LEGACY NURSING AND REHABILITATION OF PLAQUEMINE
For profit - Limited Liability company
151 Beds
LEGACY NURSING & REHABILITATION
Data: November 2025
4 Immediate Jeopardy citations
Trust Grade
0/100
#135 of 264 in LA
Photo by Legacy Nursing and Rehabilitation of Plaquemine
Photo by Legacy Nursing and Rehabilitation of Plaquemine
Photo by Legacy Nursing and Rehabilitation of Plaquemine
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Legacy Nursing and Rehabilitation of Plaquemine received an F trust grade, indicating significant concerns and a poor performance overall. They rank #135 out of 264 facilities in Louisiana, placing them in the bottom half, and are the second-best option in Iberville County, with only one facility rated higher. While the facility is improving, with issues decreasing from 28 in 2024 to 10 in 2025, it still reported serious problems, including a critical incident where staff failed to follow a resident's code status during an emergency, leading to immediate jeopardy. Staffing is a concern, with only 1 out of 5 stars, and less RN coverage than 90% of state facilities, meaning residents may not receive the oversight they need. Additionally, the facility has accumulated $245,413 in fines, which is higher than 92% of Louisiana facilities, suggesting ongoing compliance issues. However, the quality measures rating is strong at 5 out of 5 stars, indicating some aspects of care are being managed well despite these significant weaknesses.
- Trust Score
- F
- In Louisiana
- #135/264
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 43% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- $245,413 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 7 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 53 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 49%
Review needed
28 → 10 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 28 issues
2025: 10 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (43%)
5 points below Louisiana average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 43%
Near Louisiana avg (46%)
Typical for the industry
Federal Fines: $245,413
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: LEGACY NURSING & REHABILITATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 53 deficiencies on record
4 life-threatening 1 actual harm
May 2025
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
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record reviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sa...
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Based on observation, interviews, and record reviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents observed during incontinence care.
Findings:
Review of the facility's undated Resident Rights and Quality of Life policy and procedure revealed, in part, a resident had the right to be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs.
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 03/18/2025 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 06, which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 was dependent on staff assistance for toileting hygiene.
Observation of Resident #1's incontinence care on 05/27/2025 at 1:45PM revealed S3CNA did not pull the privacy curtain between Resident #1 and her roommate before providing incontinence care, allowing Resident #1's roommate to observe Resident #1 exposed genitalia during incontinence care.
In an interview on 05/27/2025 at 1:58PM, S3CNA indicated she did not pull Resident #1's privacy curtain to ensure Resident #1's privacy during incontinence care and should have.
In an interview on 05/28/2025 at 1:15PM, S2Director of Nursing indicated S3CNA should have pulled the privacy curtain prior to providing incontinence care to Resident #1.
In an interview on 05/29/2025 at 12:10PM, S1Administrator indicated S3CNA should have pulled the privacy curtain between Resident #1 and her roommate before providing incontinence care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) completed hand hygiene during incontinence care for 1 (Resident #1) of 3 (Residen...
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Based on observation, interviews, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) completed hand hygiene during incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents observed for incontinence care.
Findings:
Review of the facility's undated Incontinence Care Policy and Procedure revealed, in part, the purpose of the policy and procedure was to prevent infection. Further review revealed for staff to remove gloves prior to replacing incontinence pads or applying an adult diaper.
Observation of Resident #1's incontinence care on 05/27/2025 at 1:45PM revealed the following:
1. S3CNA did not sanitize her hands and apply clean gloves after cleaning Resident #1's perineal area with disposable wipes and removing Resident #1's soiled brief; and,
2. S3CNA placed the package of disposable wipes on Resident #1's bed and used her soiled gloves to obtain more wipes from the package multiple times while providing incontinence care to Resident #1.
In an interview on 05/27/2025 at 1:58PM, S3CNA indicated she should have removed the soiled gloves, sanitized her hands and put on clean gloves before putting a clean brief on Resident #1. S3CNA further indicated she should have not obtained personal wipes from a multi-use package with soiled gloves while providing incontinence care to Resident #1.
In an interview on 05/29/2025 at 10:30AM, S2Director of Nursing (DON) stated S3CNA should have not obtained personal wipes from a multi-use package with soiled gloves, and S3CNA should have completed hand hygiene and changed her soiled gloves before applying a clean brief after providing incontinence care to Resident #1.
In an interview on 05/29/2025 at 12:10PM, S1Administrator indicated S3CNA should have not obtained personal wipes from a multi-use package with soiled gloves, and S3CNA should have completed hand hygiene and changed her soiled gloves before applying a clean brief after providing incontinence care to Resident #1.
Jan 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review the facility failed to maintain a resident's right to privacy while performing care for 1 (Resident #17) of 22 (Resident #14, Resident #15, Residen...
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Based on observations, interviews, and record review the facility failed to maintain a resident's right to privacy while performing care for 1 (Resident #17) of 22 (Resident #14, Resident #15, Resident #17, Resident #23, Resident #32, Resident #35, Resident #36, Resident #42, Resident #48, Resident #51, Resident #52, Resident #55, Resident #64, Resident #73, Resident #76, Resident #82, Resident #84, Resident #89, Resident #93, Resident #105, Resident #106, Resident #357) sampled residents.
Findings:
Review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2024 revealed the following, in part, Resident #17 had a Brief Interview Mental Status score of 01 which indicated severe cognitive impairment. Further review revealed Resident #17 was dependent on staff for incontinence care, showering/bathing, upper body dressing, and lower body dressing.
Observation on 01/28/2025 at 10:46AM revealed S14Certified Nursing Assistant (CNA) and S15CNA provided Resident #17 with a bed bath. Observation further revealed the privacy curtain to the room was not pulled and the blinds to the window, which faces a parking lot, was pulled halfway up, which exposed Resident #17's nude body to the outside.
Observation on 01/28/2025 at 10:58AM revealed S14CNA and S15CNA changed Resident #17's bedsheets while he was in bed and his body nude. Observation further revealed the privacy curtain to the room was not pulled and the blinds to the window, which faces a parking lot, was pulled halfway up, which exposed Resident #17's nude body to the outside.
In an interview on 01/28/2025 at 11:10AM, S6CNA Supervisor indicated the privacy curtain should have been pulled and the blinds pulled down to provide Resident #17 privacy during his bed bath.
In an interview on 01/28/2025 at 11:24AM, S13Assistant Director of Nursing confirmed Resident #17's privacy should have been maintained during care.
In an interview on 01/28/2025 at 11:50AM, S2Director of Nursing further indicated privacy should have been provided for Resident #17 during care.
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, interviews, and record reviews, the facility failed to ensure care plan interventions were implemented to decrease risk of falls for 1 (Resident #84) of 3 (Resident #36, Residen...
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Based on observations, interviews, and record reviews, the facility failed to ensure care plan interventions were implemented to decrease risk of falls for 1 (Resident #84) of 3 (Resident #36, Resident #84, Resident #93) sampled residents investigated for falls.
Findings:
Review of Resident #84's current care plan revealed, in part, a care plan was initiated for Resident #84 being at risk for falls related to having an unsteady gait due to hemiplegia. Further review revealed an intervention start date of 10/19/2024 which included, in part, for staff to apply a self-release lap tray while up in his wheelchair.
Observation on 1/27/2025 at 9:30AM revealed, in part, Resident #84 sitting up in his wheelchair without a self-release lap tray.
Observation on 01/27/2025 at 10:10AM revealed, in part, Resident #84 up in his wheelchair by the nurse's station without a self-release lap tray on his wheelchair.
Observation on 01/28/2025 at 9:27AM revealed, in part, Resident #84 was sitting up in his wheelchair with no self-release lap tray.
Observation on 01/28/2025 at 11:45AM revealed Resident #84 was sitting up in his wheelchair in the dining room without a self-release lap tray on his wheelchair.
In an interview on 01/28/2025 at 11:48AM, S10Licensed Practical Nurse (LPN) indicated Resident #84 should have a self-release lap tray on while up in his wheelchair.
In an interview on 01/28/2025 at 11:50AM, S13Assistant Director of Nursing (ADON) indicated Resident #84 was supposed to have a self-release lap tray while up in his wheelchair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews the facility failed to ensure staff positioned a resident's urinary catheter bag below the level of the bladder for or 1 (Resident #64) of 4 (Resi...
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Based on observations, interviews, and record reviews the facility failed to ensure staff positioned a resident's urinary catheter bag below the level of the bladder for or 1 (Resident #64) of 4 (Resident #15, Resident #17, Resident #35, Resident #64) sampled residents investigated for urinary catheter and/or UTI.
Findings:
Review of the Centers for Disease Control's (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 2009 and revised on 06/06/2019, revealed, in part, to maintain unobstructed urine flow, the urine collection bag should be kept below the level of the bladder at all times.
Review of Resident #64's clinical record revealed Resident #64 had a suprapubic catheter related to neuromuscular dysfunction of the bladder (a condition where the bladder does not empty properly).
Review of Resident #64's care plan revealed, in part, Resident #64 had a suprapubic catheter and staff were to ensure the catheter bag was positioned below the bladder.
Review of Resident #64's infection reports revealed, in part, Resident #64 was diagnosed with a UTI on 07/08/2024, 08/22/2024, and 12/31/2024. Further review revealed Resident #64 was diagnosed with cystitis (inflammation of the bladder) on 09/24/2024 and 11/13/2024.
Observation on 01/28/2025 at 10:09AM revealed Resident #64 was lying flat in bed and Resident #64's catheter bag was positioned in her bed near her feet and not below the level of her bladder.
Observation on 01/29/2025 at 9:38AM revealed Resident #64 was lying flat in bed and S5Certified Nursing Assistant (CNA) initiated catheter care for Resident #64. Further observation revealed S5CNA placed Resident #64's catheter bag in her bed and not below the level of her bladder. Further observation revealed the catheter bag remained in Resident #64's bed until catheter care was completed at 9:50AM.
In an interview on 01/29/2025 at 9:55AM, S5CNA indicated Resident's #64's catheter bag should have been positioned below her bladder when she provided catheter care.
In an interview on 01/29/2025 at 11:20AM, S4Licensed Practical Nurse (LPN) indicated Resident #64 had a history of UTI's. S4LPN further indicated Resident #64's catheter bag should have been maintained below the level of the bladder and should not have been placed in the bed with Resident #64.
In an interview on 01/29/2025 at 3:59PM, S3Assistant Director of Nursing (ADON)/Infection Preventionist indicated Resident #64 was treated for UTI's and/or cystitis on 07/08/2024, 08/22/2024, 09/24/2024, 11/13/2024, and 12/31/2024. S3ADON/Infection Preventionist further indicated Resident #64's catheter bag should have been kept below the level of her bladder.
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 observations, interview, and record review, the facility failed to follow their policy and procedure for maintaining respiratory care equipment for 1 (Resident #23) of 3 (Resident #23, Reside...
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Based on observations, interview, and record review, the facility failed to follow their policy and procedure for maintaining respiratory care equipment for 1 (Resident #23) of 3 (Resident #23, Resident #36, Resident #51) sampled residents investigated for respiratory care.
Findings:
Review of the facility's undated Nebulizer Continuous positive airway pressure (CPAP) Machine Cleaning Policy and Procedure revealed, in part, store respiratory tubing, mouthpiece, and mask in a plastic bag when not in use.
Observation on 01/27/2025 at 10:37AM revealed Resident #23's nasal cannula, nebulizer mask, and oxygen tubing was uncontained and lying on the floor.
Observation on 1/28/2025 at 3:30PM revealed Resident #23's nebulizer mask was uncontained and lying on Resident #23's chest.
Observation on 01/29/2025 at 10:00AM revealed Resident #23's nebulizer mask was uncontained and lying on the bedside table.
In an interview on 01/29/25 at 10:09AM, S2Director of Nursing (DON) indicated Resident #23's nebulizer mask was uncontained and lying on his bedside table. She further indicated Resident #23's nebulizer mask should have been contained in a clean labeled plastic bag and was not
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure:
1. Staff had all hair restrained when in th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure:
1. Staff had all hair restrained when in the food preparation areas (S8Dietary Helper and S9Dietary Helper);
2. Food items were labeled with an open date and/or labeled with the contents of the container/bag;
3. Prepared food items was covered and refrigerated until time to serve;
4. Staff did not store their personal food items with residents' food items; and,
5. Expired foods were not available for use.
This deficient practice was identified for the facility kitchen observed during the kitchen task.
Findings:
Review of the facility's undated policy titled, Dietary Cook, revealed, in part:
Dietary staff were to ensure the kitchen was maintained as required by state and federal governing agencies' regulations and standards; food items were to be immediately labeled and stored after opening; and all staff entering the kitchen were to wear hairnets according to regulations and facility dress code.
Observation on 01/27/2025 at 8:49AM revealed, in part, S8Dietary Helper and S9Dietary Helper hair was not fully contained in a hairnet. Further observation revealed uncovered individual cups of vanilla pudding were sitting on the preparation table.
Observation on 01/27/2025 at 8:55AM of the facility's refrigerator revealed, in part, an unlabeled and undated 1.5 gallon zip lock bag three fourth full of cooked cubed chicken; an 8 ounce Styrofoam cup containing a pudding like substance with no label and undated; one-half cream cheese Danish which had no label and was undated; and a 1.5 gallon unlabeled zip lock bag of chopped cabbage dated 01/18/2025, which had a grayish black unknown substance on the cabbage.
Observation on 01/27/2025 at 9:00AM of the facility's freezer revealed, in part, an undated 16 ounce half full bag frozen fries, and an unlabeled and undated opened package of [NAME] which had 4 [NAME] remaining in the package.
In an interview on 01/27/2025 at 9:05AM, S8Dietary Helper indicated the opened cream cheese Danish in the facility's refrigerator was her personal food item and should have not been stored in the facility's food storage refrigerator.
In an interview on 01/27/2025 at 9:10AM, S7Dietary Manager indicated hairnets should be worn by all kitchen staff and all hair should be fully contained in the hairnet, the individual pudding cups should have been covered and stored in the refrigerator, the above listed items with no labels or dates should have been labeled and dated when opened, and the cabbage should have been discarded 01/25/2025 and should have not been available for use. S7Diretary Manager further indicated staff should not store their personal food in the facility's food storage refrigerator.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observations and interviews the facility failed to ensure a resident's call bell was within reach and available for use for 2 (Resident #2, Resident #95) of 2 (Resident #2, Resident #95) samp...
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Based on observations and interviews the facility failed to ensure a resident's call bell was within reach and available for use for 2 (Resident #2, Resident #95) of 2 (Resident #2, Resident #95) sampled residents investigated for call bells being within reach.
Findings:
Resident #2
In an interview on 01/27/2025 at 12:36PM, Resident #2 indicated he could not reach his call bell.
Observation on 01/28/2025 at 9:50AM revealed Resident #2's call bell was tangled and located under Resident's #2's bed.
Observation on 01/28/2025 at 1:22PM revealed, in part, Resident #2 was sitting in his room in a wheelchair next to the television. Further observation revealed Resident #2's call bell was tangled and located under Resident #2's bed.
In an interview on 01/28/2025 at 1:22PM Resident #2 indicated he could not reach the call bell because it was under the bed.
In an interview on 01/28/2025 at 1:25PM, S10Licensed Practical Nurse (S10LPN) indicated Resident #2 was capable of using a call bell and confirmed Resident #2's call bell was not in reach.
Resident #95
Observation on 01/27/2025 at 9:50AM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was unable to reach the call bell.
Observation on 01/27/2025 at 10:10AM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was not able to reach the call bell.
Observation on 01/27/2025 at 1:15PM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and, Resident #95 was not able to reach the call bell.
Observation on 01/28/2025 at 9:45AM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was not able to reach the call bell.
In an interview on 01/28/2025 at 9:45AM, Resident #95 indicated he wanted ice water but was not able to call the staff because Resident #95's call bell was not within reach.
Observation on 01/28/2025 at 1:20PM revealed, in part, Resident #95 was lying in bed. Resident #95's call bell was located on top of a dorm size refrigerator which was placed on a nightstand, and Resident #95 was not able to reach the call bell.
In an interview on 01/28/2025 at 1:20PM S10Licensed Practical Nurse (LPN) indicated Resident #95 was capable of using the call bell. S10LPN confirmed Resident #95's call bell was not within reach and should have been.
In an interview on 01/28/2025 at 1:30PM, S1Administrator indicated call bells should be within reach for residents to use.
MINOR
(B)
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0584)
Minor procedural issue · This affected multiple residents
Based on observations and interviews, the facility failed to ensure resident rooms and equipment were cleanded and maintained in a sanitary manner for 2 (Resident #32, Resident #37) of 6 (Resident #2,...
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Based on observations and interviews, the facility failed to ensure resident rooms and equipment were cleanded and maintained in a sanitary manner for 2 (Resident #32, Resident #37) of 6 (Resident #2, Resident #14, Resident #32, Resident #37, Resident #55, Resident #95) sampled residents investigated for environment.
Findings:
Resident #32
Observation on 01/28/2025 at 10:08AM revealed a dried light brown unknown substance was present on Resident #32's enteral feeding (a method of providing nutrition through a tube inserted directly into the stomach) pump pole, and on Resident #32's floor.
Observation on 01/28/2025 at 3:45PM revealed a dried light brown unknown substance was present on Resident #32's enteral feeding pump pole, and on Resident #32's floor.
In an interview on 01/28/2025 at 3:45PM, S1Administrator confirmed there was a dried light brown unknown substance present on Resident #32's enteral feeding pump pole and on Resident #32's floor and it should have been cleaned by the staff.
Resident #37
Observation on 01/27/2025 at 11:31AM revealed a dried light brown unknown substance was present on Resident #37's enteral feeding pump, enteral feeding pump pole, and on Resident #37's floor.
Observation on 01/28/2025 at 10:06AM revealed a dried light brown unknown substance was present on Resident #37's enteral feeding pump, enteral feeding pump pole, and on Resident #37's floor.
Observation on 01/28/2025 at 3:42PM revealed a dried light brown unknown substance was present on Resident #37's enteral feeding pump, enteral feeding pump pole, and on Resident #37's floor.
In an interview on 01/28/2025 at 3:46PM, S1Administrator indicated Resident #37's enteral tube feeding pump, enteral feeding pump pole, and floor had large areas of dried tube feeding formula. S1Administrator stated, that is terrible, just terrible. S1Administrator indicated Resident #32 and Resident 37's enteral feeding equipment and floor should have been cleaned by staff, and had not been.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately for 2 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately for 2 (Resident #42, Resident #51) of 22 (Resident #14, Resident #15, Resident #17, Resident #23, Resident #32, Resident #35, Resident #36, Resident #42, Resident #48, Resident #51, Resident #52, Resident #55, Resident #64, Resident #73, Resident #76, Resident #82, Resident #84, Resident #89, Resident #93, Resident #105, Resident #106, Resident #357) sampled residents reviewed for resident assessments.
Findings:
Resident #42
Review of Resident #42's record revealed, in part, Resident #42 was admitted to the facility on [DATE] with diagnoses, in part, of a right above the knee amputation (AKA) and a left AKA.
Review of Resident #42's Quarterly MDS with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Section GG: Functional Abilities and Goals, he was dependent on staff for putting on or taking off footwear.
Review of Resident #42's Quarterly MDS with an ARD of 09/25/2024 revealed, in part, Section GG: Functional Abilities and Goals, he was dependent on staff for putting on or taking off footwear.
In an interview on 01/29/2025 at 2:54 PM, S11Director of Rehabilitation (DOR)/Physical Therapy Assistant (PTA) indicated she was responsible for completing Section GG of the MDS for residents. S11DOR/PTA indicated Resident #42 cannot put on or take off footwear due to him being a bilateral amputee.
In an interview on 01/29/2025 at 3:38PM, S12MDS Nurse indicated Resident #42 could not be assessed for putting on or taking off footwear due to him being a bilateral amputee and him not having any feet. S12MDS Nurse further indicated Resident #42's MDS assessment dated [DATE] was incorrect.
In an interview on 01/29/2025 at 3:48PM, S2Director of Nursing further indicated Resident #42's Section GG for his MDS was not completed accurately.
Resident #51
Review of Resident #51's record revealed, in part, an admit date of 01/09/2024 with diagnoses which included Schizophrenia, Bipolar Disorder, and Post Traumatic Stress Disorder (serious mental illnesses that required medications).
Review of a significant change Minimal Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/22/2024 revealed, in part, Section A1500 Preadmission Screening question which inquired if Resident #51 had a serious mental illness was answered as no.
In an interview on 01/28/2025 at 2:30 PM, S16MDS nurse indicated the above mentioned MDS question was not marked correctly.
Dec 2024
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on interviews and record review it was determined that the facility failed to communicate appropriate resident information to a receiving facility for 1 (Resident #1) of 1 (Resident #1) sampled ...
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Based on interviews and record review it was determined that the facility failed to communicate appropriate resident information to a receiving facility for 1 (Resident #1) of 1 (Resident #1) sampled residents reviewed for transfer requirements.
Findings:
Review of the facility's document titled Checklist for 6P-6A Shift revealed, in part, th nurse was supposed to call report to the hospital Resident #1 was being transferred to.
Review of Resident #1's record revealed, in part, Resident #1 was discharged to the emergency department on 11/16/2024.
Review of Resident #1's record revealed no documented evidence and the facility did not provide documented evidence that the receiving facility was provided with all Resident #1's required information for the 11/16/2024 transfer.
In an interview on 12/10/2024 at 4:44 PM, S3License Practical Nurse (LPN) indicated she was assigned to work Resident #1's hall on 11/15/2024 for the 6:00 PM to 6:00 AM shift. S3LPN further indicated at 12:00 AM on 11/16/2024, Resident #1 was transferred to the emergency department. S3LPN further indicated she did not call report to the receiving facility and she should have.
In an interview on 12/11/2024 at 1:37 PM, S2Director of Nursing (DON) indicated S3LPN should have called report to the receiving facility when Resident #1 was sent to the emergency department on 11/16/2024.
In an interview on 12/11/2024 at 12:30 PM, S1Administrator indicated there was no documented evidence and she could not provide documented evidence that a thorough report was given to the receiving emergency department when Resident #1 was transferred on 11/16/2024 and should have been.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on facility records reviewed and interviews, it was determined that the facility failed to ensure a licensed nurse was designated as a charge nurse for each shift.
Findings:
Review of the facili...
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Based on facility records reviewed and interviews, it was determined that the facility failed to ensure a licensed nurse was designated as a charge nurse for each shift.
Findings:
Review of the facility's Nursing Daily Work Schedules from 12/02/2024 through 12/11/2024 revealed there was not a designated charge nurse for the 6:00 AM to 6:00 PM shift and the 6:00 PM to 6:00 AM shift.
Review of the facility's November 2024 and December 2024 Nurse Schedules revealed there was not a designated charge nurse for each shift.
In an interview on 12/11/2024 at 4:00 AM, S4Licensed Practical Nurse (LPN) indicated there was not a designated charge nurse on the night shift in the facility.
In an interview on 12/11/2024 at 4:30 AM, S9LPN indicated there was no designated charge nurse on the night shift in the facility.
In an interview on 12/11/2024 at 4:45 AM, S6LPN indicated there was no designated charge nurse on her current shift in the facility.
In an interview on 12/11/2024 at 1:37 PM, S2Director of Nursing (DON) indicated she did not designate a charge nurse on the nursing schedule for each shift. S2DON further indicated she should have designated a charge nurse for each shift according to nurse staff regulations.
In an interview on 12/11/2024 at 1:45 PM, S1Administrator indicated there was no documented evidence and she could not provide documented evidence a licensed nurse was designated as the charge nurse for each shift.
Sept 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on interviews and record reviews, the facility failed to test a resident with signs and symptoms of COVID-19 in a timely manner for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #...
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Based on interviews and record reviews, the facility failed to test a resident with signs and symptoms of COVID-19 in a timely manner for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for infection control.
Findings:
Review of the facility's undated policy titled, COVID-19 testing Policy and Procedure, revealed, in part, any resident who had signs or symptoms of COVID-19 should be tested as soon as possible.
Review of Resident #2's August 2024's physician's orders revealed, in part, an order dated 07/26/2022 for a rapid antigen (a marker that tells the immune system whether something in a body is harmful or not) test (a test that can quickly detect the presence or absence of an antigen) to be performed if resident displayed signs and symptoms of COVID-19.
Review of Resident #2's nursing note dated 08/22/2024 at 11:20 a.m. reveled, in part, a late entry of Resident #2 requested his temperature be taken. Further review revealed Resident #2's temperature was 101.2, Resident #2 was given Tylenol ( a medication used to treat fever), and Resident #2's temperature was rechecked at 3:00 a.m. Further review revealed Resident #2 indicted he felt just like he did when he had COVID-19 ,and he would like to be tested.
Review of Resident #2's nursing note dated 08/23/2024 at 2:16 p.m. reveled, in part, Resident #2 tested positive for COVID-19 on 08/23/2024.
In an interview on 09/23/2024 at 12:04 p.m., Resident #2 indicated about a month ago, he remembered feeling like he had a fever and was lethargic, similar to how he felt when he had COVID-19 in the past. Resident #2 further indicated that the staff did not test him until more than a day later.
In a telephone interview on 09/23/2024 at 2:22 p.m., S2Licensed Practical Nurse (LPN) indicated when Resident #1 had a fever, she gave him Tylenol and wrote a nurse's note so the staff would know to test him the next day.
Apr 2024
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident remained free from resident to resident physical a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident remained free from resident to resident physical abuse when the facility failed to increase supervision when residents displayed an increase in behaviors for 2 (Resident #4 and Resident #5) of 4 (Resident #1, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for abuse.
This deficient practice resulted in actual harm on 03/30/2024 at 8:20 a.m. when Resident #4 attacked Resident #5 with a belt and Resident #5 sustained scratches to the right side of his neck and his right thumb which required daily wound care. Resident #4 and Resident #5 were both identified by staff to have had increased behaviors of agitation prior to the altercation with no increase in supervision.
Findings:
Review of the facility's policy and procedure titled Abuse Prevention and Prohibition with a review date of 03/01/2024 revealed, in part, each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including but not limited to other residents. Further review revealed physical abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident, and included examples of physical abuse included, in part, hitting, slapping, pinching, biting, shoving, and kicking.
Resident #4
Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder.
Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses, in part, non-traumatic brain dysfunction, and paranoid schizophrenia.
Review of Resident #4's undated Care Plan revealed Resident #4 had potential to be verbally aggressive due to mental and emotional illness of schizophrenia, delusional/paranoid personality disorder with approaches, in part, when Resident #4 becomes agitated, intervene before agitation escalates, and guide away from source of distress.
Review of Resident #4's Nursing Note dated 08/15/2023 revealed Resident #4 was very delusional, and voiced his roommate (Resident #5) was trying to kill him and Resident #5 had a knife. Further review revealed Resident #5 was placed on a physician emergency certificate for psychiatric treatment.
Review of Resident #4's Nursing Notes dated 03/26/2024 at 4:03 p.m. revealed Resident #4 was pacing up and down the hall yelling he would call the Central Intelligence Agency (CIA) and Federal Bureau of Investigations (FBI).
Review of Resident #4's Nursing Note dated 03/30/2024 at 8:20 a.m. revealed Resident #4 was walking around the hall with a belt and a lock in his hand stating his roommate attacked him. Further review revealed Resident #4's roommate, Resident #5, voiced they were fighting.
Review of Resident #4's Nursing Note dated 03/30/2024 at 12:43 p.m., revealed S3Licensed Practical Nurse (LPN) was summoned to Resident #4's room and Resident #4 voiced Resident #5 had tried to break his neck and put Fentanyl (narcotic medication) in his coffee. Further review revealed, per staff, Resident #4 had been in a manic phase for the last couple of days.
Review of the facility's Investigation of Incident dated 03/30/2024 revealed S1Administrator received a call regarding an altercation between Resident #4 and Resident #5. S9Registered Nurse (RN)/Weekend Supervisor indicated it was reported to her that Resident #5 went into his room to use the bathroom and Resident #4 started yelling at him to get out of his room. Review revealed Resident #4 took his belt off, Resident #5 then grabbed Resident #4's arm and then wrestled Resident #4 to the bed. Further review of the Investigation of Incident revealed a predisposing situation factor was Resident #4 disliked the roommate.
In an interview on 04/03/2024 at 2:19 p.m., S10Certified Nursing Assistant (CNA) indicated last week Resident #4 was more active, and he was repeatedly saying he was going to call the FBI, and when Resident #4 was pacing and was talking about calling the FBI we knew his mental status was worsening.
In an interview on 04/03/2024 at 2:26 p.m., S11CNA indicated last week Resident #4 was having issues with his behaviors. Resident #4 was observed by staff to be walking around with a belt in his hand. S11CNA further indicated Resident #4 did not usually walk around with a belt in his hand, and appeared to be talking in codes.
In an interview on 04/03/2024 at 2:34 p.m., S12CNA Supervisor indicated on 03/30/2024 Resident #4 had been pacing back and forth and was not easily redirected. S12CNA Supervisor indicated Resident #4 had appeared agitated during the day while walking around with the belt buckle in his hand. S12CNA Supervisor indicated with the change in Resident #4's behavior the staff was not informed to increase supervision or do anything differently other than redirect him.
In an interview on 04/03/2024 at 2:53 p.m., S3Licensed Practical Nurse (LPN) indicated around 04/26/2024 Resident #4 was pacing and acting differently than usual. S3LPN indicated on Saturday, 03/30/2024, Resident #4 was yelling and then stated someone tried to break his neck. S3LPN indicated Resident #5 had stated he was going into their room and this was when he was attacked by Resident #4. S3LPN indicated she observed Resident #5 had scratches to his hand and neck. S3LPN indicated about 7 months ago she suggested to the previous Director of Nursing (DON) to separate Residents #4 and #5 related to another incident, however, there were no interventions such as increased supervision to prevent another occurrence.
In an interview on 04/04/2024 at 11:28 a.m., S2DON indicated staff had notified her of an increase in Resident #4's behaviors the week of 04/25/2024. S2DON indicated Resident #4 was observed pacing with increased agitation and redirected. S2DON indicated the facility had not increased supervision until after the incident because to her knowledge Resident #4 had never had issues with other residents. S2DON indicated she was not aware of the incident that happened in August 2023.
In an interview on 04/04/2024 at 12:39 p.m., S1Administrator indicated she was not made aware Resident #4 had an increase in behaviors and was pacing more frequently. S1Administrator indicated she was not aware of the issues Resident #4 and Resident #5 had in August 2023 and Resident #4 and Resident #5 should not have been roommates after August 2023. S1Administrator indicated the staff who witnessed Resident #4 pacing with the belt in his hands should have notified the supervisor to ensure something was done to monitor him.
In an interview on 04/04/2024 at 2:23 p.m., Resident #4's psychiatric counselor indicated he was not aware of Resident #4's delusions in August 2023 of Resident #5 trying to harm him. Resident #4's psychiatric counselor further indicated if he would have been notified of these issues, he would have recommended that Resident #4 and #5 be separated to prevent Resident #4 being triggered by Resident #5.
Resident #5
Review of Resident #5's record revealed he was admitted on [DATE] with diagnoses, in part, bipolar disorder, major depressive disorder, and paranoid personality disorder.
Review of Resident #5's MDS with an ARD dated 02/14/2024 revealed Resident #5 had a BIMS of 15 which indicated Resident #5 was cognitively intact.
Review of Resident #5's Care Plan revealed problem of, in part, Resident #5 display of aggressive behavior with a target date of 05/14/2024. Further review revealed a revision on 03/27/2024 related to Resident #5 observed on the patio yelling and making racial slurs to staff and others. Following this incident, the care plan was revised to include staff education on de-escalation techniques with documentation of Resident #5's behavior.
Review of Resident #5's March 2024 and April 2024 Physician's Orders revealed, in part,
cleanse the scratch to the right side of Resident #5's neck with wound cleanser, pat dry and apply topical antibiotic ointment every shift with start date of 03/30/2024; and cleanse the scratch to Resident #5's right thumb with wound cleanser, pat dry, apply topical antibiotic ointment and cover with a dry dressing with a start date of 03/30/2024.
Review of Resident #5's March 2024 Medication Administration Record (MAR) revealed on 03/29/2024 Resident #5 had a 17 coded for behaviors which indicated aggression to residents.
Review of Resident #5's Nurses Notes dated 03/23/2024 at 2:30 p.m. revealed Resident #5 was down hallway yelling he was going to knock a resident in the head, but was redirected.
Review of Resident #5's Nurse's Notes dated 03/27/2024 at 4:00 p.m. revealed the nurse was called to the patio due to Resident #5 making racial slurs.
In an interview on 04/02/2024 at 2:28 p.m., Resident #5 indicated on 03/30/2024 Resident #4 was really mad about something. Resident #5 indicated he was going to the restroom and all he could understand Resident #4 say was he, Resident #4, was going to whoop my a** and then he got on the bed and took off his belt and wrapped it around his hand. Resident #5 indicated Resident #4 jumped off the bed at him, and when Resident #4 swung his arm back like he was winding up to hit Resident #5, Resident #5 grabbed Resident #4's hand, and then we fell on the bed and wrestled for approximately 20 seconds. Resident #5 indicated the thing that worried him the most was he had no idea what set Resident #4 off that morning. Resident #5 indicated Resident #4 had been acting off for a while and another resident in the hall had even warned him not to go into the room. Resident #5 indicated he left the room after the fight and notified the nurse.
Observation on 04/02/2024 at 2:28 p.m. revealed a brown linear scab like tissue to Resident #5's right thumb base.
In an interview on 04/03/2024 at 2:53 p.m., S3LPN indicated even though no one saw the fight between Resident #4 and Resident #5, she had assessed Resident #5 to have a scratch to his neck and on his right hand.
In an interview on 04/04/2024 at 1:21 p.m., S2DON indicated she was not aware of either issue on 03/23/2024 or 03/27/2024, and she would have implemented something new to his care due to his behaviors.
In an interview on 04/04/2024 at 12:39 p.m., S1Administrator indicated she was not made aware of any behaviors for Resident #5 and therefore did not increase supervision for Resident #5.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of resident to resident abuse was reported to t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure an allegation of resident to resident abuse was reported to the State Survey Agency within 5 working days for 2 (Resident #4 and Resident #5) of 4 (Resident #1, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for abuse and neglect.
Findings:
Resident #4
Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder.
Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses of, in part, non-traumatic brain dysfunction, and paranoid schizophrenia.
Review of Resident #4's undated Care Plan revealed Resident #4 had potential to be verbally aggressive due to mental and emotional illness of schizophrenia, delusional/paranoid personality disorder with approaches, in part, when Resident #4 becomes agitated, intervene before agitation escalates, and guide away from source of distress.
Review of Resident #4's Nursing Note dated 03/30/2024 at 8:20 a.m. revealed Resident #4 was walking around the hall with a belt and a lock in his hand stating his roommate attacked him. Further review revealed Resident #4's roommate, Resident #5, voiced they were fighting.
Review of Resident #4's Nursing Note dated 03/30/2024 at 12:43pm revealed the nurse was summoned to Resident #4's room and Resident #4 voiced Resident #5 had tried to break his neck and put fentanyl in his coffee.
Review of the facility's Investigation of Incident dated 03/30/2024 revealed S1Administrator received a call regarding a possible altercation between Resident #4 and Resident #5. S9Registered Nurse (RN)/Weekend Supervisor indicated it was reported to her that Resident #5 went into his room to use the restroom and Resident #4 started yelling at him to get out of his room. Review revealed Resident #4 took his belt off, Resident #5 then grabbed Resident #4's arm and then wrestled Resident #4 to the bed.
Resident #5
Review of Resident #5's record revealed he was admitted on [DATE] with diagnoses of, in part, bipolar disorder, major depressive disorder, and paranoid personality disorder.
Review of Resident #5's MDS with an ARD dated 02/14/2024 revealed Resident #5 had a BIMS of 15.
Review of Resident #5's Care Plan revealed problem of, in part, Resident #5 displayed aggressive behavior with revision on 03/27/2024 of Resident #5 was on the patio yelling and making racial slurs to staff and others with a target date of 05/14/2024. Further review revealed approaches of, in part, staff educated on de-escalation techniques, resident's behavior was to be documented.
Review of Resident #5's March 2024 and April 2024 Physician Orders revealed, in part,
cleanse the scratch to the right side of Resident #5's neck with wound cleanser, pat dry and apply topical antibiotic ointment every shift with start date of 03/30/2024; and cleanse the scratch to Resident #5's right thumb with wound cleanser, pat dry, apply topical antibiotic ointment and cover with a dry dressing with a start date of 03/30/2024.
In an interview on 04/02/2024 at 2:28 p.m., Resident #5 indicated on 03/30/2024 Resident #4 was really mad about something. Resident #5 indicated he was going to the restroom and all he could understand Resident #4 say was he, Resident #4, was going to whoop my a** and then he got on the bed and took off his belt and wrapped it around his hand. Resident #5 indicated Resident #4 jumped off the bed at him, and when Resident #4 swung his arm back like he was winding up to hit Resident #5, Resident #5 grabbed Resident #4's hand, and then we fell on the bed and wrestled for approximately 20 seconds. Resident #5 indicated the thing that worries him the most was he had no idea what set Resident #4 off that morning. Resident #5 indicated Resident #4 had been acting up for a while and another resident in the hall had even warned him not to go into the room. Resident #5 indicated he left the room after the fight and notified the nurse.
Observation on 04/02/2024 at 2:28 p.m. revealed a brown linear scab like tissue to Resident #5's right thumb base.
In an interview on 04/03/2024 at 2:53 p.m., S3LPN indicated even thought the incident between Resident #4 and Resident #5 was unwitnessed, she had assessed Resident #5 to have a scratch to his neck and on his hand.
In an interview on 04/04/2024 at 12:39 p.m., S1Administrator indicated the incident was not reported to the state agency and she should have notified the state agency of Resident #4 and Resident #5's physical altercation.
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
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident had a crisis intervention plan developed per the r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident had a crisis intervention plan developed per the resident's pre-admission screening and resident review (PASRR) for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for care and services.
Findings:
Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder.
Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses, in part, non-traumatic brain dysfunction, and paranoid schizophrenia.
Review of Resident #4's Office of Behavioral Health PASRR Level II Evaluation Summary and Determination Notice for period of 03/08/2023 through 03/06/2024 revealed the nursing home was to facilitate the development of a crisis intervention plan/safety plan.
Review of Resident #4's Office of Behavioral Health PASRR Level II Evaluation Summary and Determination Notice for period of 03/19/2024 through 03/18/2025 revealed the nursing home was to facilitate the development of a crisis intervention plan/safety plan.
Review of Resident #4's record revealed no documented evidence and the facility presented no documented evidence of a crisis intervention plan/safety plan had been developed for Resident #4.
In an interview on 04/04/2024 at 2:23 p.m., Resident #4's psychiatric counselor indicated the contracted psychiatric services company he worked for had not developed and/or assisted in the development of a crisis intervention plan/safety plan for Resident #4.
In an interview on 04/04/2024 at 3:11 p.m., S2Director of Nursing indicated the facility was unable to present the surveyor with evidence a crisis intervention plan/safety plan had been developed for Resident #4.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to address signs of pain in a nonverbal resident for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, a...
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Based on observation, record review, and interview, the facility failed to address signs of pain in a nonverbal resident for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 ) reviewed for pain.
Findings:
Review of Resident #1's care plan revealed the problem of left should fracture which was initiated on 04/02/2024. Further review revealed a goal for Resident #1 was to have minimal to no discomfort. Further review revealed interventions included for Resident #1 to have medications as prescribed by the physician and report any pain not relieved by pain medication to the physician.
Review of Resident #1's March 2024 and April 2024 Electronic Medication Administration Record (EMAR) revealed the following , in part: pain level of 4 on the am shift on 03/29/2024, pain level of 8 on the am shift on 03/30/2024, pain level of 7 on the pm shift on 03/30/2024, pain level of 8 on the am shift on 03/31/2024, a pain level of 8 on the am shift on 04/03/2024 (for the pain scale 0 indicated no pain and 10 indicated the worst pain). Further review of Resident #1's March 2024 and April 2024 EMARs revealed no documented evidence and the facility was unable to provide any documented evidence that Resident #1received any pain medication.
Review of the facility's standing physician orders revealed, in part, an order for mild-moderate pain to administer 650 milligrams of acetaminophen (a medication for pain) by mouth or percutaneous endoscopic gastrostomy tube (a tube to give food or medications when a person is unable to swallow) every 6 hours as needed for 4 doses. Further review of Resident #1's March 2024 and April 2024 MARs revealed no documented evidence and the facility was unable to provide any documented evidence of Resident #1 had his pain addressed.
Observation on 04/02/2024 at 11:50 a.m., revealed S7Certified Nursing Assistant (CNA) and S5CNA provided Resident #1 with incontinence care. Observation further revealed Resident #1 had facial grimacing when he was being turned.
In an interview on 04/04/2024 at 11:48 a.m., S8Licensed Practical Nurse (LPN) stated she measured pain for nonverbal residents by looking for signs of pain such as facial grimacing.
Observation on 04/04/2024 at 11:58 a.m., revealed S6CNA and S4CNA provided Resident #1 with incontinent care. Observation further revealed Resident #1 had facial grimacing while they turned him.
In an interview on 04/04/2024 at 12:06 p.m., S4CNA confirmed Resident #1 had facial grimacing during incontinence care.
In an interview on 04/04/2024 at 12:21 p.m., S3Licensed Practical Nurse (LPN) stated pain medication should have been ordered per standing orders and given for the pain ratings of 7 and 8. S3LPN confirmed Resident #1 had no documented evidence of pain medication administered in EMAR.
In an interview on 04/04/2024 at 12:32 p.m., S2Director of Nursing (DON) confirmed Resident #1 had pain scale ratings of 7 and 8 documented in his March 2024 and April 2024 EMAR. S2DON indicated Resident #1 did not receive pain medication.
In an interview on 04/04/2024 at 2:15 p.m., Resident #1's Nurse Practitioner indicated a fracture can be painful and Resident #1 had standing orders to give acetaminophen for pain.
Feb 2024
21 deficiencies
4 IJ (2 facility-wide)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident, who had a history of unsafe smok...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident, who had a history of unsafe smoking used a safety smoking device and was supervised while smoking for 1 (Resident #90) of the 3 (Resident #29, Resident #61, and Resident #90) sampled residents reviewed for smoking.
This deficient practice resulted in an Immediate Jeopardy situation on 02/05/2024 at 9:50 a.m. when Resident #90, a resident identified by the facility as an unsafe smoker with severe cognitive impairment, was observed smoking without the use of a smoking apron (a safety device which provides protection against burns to clothing and/or skin) and without staff supervision. Resident #90 was identified as an unsafe smoker on 09/16/2023 when he dropped a lit cigarette into his lap setting his clothes on fire which required the need for staff to use water to extinguish the fire. Resident #90's care plan was updated on 09/18/2023 which included the need for Resident #90 to wear a smoking apron and may require staff supervision while smoking.
S1Administrator was notified of the Immediate Jeopardy situation on 02/06/2024 at 5:10 p.m.
The Immediate Jeopardy was removed on 02/08/2024 at 3:05 p.m., after it was verified through observations, interviews, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit.
This deficient practice had the likelihood to cause more than minimum harm to all 3 residents (Resident #29, Resident#61, and Resident #90) identified by the facility as unsafe smokers who required safety smoking devices and/or supervision while smoking.
Findings:
Review of the facility's Resident Smoking Policy and Procedure revealed, in part, the facility's staff shall consult with the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on a Safe Smoking Evaluation. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's care plan, and all personnel caring for the resident shall be alerted to these issues. Further review revealed, any resident with restricted smoking privileges requiring monitoring shall have direct supervision at all times while smoking, and sharing smoking articles among residents was prohibited.
A review of the facility's smoking list revealed, in part, Resident #90 was identified by the facility as being an unsafe smoker.
A review of Resident #90's medical record revealed, in part, Resident #90 was admitted to the facility on [DATE].
Review of Resident #90's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2024 revealed, in part, Resident #90 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #90 was severely cognitively impaired. Further review revealed Resident #90 had active medical diagnoses of hemiplegia (weakness and/or paralysis to one side of the body), and aphasia (a comprehensive and/or communication disorder).
Review of Resident #90's nursing progress note dated 09/16/2023 at 6:25 p.m. revealed, in part, Resident #90 was discovered to have a lit cigarette in his lap, burning his clothing. Further review revealed staff poured water into Resident #90's lap to extinguish the fire.
A review of Resident #90's Comprehensive Care Plan, with an initiation date of 09/19/2023 and a target date of 04/02/2024 revealed, in part, that a plan of care was developed addressing Resident #90 had a potential for injury related to being an unsafe smoker with interventions for Resident #90 to wear a smoking apron and may require staff supervision while smoking.
A review of Resident #90's Smoking Safety screening completed on 10/04/2023 revealed, in part, Resident #90 had short-term memory loss, weak grasp-drops items, could not light his cigarette, had holes and/or burn marks in his clothing, was an unsafe smoker, and required supervision and a smoker's apron when smoking.
A review of Resident #90's Smoking Safety screening completed on 01/03/2024 revealed, in part, Resident #90 had short-term memory loss, visual deficits, limitations with range of motion, and weak hand grasp. Further review revealed, Resident #90 was assessed as an unsafe smoker and required a smoking apron when smoking.
Observation on 02/05/2024 at 9:35 a.m. revealed Resident #90 was wearing a navy blue t-shirt with two cigarette burn holes present.
Observation on 02/05/2024 at 9:50 a.m. revealed Resident #90 was smoking without wearing a smoking apron and without staff supervision.
Observation on 02/05/2024 at 11:45 a.m. revealed Resident #90 was getting his cigarette lit by another resident's cigarette. Observation further revealed Resident #90 was not wearing a smoking apron and without staff supervision.
Observation on 02/06/2024 at 9:26 a.m. revealed Resident #90 smoking without wearing a smoking apron and without staff supervision.
Observation on 02/06/2024 at 9:48 a.m. revealed Resident #90 was wearing a long-sleeved faded blue hoodie with three cigarette burn holes present.
In an interview on 02/06/2024 at 10:32 a.m., S8Certified Nursing Assistant (CNA) stated Resident #90 did not require a smoking apron or supervision while smoking. S8CNA further stated she has never seen Resident #90 use a smoking apron.
In an interview on 02/06/2024 at 10:40 a.m., S13Licensed Practical Nurse (LPN) stated Resident #90 was a safe smoker and did not require a smoking apron or supervision when smoking.
In an interview on 02/06/2024 at 11:28 a.m., S6Recreational Therapist stated Resident #90 was an unsafe smoker and required a smoking apron and supervision when smoking. S6Recreational Therapist stated Resident #90 should never be allowed to smoke without a smoking apron due to his history of unsafe smoking. S6Recreational Therapist further stated residents should not share smoking materials with unsafe smokers due to safety issues.
In an interview on 02/06/2024 at 12:30 p.m., S9Minimum Data Set (MDS)/Care Plan Coordinator stated Resident #90 was listed as an unsafe smoker on the facility's smoking list. S9MDS/Care Plan Coordinator further stated Resident #90 required a smoking apron and supervision of staff while smoking due to his history of unsafe smoking. S9MDS/Care Plan Coordinator stated the nursing staff was responsible for supervising unsafe smokers and making sure each unsafe smoker used the appropriate safety measures required.
In an interview on 02/06/2024 at 3:10 p.m., S2Director of Nursing (DON) stated she was not aware who was responsible for making sure each unsafe smoker used the appropriate safety devices while smoking. S2DON further stated she was unaware of the process for making sure unsafe smokers smoked safely without causing harm or injury to themselves or others.
In an interview on 02/06/2024 at 3:10 p.m., S1Administrator stated the nursing department was responsible for making sure unsafe smokers used the appropriate safety devices and were supervised while smoking. S1Adminstrator further stated Resident #90 was identified as an unsafe smoker. S1Administrator acknowledged the facility did not have an effective process in place to ensure residents who were identified as unsafe smokers received the safety measures and staff supervision required. S1Administrator confirmed Resident #90 required a smoking apron and/or staff supervision while smoking due to his history of unsafe smoking, and residents should not share smoking materials with residents identified unsafe smokers. S1Administrator further confirmed Resident #90 should not have not been allowed to smoke without a smoking apron or staff supervision.
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0925
(Tag F0925)
Someone could have died · This affected multiple residents
Based on record reviews, observations, and interviews, the facility failed to maintain an environment that was free from roaches for 1 (Hall D) of 5 (Hall A, Hall B, Hall C, Hall D, Hall E) halls obse...
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Based on record reviews, observations, and interviews, the facility failed to maintain an environment that was free from roaches for 1 (Hall D) of 5 (Hall A, Hall B, Hall C, Hall D, Hall E) halls observed for the presence of pests.
The deficient practice resulted in an Immediate Jeopardy situation on 02/05/2024 at 09:40 a.m. when live roaches were observed in Resident #21's room on Hall D. Resident #21 stated he hated having roaches in his room and personal space. The Immediate Jeopardy situation continued on 02/05/2024 at 11:00 a.m. for Resident #80 who stated he had live roaches in his room daily. Resident #80 stated he was worried a roach might crawl in his ear at night. The Immediate Jeopardy situation continued on 02/05/2024 at 11:42 a.m. for Resident #51 when he was observed spitting out a dead roach after taking a sip from his coffee cup. Resident #51 stated having a roach in his mouth was gross and nasty. The Immediate Jeopardy situation continued on 02/06/2024 at 4:00 p.m. when a live roach was observed entering the facility through a gap in Exit Door 7. The Immediate Jeopardy continued on 02/06/2024 at 5:29 p.m. when a live roach was observed crawling on the meal tray cart located on Hall D.
S1Administrator was notified of the Immediate Jeopardy on 02/06/2024 at 5:10 p.m.
The Immediate Jeopardy was removed on 02/08/2024 at 3:05 p.m., after it was verified through observations, interviews, and record review the facility implemented an acceptable Plan of Removal, prior to the survey exit.
Findings:
Review of the facility's Pest Control Policy and Procedure revealed, in part, the facility must maintain an effective pest control program to ensure the facility is kept free of insects. Further review revealed maintenance services assist in providing pest control services.
Review of the facility's Pest Control Logs revealed, in part, roaches were identified in resident rooms on the following dates:
-In rooms f, g, i, k, and p on 09/19/2023;
-In room i on 10/21/2023;
-In rooms i, l, q, r, and t on 12/13/2023;
-In rooms h, i, j, k, m, o, p, q, r, s, and t on 01/04/2024; and
-In rooms g, h, and n on 02/02/2024.
Observation on 02/06/2024 at 3:05 p.m. revealed gaps were present between the door and the door frame for Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, Exit Door 6, and Exit Door 7.
Observation on 02/06/2024 at 5:29 p.m., revealed a live roach was crawling across the surface of the meal tray cart on Hall D.
Resident #21
Review of Resident #21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/2023 revealed, in part, Resident #21 had a Brief Interview for Mental Status (BIMS) core of 13, which indicated Resident #21 was cognitively intact.
In an interview on 02/05/2024 at 9:40 a.m., Resident #21, who lived on Hall D, stated he was concerned with the amount of roaches in his room. Resident #21 further stated roaches were very bad at night, but could also be seen crawling in his room during the day. Resident #21 stated he had placed two roach traps/baits on the top of his bedside table 2 days ago due to the amount of roaches in his room.
Observation on 02/05/2024 at 9:40 a.m., revealed two roach traps/baits on top of Resident #21's bedside table. Further observation revealed multiple roaches covering the sticky lining of the inside of Resident #21's two roach traps/baits. Observation also revealed two live roaches crawled across the surface of the second drawer of Resident #21's bedside table.
In an interview and observation on 02/06/2024 at 10:25 a.m., Resident #21 was asked if he observed any live roaches in his room today and Resident #21 stated, yes there is one right there on the wall. Observation revealed a roach crawling along the ceiling and 2 roaches crawling on the floor of Resident #21's room. Resident #21 further stated he hated having roaches in his room and personal space. Resident #21 also stated, about 6 months ago, he was bitten by a roach and it left a little red bump/bite on his arm. Resident #21 stated he purchased 3 plugin pest lights and placed them in his room, but the roaches remained with no improvement. Resident #21 stated the facility has been aware of the roach problem.
Resident #45
Observation on 02/05/2024 at 1:20 p.m. revealed in Resident #45's room on Hall D, multiple live roaches crawling across the surface of a cardboard box.
Observation on 02/06/2024 at 11:10 a.m. revealed in Resident #45's room on Hall D, multiple live roaches crawling across the surface of a cardboard box.
Resident #51
Review of Resident #51's MDS with an ARD of 11/15/2023 revealed, in part, Resident #51 had a BIMS score of 15, which indicated Resident #51 was cognitively intact
Observation on 02/05/2024 at 11:42 a.m. revealed Resident #51 was visiting Resident #42's room located on Hall D. Further observation revealed, Resident #51 was drinking coffee from a cup and noticed something other than liquid in his mouth. Further observation revealed Resident #51 spit out a dead roach.
In an interview on 02/06/2024 at 9:38 a.m., Resident #51 stated having a roach in his mouth was gross and nasty. Resident #51 further stated he observed roaches in his room and in Resident #42's room.
Resident #80
Review of Resident #80's MDS with an ARD of 11/15/2023 revealed, in part, Resident #80 had a BIMS score of 9, which indicated Resident #80 had moderate cognitive impairment.
In an interview on 02/05/2024 at 11:00 a.m., Resident #80, who lived on Hall D, stated he had problems with roaches in his room for the last year and saw live roaches in his room daily.
In an interview on 02/06/2024 1:06 p.m., Resident #80 stated he was worried a roach would crawl into his ear while he was sleeping. Resident #80 further stated he got up often during the night to use the restroom and saw roaches crawling on the walls and/or the furniture.
In an interview on 02/06/2024 at 3:50 p.m. S1Administrator confirmed she was aware of the facility's pest issues with roaches in resident's rooms. S1Administrator further stated roaches are usually attracted to food or excessive water and that could be the cause of the roach infestation on Hall D. S1Administrator stated she did not identify issues with the gaps around Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, Exit Door 6, and Exit Door 7.
Observation on 02/06/2024 at 4:00 p.m. of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6 with S1Administrator revealed gaps between the door and doorframes of the above mentioned Exit Doors. Further observation of Exit Door 7 revealed gaps between the door and the doorframe which measured 7/16th of an inch on the bottom, 7/8th of an inch on the top, and 3/8th of an inch along the interior. Further observation of Exit Door 7 revealed a live roach crawled from the exterior of the facility into the interior of the facility through a gap present in Exit Door 7.
In an interview on 02/06/2024 at 4:00 p.m. S1Administrator confirmed there were gaps present between the door and doorframes of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6. S1Administrator further confirmed she witnessed a live roach crawling into the building from a gap in Exit Door 7. She stated she was aware of the reported issues with roaches on Hall D. S1Administrator revealed she had not noticed or identified issues with gaps in the exterior doors prior to the tour with the surveyor.
In an interview on 02/06/2024 at 5:13 p.m., S1Administrator stated she was not aware Resident #51 was observed spitting a roach from his mouth after taking a sip from his coffee cup. S1Administrator further stated it was not sanitary or homelike to have residents residing were roaches were.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's code status was carried out per the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's code status was carried out per the resident's wishes by failing to have a system in place to ensure staff knew how to confirm a resident's code status in an emergency for 1 (Resident #406) of 3 (Resident #101, Resident #103, and Resident #406) residents reviewed for death in the facility.
The deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 4:20 p.m. for Resident #406 when she was found in distress by Emergency Medical Services (EMS) and Cardiopulmonary Resuscitation (CPR) was initiated after S30Licensed Practical Nurse (LPN) presented EMS with a Louisiana Physician Order for Scope of Treatment (LaPOST) (a document that notes a resident's wishes as it relates resuscitation status) unsigned by Resident #406's physician.
S1Administrator was notified of the Immediate Jeopardy on [DATE] at 4:45 p.m.
The Immediate Jeopardy was removed on [DATE] at 3:05 p.m., after it was verified through observations, interviews, and record review the facility implemented an acceptable Plan of Removal, prior to the survey exit.
This deficient practice had the likelihood to cause more than minimum harm to the remaining 99 residents who reside in the facility and may need to receive emergency care.
Findings:
Review of the facility's Advanced Directive Policy and Procedure revealed, in part, advanced directives will be respected in accordance with state law and facility policy. Further review revealed the interdisciplinary team will review annually with the resident his or her advanced directives. Further review revealed the nurse supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance is needed.
Review of the Resident #406's LaPOST dated [DATE] revealed, in part, in the event of a cardiopulmonary arrest, Resident #406 elected to be a DNR (Do Not Resuscitate).
Review of Resident #406's LaPOST dated [DATE], which was provided to EMS upon arrival, revealed, in part, in the event of a cardiopulmonary arrest, Resident #406 elected to be a DNR (Do Not Resuscitate). Further review revealed Resident #406's LaPOST was not signed by a physician.
Review of Resident #406's progress note (late entry) dated [DATE] at 7:27 p.m. revealed, in part, EMS arrived at facility at approximately 4:20 p.m., and when walking into Resident #406's room, found Resident #406 in distress. Further review revealed, S30LPN presented EMS with Resident #406's LaPOST, and EMS informed S30LPN CPR had to be initiated because Resident #406's LaPOST was not signed by a physician. Further review revealed Resident #406's CPR was stopped at 5:00 p.m. when administration was able to locate a signed LaPOST.
In a phone interview on [DATE] at 10:07 a.m., Resident #406's responsible party stated Resident #406's code status was DNR, and Resident #406 would not have wanted to have CPR performed.
In a phone interview on [DATE] at 10:53 a.m., S30LPN stated on [DATE], she presented Resident #406's LaPOST to EMS, but EMS stated since Resident #406's LaPOST was not signed by a physician, EMS had to initiate CPR. S30LPN confirmed CPR was performed by EMS on Resident #406. S30LPN further stated she thought it was a problem that the facility had an unsigned LaPOST with a DNR order in Resident #406's EMR.
In an interview on [DATE] at 12:11 p.m., S1Administrator stated the code status of resident should be reviewed every quarter. S1Administrator further confirmed there was a discrepancy with the LaPOSTs uploaded into Resident #406's Electronic Medical Record (EMR) because the LaPOST dated [DATE] was not signed by a physician. S1Administrator further stated CPR should not have been initiated if Resident #406's wishes were to be a DNR.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequat...
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Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure:
1. a resident who had a history of unsafe smoking used the required safety smoking device and was supervised while smoking for 1 (Resident #90) of the 3 (Resident #29, Resident #61, Resident #90) sampled residents reviewed for smoking;
2. an environment that was free from roaches for 1 (Hall D) of 5 (Hall A, Hall B, Hall C, Hall D, Hall E) halls observed for the presence of pests; and
3. a resident's code status was carried out per the resident's wishes by failing to have a system in place to ensure staff knew how to confirm a resident's code status in an emergency for 1 (Resident #406) of 3 (Resident #101, Resident #103, and Resident #406) residents reviewed for death in the facility.
This lack of administrative oversight resulted in Immediate Jeopardy situations:
1. On 02/05/2023 at 9:50 a.m. when Resident #90, a resident identified by the facility as an unsafe smoker with severe cognitive impairment, was observed smoking without the use of a smoking apron (a safety device which provides protection against burns to clothing and/or skin) and without staff supervision. Resident #90 was identified as an unsafe smoker on 09/16/2023 when he dropped a lit cigarette into his lap setting his clothes on fire which required the need for staff to use water to extinguish the fire. Resident #90's care plan was updated on 09/18/2023 which included the need for Resident #90 to wear a smoking apron and may require staff supervision while smoking;
2. On 02/05/2024 at 9:48 a.m. when Resident #21was observed to have live roaches crawling in his room and stated he hated having roaches living in his personal space; On 02/05/2024 at 11:00 a.m., Resident #80 stated he had live roaches in his room daily and he was worried a roach might crawl in his ear at night. On 02/05/2024 at 11:42 a.m., Resident #51 was observed spitting out a dead roach after taking a sip from his coffee cup. Resident #51 stated having a roach in his mouth was gross and nasty. On 02/05/2024 at 1:20 p.m., an observation in Resident #45's room revealed multiple live roaches crawling in the room. On 02/06/2024 at 4:00 p.m., a live roach was observed entering the facility through a gap in Exit Door 7. On 02/06/2024 at 5:29 p.m., a live roach was observed crawling on the meal tray cart located on Hall D. Residents #21, #51, and #80 resided on Hall D; and
3. On 01/24/2024 at 4:20 p.m. when Resident #406 was found in distress by Emergency Medical Services (EMS) and Cardiopulmonary Resuscitation (CPR) was initiated after S30Licensed Practical Nurse (LPN) presented EMS with a Louisiana Physician Order for Scope of Treatment (LaPOST) (a document that notes a resident's wishes as it relates resuscitation status) dated 03/28/2022 and unsigned by Resident #406's physician.
S1Administrator was notified of the Immediate Jeopardy on 02/06/2024 at 5:10 p.m. for Resident #90, Resident #21, Resident #45, Resident #51 and Resident #80, and on 02/07/2024 at 4:45 p.m. for Resident #406.
The Immediate Jeopardy was removed on 02/08/2024 at 3:05 p.m., after it was verified through observations, interviews, and record review the facility implemented an acceptable Plan of Removal, prior to the survey exit.
Findings:
1.
Cross Reference F689
In an interview on 02/06/2024 at 3:10 p.m., S1Administrator acknowledged the facility did not implement an effective process in place to ensure residents who had been identified as unsafe smokers received the safety measures and staff supervision required. S1Administrator confirmed Resident #90 required a smoking apron and supervision when smoking due to his history of unsafe smoking and residents should not share smoking materials with other residents identified as unsafe smokers. S1Administrator further confirmed Resident #90 should not have been allowed to smoke without a smoking apron or without staff supervision.
2.
Cross Reference F925
In an interview on 02/06/2024 at 3:50 p.m. S1Administrator confirmed she was aware of the facility's pest issues with roaches in resident's rooms. S1Administrator further stated roaches are usually attracted to food or excessive water and that could be the cause of the roach infestation on Hall D. S1Administrator stated she did not identify issues with the gaps around Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, Exit Door 6, and Exit Door 7.
Observation on 02/06/2024 at 4:00 p.m. of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6 with S1Administrator revealed gaps between the door and doorframes of the above mentioned Exit Doors. Further observation of Exit Door 7 revealed gaps between the door and the doorframe which measured 7/16th of an inch on the bottom, 7/8th of an inch on the top, and 3/8th of an inch along the interior. Further observation of Exit Door 7 revealed a live roach crawled from the exterior of the facility into the interior of the facility through a gap present in Exit Door 7.
In an interview on 02/06/2024 at 4:00 p.m. S1Administrator confirmed there were gaps present between the door and doorframes of Exit Door 1, Exit Door 2, Exit Door 3, Exit Door 4, Exit Door 5, and Exit Door 6. S1Administrator further confirmed she witnessed a live roach crawling into the building from a gap in Exit Door 7. She stated she was aware of the reported issues with roaches on Hall D. S1Administrator revealed she had not noticed or identified issues with gaps in the exterior doors prior to the tour with the surveyor.
In an interview on 02/06/2024 at 5:13 p.m., S1Administrator stated she was not aware Resident #51 was observed spitting a roach from his mouth after taking a sip from his coffee cup. S1Administrator further stated it was not sanitary or homelike to have residents residing were roaches were.
3.
Cross Reference F678
In an interview on 02/09/2024 at 3:00 p.m., S2Director of Nursing stated that the facility was not checking the resident's advance directives for signatures during the quarterly care plan meetings.
In an interview on 02/07/2024 at 12:11 p.m., S1Administrator confirmed there was a discrepancy with the LaPOSTs uploaded into Resident #406's Electronic Medical Record (EMR) because the LaPOST dated 03/28/2022 was not signed by a physician. S1Administrator further stated CPR should not have been initiated if Resident #406's wishes were to be a DNR.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #21) of 27 (Resident #5, Resident #7, Resident #10, Resident #14, Resident #19, Resident #20, Resident #21, Resident #22, Resident #25, Resident #29, Resident #36, Resident #39, Resident #42, Resident #45, Resident #48, Resident #52, Resident #61, Resident #62, Resident #63, Resident #73, Resident #80, Resident #87, Resident #88, Resident #89, Resident #90, Resident #97, and Resident #456) sampled residents reviewed for environment.
Findings:
Review of the facility's Self-Administration of Medications policy revealed, in part, residents who request to self-administer medications would be assessed by the interdisciplinary team using the Self-Administration Safety Screen UDA (user defined assessment). Further review revealed the resident must know the reason for the medication, frequency, route, and the medication must be stored in a locked area away from other residents. Further review revealed the resident would be educated for self-administration of medication and evaluated quarterly to ensure resident continued to be safe.
Review of Resident #21's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/06/2023 revealed, in part, Resident #21 was admitted to the facility on [DATE], had a BIMS (Brief Interview for Mental Status) score of 13, indicating cognitively intact.
There was no documented evidence, and the facility did not present any documented evidence, that Resident #21 was assessed as being able to self-administer medications and/or able to keep medications at the bedside.
Review of Resident #21's February 2024 Physician's Orders revealed, in part, an order for Advair Diskus Inhalation Aerosol Powder (a prescription medicine used to treat chronic obstructive pulmonary disease) 250-50 Micrograms per actuation 1 inhalation orally two times a day related to COPD (Chronic Obstructive Pulmonary Disease, that causes blocked airflow making it difficult to breath). Further review revealed an order for Diphenhydramine Hydrochloride oral tablet 25 milligrams (mg) (a medication used to treat allergy symptoms that can cause drowsiness) give 1 tablet by mouth every 24 hours as needed for Insomnia (difficulty falling or staying asleep).
Observation on 02/05/2024 at 12:50 p.m. revealed, in part, Resident #21 had an Advair Diskus inhaler laying on Resident #21's rolling bedside table.
Observation on 02/06/2024 at 10:25 a.m. revealed, in part, Resident #21 had an Advair Diskus inhaler inside Resident #21's bedside table drawer that was unlocked.
Observation on 02/07/2024 at 4:10 p.m., revealed, in part, a 500 count bottle of Diphenhydramine Hydrochloride 25mg tablets on Resident #21's rolling bedside table.
In an interview on 02/07/2024 at 4:10 p.m. Resident #21 stated he self-administers two diphenhydramine hydrochloride tablets every morning and every evening for allergy symptoms and nasal congestion. Resident #21 then asked if he was taking the correct dose of diphenhydramine hydrochloride. Resident #21 stated he would self-administer the Advair Diskus inhaler about once a day if he felt short of breath. Resident #21 stated the last time he self-administered the inhaler was yesterday. Resident #21 stated he had been self-administering both medications for weeks. Resident #21 stated he was never educated by staff concerning the above mentioned medications that he kept at his bedside and/or self-administration of the medications.
In an interview on 02/08/2024 at 11:17 a.m., S10Licensed Practical Nurse (LPN) stated she observed the bottle of Diphenhydramine Hydrochloride tablets at Resident #21's bedside this morning and she instructed him that this was against the rules. S10LPN further stated she could not find Resident #21's Advair Diskus inhaler on the medication cart yesterday evening when she was scheduled to administer it. S10LPN further stated she was not aware Resident #21 had the Advair Diskus inhaler in his possession. S10LPN confirmed Resident #21 did not have an order to keep the above mentioned medications at his bedside or an order to self-administer the medications.
In an interview on 02/08/2024 at 12:59 p.m., S9MDS/Care Plan Coordinator stated she was not aware Resident #21 had the above mentioned medications at his bedside and was self-administering the medications. S9MDS/Care Plan Coordinator confirmed Resident #21 did not have a Self-Administration Safety Screen UDA completed.
In an interview on 02/09/2024 at 3:50 p.m., S2Director of Nursing confirmed Resident #21 did not have an assessment or orders to self-administer the above medications and should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to provide maintenance services by failing to ensure a resident's wall was repaired. This deficient practice was identified f...
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Based on observations, interviews, and record reviews, the facility failed to provide maintenance services by failing to ensure a resident's wall was repaired. This deficient practice was identified for 1 (Resident #48) of 27 (Resident #5, Resident #7, Resident #10, Resident #14, Resident #19, Resident #20, Resident #21, Resident #22, Resident #25, Resident #29, Resident #36, Resident #39, Resident #42, Resident #45, Resident #48, Resident #52, Resident #61, Resident #62, Resident #63, Resident #73, Resident #80, Resident #87, Resident #88, Resident #89, Resident #90, Resident #97, and Resident #456) residents investigated for environment.
Findings:
Review of Resident #48's Minimum Data Set with an Assessment Reference Date of 11/01/2023 revealed Resident #48 had a Brief Interview for Mental Status score of 15 which indicated Resident #48 was cognitively intact.
Observation on 02/05/2024 at 11:34 a.m. revealed the wall next to Resident #48's bed had paint and the top layer of the wall missing which was approximately 6 inches long and 10 inches high.
Observation on 02/06/2024 at 10:48 a.m. revealed the wall next to Resident #48's bed had paint and the top layer of the wall missing which was approximately 6 inches long and 10 inches high.
In an interview on 02/06/2024 at 10:48 a.m., Resident #48 stated she reported that the wall needed to be repaired to maintenance and to dietary staff.
Observation on 02/07/2024 at 9:24 a.m. revealed the wall next to Resident #48's bed had paint and the top layer missing which was approximately 6 inches long and 10 inches high.
In an interview on 02/07/2024 at 9:24 a.m., Resident #48 stated the wall needing to be repaired bothers her.
In an interview on 02/07/2024 at 9:35 a.m., S17Dietary Manager stated she marked Resident #48's room down to be repaired in the maintenance log about three weeks ago when she (S17Dietary Manager) was making ambassador rounds.
Review of the facility's Ambassador Rounds sheets revealed S17Dietary Manager wrote the paint was peeling on the wall in Resident #48's room on 12/05/2023, 12/06/2023, 12/14/2023, 12/21/2023, and 01/04/2024.
In an interview on 02/07/2024 at 10:06 a.m., S23Maintenance Supervisor stated maintenance requests should be taken care of as soon as possible.
In an interview on 02/07/2024 at 10:15 a.m., S1Administrator stated maintenance requests should be taken care of when they are reported or within a couple of days. S1Administrator further stated the wall in Resident #48's room should have been taken care of.
In an interview on 02/07/2024 at 10:27 a.m., S24Maintenance stated he would have repaired the wall in Resident #48's rooms if he had been made aware of it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of abuse for 1 (Resident #104) of 11 (Resident #3, Resident #25, Resident #50, R...
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Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of abuse for 1 (Resident #104) of 11 (Resident #3, Resident #25, Resident #50, Resident #51, Resident #52, Resident #83, Resident #87, Resident #102, Resident #104, Resident #205, and Resident #355) sampled residents investigated for abuse.
Findings:
Review of Resident #104's progress note dated 10/14/2023 revealed, in part, a resident in Resident #104's room was observed hitting him on the shoulder and screaming, I am going to beat your a**.
Review of the facility's incident report log from October 2023 to present revealed no documentation of an incident regarding the above mentioned allegation of abuse.
There was no documented evidence and the provider did not present any documented evidence that the allegation of abuse noted in Resident #104's progress note on 10/14/2023 was investigated.
In an interview on 02/09/2024 at 2:54 p.m., S1Administrator stated she would have to look for documentation to see if an investigation was completed regarding the above allegation of abuse noted in Resident #104's progress note dated 10/14/2023.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with diagnoses of Bipolar Disorder and Schizophre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with diagnoses of Bipolar Disorder and Schizophrenia was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #63) of 2 (Resident #42 and Resident #63) sampled residents reviewed for PASARR.
Findings:
Review of Resident #63's Electronic Medical Record (EMR) revealed, in part, Resident #63 was admitted on [DATE] with diagnoses which included, in part, Bipolar Disorder and Schizophrenia. Further review of Resident #63's EMR revealed, in part, no evidence that a Level II evaluation was completed.
There was no documented evidence and the facility did not present any documented evidence of completing a Level II PASARR evaluation as required for Resident #63.
In an interview on 02/08/2024 at 10:40 a.m., S1Administrator confirmed the facility did not have documentation that a Level II evaluation was completed for Resident #63, and S15Social Services should have referred Resident #63 for a Level II evaluation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to notify the appropriate state-designated authority for a Level II P...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to notify the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation for a resident after a significant change in physical condition for 1 (Resident #42) of 2 (Resident #42 and Resident #63) sampled residents reviewed for PASARR.
Findings:
Review of the facility's Preadmission Screening, PASARR Resident Review policy and procedure revealed, in part, a resident review for level II evaluation should be considered for residents who have changes to their physical health, which negatively affect their behavioral, psychiatric, or mood-related symptoms, or cognitive abilities impacting their daily living.
Review of Resident #42's medical records revealed, in part, Resident #42 was admitted to the facility on [DATE] to receive hospice care for comfort measures. Further review revealed Resident #42 had diagnoses of bipolar disorder and unspecified psychosis upon admit.
Review of Resident #42's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/18/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status score of 12 which indicated Resident #42 had moderate cognitive impairment and had active diagnoses of bipolar disorder and psychotic disorder other than schizophrenia.
Review of Resident #42's Level I PASARR dated 02/10/2023 revealed, in part, Resident #42 did not have a diagnosis of mental illness/disorders.
Review of Resident #42's Office of Behavior Health-PASARR Level II Evaluation Summary and Determination Notice dated 04/25/2023 revealed, in part, a full Level II determination was not required due to Resident #42 being approved under a categorical determination of terminal illness.
Review of Resident #42's medical record revealed, in part, Resident #42 was discharged from hospice care on 10/13/2023 because Resident #42 was no longer terminally ill.
Review of Resident #42's Social Service progress note dated 10/18/2023 completed by S15Social Services revealed, in part, Resident #42 had a significant change because she no longer received hospice care.
Review of Resident #42's medical record revealed there was no documented evidence Resident #42 had a Level II screening completed after Resident #42 was no longer considered to have a terminal illness and was discharged from hospice services. The facility did not present any documented evidence a Level II screening was completed for Resident #42.
In an interview on 02/08/2024 at 10:40 a.m. S1Administrator confirmed Resident #42 did not have a Level II PASARR completed after Resident #42 was no longer considered terminally ill and discharged from hospice care, and it should have been.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure an unsafe smoker's care plan was implemente...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure an unsafe smoker's care plan was implemented for 1(Resident #90) of the 3 (Resident #29, Resident #61, Resident #90) sampled residents reviewed for smoking.
Findings:
Review of Resident #90's medical record revealed, in part, Resident #90 was admitted to the facility on [DATE] and was listed as an unsafe smoker.
Review of Resident #90's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2024 revealed, in part, Resident #90 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognition.
Review of Resident #90's Comprehensive Care Plan, with an initiation date of 09/19/2023 revealed, in part, Resident #90 was identified as being an unsafe smoker and interventions included Resident #90 was to wear a smoking apron when smoking.
Observation on 02/05/2024 at 9:50 a.m. revealed Resident #90 was not wearing a smoking apron while smoking.
Observation on 02/05/2024 at 11:45 a.m. revealed Resident #90 was not wearing a smoking apron while smoking.
Observation on 02/06/2024 at 9:26 a.m. revealed Resident #90 was not wearing a smoking apron while smoking.
In an interview on 02/06/2024 at 10:32 a.m., S8Certified Nursing Assistant stated Resident #90 did not need a smoking apron when smoking and further stated Resident #90 did not have a smoking apron.
In an interview on 02/06/2024 at 10:40 a.m., S13Licensed Practical Nurse stated Resident #90 was a safe smoker and did not need a smoking apron when smoking.
In an interview on 02/06/2024 at 12:30 p.m., S9Minimum Data Set (MDS)/Care Plan Coordinator stated Resident #90's care plan was correct in that Resident #90 was an unsafe smoker and needed to wear a smoking apron when smoking.
In an interview on 02/06/2024 at 3:10 p.m., S2Director of Nursing (DON) stated Resident #90 should have been provided a smoking apron by staff to use when smoking as listed in Resident #90's care plan interventions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review, interview, and observation the facility failed to perform catheter care per policy and procedures. This deficient practice was identified for 1 (Resident #20) of 3 (Resident #7...
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Based on record review, interview, and observation the facility failed to perform catheter care per policy and procedures. This deficient practice was identified for 1 (Resident #20) of 3 (Resident #7, Resident #20, Resident #36) sampled resident(s) reviewed for catheter care.
Findings:
Review of Resident #20's February 2024 physician orders revealed, in part, an order for catheter care every shift and as needed.
Review of facility's Catheter Care, Indwelling Catheter Policy and Procedure revealed, in part, catheter care should be performed by pouring warm water over perineal area, washing with soap and water, cleansing the catheter tubing at the insertion, rinse well with warm water and pat dry gently with a clean towel.
Review of Quarterly Minimum Data Set (MDS) with an assessment reference date(ARD) date of 11/08/2023 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #20 was cognitively intact.
In an interview on 02/07/2024 at 1:50 p.m. Resident #20 stated catheter care was not performed daily. Resident #20 further indicated catheter care was performed when he showers on Monday, Wednesday and Friday.
Observation on 02/08/2024 at 9:57 a.m. revealed S28Certified Nursing Assistant (CNA) at the bedside preparing Resident #20 for catheter care. S28CNA put on gloves and placed Resident #20 on his back with the head of the bed elevated to 30 degrees. Resident #20's brief was then folded down and his catheter was exposed. S28CNA then removed a cleansing towelette from the container and washed Resident#20's perineal area, excluding the insertion site at the tip of the penis and catheter tubing. S28CNA removed gloves and disposed of them. S28CNA cleaned hands with hand sanitizer, left room, and returned with clean towels. S28CNA washed hands with soap and water, put on gloves, wet wash cloth with soap and water, opened Resident #20's brief exposing perineal area, wiped perineal area with soapy wash cloth, excluding insertion site at the tip of the penis and catheter. S28CNA dried area with towel, closed brief, covered Resident#20, emptied genitourinary (GU) bag into urinal, emptied urinal into toilet and removed gloves. S28CNA washed her hands with soap and water and positioned the resident for comfort.
In an interview on 02/08/2024 at 12:10 p.m. S28CNA stated she did not clean Resident #20's catheter tubing at insertion site or tip of the penis during catheter care and should have.
In an interview on 02/08/2024 at 12:14 p.m. S2Director of Nursing (DON) stated catheter care consisted of cleaning the perineal area, tip of the penis and catheter tubing.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to follow a speech therapist's therapeutic diet recommendation for 1 (Resident #97) of 3 (Resident #7, Resident #73, and Resid...
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Based on observations, interviews, and record review, the facility failed to follow a speech therapist's therapeutic diet recommendation for 1 (Resident #97) of 3 (Resident #7, Resident #73, and Resident #97) sampled residents investigated for nutrition.
Findings:
In an interview on 02/06/2024 at 10:15 a.m., Resident #97's family member stated she did not understand why Resident #97 was not getting a meal tray.
Review of Resident #97's Speech Therapy notes signed by S25Speech Language Pathologist (SLP) on 12/19/2023 revealed, in part, a discharge recommendation that Resident #97 receive a pureed consistency diet.
Observation on 02/07/2024 at 12:10 p.m., revealed S22Certified Nursing Assistant (CNA) did not provide Resident #97 with a lunch tray.
In an interview on 02/07/2024 at 12:10 p.m., S22CNA stated that Resident #97 did not get a meal tray.
In an interview on 02/08/2024 at 12:13 p.m., S25SLP stated if Resident #97 had a recommendation for a pureed consistency diet, an order should have been placed for Resident #97 to receive a pureed consistency meal tray by a nurse.
Observation on 02/08/2024 at 12:30 p.m., revealed S22CNA did not provide Resident #97 with a lunch tray.
In an interview on 02/08/2024 at 12:30 p.m., S22CNA stated that Resident #97 did not get a meal tray.
In an interview on 02/08/2024 at 2:00 p.m., S26Director of Therapy stated the order for Resident #97 to receive a pureed consistency diet should have been placed into Resident #97's record, and Resident #97 should have been receiving a pureed consistency meal tray.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to administer the Influenza vaccine and Pneumococcal vaccine for 1 (Resident #42) of 5 (Resident #5, Resident #7, Resident #20, Resident #24, a...
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Based on record review and interview the facility failed to administer the Influenza vaccine and Pneumococcal vaccine for 1 (Resident #42) of 5 (Resident #5, Resident #7, Resident #20, Resident #24, and Resident #42) sampled residents reviewed for Influenza vaccines and Pneumococcal vaccines.
Findings:
Record review revealed, in part, Resident #42 signed a consent to receive the Influenza vaccine and the Pneumococcal vaccine on 10/17/2023.
There was no documented evidence and the facility failed to present documented evidence the Influenza vaccine and the Pneumococcal vaccine were administered for Resident #42 as per the consent, signed on 10/27/2023, in which she requested to receive the vaccine.
In an interview on 02/07/2024 at 9:30 a.m., S2Director of Nursing confirmed the consent for the Influenza vaccine and Pneumococcal vaccine was signed for Resident #42, but there was no documented evidence the facility had administered the vaccines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure the COVID-19 vaccine was administered for 1 (Resident #42) of 5 (Resident #5, Resident #7, Resident #20, Resident #24, and Resident #...
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Based on record review and interview the facility failed to ensure the COVID-19 vaccine was administered for 1 (Resident #42) of 5 (Resident #5, Resident #7, Resident #20, Resident #24, and Resident #42) sampled residents reviewed for COVID-19 vaccines.
Findings:
Record review revealed, in part, Resident #42 signed a consent to receive the COVID-19 vaccine on 10/17/2023.
There was no documented evidence and the facility failed to present documented evidence the COVID-19 vaccine was administered to Resident #42 as per the consent, signed on 10/27/2023, in which she requested to receive the vaccine.
In an interview on 02/07/2024 at 9:30 a.m., S2Director of Nursing confirmed the consent for the COVID-19 vaccine was signed for Resident #42, but there was no documented evidence the facility had administered the vaccine.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 6 (Resident #3, Resident #51, Resident #102, Residen...
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Based on interviews and record reviews, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 6 (Resident #3, Resident #51, Resident #102, Resident #104, Resident #205, and Resident #355) of 11 (Resident #3, Resident #25, Resident #50, Resident #51, Resident #52, Resident #83, Resident #87, Resident #102, Resident #104, Resident #205, and Resident #355) sampled residents investigated for abuse.
Findings:
Resident #3
Review of Resident #50's progress noted dated 12/16/2023, revealed, in part, Resident #3 approached Resident #50, and Resident #50 put hands around Resident #3's neck and called him racial slurs.
In an interview on 02/09/2024 at 2:28 p.m., S13Licensed Practical Nurse (LPN) confirmed that she saw Resident #50 put his hands around Resident #3's neck.
In an interview on 02/09/2024 at 2:51 p.m., S1Administrator confirmed the above physical abuse happened between Resident #3 and Resident #50 with her own investigation, and would consider this resident to resident abuse.
Resident #51
Review of Resident #83's progress note dated 09/11/2023 revealed, in part, Resident #83 physically assaulted Resident #51.
Review of the facility's documentation related to Resident #51 being physically assaulted by Resident #83 dated 09/13/2023 revealed, in part, that Resident #51 was noted lying on the floor while Resident #83 was punching him in his face and pounding his head onto the floor aggressively.
In an interview on 02/09/2024 at 2:44 p.m., S1Administrator confirmed the above physical abuse happened between Resident #83 and Resident #51 with her own investigation, and would consider this resident to resident abuse.
Resident #102
Review of Resident #102's progress note dated 11/11/2023 revealed, in part, Resident #102 and Resident #355 were physically fighting in the middle of the hallway by hitting each other in the face and upper body.
Review of the facility's documentation dated 11/11/2023 related to the above mentioned incident revealed, in part, that Resident #102 was physically fist fighting.
In an interview on 02/09/2024 at 2:49 p.m., S1Administrator confirmed the above mentioned physical abuse happened between Resident #102 and Resident #355 with her own investigation, and would consider this resident to resident abuse.
Resident #104
Review of Resident #104's progress note dated 05/19/2023 revealed, in part, a resident hit Resident #104 on the left side of his face with an open hand.
In an interview on 02/09/2024 at 11:42 a.m., S7Licensed Practical Nurse stated Resident #23 hit Resident #104.
In an interview on 02/09/2024 at 2:54 p.m., S1Administrator stated she confirmed the abuse happened between Resident #23 and Resident #104 with her own investigation, and would consider this resident to resident abuse.
Resident #205
Review of Resident #205's progress notes dated 11/10/2023 at 5:05 p.m. revealed, Resident #205 was hit in the face by another resident. Resident #205 had 3 small scratches noted to the left side of his face.
Review of Resident #205's Minimum Data Set with an Assessment Reference Date of 10/25/2023 revealed in part Resident #205 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact.
In an interview on 02/08/2024 at 10:58 a.m., S10Licensed Practical Nurse stated Resident #205 reported to her he was hit by Resident #10 in the face. S10LPN further stated this should have never occurred.
In an interview on 02/09/2024 at 12:49 p.m., S1Administrator confirmed through her investigation Resident #10 hit Resident #205 in the face.
Resident #355
Review of Resident #355's progress note dated 11/11/2023 revealed, in part, Resident #355 was punched by Resident #102 and both were physically throwing punches.
Review of the facility's documentation dated 11/11/2023 related to the above revealed, in part, Resident #355 was physically throwing punches.
In an interview on 02/09/2024 at 2:49 p.m., S1Administrator confirmed the above physical abuse happened between Resident #102 and Resident #355 with her own investigation, and would consider this resident to resident abuse.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
Based on interviews and record reviews the facility failed to report an allegation of abuse and the results of the investigation as required for 4 (Resident #3, Resident #102, Resident #205, and Resid...
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Based on interviews and record reviews the facility failed to report an allegation of abuse and the results of the investigation as required for 4 (Resident #3, Resident #102, Resident #205, and Resident #355) of 11 (Resident #3, Resident #25, Resident #50, Resident #51, Resident #52, Resident #83, Resident #87, Resident #102, Resident #104, Resident #205, and Resident #355) sampled residents investigated for abuse.
Findings:
Review of the facility's Abuse Reporting and Investigation Policy and Procedure revealed, in part, all alleged violations involving abuse, neglect, exploitation or mistreatment would be reported to the facility Administrator, or his/her designee, and in turn they would notify the following persons or agencies, as applicable. Further review revealed alleged violations of abuse would be reported immediately, but no later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury or 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Further review revealed, in part, the Administrator, or his/her designee, would provide the appropriate agencies or individuals a written report of the findings of the investigation within 5 working days of the occurrence of the incident.
Resident #3
Review of Resident #50's progress note dated 12/16/2023, revealed, in part, Resident #3 approached Resident #50, and Resident #50 put his hands around Resident #3's neck and called him racial slurs.
In an interview on 02/09/2024 at 2:28 p.m., S13Licensed Practical Nurse (LPN) confirmed that she saw Resident #50 put his hands around Resident #3's neck.
In an interview on 02/09/2024 at 2:51 p.m., S1Administrator confirmed the above physical abuse happened between Resident #3 and Resident #50. S1Administrator further stated she should have reported the incident between Resident #3 and Resident #50 to the state agency and did not.
Resident #102
Review of Resident #102's progress note dated 11/11/2023 revealed, in part, Resident #102 and Resident #355 were physically fighting in the middle of the hallway by hitting each other in the face and upper body.
Review of the facility's documentation dated 11/11/2023 related to the above mentioned incident revealed, in part, that Resident #102 was physically fist fighting.
In an interview on 02/09/2024 at 2:49 p.m., S1Administrator confirmed the above mentioned physical abuse happened between Resident #102 and Resident #355. S1Administrator further stated she should have reported the incident between Resident #102 and Resident #355 to the state agency and did not.
Resident #205
Review of Resident #205's progress note dated 11/10/2023 at 5:05 p.m. revealed, Resident #205 was slapped in the face by another resident. Further review revealed Resident #205 had 3 small scratches noted to the left side of his face.
In an interview on 02/08/2024 at 10:58 a.m. S10LPN stated Resident #205 reported he was hit by Resident #10 in the face.
In an interview on 02/09/2024 at 12:49 p.m., S1Administrator confirmed the above mentioned physical abuse happened between Resident #10 and Resident #205. S1Administrator further stated she should have reported the incident between Resident #10 and Resident #205 to the stated agency and did not.
Resident #355
Review of Resident #355's progress note dated 11/11/2023 revealed, in part, Resident #355 was punched by Resident #102 and both were physically throwing punches and hitting one another,
Review of the facility's documentation dated 11/11/2023 related to the above mentioned incident revealed, in part, Resident #355 was physically throwing punches.
In an interview on 02/09/2024 at 2:49 p.m., S1Administrator confirmed the above physical abuse happened between Resident #102 and Resident #355. S1Administrator further stated she should have reported the incident between Resident #102 and Resident #355 to the state agency and did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to provide nail care to dependent residents. This deficient practice was identified for 2 (Resident #7 and Resident #89) of 4...
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Based on observations, interviews, and record reviews, the facility failed to provide nail care to dependent residents. This deficient practice was identified for 2 (Resident #7 and Resident #89) of 4 (Resident #7, Resident #63, Resident #89, and Resident #97) sampled residents investigated for activities of daily living (ADLs).
Findings:
Review of the facility's nail care policy and procedure revealed, in part, the care of fingernails and toenails were part of the bath, nails were to be clipped and filed smoothly, and nails were to be kept clean.
Resident #7
Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/2023 revealed, in part, Resident #7's cognition was unable to be conducted due to resident rarely or never being understood. Further review revealed Resident #7 had impairment of her upper and lower extremities.
Review of Resident #7's care plan revealed, in part, Resident #7 was totally dependent on staff for nail care.
Observation on 02/06/2024 at 10:00 a.m. revealed Resident #7 had jagged fingernails about ¼ inch in length with a light brown unknown substance underneath them.
Observation on 02/07/2024 at 10:48 a.m. revealed Resident #7 had jagged fingernails on both hands extending about ¼ inch past the fingertips with a light brown unknown substance underneath them.
Observation on 02/07/2024 at 3:48 p.m. revealed Resident #7 had jagged fingernails on both hands about ¼ inch past the fingertips with a light brown unknown substance underneath them. Observation further revealed Resident #7 to have toenails about ¼ inch long.
In an interview on 02/07/2024 at 3:52 p.m., S12Licensed Practical Nurse stated Resident #7's fingernails and toenails needed to be cleaned and cut.
In an interview on 02/07/2024 at 3:55 p.m., S13Certifiend Nursing Assistant Supervisor stated Resident #7's fingernails and toenails needed to be cleaned and cut.
In an interview on 02/07/2024 at 4:02 p.m., S3Assistant Director of Nursing confirmed Resident #7's fingernails and toenails needed to be cut and they should not be that long.
Resident #89
Review of Resident #89's MDS with an ARD of 01/05/2024 revealed, in part, Resident #89 had a Brief Interview Mental Status score of 5 which indicated Resident #89 had severe cognitive impairment. Further review revealed Resident #89 required assistance with personal hygiene.
Review of Resident #89's care plan revealed, in part, Resident #89 required staff assistance for personal hygiene and grooming.
Observation on 02/05/2024 at 11:27 a.m. revealed Resident #89 had jagged fingernails extending about ¼ inch long past the fingertips on both hands.
Observation on 02/06/2024 at 11:00 a.m. revealed Resident #89 had jagged fingernails extending about ¼ inch long past the fingertips on both hands.
Observation on 02/07/2024 at 9:32 a.m. revealed Resident #89 had jagged fingernails extending about ¼ inch long past the fingertips on both hands.
Observation on 02/07/2024 at 11:15 a.m. revealed Resident #89 had jagged fingernails extending about ¼ inch long past the fingertips on both hands.
Observation on 02/07/2024 at 11:50 a.m. revealed S5Certified Nursing Assistant (CNA) assisted Resident #89 into the whirlpool. Observation further revealed Resident #89's toenails extended about ½ inch past the top of the toe on both feet. Further observation revealed Resident #89's fingernails were jagged and extended about ¼ of an inch past the fingertips on both hands.
In an interview on 02/07/2024 at 11:58 a.m., S5CNA stated Resident #89's toenails and fingernails should not be that long.
In an interview on 02/07/2024 at 12:05 p.m., S27Licensed Practical Nurse stated Resident #89's toenails and fingernails should not be that long.
In an interview on 02/07/2024 at12:08 p.m., S3Assistant Director of Nursing confirmed Resident #89's toenails and fingernails should not be that long.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received behavioral health care services for 2 (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received behavioral health care services for 2 (Resident #42 and Resident #61) of 2 (Resident #42 and Resident #61) sampled residents investigated for behavioral health care services.
Findings:
Resident #42
Review of Resident #42's medical records revealed, in part, Resident #42 was admitted to the facility on [DATE] on hospice care. Further review revealed Resident #42 was discharged from hospice care on 10/13/2023 after she was no longer considered terminally ill.
Review of Resident #42's February 2023 Physician's Orders and February 2023 electronic Medication Administration Record revealed, in part, Resident #42 had orders and received anti-psychotic medication, anti-depressant medication, and anti-anxiety medication.
Review of Resident #42's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition and had diagnoses of bipolar disorder and other psychotic disorder other than schizophrenia. Further review revealed Resident #42 received anti-psychotic, anti-depressant, and anti-anxiety medication during the observation period.
Review of Resident #42's medical record revealed, in part, an order dated 10/12/2023 to consult facility's psychiatric Nurse Practitioner (NP) for evaluation and treatment of increased anxiety related to hospice discharge.
In an interview on 02/08/2024 at 9:54 a.m., S19Licensed Practical Nurse (LPN) stated Resident #42 complained of anxiety at least daily and received medication for anxiety.
In an interview on 02/08/2024 at 10:03 a.m., S3Assistant Director of Nursing (ADON) stated the facility's psychiatric NP made rounds in the facility on 02/07/2024, and S3ADON further stated Resident #42 was not seen by the psychiatric NP.
In an interview on 02/08/2024 at 11:20 a.m., Resident #42 stated she is not receiving psychiatric services and stated she thinks she could benefit from these services.
In an interview on 02/08/2024 at 10:40 a.m., S1Administrator stated Resident #42 was not seen by psychiatric services for increased anxiety after her hospice discharge as order on 10/12/2023, and she should have been.
Resident #61
Review of Resident #61's medical records revealed, in part, Resident #61 was admitted to the facility on [DATE] and current diagnoses include, in part, unspecified psychosis, major depressive disorder, and generalized anxiety disorder.
Review of Resident #61's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/10/2024 revealed, in part, Resident #61 had a Brief Interview for Mental Status score of 12 which indicated Resident #61 had moderately impaired cognition. Further review revealed Resident #61 had rejected care, hallucinations, and delusions during the observation period.
Review of Resident #61's Comprehensive Care Plan revealed, in part, a plan of care was developed for Resident #61's exhibited behaviors of rejection of care and he refused medications, body audits, treatments, and weights. Further review revealed Resident #61 would not store his urinal properly.
Review of Resident #61's Order Administration Notes revealed, in part, Resident #61 refused medications on 28 of 31 days in October of 2023, on 25 of 30 days in November of 2023, on 25 of 31 days in December of 2023, and 28 of 31 days in January of 2024. Further review revealed Resident refused medications from 02/01/2024 through 02/09/2024.
Review of Resident #61's Social Service Quarterly Assessment revised on 10/18/2023 revealed, in part, Resident #61 had behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) occurred 4 to 6 days during the observation period. Further review revealed Resident #61 screamed and hollered at himself.
Review of Resident #61's Social Service Assessment Progress Note dated 01/10/2024 revealed, in part, Resident #61 had conversations with himself.
Observation on 02/05/2024 at 2:24 p.m. revealed Resident #61 was in the common area at a desk sitting in front of a computer. Further observation revealed Resident #61 had a urinal which contained urine hanging on the back of his wheelchair and the urinal lid was open.
In an interview on 02/05/2024 at 2:24 p.m., Resident #61 would not answer questions related to his urinal on the back of his wheelchair, he became agitated, and asked to be left alone.
Observation on 02/05/2024 at 12:45 p.m. revealed Resident #61 was sitting in the dining room in his wheelchair at a table with other residents. Observation further revealed Resident #61 had a urinal which contained urine hung on the back of his wheelchair and the urinal lid was open.
On 02/06/2024 at 10:09 a.m., Resident #61 refused to answer questions or be interviewed.
In an interview on 02/08/2024 at 10:17 a.m., S10MDS/Care Plan Coordinator stated #61 had a history of refusing all medications, baths, weights, body audits, and to wear a smoking apron. S10MDS/Care Plan Coordinator stated Resident #61 would often sit outside her office window and she could hear him hollering and screaming at himself.
Observation on 02/09/2024 at 10:54 a.m. revealed Resident #61 was sitting outside in the courtyard talking to himself.
Observation on 02/09/2024 at 12:45 p.m. revealed Resident #61 was sitting at the dining room table with another resident. Observation further revealed Resident #61 had a urinal which contained urine hung on the back of his wheelchair and the urinal lid was open to air.
In an interview on 02/09/2024 at 12:53 p.m., S31Certified Nursing Assistant (CNA) stated when the staff tried to keep Resident #61 from bringing his urinal into the dining room he became very agitated and cursed at the staff. S31CNA further stated she did not try to encourage or enforce Resident #61 from bringing his urinal into the dining room anymore because she was scared of him and how he might react.
In an interview on 02/09/2024 at 1:10 p.m., with S32Director of Operations stated the staff has tried to encourage Resident #61 not to bring his open urinal into to the dining room during meals, but Resident #61 would not comply. S32Director of Operations further stated Resident #61 had a history of behaviors and became agitated when staff would attempt to empty his urinal and/or remove his urinal from the dining room.
Review of Resident #61's record revealed no documented evidence and the facility did not present any documented evidence Resident #61 received a psychiatric evaluation to address his continued rejection of care and increased behaviors.
In an interview on 02/09/2024 at 2:57 p.m., S2Director of Nursing (DON) stated Resident #61 refused medications, body audits, and weights. S2DON confirmed Resident #61 refused to allow staff to empty his urinal and would bring his open urinal which contained urine into the dining room during meals. S2DON stated she had no knowledge a psychiatric evaluation was completed for Resident #61 since 08/30/2023.
In an interview on 02/09/2024 at 3:16 p.m., S3ADON stated the facility had a list of residents who required psychiatric evaluations. S3ADON confirmed Resident #61 was not included on the list of resident who required psychiatric evaluations. S3ADON stated she had no knowledge a psychiatric evaluation was completed for Resident #61 since 08/30/2023.
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:
1. Failed to ensure serve food that was free from contamination; and,
2. Failed to ensure a bottle of sanitizer was not placed on the food preparatio...
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Based on observation and interview, the facility:
1. Failed to ensure serve food that was free from contamination; and,
2. Failed to ensure a bottle of sanitizer was not placed on the food preparation area.
Findings:
1.
Observation on 02/06/2024 at 11:30 a.m. revealed S17Dietary Manager dropped an unopened alcohol prep wipe in the broccoli on the steam table. Further observation revealed S17Dietary Manager removed the unopened alcohol prep wipe from the broccoli, but did not remove any of broccoli.
Observation on 02/06/2024 at 12:00 p.m. revealed kitchen staff served the broccoli in which the alcohol prep wipe fell into.
In an interview on 02/07/2024 1:20 p.m. S17Dietary Manager confirmed it was unsanitary to serve the broccoli in which the alcohol prep wipe fell in.
2.
Observation on 02/06/2024 at 12:00 p.m. revealed S29Dietary Aide placed a bottle of sanitizer on the food prep table.
In an interview on 02/06/2024 at 12:08 p.m., S17Dietary Manager stated the bottle of sanitizer should not have been placed on the food prep table.
In an interview on 02/08/2024 at 2:49 p.m., S1Administrator confirmed it was unsanitary to serve the broccoli where the alcohol prep wipe fell into. S1Administrator further confirmed the bottle of sanitizer should not have been placed on the food prep table.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected multiple residents
Based on record review and interview, the facility failed to ensure the results of the last standard survey were readily accessible to residents.
Findings:
Review of the facility's Survey Results Bind...
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Based on record review and interview, the facility failed to ensure the results of the last standard survey were readily accessible to residents.
Findings:
Review of the facility's Survey Results Binder revealed, in part, the statement of deficiencies from the annual survey on 02/08/2023 was not present in the binder.
There was no documented evidence and the provider did not present any documented evidence that the most recent survey results were posted in the facility, which were accessible to residents, family members, and/or legal representatives.
In an interview on 02/07/2024 at 10:29 a.m., S1Administrator confirmed that the statement of deficiencies from the facility's annual survey on 02/08/2023 was not present in the facility's Survey Results Binder, which was accessible to residents, family members, and/or legal representatives and should have been.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observations and interviews, the facility failed to post the required Nurse Staffing information.
Findings:
Observation during building rounds on 02/05/2024 between 9:20 a.m. - 9:45 a.m., rev...
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Based on observations and interviews, the facility failed to post the required Nurse Staffing information.
Findings:
Observation during building rounds on 02/05/2024 between 9:20 a.m. - 9:45 a.m., revealed no visible sign of the required nursing staffing data posted.
Observation during building rounds on 02/06/2024 between 11:00 a.m. - 11:45 a.m., revealed no visible sign of the required nursing staffing data posted.
In an interview on 02/07/2024 at 3:35 p.m., S4Medical Records stated she did not know of any required nursing staffing data posted in the facility. S4Medical Records further stated she did not know anything about staffing being posted and did not know how many staff were required to be in the building.
In an interview on 02/07/2024 at 3:55 p.m., S3Assistant Director of Nursing stated she was not aware of any required nursing staffing data posted in the building.
In an interview on 02/07/2024 at 3:58 p.m., S2Director of Nursing stated she had not seen a posted nursing staffing hours in the building.
Dec 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the certified nursing assistant (CNA) reported an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resi...
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Based on record review and interview, the facility failed to ensure the certified nursing assistant (CNA) reported an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for neglect.
Findings:
Review of the facility's Policy and Procedure for Abuse Reporting and Investigation revealed, in part, all alleged violations involving neglect will be reported to the administrator immediately.
In an interview on 12/28/2023 at 1:39 p.m., S3CNA stated about 2 weeks ago she was in the hallway and she heard Resident #1 yelling that she, S3CNA, had left stool and urine on him. S3CNA stated she had not told anyone about the accusations, but she should have because Resident #1 accused her of neglect.
In an interview on 12/28/2023 at 1:53 p.m., S1Administrator stated any allegations or grievances of potential neglect should be reported to her immediately for investigation.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, the facility failed to ensure a resident's catheter was properly assessed for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter. ...
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Based on record review, observation, and interview, the facility failed to ensure a resident's catheter was properly assessed for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter.
Findings:
Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/2023 revealed Section H Bladder and Bowel appliances was coded as none of the above (section where indwelling Foley catheter was listed). Further review revealed no documented evidence and the facility presented no documented evidence Resident #3 had been assessed as having a Foley catheter.
Review of Resident #3's readmission Note dated 12/05/2023 revealed, in part, 16 french/10 cubic centimeters (cc) Foley catheter (artificial tube placed in bladder to drain urine) in place and draining yellow urine to genitourinary bag.
Observation on 12/28/2023 at 11:06 a.m. revealed Resident #3 had a catheter draining clear yellow urine to the genitourinary bag.
In an interview on 12/28/2023 at 1:14 p.m., S4Licensed Practical Nurse (LPN) stated she had worked at the facility with Resident #3 for 3 weeks, and Resident #3 had the Foley catheter for the time she had been employed.
In an interview on 12/28/2023 at 3:21 p.m., S6MDS/Care Plan Nurse stated Resident #3's the MDS did not accurately reflect Resident #3's catheter use.
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
Based on record review, observation, and interview, the facility failed to ensure a resident's catheter was care planned with interventions for 1 (Resident #3) of 1 (Resident #3) sampled residents wit...
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Based on record review, observation, and interview, the facility failed to ensure a resident's catheter was care planned with interventions for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter use.
Findings:
Review of Resident #3's readmission Note dated 12/05/2023 revealed, in part, 16 french/10 cubic centimeters (cc) Foley catheter (artificial tube placed in bladder to drain urine) in place and draining yellow urine to genitourinary bag.
Observation on 12/28/2023 at 11:06 a.m. revealed Resident #3 with a catheter draining clear yellow urine to the genitourinary bag.
Review of Resident #3's Care Plan revealed no documented evidence and the facility presented no documented evidence of a care plan for Resident #3's Foley catheter use.
In an interview on 12/28/2023 at 1:14 p.m., S4Licensed Practical Nurse (LPN) stated she had worked at the facility with Resident #3 for 3 weeks, and Resident #3 had been having the Foley catheter for the time she had been employed. S4LPN stated there were no interventions on the medication administration record or the electronic system for Resident #3's Foley catheter.
In an interview on 12/28/2023 at 3:21 p.m., S6MDS/Care plan Nurse stated Resident #3 was not care planned for interventions for the Foley catheter.
In an interview on 12/28/2023 at 1:48 p.m., S2Director of Nursing stated the facility did not have any orders, care plan, or interventions for Resident #3's catheter.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, the facility failed to ensure a resident with a catheter received appropriate catheter care for 1 (Resident #3) of 1 (Resident #3) sampled residents...
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Based on record review, observation, and interview, the facility failed to ensure a resident with a catheter received appropriate catheter care for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter.
Findings:
Review of Resident #3's readmission Note dated 12/05/2023 revealed, in part, 16 french/10 cubic centimeters (cc) Foley catheter (artificial tube placed in bladder to drain urine) in place and draining yellow urine to genitourinary bag.
Observation on 12/28/2023 at 11:06 a.m. revealed Resident #3 with a catheter draining clear yellow urine to the genitourinary bag.
Review of Resident #3's record revealed no documented evidence of orders or interventions for Resident #3's catheter, nor did Resident #3's record reveal any documented evidence any catheter care had been performed.
In an interview on 12/28/2023 at 1:14 p.m., S4Licensed Practical Nurse (LPN) stated she had worked at the facility with Resident #3 for 3 weeks, and Resident #3 had been having the Foley catheter for the time she had been employed. S4LPN stated there were no interventions on the medication administration record (MAR) or the electronic system for Resident #3's Foley catheter. S4LPN stated Resident #3's catheter care was not on the MAR; therefore, she was not doing catheter care.
In an interview on 12/28/2023 at 1:20 p.m., S5Certified Nursing Assistant (CNA) stated she only emptied the catheter bag and confirmed she did not have any other interventions to complete for Resident #3's catheter.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to:
1. Ensure routine drugs were available for resident usage for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident...
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Based on record review and interview, the facility failed to:
1. Ensure routine drugs were available for resident usage for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for medication availability; and
2. Ensure an accurate system for account of controlled drugs for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for controlled substance reconciliation.
Findings:
1. Resident #1
Review of Resident #1's December 2023 Physician Orders revealed in part, Oxycodone (narcotic medication used to treat pain) 10 milligrams (mg) one tablet by mouth every six hour as needed for pain.
Review of the facility's communication to Resident #1's physician dated 12/14/2023 revealed Resident #1 needed a refill for Oxycodone 10 mg.
Review of Resident #1's Progress Note dated 12/18/2023 revealed the nurse contacted Resident #1's pharmacy and was informed Resident #1 required a prescription to refill Oxycodone 10 mg.
Review of Resident #1's Prescription Delivery Audit revealed Resident #1's Oxycodone 10 mg was delivered on 12/19/2023 at 10:06 p.m.
Review of Resident #1's Individual Controlled Substances Record revealed Resident #1 had received his last Oxycodone 10mg on 12/16/2023 at 8:00 p.m., and did not receive his next dose until 12/20/2023 at 7:00 a.m.
Review of Resident #1's record revealed no documented evidence and the facility presented no documented evidence the facility had continued to contact Resident #1's physician between the 12/14/2023 and 12/18/2023 to ensure Resident #1 did not have an interruption in the access to Oxycodone 10 mg.
In an interview on 12/28/2023 at 2:51 p.m., S2Director of Nursing (DON) stated the facility only had one communication to Resident #1's physician on 12/14/2023 regarding Resident #1's Oxycodone running low with no response received from Resident #1's physician. S2DON further stated the nurses' should have continued to contact the physician to ensure Resident #1 did not run out of his Oxycodone 10 mg.
Resident #2
Review of Resident #2's December 2023 Physician Orders revealed in part, Lyrica (medication used to treat nerve pain) 75 mg capsule, administer one capsule by mouth two times a day for pain.
Review of the facility's communication to Resident #2's physician dated 12/14/2023 revealed Resident #2 required a refill of Lyrica and would be out the weekend.
Review of the facility's communication to Resident #2's physician dated 12/18/2023 revealed Resident #2 was out of Lyrica 75 mg.
Review of Resident #2's Individual Controlled Substances Record revealed Resident #2 had received his last Lyrica 75 mg on 12/15/2023 at 8:00 p.m., and did not receive his next dose until 12/19/2023 at 8:30 a.m.
Review of Resident #2's record revealed no documented evidence and the facility presented no documented evidence the facility had continued to contact Resident #2's physician between the 12/14/2023 and 12/18/2023 to ensure Resident #2 did not have an interruption in the access to Lyrica 75 mg.
In an interview on 12/28/2023 at 2:51 p.m., S2DON stated the facility only had the above mentioned communications to Resident #2's physician. S2DON further stated the nurses' should have continued to contact the physician to ensure Resident #2 did not run out of his Lyrica 10 mg.
2. Resident #1
Review of Resident #1's December 2023 Physician Orders revealed, in part, Oxycodone 10 mg one tablet by mouth every six hour as needed for pain.
Review of Resident #1's December 2023 Medication Administration Record (MAR) revealed Oxycodone 10 mg was administered as follows:
-12/01/2023 at 844 p.m.;
-12/03/2023 at 8:00 a.m.;
-12/05/2023 10:29 a.m. and 4:34 p.m.;
-12/07/2023 at 1:02 a.m.;
-12/09/2023 at 9:56 p.m.;
-12/11/2023 at 12:53 a.m.;
-12/12/2023 at 8:50 p.m.;
-12/13/2023 at 2:36 a.m. and 9:44 p.m.;
-12/14/2023 at 6:22 p.m.;
-12/22/2023 at 2:58 p.m.;
-12/24/2023 at 5:44 p.m.; and,
-12/25/2023 at 10:00 p.m.
Review of Resident #1's Individual Controlled Substances Record for Oxycodone 10 mg revealed the Oxycodone 10 mg was documented as being administered, in part:
-12/03/2023 at 6:00 p.m.;
-12/04/2023 at 12:00 a.m., 7:20 a.m., and 8:00 p.m.;
-12/05/2023 at 10:30 a.m. and 4:35 p.m.;
-12/06/2023 at 12: 00 a.m.;
-12/07/2023 at 7:00 a.m. and 5:00 p.m.;
-12/08/2023 at 12:00 a.m., 9:00 a.m., 9:55 a.m.;
-12/09/2023 at 9:00 a.m. and 9:55 p.m.;
-12/10/2023 at 9:35 a.m. and 8:35 p.m.;
-12/11/2023 at 7:30 a.m. and 3:30 p.m.;
-12/12/2023 at 7:00 a.m., 2:45 p.m., and 8:50 p.m.;
-12/13/2023 at 2:50 a.m., 9:50 a.m., and 9:00 p.m.;
-12/14/2023 at 9:24 a.m. and 6:30 p.m.;
-12/15/2023 at 8:00 a.m. and 9:00 p.m.;
-12/16/2023 at 11:00 a.m. and 8:00 p.m.;
-12/20/2023 at 7:00 a.m., 3:00 p.m., and 10:00 p.m.;
-12/21/2023 at 4:30 a.m., 10:30 a.m., 4:30 p.m., and 10:30 p.m.;
-12/22/2023 at 6:00 a.m., 12:10 p.m., 7:50 p.m.;
-12/23/2023 at 8:00 a.m., and another dose with time recorded;
-12/24/2023 at 8:30 a.m., 2:50 p.m., and 10:00 p.m.;
-12/25/2023 at 7:30 a.m., 4:00 p.m., and 10:00 p.m.;
-12/26/2023 at 7:00 a.m., 2:00 p.m., 10:00 p.m.; and
-12/27/2023 at 5:30 a.m. and 12:25 p.m.
Resident #2
Review of Resident #2's December 2023 Physician Orders revealed, in part, Oxycodone-Acetaminophen 10-325mg one tablet by mouth every eight hours as needed for pain.
Review of Resident #2's December 2023 MAR revealed Oxycodone-Acetaminophen 10-325mg was administered as follows:
-12/05/2023 at 7:13 a.m.;
-12/08/2023 at 5:00 a.m.;
-12/09/2023 at 7:00 p.m.;
-12/14/2023 at 9:46 a.m.;
-12/18/2023 at 5:01 a.m.;
-12/22/2023 at 10:17 p.m.;
-12/26/2023 at 7:00 a.m.; and
-12/27/2023 at 7:58 a.m.
Review of Resident #2's Individual Controlled Substances Record for Oxycodone-Acetaminophen 10-325 mg revealed the Oxycodone-Acetaminophen 10-325mg was documented as being administered, in part:
-12/05/2023 at 11:00 p.m.;
-12/06/2023 at 7:00 a.m. and 3:00 p.m.;
-12/07/2023 at 7:00 a.m. and 3:00 p.m.;
-12/08/2023 at 5:00 a.m., 1:00 p.m., and 9:00 p.m.;
-12/09/2023 at 8:00 a.m. and 8:00 p.m.;
-12/10/2023 at 8:00 a.m. and 4:45 p.m.;
-12/11/2023 at 7:00 a.m. and 3:00 p.m.;
-12/12/2023 at 6:15 a.m., 2:15 p.m.; and 10 p.m.;
-12/13/2023 at 1:50 p.m.;
-12/14/2023 at 7:23 a.m.; 2:30 p.m.; and 8:30 p.m.;
-12/15/2023 at 8:00 a.m. and 8:00 p.m.;
-12/16/2023 at 8:00 a.m., 2:00 p.m., and 10:00 p.m.;
-12/17/2023 at 7:18 a.m., at 3:00 p.m.;
-12/18/2023 at 5:00 a.m., 11:40 a.m., 8:00 p.m.;
-12/19/2023 at 6:15 a.m., 1:00 p.m., and 8:00 p.m.;
-12/20/2023 at 7:00 a.m., 3:00 p.m., and 11:00 p.m.;
-12/21/2023 at 7:00 a.m. and 3:00 p.m.;
-12/22/2023 no time documented for first dose, 7:20 a.m., 2:20 p.m., and 10:23 p.m.;
-12/23/2023 at 8:00 a.m., 2:23 p.m., and 8:00 p.m.;
-12/24/2023 at 7:30 a.m. and 4:30 p.m.;
-12/25/2023 at 8:00 a.m. and 4:00 p.m.;
-12/26/2023 at 7:00 a.m. and 3:00 p.m.; and
-12/27/2023 at 12:15 a.m., 8:00 a.m., and 4:00 p.m.;
Resident #3
Review of Resident #3's November 2023 and December 2023 Physician Orders revealed, in part, Tramadol (medication used to treat pain) 50 mg one per percutaneous endoscopic gastrostomy (peg) tube every eight hours as needed for pain 4-10.
Review of Resident #3's November 2023 and December 2023 MAR revealed the only Tramadol 50 mg documented as being administered was on 11/08/2023 and 11/09/2023.
Review of Resident #3's Individual Controlled Substances Record for Tramadol 50mg revealed the Tramadol was received at the facility on 11/08/2023. Review of Resident #3's Individual Controlled Substances Record for Tramadol 50mg revealed no documented evidence Tramadol was administered on 11/08/2023. Further review revealed Tramadol 50mg was administered on 11/09/2023, 11/20/2023, and 12/06/2023.
In an interview on 12/28/2023 at 4:12 p.m., S11Licensed Practical Nurse (LPN) stated there are times she will get distracted and sign out a controlled substance in one area but not the other, but we should sign out the medication on the controlled substance record and the MAR as medication was administered.
In an interview on 12/28/2023 at 4:20 p.m., S2DON stated she had reviewed Resident #1, Resident #2, and Resident #3's Individual Controlled Substance Records and MARs and the facility did not have any documented evidence controlled substances were being accurately accounted for at the end of each shift.
Dec 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
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure restorative services were provided for 1 (Resident #1) of 2 (Resident #1 and Resident #3) residents reviewed for therapy services.
...
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Based on record review and interviews, the facility failed to ensure restorative services were provided for 1 (Resident #1) of 2 (Resident #1 and Resident #3) residents reviewed for therapy services.
Findings:
Review of Resident #1's record revealed, in part, a therapy referral dated 10/18/2023 to the Restorative Nursing Program (RNP) (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible).
Review of Resident #1's October, November and December 2023 Physician Order Summary Reports revealed, in part, no order for restorative services.
In an interview on 12/05/2023 at 9:51 a.m., S3Restorative Certified Nursing Aide (Restorative CNA) stated Resident #1 was not on her work load for residents receiving restorative services.
In an interview on 12/05/2023 at 9:52 a.m., S4Restorative CNA stated Resident #1 was not on her work load for restorative services.
In an interview on 12/05/2023 at 10:10 a.m., S2Director of Rehabilitative Services stated a referral was given to administration for restorative care in morning meeting on 10/18/2023.
In an interview on 12/05/2023 at 11:27 a.m., S1Director of Nursing (DON) stated restorative services were not started for Resident #1 and should have been started on 10/18/2023, the day of Resident #1's referral.
Oct 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to have accurate and complete records which documented the activities of daily living (ADL) documentation for a resident's bath and/or shower/...
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Based on record review and interview, the facility failed to have accurate and complete records which documented the activities of daily living (ADL) documentation for a resident's bath and/or shower/bed bath for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for ADL care documentation.
Findings:
Resident #1
Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/13/2023 revealed, in part, Resident #1 was totally dependent on staff assistance for bathing.
Review of Resident #1's Activities of Daily Living (ADL) documentation for October 2023 revealed Resident #1 was to receive a bath and/or shower on Tuesdays, Thursdays, and Saturdays. Review further revealed no documented evidence and the facility presented no documented evidence that Resident #1 received a bath and/or shower or the reason as to why Resident #1 did not receive a bath and/or shower on 10/05/2023.
Resident #2
Review of Resident #2's MDS ARD dated 08/23/2023 revealed, in part, Resident #3 was totally dependent on staff assistance for bathing.
Review of Resident #2's Activities of Daily Living (ADL) documentation for October 2023 revealed Resident #2 was to receive a bath and/or shower on Tuesdays, Thursdays, and Saturdays. Review further revealed no documented evidence and the facility presented no documented evidence, Resident #2 received a bath and/or shower or the reason as to why Resident #2 did not receive a bath and/or shower on 10/05/2023 and 10/21/2023.
Resident #3
Review of Resident #3's MDS ARD dated 08/02/2023 revealed, in part, Resident #3 was totally dependent on staff assistance for bathing.
Review of Resident #3's ADL documentation for October 2023 revealed Resident #3 was to receive a bath and/or shower on Mondays, Wednesdays, and Fridays. Review further revealed on 10/06/2023, 10/11/2023, and 10/30/2023 Resident #3's bath and/or shower was documented as not applicable. Further review revealed no documented evidence, and the facility presented no documented evidence of Resident #3 having received a bath and/or shower on the above mentioned dates and/or the reason as to why a bath and/or shower would have been documented as not applicable.
In an interview on 10/31/2023 at 4:42 p.m., S5CNA Supervisor stated she had noticed the facility CNAs had issues with incomplete ADL documentation for bathing. S5CNA Supervisor stated she tried to back chart some of the bath and/or showers for October 2023. S5CNA Supervisor stated she was unable to present accurate and complete bath and/or shower records for Resident #1, Resident #2, and Resident #3 which documented the inconsistencies of the missing documentation.
In an interview on 10/31/2023 at 4:45 p.m., S2DON stated the facility did not have complete and accurate documentation for the above mentioned ADL bath documentation for Resident #1, Resident #2, and Resident #3.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure the wound care nurse performed hand hygiene when changing gloves for 1 (S3Licensed Practical Nurse (LPN)/Wound Care Nu...
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Based on observation, record review, and interview, the facility failed to ensure the wound care nurse performed hand hygiene when changing gloves for 1 (S3Licensed Practical Nurse (LPN)/Wound Care Nurse) of 2 (S3LPN/Wound Care Nurse and S4Certified Nursing Assistant) sampled staff observed during wound care observations.
Findings:
Review of the facility's policy and procedure on Hand Washing/Hand Hygiene revealed use of alcohol based hand rub containing at least 62% alcohol or soap and water used an alternative should be used after removing gloves.
Observation on 10/30/2023 at 1:26 p.m. of wound care provided to Resident #2 by S3LPN/Wound Care Nurse revealed after cleaning Resident #2's right knee wound, S3LPN/Wound Care Nurse removed her gloves, and placed a new pair of gloves on her hands without having performed hand hygiene, and placed a dressing on Resident #2's right knee wound. Further observation during wound care to Resident #2's left posterior lower leg revealed S3LPN/Wound Care Nurse removed her gloves, and placed a new pair of gloves on her hands without having performed hand hygiene. S3LPN/Wound Care Nurse then cleaned Resident #2's left posterior lower leg wound.
In an interview on 10/31/2023 at 2:36 p.m., S3LPN/Wound Care Nurse was informed of the above observations of Patient #2's wound care, and S3LPN/Wound Care Nurse stated she was aware during wound care she did not perform hand hygiene after removing gloves and prior to having applied new gloves, and performing wound care for Resident #2.
In an interview on 10/31/2023 at 3:17 p.m., S2Director of Nursing (DON) stated S3LPN/Wound Care Nurse should have performed hand hygiene with each glove change.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on record review, observation, and interview, the facility failed to:
1. Ensure residents rooms did not contain a dried dark tan sticky unknown substance on the floor for 2 (Resident #2 and Resi...
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Based on record review, observation, and interview, the facility failed to:
1. Ensure residents rooms did not contain a dried dark tan sticky unknown substance on the floor for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident rooms; and
2. Ensure air conditioners in resident rooms were sealed to prevent any access to the outside for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents observed for environmental observations.
Findings:
Review of the facility's policy and procedure on Infection Prevention and Control Environmental Services revealed, in part, hard floor surfaces shall be wet cleaned daily, tile floors shall be wet mopped daily with an approved solution, and spills shall be attended to immediately.
Resident #2
Observation on 10/30/2023 at 12:41 p.m. revealed a 12 inch by 11 inch area of dried sticky dark tan substance under Resident #2's tube feeding pole.
Observation on 10/31/2023 at 9:29 a.m. revealed under Resident #2's tube feeding pole was a large area of dried sticky dark tan unknown substance, approximately 12 inch by 11 inches. Further observation revealed an area to the left upper corner of the air conditioner unit where the daylight from outside could be seen.
On 10/31/2023 at 9:47 a.m. revealed S1Administrator and S2Director of Nursing (DON) observed the above mentioned findings with the surveyor.
In an interview on 10/31/2023 at 9:47 a.m., S2DON stated the tan dried substance under the tube feeding pole in Resident #2's room was dried tube feeding and would need to be scraped up off of the floor.
In an interview on 10/31/2023 at 9:48 a.m., S2DON and S1Administrator further stated the hole to the upper left corner of Resident #2's air conditioner unit which exposed to the outside should be closed because pests and items from the outside to enter the room.
Resident #3
Observation on 10/30/2023 at 3:34 p.m. revealed more than five half dollar sized spots of a dark tan dried sticky unknown substance next to Resident #3's roommate's bed.
Observation on 10/31/2023 at 9:33 a.m. revealed more than five half dollar sized spots of a dark tan dried sticky unknown substance next to Resident #3's roommate's bed.
On 10/31/2023 at 9:51 a.m. revealed S1Administrator and S2DON observed the above mentioned finding with the surveyor.
In an interview on 10/31/2023 at 9:51 a.m., S2DON stated the dried sticky tan substance under Resident #3's roommate's tube feeding pole was dried tube feeding. S2DON further stated the area would need to be scrapped up and could be a potential source for pests and was not sanitary.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 allegation of the misappropriation of resident funds and the results of the investigation were reported as required for 1 (Reside...
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Based on record review and interview, the facility failed to ensure an allegation of the misappropriation of resident funds and the results of the investigation were reported as required for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents investigated for misappropriation of property.
Findings:
Review of the facility's Abuse Reporting and Investigation Policy and Procedure revealed, in part, all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of property would be reported to the facility Administrator, or his/her designee, and in turn they would notify the following persons or agencies, as applicable. Further review revealed alleged violations of misappropriation of resident property would be reported immediately, but no later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury or 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Further review revealed, in part, the Administrator, or his/her designee, would provide the appropriate agencies or individuals a written report of the findings of the investigation within 5 working days of the occurrence of the incident.
In an interview on 10/10/2023 at 11:40 a.m., S2Regional Director of Operations stated approximately 6 or 7 months ago, S3Business Office Manager's husband notified him by telephone and said S3Business Office Manager was stealing money from Resident #1.
In an interview on 10/11/2023 at 10:50 a.m., S1Administrator stated S2Regional Director of Operations notified her approximately 3 months ago, of the above stated findings.
Review of facility's Statewide Incident Management System (SIMs) report log for September 2022 to September 2023 revealed there was no documented evidence and the facility could not provide any documented evidence that a SIMs report was submitted for the allegation of the misappropriation of Resident #1's funds.
There was no documented evidence and the facility did not present any documented evidence of reporting any findings of the investigation results of the above mentioned allegation.
In an interview on 10/11/2023 at 1:08 p.m. S1Administrator stated a SIMs report should be opened for allegations of misappropriation of funds, abuse, and/or neglect and confirmed a SIMs report should have been filled in regards to the allegation of theft of Resident #1's money.
Apr 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on record reviews, interviews, and observations the facility failed to cover the urinary catheter bag for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #4) sampled residents. This...
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Based on record reviews, interviews, and observations the facility failed to cover the urinary catheter bag for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #4) sampled residents. This failed practice had the potential to affect any of the 17 residents with urinary catheters in the facility as documented on the Matrix for Providers, CMS-802.
Findings:
Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 09/22/2022 revealed, in part, a Brief Interview for Mental Status score of 15 which indicated high cognitive status.
Observation on 04/19/2023 at 10:00 a.m. revealed Resident #1 up in her wheelchair. Resident #1's urinary catheter bag secured to underside of wheelchair and not covered.
Observation on 04/19/2023 at 11:40 a.m. reveled Resident #1 sitting in her wheelchair on the smoker patio with her urinary catheter bag secured under the seat of her wheelchair, and uncovered.
Observation on 04/19/2023 at 2:00 p.m. revealed Resident #1 lying in her bed. Resident #1's urinary catheter bag was secured to the right side of her bed frame, facing the doorway, uncovered.
Observation on 04/20/2023 at 9:42 a.m. revealed Resident #1 in her wheelchair, S6Certified Nurses Aid (CNA) pushed Resident #1 in the hallway. Resident #1's urinary catheter bag was secured to the underside of her wheelchair and was uncovered.
Observation on 04/20/2023 at 10:20 a.m. reveled Resident #1 was in her wheelchair on the smoker patio with her urinary catheter bag secured under the seat of her wheelchair and was uncovered.
Observation on 04/20/2023 at 10:35 a.m. Resident #1 was in her wheelchair by the side of end of her bed facing the foot of the bed. Resident #1's urinary catheter bag was secured on the underside of her wheelchair and was uncovered.
In an interview on 04/20/2023 at 10:35 a.m. Resident #1 stated it bothered her that her urinary catheter bag was not covered.
In an interview on 04/20/2023 at 10:40 a.m. S6CNA stated Resident #1's urinary catheter bag should be covered.
In an interview on 04/20/2023 at 10:54 a.m. S2Licensed Practical Nurse stated Resident #1's urinary catheter bag should be covered.
In an interview on 04/20/2023 at 11:30 a.m. S1Director of Nursing stated Resident #1's urinary catheter bag should be covered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for nail care received assistance to ensure their toenails were kept clean and trimme...
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Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for nail care received assistance to ensure their toenails were kept clean and trimmed for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents reviewed for activities of daily livings (ADLs) in a total sample of 5.
Findings:
Observation on 04/20/2023 at 3:20 p.m. revealed Resident #2's toenails on her right foot extended past the tip of each toe. There was a dark brown substance under the nail of the right great toe. There was a white substance under the nails of the 2nd and 3rd toes of the right foot.
In an interview on 04/20/2023 at 3:25 p.m. S4MasterSocialWorker (MSW) was unsure if a podiatrist (physician specializing in foot care) came into the building to provide resident care.
In an interview on 04/20/2023 at 3:30 p.m. S3LicensedPracticalNurse (LPN) stated there hadn't been a podiatrist in the building since COVID-19 stopped all outside visitors in March 2020.
In an interview on 04/20/2023 at 3:45 p.m. S2LPN confirmed Resident #2's toenails on her right foot extended past the tip of each toe. S2LPN further confirmed there was a dark brown substance under nail of the right great toe and the presence of a white substance under the nails of the 2nd and 3rd toes of the right foot.
In an interview on 04/20/2023 at 3:55 p.m. S1DirectorofNursing (DON) confirmed the toenails Resident #2's right foot extended past the tip of the each toe. S1DON further confirmed the presence of a dark brown substance between the toenail of the right great toe and the skin and the presence of a white substance between the toenail and the skin of the 2nd and 3rd toes of the right foot. She further stated nail care should have been provided to Resident #2.
Feb 2023
3 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to develop a person- centered comprehensive Care Plan for 1 resident (Resident #85) of 19 sampled residents reviewed. This deficient practice ...
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Based on record review and interview, the facility failed to develop a person- centered comprehensive Care Plan for 1 resident (Resident #85) of 19 sampled residents reviewed. This deficient practice had the potential to affect any of the 95 residents residing in the facility.
Findings:
Review of the facility's Care Planning Policy and Procedure revealed, in part, a comprehensive care plan will be completed according to the Resident Assessment Instrument upon admission, annually, significant change, and as needed.
Review of Resident #85's medical record, in part, revealed an admit date to the facility of 09/21/2022 with the following diagnosis: Spinal Stenosis of the Cervical Region, Embolism and Thrombosis of Right Femoral Vein (blood clot), Major depressive disorder, and Anxiety.
Review of Resident #85's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/2022 revealed, in part, Resident #85 received antianxiety medication, antidepressant medication, and anticoagulant medication all 7 days of the 7 day look back period.
Review of Resident #85's care plan did not reveal nor did the facility present any documented evidence of a comprehensive care plan to address Resident #85's use of antianxiety medication, antidepressant medication, or anticoagulant medication.
Review of Resident #85's February 2023 Physician's Orders revealed, in part, the following orders: Buspirone HCI (medication for anxiety) 5 milligrams (mg), Eliquis 5mg (medication to prevent blood clots), Escitalopram Oxalate 10mg (medication for depression), Trazodone 50mg (medication for anxiety).
In an interview on 02/08/2023 at 11:21a.m., S9MDS Coordinator confirmed Resident #85 did not have a comprehensive care plan completed. S9MDS Coordinator further confirmed Resident #85 only had an initial temporary care plan which was completed on admit. S9MDS Coordinator further confirmed a comprehensive care plan should have been completed on Resident #85 within 21 days of admission and stated it was not completed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure side effect monitoring for the use of anticoagulant medication was completed for 1 (Resident #85) of 5 residents reviewed for unnece...
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Based on record review and interview, the facility failed to ensure side effect monitoring for the use of anticoagulant medication was completed for 1 (Resident #85) of 5 residents reviewed for unnecessary medications. This deficient practice had the potential to affect any of the 16 residents receiving anticoagulation as identified on the facility's Order Listing Report.
Findings:
Review of Resident #85's medical record revealed, in part, an admit date to the facility of 09/21/2022 with a diagnosis of Embolism and Thrombosis of Right Femoral Vein.
Review of Resident #85's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/2022 revealed, in part, Resident #85 received anticoagulant medication (medication to prevent blood clots) 7 days of the 7 day look back period.
Review of Resident #85's care plan did not reveal nor did the facility present any documented evidence of a comprehensive care plan to address Resident #85's use of anticoagulant medication or the monitoring of any side effects of anticoagulant medications.
Review of Resident #85's February 2023 Physicians Orders revealed, in part, an order for Eliquis 5 milligrams (anticoagulant). Further review did not reveal nor did the facility present any documented evidence of an order to monitor for anticoagulant side effects.
In an interview on 02/07/2023 at 10:39 a.m., S3Licenced Practical Nurse (LPN) stated Resident #85 is on Eliquis but she does not document any monitoring for side effects of anticoagulants because it is not ordered on Resident #85's medication administration record.
In an interview on 02/08/2023 at 9:35 a.m., S4LPN stated Resident #85 is on Eliquis but she does not document any monitoring for side effects of anticoagulants because it does not come up on Resident #85's medication administration record to document.
In an interview on 02/08/2023 at 11:07 a.m., S2Director of Nursing (DON) stated she is unsure why there is no documentation of monitoring of anticoagulant side effects for Resident #85. S2DON confirmed nurses should have been monitoring for anticoagulant side effects every shift due to Resident #85 being on Eliquis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to properly check temperatures of food and log temperatures of food before being served from the steam table. This deficient ...
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Based on observations, interviews, and record reviews, the facility failed to properly check temperatures of food and log temperatures of food before being served from the steam table. This deficient practice had the potential to affect any of the 81 residents who received meals from the facility's kitchen as documented on the facility's Resident Census and Conditions of Residents Form (CMS-672 form).
Findings:
Review of the facility's Food Temperature Policy and Procedure revealed all temperatures will be taken and recorded as required by state and federal regulations.
Review of the facility's kitchen's food temperature logs revealed the following food temperatures were not recorded:
-dinner on 12/23/2022 and 12/24/2022;
-breakfast and lunch on 12/25/2022, 12/26/2022 and 12/28/2022;
-breakfast, lunch and dinner on 12/27/2022 and 12/31/2022, and;
-lunch on 02/03/2023.
In an interview on 02/07/2023 at 1:30 p.m., S7Dietary Manager confirmed and stated the above temperatures were not recorded and should have been recorded prior to food being served from the steam table.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 43% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 4 life-threatening violation(s), 1 harm violation(s), $245,413 in fines. Review inspection reports carefully.
- • 53 deficiencies on record, including 4 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $245,413 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 4 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Legacy Nursing And Rehabilitation Of Plaquemine's CMS Rating?
CMS assigns LEGACY NURSING AND REHABILITATION OF PLAQUEMINE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Legacy Nursing And Rehabilitation Of Plaquemine Staffed?
CMS rates LEGACY NURSING AND REHABILITATION OF PLAQUEMINE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 43%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Legacy Nursing And Rehabilitation Of Plaquemine?
State health inspectors documented 53 deficiencies at LEGACY NURSING AND REHABILITATION OF PLAQUEMINE during 2023 to 2025. These included: 4 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 44 with potential for harm, and 4 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Legacy Nursing And Rehabilitation Of Plaquemine?
LEGACY NURSING AND REHABILITATION OF PLAQUEMINE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LEGACY NURSING & REHABILITATION, a chain that manages multiple nursing homes. With 151 certified beds and approximately 112 residents (about 74% occupancy), it is a mid-sized facility located in PLAQUEMINE, Louisiana.
How Does Legacy Nursing And Rehabilitation Of Plaquemine Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, LEGACY NURSING AND REHABILITATION OF PLAQUEMINE's overall rating (2 stars) is below the state average of 2.4, staff turnover (43%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Legacy Nursing And Rehabilitation Of Plaquemine?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Legacy Nursing And Rehabilitation Of Plaquemine Safe?
Based on CMS inspection data, LEGACY NURSING AND REHABILITATION OF PLAQUEMINE has documented safety concerns. Inspectors have issued 4 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Legacy Nursing And Rehabilitation Of Plaquemine Stick Around?
LEGACY NURSING AND REHABILITATION OF PLAQUEMINE has a staff turnover rate of 43%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Legacy Nursing And Rehabilitation Of Plaquemine Ever Fined?
LEGACY NURSING AND REHABILITATION OF PLAQUEMINE has been fined $245,413 across 3 penalty actions. This is 6.9x the Louisiana average of $35,533. 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 Legacy Nursing And Rehabilitation Of Plaquemine on Any Federal Watch List?
LEGACY NURSING AND REHABILITATION OF PLAQUEMINE 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.