with target date of 06/05/2023 revealed in part
I have bladder incontinence and bowel incontinence. Wears adult brief, doesn't recognize the need to void or eliminate due to CVA.
Observation on 05/08/2023 at 11:45 a.m. revealed Resident #28 propelling himself in a wheelchair. Resident #28 was observed wearing a t-shirt and blue jogging pants. Resident #28's jogging pants were noted to be heavily soiled, with what smelled like urine. A lift pad was observed underneath the resident in the wheelchair at the time of observation.
Interview on 05/28/2023 at 11:58 a.m. with Resident #28 revealed staff did not change him every 2 hours because they have to use the lift to put him in bed to change him. Resident #28 stated he had not been changed since 7:00 a.m. this morning. Resident #28 confirmed his pants were soiled with urine.
Interview on 05/08/2023 at 12:06 p.m. with S6 CNA revealed she was assigned to Resident #28. S6 CNA stated she started her shift at 6:00 a.m. and had not checked Resident #28 since around 6:30 a.m. that morning. S6 CNA stated Resident#28 usually let them (CNAs) know when he needed to be changed. S6 CNA stated she had not noticed that Resident #28's pants were soiled. S6 CNA stated rounds were supposed to be done every 2 hours on incontinent residents. S6 CNA confirmed Resident #28's pants were soiled with urine. S6 CNA confirmed she had not checked and/or performed incontinent care on Resident #28 since 6:30 a.m. and should have.
Interview on 05/08/2023 at 12:07 p.m. with S7 CNA revealed she was assigned to Resident #28's hall and assisted S6 CNA with transfers and providing incontinent care. S7 CNA stated Resident #28 usually told them when he needed to be changed, but he hadn't said anything to them as of yet about needing to be changed. S7 CNA stated CNA's were supposed to make rounds every 2 hours on residents and provide incontinent care to those that need it. S7 CNA confirmed she started her shift at 6:00 a.m. and had not checked Resident #28 for incontinent care until the time of interview.
Interview on 05/09/2023 at 3:15 p.m. with S2 DON revealed incontinent residents should be checked every 2 hours and provided incontinent care if needed regardless of if they report to staff that they are soiled or not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 1( Resident #14) of 4 Residents (Resident #14, Resident #44...
Read full inspector narrative →
Based on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 1( Resident #14) of 4 Residents (Resident #14, Resident #44, Resident #252 and Resident #253) reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored. Total sample was 39.
Findings:
Review of Resident #14's medical record revealed an admit date of 08/23/2017 with a BIMS score of 12 (indicating moderately impaired cognition) and diagnoses which included: Chronic Obstructive Pulmonary Disease, Acute Upper Respiratory Infection, Shortness of Breath and Edema.
Review of Resident #14's Physician's Orders dated 05/2023 revealed an order for oxygen at 2 liters per minute per nasal cannula continuous.
Review of Resident #14's care plan with a target date of 07/02/2023 revealed a problem for altered respiratory status/difficulty breathing; diagnosis: Chronic Obstructive Pulmonary Disease with approaches to change nebulizer and tubing as ordered.
Review of Resident #14's Medication Administration Record dated May 2023 read .Clean filter, change date and initial on tubing every week every night shift every 7 days.
Observation on 05/08/2023 at 10:15 a.m. revealed Resident #14 lying in bed receiving oxygen per nasal cannula connected to an oxygen concentrator. The humidifier bottle nor oxygen tubing was dated. Resident #14 stated she did not remember staff ever changing her oxygen tubing.
Observation on 05/09/2023 at 9:23 a.m. revealed Resident #14 lying in bed with oxygen per nasal cannula connected to an oxygen concentrator. The humidifier bottle nor oxygen tubing was dated.
Observation and interview on 05/09/2023 at 10:12 a.m. with S2 DON in Resident #14's room confirmed the oxygen tubing nor humidifier bottle was dated and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly.
Findings:
Observation on 05/08/2023 at 8:40 a.m. of the outside kitchen area accompanied...
Read full inspector narrative →
Based on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly.
Findings:
Observation on 05/08/2023 at 8:40 a.m. of the outside kitchen area accompanied by S3 DM revealed 2 large blue dumpsters. Both of the dumpsters' lids was open and trash was spilling over onto the ground. Dirty gloves and trash littered the area surrounding the dumpsters. S3 DM confirmed the dumpster doors were open and the ground surrounding the dumpsters was littered with dirty gloves and trash and should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 4 (Resident #22, Resident #33, Resident #70, and Resident #72...
Read full inspector narrative →
Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 4 (Resident #22, Resident #33, Resident #70, and Resident #72 ) of 4 sampled residents with MDS record over 120 days old.
Findings:
Review of the facility's MDS (Minimum Data Set) transmission report revealed Resident #22 and Resident #72's Annual MDS Assessments with ARD's (Assessment Reference Date) of 03/22/2023 had not been transmitted until 04/30/2023. Review of the facility's MDS transmission report revealed Resident #70's Quarterly MDS Assessment with ARD of 03/22/2023 and Resident #33's Quarterly MDS Assessment with ARD of 03/15/2023 had not been transmitted until 04/30/2023.
Interview on 05/09/2023 at 3:15 p.m. with S2 DON confirmed the above MDS assessments had not been transmitted timely and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide pharmaceutical services that assure accurate ac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident by:
1.Failing to ensure accurate accounting for controlled medications were completed at the time of receiving narcotics on Hall 1 medication cart for Resident #40 and failing to ensure controlled medications were reconciled for the Hall 1 medication cart by the nurse coming on duty.
2. Failing to provide medications to meet the needs of residents for 1 (Resident #251) of 1 sampled resident on Contact Precautions.
Findings:
#40
Review of the facility's Controlled Substance policy read in part . 3. Controlled substance must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication must count the controlled substance together. 9. Nursing staff must count the controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.
Observation of Hall 1 medication cart on 05/10/2023 at 9:30 a.m. with S8 LPN revealed a medication card for Resident #40 for Tramadol 50 mg tablet with instructions to give 1 tablet by mouth 3 times a day. 57 tablets were observed in the medication card.
Review of the Individual Resident Narcotic Record for Tramadol 50 mg, for Resident #40 read as follows: S8 LPN 05/10/2023, 08:12 a.m. amount on hand 57, amount given 1, amount remaining 56.
Review of Resident #40's May 2023 Medication Administration Record revealed during the AM medication pass on 05/10/2023, S8 LPN documented that Resident #40 complained of pain 2/10, and S8 LPN administered the scheduled dose of Tramadol 50 mg tablet.
Interview on 05/10/2023 at 9:40 a.m. with S8 LPN revealed she administered Tramadol 50 mg tablet to Resident #40 during morning medication pass on 05/10/2023. S8 LPN stated that she did not complete a narcotic count at the beginning of her shift on 05/10/2023 when she received the keys to the medication cart, but should have.
Interview on 05/10/2023 at 10:00 a.m. with S2 DON revealed the nurse coming on duty and the nurse going off duty are required to count narcotics at the beginning and end of every shift. S2 DON confirmed Resident #40's Individual Resident Narcotic Record for Tramadol 50 mg tablet was not correct, and was not accurately reconciled according to the locked narcotics within Hall 1 medication cart.
#251
Review of the facility policy titled Medication Therapy revealed in part . Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and response to treatment. All medication orders will be supported by appropriate care processes and practices.
Review of Resident #251's clinical record revealed laboratory results dated [DATE] stating Resident #251's stool specimen was positive for Clostridium Difficile.
Review of Resident #251's Physician's Orders revealed an order dated 05/08/2023 at 3:59 p.m. for Flagyl (antibiotic) 500mg by mouth every 8 hours every 10 days. Review of Resident #251's Physician's Orders also revealed an order dated 05/09/2023 at 10:25 a.m. for Flagyl 500mg by mouth every 8 hours for 10 days for C-diff (Clostridium Difficile).
Review of Resident #251's Medication Administration Record revealed Resident #251 received doses of Flagyl 500mg at 4:00 p.m. on 05/08/2023, 4:00 p.m. on 05/09/2023, and at 12:00 a.m. and 8:00 a.m. on 05/10/2023.
Interview on 05/10/2023 at 10:00 a.m. with S4 LPN revealed the duration of the Flagyl ordered had been entered incorrectly on 05/08/2023. S4 LPN stated she realized the error on 05/09/2023 and reentered the order at 10:25 a.m.
Interview on 05/10/2023 at 10:32 p.m. with S4 LPN revealed Resident #251 did not receive Flagyl 500mg every 8 hours as ordered for her diagnosis of C-diff. S4 LPN stated she should have entered a one time order to administer Flagyl on 05/09/2023 at 10:25 a.m. when she noticed the error but she did not. S4 LPN confirmed Resident #251 missed doses of Flagyl (antibiotic) on 05/09/2023 at 12:00 a.m. and 05/09/2023 at 8:00 a.m. and should not have.
Interview on 05/10/2023 at 10:49 a.m. with S2 DON confirmed Resident #251 did not receive antibiotics as ordered. S2 DON stated Flagyl (antibiotic) doses had been missed and should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the Facility failed to ensure food was stored in accordance with professional standards for food service safety.
Findings:
Observation on 05/08/2023 at 8:20 a.m. of ...
Read full inspector narrative →
Based on observation and interview the Facility failed to ensure food was stored in accordance with professional standards for food service safety.
Findings:
Observation on 05/08/2023 at 8:20 a.m. of the walk in freezer/cooler revealed:
1. 1 box of beef patties open to air and undated.
2. 1 bag of French fries open to air and undated.
3. 1 bag of potatoes open to air and undated.
4. 1 bag of meatballs open to air and undated.
Interview at the time of observation with S3 DM revealed the staff who opens a food item should label and date it and store it properly. S3 DM confirmed: The above listed items were not dated and they should have been; the above listed items were open to air and they should not have been.
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 observations, record reviews, and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and t...
Read full inspector narrative →
Based on observations, record reviews, and interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections, by failing to isolate a resident who was suspected to have Clostridium Difficile Infection (C -Diff) in a timely manner (Resident #251), and failing to implement appropriate infection prevention and control practices during the medication administration pass ( Resident # 19).
Findings:
Resident #251
Review of the facility's policy titled Clostridium Difficile (C-Diff) Infection Control Precautions read in part .
If there is a suspicion of C-diff infection, Contact precautions/isolation will be initiated for symptomatic residents pending confirmation of C-Diff infections. Suspected C-Diff infections will be confirmed by a stool culture.
Record review for Resident #251 revealed an admit date of 02/03/2023, with diagnoses which included: ST Elevation Myocardial Infarction Involving Right Coronary Artery, Ischemic Cardiomyopathy, Cognitive Communication Deficit, Unspecified Atrial Fibrillation, Essential Hypertension and Chronic Kidney Disease.
An observation on 05/09/2023 at 10:00 a.m. revealed Resident #251's door was closed and noted with isolation supplies and a sign that stated Resident #251 was on contact precautions.
A staff interview on 05/09/2023 at 10:18 a.m. with S9 LPN revealed Resident #251 complained of abdominal pain and increased flatulence. The nurse practitioner was notified and a new order was written for a stool sample to check for C-Diff. S9 LPN stated the stool was collected from Resident #251 on 05/06/2023 at 3:00 p.m. The lab notified the facility to keep the stool in the refrigerator until they could pick it up on 05/08/2023. S9 LPN stated the positive C-Diff results came in on 05/8/2023 at 4:00 p.m. The nurse practitioner was notified with new orders for contact isolation and Flagyl 500 mg by mouth every 8 hours for 10 days.
A staff interview on 05/09/2023 at 2:05 p.m. with S7 LPN revealed she received a telephone call from the laboratory on 05/08/2023 at 4:00 p.m. with a positive C-Diff result for Resident #251. S7 LPN stated she notified the nurse practitioner and received new orders for Flagyl (an antibiotic) and contact precautions. S7 LPN stated she then educated the staff on contact precautions and notified Resident #251's family of the positive C-Diff results. S7 LPN confirmed that Resident #251 had no contact precautions/isolation in place prior to the confirmation of positive C-Diff test from the laboratory on 05/08/2023.
A staff interview on 05/10/2023 at 11:29 a.m. with S10 CNA stated she worked over the weekend (05/06/2023-05/07/2023) and helped collect the stool for Resident #251 on 05/06/2023. S10 CNA stated Resident #251 complained of burning to her rectal area. S10 CNA stated there were no isolation supplies set up for Resident #251's room and she was never told that Resident #251 was on contact precautions or had to wear any protective gear to enter the room during her weekend shift.
An interview on 05/10/2023 at 1:15 p.m. with the nurse practitioner revealed that she ordered a C-Diff stool test on resident #251 due to Resident #251's complaints of increased flatulence and burning sensation to rectal area. The nurse practitioner stated the C-Diff test was necessary due to the amount of antibiotics given during Resident #251's recent lengthy hospitalization.
A staff interview on 05/09/2023 at 2:15 p.m. with S2 DON confirmed that Resident #251 was not put on contact precautions/isolation after the order to collect the stool or at the time a specimen was collected. S2 DON confirmed that contact isolation was put in place after the positive C-Diff results came back from the laboratory.
Resident #19
Review of Resident #19's May 2023 Physician Orders revealed an order for Artificial tears solution, apply 1 drop to both eyes once daily and Flonase suspension 50 mcg/act 2 sprays in each nostril daily.
On 05/09/2023 at 9:30 a.m. during a medication administration observation, S8 LPN uncapped Resident # 19's Flonase nasal spray and Artificial tears eye drops then held both bottles along with her gloves in her hand. S8 LPN walked into Resident #19's room, laid the uncapped bottle of artificial tear and Flonase on Resident #19's bed, applied gloves then administered the eye drops and nasal spray to resident.
A staff interview on 05/09/2023 at 9:35 a.m. with S8 LPN confirmed that she laid the uncapped bottles of Artificial tear and Flonase on Resident #19's bed while applying gloves then administered medications that were contaminated by the bed linens when she should not have.
Mar 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a CNA implemented a resident's Care Plan Interve...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a CNA implemented a resident's Care Plan Interventions, and transferred the resident with a mechanical lift with 2 person physical assistance from bed to wheelchair, for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled Residents.
Findings:
Review of the Facility's Transfer and Lift Policy revealed the following in part .
1.0 Purpose: The purpose of the Resident Transfer and Lift Policy is to provide Facility Staff guidelines for the use of appropriate techniques for lifting, transferring, moving, and repositioning residents in order to protect the well-being and safety of Facility residents and staff.
3.0 Procedure:
Lift Assessment
The Resident Lift Assessment will be completed by a licensed nurse upon admission, quarterly, annually, and with significant change as needed. Lifts: Green-independent, Yellow-CNA (include the number of staff required for safe transfer), Orange-Stand up lift for 2 person, Red-Mechanical lift using 2 people.
1. Assigned lift and sling assessment color code is placed at the head of the resident's bed.
2. Information from the resident's lift assessment is incorporated into the plan of care.
3. All staff are responsible for using the required number of staff members for resident transfer and lifts as per the resident's personal lift assessment.
Staff Training: Transfer and Lift
1. During orientation and annual staff training all facility nursing and therapy staff shall review the Transfer and Lift Policy.
4. Each staff member will read and sign the NS-758-Lifting Policy Acknowledgment Form.
Review of the Facility's Over Bed Signage Legend (included in the Facility Transfer and Lift Policy) revealed the following pictures/symbols related to transfers:
Leaf - Fall Risk
Red Circle - Mechanical Bed Lift (2 person assist).
Yellow circle with #1 - 1 person assist with transfer.
Yellow circle with #2 - 2 person assist with transfer.
Orange Circle - Stand up lift 2 person assist).
Purple circle - [NAME] Care Lift (2 person assist).
Green Circle - Independent with transfer.
Bed with #1 - Bed Mobility - 1 person assist.
Bed with #2 - Bed Mobility - 2 person assist.
Review of Resident #3's Medical Record revealed an admission date of 11/11/2013, and a readmission date of 02/10/2023. Resident #3 had the following diagnoses in part .End Stage Renal Disease; Other Lack of Coordination; Osteoarthritis of Hip, unspecified; Other Specified Disorders of Bone Density and Structure, Unspecified Site; and Syncope and Collapse. Resident#3's Medical Record revealed he received dialysis on Monday, Wednesday and Friday.
Review of Resident #3's Quarterly MDS Assessment with ARD of 02/17/2023 revealed Resident #3 was coded as a BIMS Score of 8 (moderately impaired), and required extensive assistance of 1 person for bed mobility, and was dependent upon 2+ persons physical assistance with transfers.
Review of Resident #3's Care Plan with target date of 01/03/2023 revealed in part Problem: I have an ADL self-care performance deficit r/t CVA with right sided Hemiparesis/Hemiplegia; Goal: I will maintain current level of ADL function through the review date. Approaches: in part . Transfer: I require extensive assistance by (2) staff. On dialysis days x 2 person total assistance using mechanical lift.
Review of Resident #3's Nurses' Notes revealed the following in part . Resident #3 attended dialysis 3 times a week and went to dialysis on 01/30/2023. On 01/30/2023 at 10:00 a.m., Resident #3 c/o pain to his right leg. Resident #3 stated the girl was trying to help me get out of bed this morning when she twisted my right leg. The note revealed Resident #3 stated the girl that worked last night, she didn't do it on purpose, she was just helping me. The NP was notified and an X-ray was ordered of the right leg. The NP approved Resident #3 going to dialysis prior to being X- rayed Resident #3 returned from dialysis the evening of 01/30/2023, and an X-ray was performed. The results were not obtained until the morning of 01/31/2023 and Resident #3 was sent to the ER for evaluation. Resident #3 was admitted to the hospital on [DATE] with a diagnosis of Acute Fracture of the distal right femur, and returned to the facility on [DATE].
Review of Resident #3's Investigation Folder revealed a statement written by S12 CNA which read as follows: On Sunday 01/29/2023 I, assisted Resident #3 with a bed bath. I went to transfer him to a wheelchair when pivoting him to the chair he complained that his right leg was hurting. I stayed with him for a few minutes and went and reported the incident to the nurse.
Observation on 03/06/2023 at 9:02 a.m. revealed Resident #3 sitting in his wheelchair in his room. Resident #3 was alert and oriented, and answered appropriately when questioned. There was a Red Circle (which indicated Mechanical Bed lift with 2 person assist) included in the signage at the head of Resident #3's bed.
Interview on 03/13/2023 at 10:52 a.m. with S1 Administrator revealed that the over bed signage in Resident #3's room was derived from Resident #3's plan of care, and gave instructions to staff on care of the resident to include transfer instructions. S1 Administrator stated S12 CNA was doing what Resident #3 asked her to do. S1 Administrator stated S12 CNA stated she did not look at the over bed signage prior to transferring Resident #3 on 01/30/2023.
Interview on 03/13/2023 at 11:34 a.m. with S2 DON revealed staff members used over bed signage to provide resident care, and when charting on a resident in the kiosk, a specific task such as I am a 2 person assist with transfer will show up to guide the CNA in resident care. S2 DON stated this would paint a picture for the CNA.
Observation and interview with Resident #3 on 03/13/2023 at 3:35 p.m. revealed Resident #3 had just returned from dialysis, and was lying in bed. Resident #3 stated S12 CNA was alone when she transferred him the morning his leg was hurt (01/30/2023). Resident #3 stated he had asked S12 CNA to lift him by herself and she did so. Resident #3 stated his leg was hurt during the transfer. Resident #3 stated S12 CNA had worked with him prior to that day, and that Staff did not normally use a lift prior to his leg getting hurt.
The surveyor was unable to interview S12 CNA as she was no longer employed at the facility, and telephones calls were unsuccessful.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0777
(Tag F0777)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to promptly notify the ordering physician, physician assistant, nurse p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with Facility policies and procedures for notification of a practitioner for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) of 5 sampled Residents. Findings:
Review of the Facility policy titled Test Results revealed the following in part:
Policy Statement - The resident's attending physician will be notified of the results of diagnostic tests.
Policy Interpretation and Implementation - Results of radiological tests shall be reported to the resident's attending physician or to the facility; Should the test result be provided to the facility, the attending physician shall be promptly notified of the results.
Review of Resident #3's 01/2023 - 03/2023 Nurses' Notes revealed Resident #3 attended dialysis 3 times a week. On 01/30/2023 Resident #3 complained of pain to his right leg. The NP was notified and an x-ray was ordered. The NP approved of Resident #3 going to dialysis prior to the X-ray. Resident #3 returned from dialysis and an x-ray was performed. The x-ray results were not obtained until the morning of 01/31/2023 and Resident #3 was sent to the ER for evaluation based on the x-ray findings. Resident #3 was admitted to the hospital on [DATE] and returned to the facility on [DATE].
Review of Resident #3's 01/30/2023 x-ray results revealed the following in part .
Right Femur - Acute fracture of the distal femur. These results were digitally signed at 01/30/2023 at 21:02:03 CST.
Interview on 03/13/2023 at 11:34 a.m. with S2 DON concerning Resident #3's 01/30/2023 x-ray results revealed that the x-ray provider did not call the Facility with abnormal results. S2 DON stated that Resident #3's x-ray result was sent through the Facility electronic fax instead of the computer system and not all staff have access to information received through the electronic fax.
Interview on 03/13/2023 at 12:36 p.m. with S1 Administrator revealed Resident #3's x-ray results went to the Facility's electronic fax but it was also sent into the Facility computer system on 01/30/2023 at 9:02 p.m. S1 Administrator stated all nurses in the facility have access to diagnostic results using the Facility's computer system. S1 Administrator stated that S18 LPN did not look for Resident #3's X-ray result during the night shift she worked and should have. S1 Administrator confirmed the NP should have been notified as soon as the abnormal x-ray results were received by the Facility and had not been.
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 safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s), $113,886 in fines. Review inspection reports carefully.
- • 23 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $113,886 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (20/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Tioga Community's CMS Rating?
CMS assigns TIOGA COMMUNITY CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Louisiana, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Tioga Community Staffed?
CMS rates TIOGA COMMUNITY CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Tioga Community?
State health inspectors documented 23 deficiencies at TIOGA COMMUNITY CARE CENTER during 2023 to 2025. These included: 1 that caused actual resident harm and 22 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Tioga Community?
TIOGA COMMUNITY CARE CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by COMMCARE CORPORATION, a chain that manages multiple nursing homes. With 154 certified beds and approximately 95 residents (about 62% occupancy), it is a mid-sized facility located in PINEVILLE, Louisiana.
How Does Tioga Community Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, TIOGA COMMUNITY CARE CENTER's overall rating (3 stars) is above the state average of 2.4, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Tioga Community?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the facility's high staff turnover rate.
Is Tioga Community Safe?
Based on CMS inspection data, TIOGA COMMUNITY CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 3-star overall rating and ranks #1 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 Tioga Community Stick Around?
Staff turnover at TIOGA COMMUNITY CARE CENTER is high. At 60%, the facility is 14 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Tioga Community Ever Fined?
TIOGA COMMUNITY CARE CENTER has been fined $113,886 across 1 penalty action. This is 3.3x the Louisiana average of $34,218. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Tioga Community on Any Federal Watch List?
TIOGA COMMUNITY CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.