LANDMARK OF RAYNE
For profit - Limited Liability company
130 Beds
THE BEEBE FAMILY
Data: November 2025
Trust Grade
35/100
#218 of 264 in LA
Photo by LCP Media
Photo by LCP Media
Photo by LCP Media
1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Landmark of Rayne has a Trust Grade of F, which indicates significant concerns about the quality of care provided, placing it in the poor category. It ranks #218 out of 264 facilities in Louisiana, meaning it is in the bottom half of nursing homes in the state, and is the least favorable option in Acadia County at #5 out of 5. The facility is experiencing a worsening trend, with issues increasing from 9 in 2024 to 10 in 2025. Staffing is a concern, with a rating of 2 out of 5 and a high turnover rate of 66%, which is above the state average of 47%. While the facility has not incurred any fines, which is a positive sign, it does have average RN coverage, meaning nursing staff may not be consistently present to oversee care, potentially leading to missed issues. Specific incidents raised by inspectors include failures to complete required resident assessments on time for 17 out of 24 residents, which could affect their care plans. Additionally, there was a failure to properly transmit discharge assessments for 7 residents within the mandated timeframe, risking delays in necessary care updates. Lastly, the facility’s quality assurance program was found lacking, as it did not adequately track or measure improvements after identifying areas needing attention, which could affect the care of its residents. Overall, while there are no fines and some staff are present, the significant operational issues and poor rankings raise concerns for families considering this nursing home.
- Trust Score
- F
- In Louisiana
- #218/264
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Louisiana facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 18%
No red flags
9 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Louisiana average (2.4)
Significant quality concerns identified by CMS
Staff Turnover: 66%
20pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Chain: THE BEEBE FAMILY
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (66%)
18 points above Louisiana average of 48%
The Ugly 26 deficiencies on record
Apr 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
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 notify the State Long Term care Ombudsman of facility-initiated tra...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of facility-initiated transfer for 1 (#7) resident in a final sample size of 33. The deficient practice has the potential to affect a census of 96.
Findings:
Review of Resident #7's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, epilepsy, hemiplegia and hemiparesis, urinary tract infection, major depressive disorder, anxiety disorder, and abnormalities of gait and mobility.
Review of Resident #7's nurse's notes revealed on 12/13/2024 at 1:20 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 12/15/2024 at 2:20 p.m., the resident returned from the hospital back to the facility.
Review of Resident #7's nurse's notes revealed on 12/24/2024 at 8:15 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 12/24/2024 at 1:02 p.m., the resident returned from the hospital back to the facility.
Review of the Emergency Transfer Log for December 2024 revealed Resident #7's transfer to the hospital on [DATE] and 12/24/2024 was not identified on the list.
Review of Resident #7's nurse's notes revealed on 03/07/2025 at 6:15 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 03/09/2025 at 12:27 p.m., the resident returned from the hospital back to the facility.
Review of Resident #7's nurse's notes revealed on 03/14/2025 at 3:14 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 03/14/2025 at 5:24 a.m., the resident returned from the hospital back to the facility.
Review of Resident #7's nurse's notes revealed on 03/17/2025 at 7:45 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 03/17/2025 at 10:25 p.m., the resident returned from the hospital back to the facility.
Review of the Emergency Transfer Log for March 2025 revealed Resident #7's transfer to the hospital on [DATE], 03/14/2025 and 03/17/2025 were not identified on the list.
On 04/09/2025 at 12:45 p.m., an interview and record review was conducted with S8AM (Accounts Manager), who confirmed she was responsible for sending the Emergency Transfer Log to the State Long Term Care Ombudsman. S8AM reviewed Resident #7's nurse's notes and confirmed the resident was transferred to the hospital on [DATE], 12/24/2024, 03/07/2025, 03/14/2025, and 03/17/2025. She then reviewed the Emergency Transfer Log for December 2024 and March 2025 and confirmed the resident was not listed as having been transferred on the above dates. S8AM stated she had emailed the State Long Term care Ombudsman of facility-initiated transfers for the month of March 2025 on 04/07/2025. S8AM also stated she was not aware that facility initiated transfers for less than 24 hours had to be listed on the Emergency Transfer Log and sent to the State Long Term Care Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
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 accurately code the resident's Minimum Data Set (MDS) assessment fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for restraint use for 1 (#28) of 33 sampled residents whose records were reviewed.
Findings:
Review of Resident #28's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diabetes mellitus, acquired absence of right leg below knee and acquired absence of other left toes.
A review of Resident #28's December 2024 Physician's Orders revealed no order for a restraint.
Further review of resident #28's medical record revealed an Annual MDS assessment with an ARD (Assessment Reference Date) of 12/12/2024, which read in part . Section P. Restraints and Alarms .Used in Chair or Out of Bed .Trunk restraints .were indicated.
On 04/09/2025 at 4:29 p.m., an interview and record review was conducted with S5MDS who confirmed Resident #28 did not have an order for a restraint. She reviewed the referenced MDS, and confirmed the use of a restraint was indicated on the assessment and should not 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 review and interview, the facility failed to develop a comprehensive centered care plan for a Level II PASRR (Pr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive centered care plan for a Level II PASRR (Preadmission Screening and Resident Review) for 1 (Resident #47) out of 33 sampled residents. This deficient practice had the potential to affect a census of 96.
Findings:
Review of Resident #47's medical record revealed she was admitted on [DATE] with a diagnosis that included, but not limited to, Schizoaffective Disorder, Depressive Type.
Review of Resident #47's Notice of Medical Certification dated 08/28/2024 read in part, Section II. H. Approved for admission by Level II Authority for a temporary period effective 09/07/2024 through 09/06/2025.
Review of OBH-PASRR (Office of Behavioral Health-Preadmission Screening and Resident Review) Evaluation Summary and Determination Notice Evaluation and Placement Recommendations read in part, the individual has a serious mental illness and is recommended nursing home admission.
Review of Resident #47's comprehensive person-centered care plan revealed she was not care planned for a Level II PASRR.
On 04/09/2025 at 3:04 p.m., an interview and record review was conducted with S5MDS (Minimum Data Set). She confirmed that Resident #47 was a Level II PASRR and this should have been included in her comprehensive care plan and it was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident was invited to the resident's care planning...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident was invited to the resident's care planning meetings for 1 (Resident #54) out of a sample of 33 residents. This deficient practice had the potential to affect a census of 96.
Findings:
A review of the facility's policy titled Care Plan Process with a review date of 01/29/2025, read in part: Baseline Care Plan and Summary: The facility must provide the resident and the resident representative, if applicable, with a written summary of the baseline care plan by completion of the comprehensive care plan. Step 3: Obtain and consider input from resident and/or family/resident's representative regarding the care area. The IDT (Interdisciplinary Team) will minimally include in part the resident and the resident's representative. If the participation of the resident and their representative is determined to be not practicable for the development of the resident's care plan, and explanation shall be included in the resident's medical record.
Review of Resident #54's electronic medical record revealed an admission date of 09/09/2024 with diagnosis diagnoses that included in part, chronic kidney disease, heart failure, and major depressive disorder.
A review of Resident #54's quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 02/25/2025 revealed she had a BIMS (Brief Interview for Mental Status) score of 15, suggesting the resident's cognition was intact.
A review of Resident #54's electronic medical record revealed that she had a Significant Change MDS assessment on 02/25/2025 and 01/25/2025, and a Quarterly MDS assessment on 12/17/2024.
On 04/07/2025 at 12:07 p.m., an interview was conducted with Resident #54. Resident #54 stated that she had never been to a care plan meeting and had never heard of a care plan meeting since she had lived in the facility.
On 04/09/2025 at 10:18 a.m., an interview and record review was conducted with S5MDS (Minimum Data Set Nurse) and S7MDS. S5MDS explained one of the MDS staff provided SSD (Social Service Director) a calendar indicating who the specific residents or residents' representatives were for the SSD to invite to the care plan meetings. Both S5MDS and S7MDS stated that resident or representatives were not invited to care plan meetings when a Significant Change MDS assessment was completed. Both stated that residents and representatives were only invited to care plan meetings associated with quarterly and annual MDS assessments. S7MDS confirmed that there was no documentation that a care plan meeting was conducted for Resident #54 for the MDS assessment dated [DATE], nor that the resident or the residents' representative was present or had declined to attend. Both confirmed that they did not have knowledge of the resident attending this care plan meeting.
On 04/09/2025 at 10:52 a.m., an interview was conducted with S9SSD. S9SSD stated that she had never been instructed to invite the residents to their care plan meetings and had not invited Resident #54 to past care plan meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure residents received food in the amount required to meet nutritional needs of residents by failing to use the appropriat...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure residents received food in the amount required to meet nutritional needs of residents by failing to use the appropriate serving sizes as indicated by the diet spreadsheet.
This deficient practice had the potential to affect the 21 residents residing on the secured unit.
Findings:
Review of the diet spreadsheet for 04/07/2025 revealed dietary staff was required to serve the following: 7 oz (ounces) of ham and beans and 1/2 cup of greens for residents who received regular and mechanical soft diets, and 2 #8 scoops of pureed ham and beans for residents who received pureed diets.
On 04/07/2025 at 11:00 A.M., an observation was made of the kitchen staff while they served lunch. Observations were then made of dietary staff as they prepared meal trays for the secure unit. S3Dietary placed greens onto the residents' plates using a 1/3 cup sized scoop. S8Dietary proceeded to prepare meal trays using a 6 oz scoop for the regular ham and beans. S2DM confirmed the staff were using the incorrect scoop sizes for the regular ham and beans and greens. Further observation was made of the dietary staff while they prepared pureed meal trays. The staff prepared two meal trays using a 6 oz scoop for pureed ham and beans. S2DM confirmed the staff should have been using 2 #8 scoops as the spreadsheet stated. The dietary staff did not re-make residents' plates using the correct serving sizes prior to distributing them to the secured unit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and cont...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to esnure:
1. S6TXN (Treatment Nurse) wore proper PPE (Personal Protective Equipment) while providing wound care to Resident #11, and S10CNA (Certified Nursing Assistant) wore proper PPE while providing care to Resident #83 who was on Enhanced Barrier Precautions;
2. S6TXN appropriately removed and discarded soiled PPE; after completing wound care.
This deficient practice had the potential to affect a census of 96 residents.
Findings:
Review of facility policy and procedure titled Enhanced Barrier Precautions (EBP) with a review date of 01/29/25, read in part .enhanced barrier precautions require the use of gown and gloves only for high-contact resident care activities. The following high-contact resident care activities include but limited to: Providing hygiene, and wound care (chronic wounds include, but not limited to, diabetic foot ulcers, and venous stasis ulcers)
Resident #11:
Review of Resident #11 Electronic Medical Record (EMR) revealed he was admitted on [DATE] with diagnoses which included peripheral vascular disease, and diabetes mellitus. The resident also had bilateral lower extremity arterial ulcers which required wound care.
On 04/08/2025 at 9:00 a.m., a wound care observation and immediate interview was conducted with S6TXN. Further observation revealed an EBP sign posted on the wall above the residents bed. S6TXN was observed cleaning the stasis ulcer on the resident's lower legs, and left heel. Further observation did not reveal that S6TXN had donned the appropriate PPE. S6TXN was asked if she should be wearing a gown while providing wound care, and she then stated that she should have donned a protective covering, which was a gown.
On 04/08/2025 at 9:15 a.m., after completing wound care S6TXN was observed exiting Resident #11's room, with her soiled PPE rolled up and, placed onto a silver tray, and going into the hallway, she placed it into a clear plastic bag. S6TXN was asked if she should have removed the soiled PPE inside of the room, and she confirmed that the PPE should have remained inside the resident's room and placed into a bag.
Resident #83:
Review of Resident #83's electronic medical record revealed an admission date of 07/02/2024 with diagnosis that included in part, gastrostomy status and Alzheimer's disease.
On 04/08/25 3:03 p.m., an assessment of Resident #83's mouth and an interview was conducted with S10CNA. A sign indicating EBP (Enhanced Barrier Precautions) was present on the outside of Resident #83's door. S10CNA was observed without a gown while placing her gloved hands in the resident's mouth to assist with an oral assessment. S10CNA stated that she is not required to wear a gown when providing any care for Resident #83. She stated that the EBP sign on Resident #83's door only indicated what PPE (Personal Protective Equipment) to wear if the resident was on special precautions, and that Resident #83 was not.
04/09/25 3:12 p.m., an interview was conducted with S11IP (Infection Preventionist). He stated that Resident #83 is on EBP, and that a gown should be worn for direct care of his mouth.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected most or all residents
Based on record reviews and interview, the facility failed to ensure a Minimum Data Set (MDS) assessments were completed using the Resident Assessment Instrument (RAI) process within regulatory timefr...
Read full inspector narrative →
Based on record reviews and interview, the facility failed to ensure a Minimum Data Set (MDS) assessments were completed using the Resident Assessment Instrument (RAI) process within regulatory timeframes for 17 (#3, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #61, #66, #67, #82, #89, #307) out of 24 (#3, #9, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #52, #61, #66, #67, #68, #74, #82, #83, #89, #90, #95, #307) total residents reviewed for assessments.
Findings:
Review of Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual- RAI Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary revealed that Assessment Reference Date (ARD) for Resident Assessments should be completed no later than the 14th calendar day of the resident's ARD.
The following Resident records were reviewed on 04/07/2025 .
Review of Resident #3's Electronic Health Record (EHR) revealed a quarterly MDS assessment with an ARD of 02/14/2025 and a required completion date of 02/28/2025. Continued review of Resident #3's EHR revealed a discharge MDS assessment with an ARD of 03/05/2025 and a required completion date of 03/19/2025.
Further review of Resident #3's quarterly and discharge assessments revealed they remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #10's EHR revealed a quarterly MDS assessment with an ARD of 02/22/2025 and a required completion date of 03/08/2025.
Further review of Resident #10's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #14's EHR revealed a quarterly MDS assessment with an ARD of 02/07/2025 and a required completion date of 02/21/2025.
Further review of Resident #14's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #15's EHR revealed an annual MDS assessment with an ARD of 03/05/2025 and a required completion date of 03/19/2025.
Further review of Resident #15's annual assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #18's EHR revealed a quarterly MDS assessment with an ARD of 03/01/2025 and a required completion date of 03/15/2025.
Further review of Resident #18's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #20's EHR revealed a quarterly MDS assessment with an ARD of 03/20/2025 and a required completion date of 04/03/2025.
Further review of Resident #20's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #27's EHR revealed a quarterly MDS assessment with an ARD of 02/20/2025 and a required completion date of 03/06/2025.
Further review of Resident #27's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #28's EHR revealed a quarterly MDS assessment with an ARD of 03/14/2025 and a required completion date of 03/28/2025.
Further review of Resident #28's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #36's EHR revealed a quarterly MDS assessment with an ARD of 02/13/2025 and a required completion date of 02/27/2025.
Further review of Resident #36's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #37's EHR revealed a quarterly MDS assessment with an ARD of 02/25/2025 and a required completion date of 03/11/2025.
Further review of Resident #37's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #46's EHR revealed an annual MDS assessment with an ARD of 02/21/2025 and a required completion date of 03/07/2025.
Further review of Resident #46's annual assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #61's EHR revealed an annual MDS assessment with an ARD of 02/25/2025 and a required completion date of 03/11/2025.
Further review of Resident #61's annual assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #66's EHR revealed a quarterly MDS assessment with an ARD of 02/22/2025 and a required completion date of 03/08/2025.
Further review of Resident #66's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #67's EHR revealed a quarterly MDS assessment with an ARD of 03/02/2025 and a required completion date of 03/16/2025.
Further review of Resident #67's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #82's EHR revealed an annual MDS assessment with an ARD of 02/25/2025 and a required completion date of 03/11/2025. Continued review revealed a death MDS assessment with an ARD of 03/19/2025 and a required completion date of 03/26/2025.
Further review of Resident #82's annual and death assessment revealed they remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #89's EHR revealed a quarterly MDS assessment with an ARD of 02/13/2025 and a required completion date of 02/27/2025.
Further review of Resident #89's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
Review of Resident #307's EHR revealed an admission MDS assessment with an ARD of 03/04/2025 and a required completion date of 03/04/2025.
Further review of Resident #307's quarterly assessment revealed it remained in progress and had not been completed within the 14 day timeframe.
On 04/09/2025 at 1:47 p.m., an interview and records review was conducted with S5MDS who reviewed each of the Resident's records and confirmed each one was incomplete and remained open and in progress. S5MDS confirmed that each assessment should have been completed no later than the 14th calendar day of the resident's ARD and was not.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected most or all residents
Based on interview and record review, the provider failed to transmit a completed Discharge MDS (Minimum Data Set) Assessments within 14 days after completion for 7 (#9, #52, #68, #74, #83, #90, #95) ...
Read full inspector narrative →
Based on interview and record review, the provider failed to transmit a completed Discharge MDS (Minimum Data Set) Assessments within 14 days after completion for 7 (#9, #52, #68, #74, #83, #90, #95) out of 24 (#3, #9, #10, #14, #15, #18, #20, #27, #28, #36, #37, #46, #52, #61, #66, #67, #68, #74, #82, #83, #89, #90, #95, #307) resident's investigated for resident assessments.
Findings:
Review of Resident #9's electronic clinical record revealed a quarterly MDS assessment, with an ARD (Assessment Reference Date) of 01/28/2025, was completed on 01/31/2025.
Review of the facility's CMS (Center for Medicare Services) transmittal validation report indicated Resident #9's quarterly MDS assessment with the ARD of 01/28/2025 was transmitted on 04/07/2025 and was more than 14 days late.
Review of Resident #52's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 01/25/2025, was completed on 01/28/2025.
Review of the facility's CMS transmittal validation report indicated Resident #52's quarterly MDS assessment with the ARD of 01/25/2025 was transmitted on 04/07/2025 and was more than 14 days late.
Review of Resident #68's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 02/05/2025, was completed on 02/19/2025.
Review of the facility's CMS transmittal validation report indicated Resident #68's quarterly MDS assessment with the ARD of 2/05/2025 was transmitted on 04/09/2025 and was more than 14 days late.
Review of Resident #74's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 02/14/2025, was completed on 02/14/2025.
Review of the facility's CMS transmittal validation report indicated Resident #74's quarterly MDS assessment with the ARD of 02/14/2025 was transmitted on 04/04/2025 and was more than 14 days late.
Review of Resident #83's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 01/10/2025, was completed on 01/24/2025.
Review of the facility's CMS transmittal validation report indicated Resident #83's quarterly MDS assessment with the ARD of 01/10/2025 was transmitted on 04/07/2025 and was more than 14 days late.
Review of Resident #90's electronic clinical record revealed a significant change MDS assessment, with an ARD of 01/29/2025, was completed on 02/03/2025.
Review of the facility's CMS transmittal validation report indicated Resident #90's quarterly MDS assessment with the ARD of 01/29/2025 was transmitted on 04/07/2025 and was more than 14 days late.
Review of Resident #95's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 02/06/2025, was completed on 02/20/2025.
Review of the facility's CMS transmittal validation report indicated Resident #95's quarterly MDS assessment with the ARD of 02/06/2025 was transmitted on 04/09/2025 and was more than 14 days late.
On 04/09/2025 at 1:47 p.m., a concurrent interview and records review was conducted with S5MDS (Minimum Data Set Nurse). S5MDS reviewed each of the Resident's records and compared them to the facility's transmittal validation report that was received from CMS. S5MDS confirmed each assessment had been submitted greater than 14 days after completion and should not have been.
Mar 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.
Resident #2
Review of Resident #2's electronic medical record revealed she was admitted to the facility on [DATE]. Her diag...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.
Resident #2
Review of Resident #2's electronic medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included the following in part, unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, protein-calorie malnutrition, cerebral infarction, atrial fibrillation, anxiety disorder, major depressive disorder, hypertension, and, muscle weakness. Further review revealed the resident had a facility acquired pressure ulcer identified on her left heel on 01/04/2025.
Review of Resident #2's February 2025 TAR (Treatment Administration Record) revealed the following:
An order with a start date: 01/24/2025 and stop date: 02/04/2025: Stage II to left heel apply collagen powder and cover with foam dressing daily. Further review revealed missed wound care treatments on 02/01/2025 and 02/02/2025.
An order with a start date: 02/05/2025 and stop date: 02/13/2025. Stage II to left heel paint with betadine and dry dressing until resolved every day shift. Further review revealed missed wound care treatments on 02/08/2025, 02/09/2025 and 02/12/2025.
An order with a start date 02/14/2025: Stage II to left heel paint with betadine, non-adherent pad and dry dressing until resolved every day shift. Further review revealed missed wound care treatments on 02/15/2025, 02/18/2025, 02/22/2025, and 02/23/2025.
Review of the resident's March 2025 TAR revealed the following:
An order with a start date: 02/14/2025: Stage II to left heel paint with betadine, non-adherent pad and dry dressing until resolved. Further review revealed missed wound care treatments on 03/03/2025, 03/08/2025, and 03/09/2025.
On 03/12/2025 at 4:20 PM, an interview was conducted with S2DON (Director of Nursing). She stated that they were aware of the missed wound care treatments for Resident #2. She stated the treatments should have been done as ordered.
Based on record review, observations and interview, the facility failed to ensure that residents received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 2 residents (#2 and #3) out of a total of 6 (#1, #2, #3, #R4, #R5 and #R6) sampled residents. This deficient practice was evidenced by the facility staff failing to:
1. Conduct weekly body audits for Resident #3;
2. Identify a Stage 2 Pressure Ulcer for Resident #3; and
3. Provide ordered treatments for Resident #2.
Findings:
A review of the facility's policy titled, Weekly Body Audit, with a latest review date of 08/2021 revealed, in part: To be completed weekly for all residents to identify any new alterations in skin integrity. On a designated day of the week, per facility schedule as developed by the DON (Director of Nursing), a body audit will be performed. The Licensed Nurse completes a head to toe inspection of the skin with notation of no new problem or new problem noted. If a new issue is noted, additional documentation in the nurse notes is required. The Licensed Nurse proceeds forward per policy if a change in the resident's condition is noted. Communicate to Interdisciplinary Team, Physician/ NP (Nurse Practitioner) and family/designee any changes in skin integrity.
1.
Resident #3
Resident #3 was admitted to the facility on [DATE] with the following pertinent diagnoses: COPD (chronic obstructive pulmonary disease), type 2 DM (diabetes mellitus) w/ diabetic neuropathy, paranoid schizophrenia, bipolar disorder, pulmonary nodule, vitamin b12 deficiency anemia, adult failure to thrive, weakness, dependence on supplemental oxygen, anxiety and major depressive disorder and protein-calorie malnutrition.
Review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed under Section M, Skin Conditions, Resident #3 was assessed at risk for developing pressure ulcers.
Review of Resident #3's care plan revealed the resident had an intervention to conduct weekly body audits as scheduled.
Further review of Resident #3's EHR failed to include evidence that weekly body audits were conducted the weeks of: 11/03/2024, 11/10/2024, 12/15/2024, 12/29/2024, 01/12/2025, 01/19/2025 and 01/26/2025.
2.
Review of Significant Change MDS assessment dated [DATE] revealed under Section M, Skin Conditions, Resident #3 was assessed at risk for developing pressure ulcers.
Further review of Resident #3's EHR revealed the last weekly body audit to identify any new skin issues was last conducted on 01/11/2025 which revealed no skin issues. There were no furher records of weekly body audits after this date.
Review of Resident #3's EHR (Electronic Health Record) revealed the resident was sent to the emergency room on [DATE] and admitted inpatient from 02/05/2025 through 02/08/2025. Hospital records revealed visual evidence via photo of a Stage 2 pressure ulcer to Resident #3's sacral spine which was present on admission to the hospital measuring length (l) x width (w) x depth (d) in centimeters (cm) 1.5cm x 1.5 cm x 0.2 cm.
On 03/11/2025 at 2:00 PM, an interview was conducted with S3TxLPN (Treatment Licensed Practical Nurse) who stated weekly body audits were completed by the floor nurses and any new skin conditions or skin changes identified were reported to her.
On 03/12/2025 at 4:10 PM, an interview was conducted with S1CN (Corporate Nurse) and S2DON (Director of Nursing). S1CN was unable to provide documentation that weekly body audits were conducted for the weeks of 11/03/2024, 11/10/2024, 12/15/2024, 12/29/2024, 01/12/2025, 01/19/2025 and 01/26/2025. S1CN was also unable to provide documentation of Resident #3's weekly body audit being conducted prior to Resident #3 being hospitalized week of 02/02/2025.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to measure its success and track performance after identifying an area of impro...
Read full inspector narrative →
Based on record review and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to measure its success and track performance after identifying an area of improvement as evidenced by failing to have documented evidence of monitoring the effectiveness of the proposed plan of action.
This deficient practice had the potential to affect a census of 98 residents.
Findings:
Review of the facility's form titled, Corrective Action Plan, dated 02/12/2025 revealed:
1. Problem Identified: Tasks not firing correctly due to facility changed from 12 hour shifts to 8 hour shifts. 12 hour shifts continued to fire to tasks in addition to 8 hours. Several time code discrepancies resulted in facility wide tasks audit to make corrections.
2. Plan of Action: Immediate action of Task audits of each resident correcting each task time code. Audit of Every individual task for each resident audited and corrected. Nursing staff were in-serviced on task time codes (8 hours) and correct body audit schedules must be verified on each new admit and hospital return/readmission. Projected completion date: 02/14/2025.
3. Monitoring: DON (Director of Nursing)/ designee to randomly audit 5 resident tasks 3 times weekly to ensure time codes are accurately reflecting 8 hour shifts and body audits are set up weekly per schedule. Hospital returns are to be audited within 24-72 hours of return to ensure any cancelled tasks that still apply to resident are reactivated.
4. Follow- up for Effectiveness: Section remained blank and failed to include a resolved date.
On 03/12/2025 at 4:30 PM, a review of the facility's corrective action plan and an interview was conducted with S1CN (Corporate Nurse) and S2DON (Director of Nursing). There was no documented evidence that the actions implemented were measured or that performance of the action plans were tracked from 02/12/2025 through 03/10/2025. There was also no evidence of data collection and analysis. S1CN and S2DON confirmed there was no documented evidence of monitoring, or performance tracking conducted from 02/12/2025 thru 03/10/2025.
Mar 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on record review, interviews, and policy and procedure reviews the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident coun...
Read full inspector narrative →
Based on record review, interviews, and policy and procedure reviews the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and demonstrate the facility's response for such grievances in the facility.
Findings:
On 03/21/2024, a review of the facility's policy, Resident Council, with a last reviewed date of 01/25/2024, revealed in part, the following, Policy: A Resident Council will be organized within the facility with regularly scheduled meetings (at least quarterly). If a formal Resident Council cannot be established within the facility, an alternate process is established . Purpose: To provide a forum for residents to share in the governance of the facility by providing opinions, suggestions, and problem solving in relation to areas of concern or community issues. Procedures: . 8. The facility must consider the views of the group and act promptly upon recommendations regarding issues of resident care and life in the facility. The Grievances-Residents process shall be followed. The grievance report shall reflect the rationale of facility response.
On 03/21/2024, a review of the facility's policy, Grievances -Residents, with a last reviewed date of 01/25/2024, revealed in part, the following, All residents are encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff and other resident's and other concerns regarding their facility stay, in the event that they have a need to make a concern. The following outlines the process: . Upon receipt of a grievance/complaint the staff receiving the complaint will initiate the Grievance/Complaint Form . The administrator and his/her designees will conduct an impartial investigation of the allegations and will discuss the findings and recommendations within five (5) work days of receiving the complaint, with the complainant .
A review of the Resident Council Meeting Minutes was conducted and revealed notes by S11AD (Activity Director) for 03/13/2024 with a nursing complaint of some residents are complaining about not getting a shower. There was no evidence the complaints were reviewed by S1DON (Director of Nursing) nor that the facility provided a response to the complaint.
A review of the facility's grievance log from 03/2024 failed to include the complaint addressed during the monthly Resident Council Meeting Minutes for 03/13/2024.
On 03/18/2024 at 1:53 p.m., an interview was conducted with S11AD. S11AD confirmed she was the designated staff who sat in on the monthly Resident Council meetings. A review of the Resident Council Meeting Minutes from 03/13/2024 was conducted with S11AD. S11AD stated the resident that complained about not getting a shower was Resident #246 and she confirmed she had given a copy of all complaints during the monthly meeting to the administrative staff.
On 03/18/2024 at 1:30 p.m., an interview was conducted with Resident #246. Resident #246 is interviewable and able to answer questions appropriately. Resident #246 reported she attended the Resident Council meeting on 03/13/2024. Resident #246 reported she voiced a complaint during the monthly meeting that she did not receive a shower on Tuesday 03/12/2024 with S11AD present. She confirmed that after the complaint was voiced in the monthly meeting no one spoke to her about it further.
On 03/19/2024 at 4:08 p.m. an interview was conducted with S1DON (Director of Nursing) who stated if there is a nursing complaint during the resident council meeting, she has to file a grievance and further investigate the complaint. S1DON reviewed Resident Council Meeting Minutes from 03/13/2024 and stated that since there was a nursing complaint about some residents not getting a shower a grievance should have been started and investigated by her and it was not done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents were free from unnecessary physical...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents were free from unnecessary physical restraints for 1 (#76) resident out of 2 (#75, #76) residents investigated for physical restraints.
Findings:
On 03/20/2024, a review of the facility's policy titled Restraints and Safety Devices with a last reviewed date of 01/25/2024 read in part .The use of a restraint will require a determination of need to be completed by a licensed nurse, a signed consent and a physician's order prior to applying restraints Before a restraint may be use, the following steps must be followed unless it is an emergency situation: 1. Identify reason for symptoms that indicate the need for a restraint. 2. Remove, if possible, the causes of these symptoms. This may include taking care of special needs, increased rehabilitation and restorative nursing, modifying the environment and increasing supervision .4. Restraints should be used only after practicable alternatives have failed. The least restrictive device that will protect the resident should be selected and used for the shortest time while less restrictive alternatives are sought.Residents must be screened for use of approved restraints to meet their particular needs.
Review of Resident #76's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alzheimer's Disease, Weakness, and Hemiplegia.
Review of Resident #76's plan of care revealed the following problem and intervention: Resident is at risk for falls r/t (related to) impaired cognition secondary to Alzheimer's Disease and an intervention implemented on 09/30/2022 to maintain bolsters to bed. Further review of Resident #76's plan of care also revealed the resident had functional limited range of motion in lower extremity and an intervention to assist resident with Activities of Daily Living as needed.
Review of Resident #76's March 2024 physician's orders revealed the following order dated 02/07/2023: Maintain bed bolsters while in bed every shift.
Review of Resident #76's EHR and paper chart failed to reveal an assessment or evaluation for the use of bolsters to the resident's bed.
On 03/19/2024 at 9:30 a.m., an observation was made of Resident #76's room. The resident's bed had bolsters to each side of the bed. 2 half- length bed rails were raised at the head of the resident's bed. The bolsters were adjacent to the side rails, preventing the resident from exiting the bed or rolling out of bed. The bolsters were the length of the side rails.
On 03/19/2024 9:43 a.m., an interview was conducted with S14CNA (Certified Nursing Assistant). S14CNA stated Resident #76 can reposition herself in bed with assistance, but she cannot turn herself. She also stated that the resident cannot walk and does not try to get out of bed. S14CNA stated she was not sure why the resident had bolsters to the sides of the bed, but she cannot remove the bolsters.
On 03/19/2024 at 12:42 p.m., a joint interview was conducted with S1DON (Director of Nursing), S2ADONIP (Assistant Director of Nursing/Infection Preventionist), and S3CorpRN (Corporate Registered Nurse). S2ADON stated Resident #76 had bolsters in place because the resident was trying to get out of bed, and it was a fall intervention. S2ADON stated the resident still throws her legs on the side of the bolsters, but does not get out of bed. Resident #76's plan of care was reviewed with S3CorpRN who stated the resident was care planned for the bolsters when she fell on [DATE], but she did not see that she had any falls since then. S2DON then stated that the resident had the bolsters in place as a deterrent to prevent her from getting out of bed. S2DON also stated that even though Resident #76 had not had any falls since 09/30/2022, the bolsters were not removed because it is used for fall prevention. S1DON, S2ADON, and S3CorpRN were asked to provide documentation or assessments for the implementation of the bolsters or continued use of the bolsters but failed to provide any assessments.
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 interview, record review ,and policy review the facility failed to implement the resident's care plan by failing to adm...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review ,and policy review the facility failed to implement the resident's care plan by failing to administer medications per physician's orders for 1 ( #94) out of a total sample of 30 residents.
Findings:
On 03/20/2024, review of the facility's policy, Drug Administration and Documentation, last reviewed on 01/25/2024, revealed in part, the following . Routine medications must be administered no more than sixty (60) minutes before or after the
prescribed time.
Review of Resident #94's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Malignant Neoplasm Of Colon Unspecified, Neoplasm Related Pain (Acute) (Chronic), Hyperlipidemia, Other Specified Arthritis, Unspecified Site, and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms.
Review of Resident #94's physician orders dated 03/01/2024 revealed:
1.
Clarithromycin 500 mg (milligram) tablet give one tablet by mouth twice daily for 12 doses
2.
Pravastatin 10 mg tablet give 1 tablet by mouth at night daily
3.
Tamsulosin 0.4 mg capsule give 1 capsule by mouth at night daily
4.
Pantoprazole 40 mg tablet give 1 tablet by mouth twice daily
5.
Morphine ER (extended release) 30 mg tablet extended release, administer 1 tablet by mouth twice daily for
14 days
6.
Metronidazole 500 mg tablet give 1 tablet by mouth three time daily for 18 doses
Review of MAR (Medication Administration Record) for 03/01/2024, revealed doses of Clarithromycin, Pravastatin, Tamsulosin, Pantoprazole, Morphine ER, and Metronidazole timed for 8 p.m. were not administered as ordered.
On 03/20/2024 at 12:31 p.m. a joint interview was conducted with S1DON (Director of Nursing) and S10ADON (Assistant Director of Nursing). S1DON stated that medications are ordered as soon as the resident arrives to the facility. S10ADON confirmed that Resident #94 arrived to the facility at around 3:05 p.m. on 03/01/2024. She stated after the resident arrived to the facility his medications were ordered. S10ADON stated Resident #94's medications arrived to the facility at 8:35 p.m. on 03/01/2024. S10ADON confirmed that Resident #94 should have received his medications after they arrived from the pharmacy but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily l...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for 1 (#18) out of 2 (#18, #69) residents investigated for ADLs out of a total sample of 30 residents.
Findings:
On 03/20/2024, a review of the facility's policy titled Activities for Daily Living with a last reviewed date of 01/25/2024 read in part .Procedure .7. CNAs will document completion of resident assignments every shift by marking with their initials or by entering in electronic charting system 9. CNA's will initial indicating completion of assignments for the specific date and shift at the end of the ADLs or enter electronically.
Review of the Nursing Assistant-Certified Job Summary read in part .Responsibilities .16. Follows baths and whirlpool schedules as outlined for each resident.
Review of Resident #18's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Cervical Disc Disorder, and Other chronic pain.
Review of Section C of Resident #18's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating his cognition was intact. Review of Section GG of Resident #18's quarterly MDS assessment revealed the resident was dependent for showering/bathing.
Review of Resident #18's most current plan of care revealed the resident had a diagnosis of Quadriplegia with an intervention to provide assist with ADLs as needed.
A review of Resident #18's February 2024 completed care tasks revealed no documented evidence that the resident received a bed bath on the following dates: 02/24/2024 and 02/27/2024. Review of March 2024 completed care tasks revealed no documented evidence that the resident received a bed bath on the following dates: 03/02/2024, 03/05/2024, 03/09/2024, and 03/16/2024. Further review of the completed care tasks revealed the following documentation: S15CNA (Certified Nursing Assistant) Reason the resident was not bathed on 03/09/2024 at 10:22 a.m.: It was not shower day.
On 03/18/2024 at 9:46 a.m., an interview was conducted with Resident #18 who stated that he did not receive baths when he was supposed to. Last week he was supposed to receive a bed bath on Tuesday and Thursday, but did not receive one until Friday. He further stated that he did not receive his scheduled bath on Saturday and was not informed of the reason he did not receive one.
On 03/19/2024 at 12:14 p.m., an interview was conducted with S4CNASup (Certified Nursing Assistant Supervisor). S4CNASup stated that residents in odd rooms received their showers or baths on Tuesdays, Thursdays, and Saturdays, and CNAs (Certified Nursing Assistants) on the halls were responsible for completing the bed baths. S4CNASup stated that there was a shower and bath log that was signed by the CNAs and the nurses documenting which showers and baths were completed. The completed baths and showers were also documented in the electronic health record. The 500 hall shower and bath log was then reviewed with S4CNASup. The log was not completed with dates or room numbers for several days for the months of February and March 2024. S4CNASup confirmed that the log was not complete, but the showers and baths were documented in the residents' electronic health records.
On 03/20/2024 at 9:10 a.m., a review of Resident #18's completed care tasks for February and March 2024 were reviewed with S4CNASup. She confirmed that the resident had no documented baths on 02/24/2024, 02/27/2024 03/02/2024, 03/05/2024, 03/09/2024, and 03/16/2024, and he should have had baths on those days because he was scheduled to receive bed baths on Tuesdays, Thursdays, and Saturdays. S4CNASup also stated that if the baths were not documented, then they were not done. S4CNASup further confirmed that on 03/09/2024, S15CNA documented that she did not give the resident a bath because it was not his shower day, but he should have received a bath because he was scheduled to receive a bath on that day.
On 03/20/2024 at 10:30 a.m., an interview was conducted with S1DON who confirmed that Resident #18's baths were not documented and he should have received a bath on his scheduled bath days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
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 residents were re-evaluated for the continued use of PRN (as...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were re-evaluated for the continued use of PRN (as needed) antipsychotic medications after 14 days for 1 (#75) resident out of a final sample of 30 residents.
Findings:
On 03/20/2024, a review of the facility's policy titled Anti-Psychotic-Use of Anti-Psychotics with a last reviewed date of 01/25/2024, read in part .The facility will not use Antipsychotic medications, unless it is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use antipsychotic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to safely reduce and discontinue these drugs .PRN orders for antipsychotic drugs are limited to 14 days and require the evaluation of the attending physician or prescribing practitioner to renew.
Review of Resident #75's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Dementia, Vascular Dementia, Alzheimer's Disease, Mood Disorder, Anxiety Disorder and Major Depressive Disorder.
Review of Resident #75's March 2024 physician's orders revealed an order dated 01/11/2024 that read: Xanax (Alprazolam) 0.5 mg (Milligrams) Tablet; Administer (1) tablet by mouth every 4 hours as needed for agitation/anxiety. There was no stop date ordered on the medication. Further review of March 2024 physician's orders revealed an order dated 02/03/2024 that read: Xanax 0.5 mg tablet, administer one tablet by mouth every 8 hours as needed for agitation or dyspnea. There was no stop date ordered on the medication.
Review of Resident #75's March 2024 MAR (Medication Administration Record) revealed the resident did not receive Xanax 0.5mg every 4 hours as needed nor did she receive Xanax 0.5 mg every 8 hours as needed.
Review of Resident #75's GDR (Gradual Dose Reduction) recommendation dated 01/08/2024 revealed in part, a pharmacist recommendation for a dose reduction for Xanax 0.5 mg Q4HR (every 4 hours) PRN. GDR signed and dated 01/24/2024 revealed a nurse practitioner's documentation that read in part .to continue current use of above stated medication .rationale for continuance is a follows: Hospice care.
A review of Resident #75's February and March 2024 physician and nurse practitioner progress notes failed to address or evaluate the need for the resident's continued use of Xanax PRN for longer than 14 days.
On 03/20/24 10:30 at a.m., and interview and record review was conducted with S1DON (Director of Nursing). S1DON confirmed the resident's order for Xanax 0.5 mg every 4 hours as needed for agitation/anxiety was ordered on 01/11/2024, and there was no stop date. She also confirmed the resident's order for Xanax 0.5 mg every 8 hours as needed for agitation or dyspnea was ordered on 02/03/2024, and there was no stop date. Further review of the resident's electronic health record was conducted with S1DON, and she confirmed that there were no physician or nurse practitioner progress notes in record that provided rationale or evaluation for the continued use of Resident #75's orders for Xanax as needed for longer than 14 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations and interview the facility failed to maintain an infection prevention and control program as evidenced by staff failing to sanitize reusable resident care equipment after use and...
Read full inspector narrative →
Based on observations and interview the facility failed to maintain an infection prevention and control program as evidenced by staff failing to sanitize reusable resident care equipment after use and between residents. The deficient practice had the potential to effect a census of 93.
Findings:
On 03/19/2024 at 4:30 p.m., a review of the facility's policy titled Infection Control Policy for General Cleaning and Maintenance of Equipment reviewed on 01/25/2024 read in part . It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. Further review of facility's policy titled Blood Glucose Quality Control reviewed on 01/25/2024 read in part #18. Clean the meter using a disinfectant wipe. Maintenance of Blood Glucose Monitoring Systems, Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe per facility policy.
On 03/19/2024 at 8:14 a.m., during medication pass, S9LPN (Licensed Practical Nurse) was observed using a tray to carry Resident #13's medications into his room to be administered. She placed the tray on Resident #13's bedside table. S9LPN was observed not sanitizing the tray after leaving Resident #13's room. S9LPN began preparing medications for the next resident and placed the medications for the next resident on the same tray that had not been sanitized. S9LPN was asked about sanitization of the tray between residents and she confirmed that she had not sanitized the tray between residents and should have.
On 03/19/2024, at 10:59 am, during medication pass, S8LPN, was observed using a blood glucose meter to check Resident #63's blood sugar. S8LPN returned to her cart and placed the blood glucose meter back into the cart without cleaning it. S8LPN was then observed entering another resident's room with the same uncleaned blood glucose meter. Before S8LPN used the meter, she was asked about the process on cleaning equipment between residents. S8LPN confirmed that she had not cleaned the blood glucose meter after she used it on Resident #63 and stated that she should have cleaned the blood glucose meter after it is used and between residents.
On 3/19/2024 at 3:30 p.m., an interview was conducted with S2ADONIP (Assistant Director of Nursing Infection Preventionist) and she confirmed that medication trays used to deliver medication to residents should have been cleaned/disinfected after use and between residents. S2ADONIP also confirmed that blood glucose meters should have been cleaned/disinfected after use and between residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards as evidenced by:
1.Failing to ensure oxygen equipment was stored appropriately when not in use for Resident #5 and Resident #68;
2.Failing to ensure oxygen equipment was changed for Resident #53, Resident #68, and Resident #80;
3.Failing to ensure oxygen equipment was properly dated for resident #80.
Findings:
On 03/19/2024, a review of the facility's policy titled Infection Control Oxygen Equipment Cleaning with a last reviewed date of 01/25/2024 read in part . 5. Pre-filled humidifiers are to be dated .6. Refillable humidifiers should be washed and refilled every 72 hours with distilled or sterile water and dated. 7. Tubing should be replaced every 7 days. 8. Masks should be replaced every 7 days. 9. Cannulas should be replaced every 7 days. 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date.
Resident #5
Review of Resident #5's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), and COVID-19.
Review of Resident #5's March 2024 physician's orders revealed an order dated 03/06/2024 for O2 (oxygen) at 2 Liters per minute per Nasal Cannula as needed for SOB (shortness of breath), or decreased sats (oxygen saturation).
Review of Resident #5's care plan read in part .Resident has a Dx (diagnosis) of COPD. Interventions included: Oxygen as ordered .Resident at risk for COVID-19: 02/20/2024: COVID-19 positive.
On 03/18/2024 at 9:20 a.m., an observation was made of Resident #5's room. An oxygen concentrator was observed near the resident's bedside dresser while not in use. The nasal cannula tubing was draped over the oxygen concentrator open to air, with the nose piece of the tubing making contact with the machine.
On 03/18/2024 at 10:42 a.m., a second observation was made of Resident #5's room. The nasal cannula tubing remained draped over the oxygen concentrator open to air with the nose piece of the tubing making contact with the machine.
On 03/18/2024 at 10:53 a.m., S8LPN (Licensed Practical Nurse) was asked to enter Resident #5's room. S8LPN observed the oxygen concentrator machine and confirmed the nasal cannula tubing was open to air and not stored appropriately. S8LPN stated the nursing staff was responsible for storing nasal cannula tubing in a bag when not in use.
Resident #53
Review of Resident #53's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included Shortness of Breath and Chronic Obstructive Pulmonary Disease.
Review of Resident #53's current physician's orders revealed an order dated 12/30/2022 that read, Oxygen 2L (Liters)/Minute via nasal cannula every day as needed for shortness of breath/increased respirations.
Review of Resident #53's care plan with problem onset dated 08/27/2021 that read, Resident receives oxygen therapy as needed. One of the approaches read, Change tubing to oxygen every 7 days of used.
On 03/18/2024 9:20 a.m., an observation was made of Resident #53's oxygen nasal cannula in a bag with a date of 2/18/2024 attached to a humidifier dated 2/18/2024.
On 03/18/2024 at 10:41 a.m., an observation and interview was conducted with S2ADONIP (Assistant Director of Nursing Infection Preventionist). She confirmed that Resident #53's oxygen nasal cannula and humidifier were in the resident's room at the bedside and dated 02/18/2024. S2ADONIP confirmed that oxygen tubing and humidifier should have been changed, and had not been.
Resident #80
Review of Resident #80's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Acute Respiratory Failure with Hypoxia.
Review of Resident #80's current physician's orders dated 11/27/2023 that read, Oxygen 2L(Liters)/Min(Minute) per nasal cannula as needed for Shortness of Breath.
Review of Resident #80's care plan revealed a problem with an onset date of 10/17/2023 that read, Resident receives oxygen therapy. The approaches for this problem read in part, administer oxygen as ordered, change tubing to oxygen every 7 days, change humidifier bottle at least every month.
On 03/18/2024 at 10:25 a.m., and observation was made Resident #80's oxygen at bedside with nasal cannula in a bag with a date of 02/19/2024 attached to a humidifier that was not dated. At that time S8LPN was in the hall and an interview and observation was conducted. She confirmed that the bagged nasal cannula in Resident #80's room at his bedside had a date of 02/19/2024 and the humidifier did not have a date. S8LPN confirmed the nasal cannula should have been changed after 7 days of use, along with the humidifier.
Resident #68
Review of Resident #68's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety.
Review of Resident #68's March 2024 physician's orders revealed the following order dated 03/18/2024: O2 (Oxygen) at 2L/Minute (Liters per Minute) per nasal cannula prn (As Needed) SOB (Shortness of Breath).
On 03/18/2024 at 9:27 a.m., an observation was made of Resident #68's room. An oxygen concentrator was observed with the nasal cannula tubing attached to a refillable humidifier. The nasal cannula was draped over the oxygen concentrator and was not in bag. The refillable humidifier was labeled with a date of 02/18/2024.
On 03/18/2024 at 9:29 a.m., an observation was made of Resident #68's oxygen concentrator, nasal cannula and refillable humidifier with S7LPN (Licensed Practical Nurse). S7LPN stated that the residents' humidifiers were supposed to be changed weekly. S7LPN confirmed the humidifier had a date of 02/18/2024 and should have been changed. S7LPN also stated that the resident uses the oxygen and nasal cannula that were in room. S7LPN confirmed that the resident's nasal cannula should have been stored in a bag since it was not in use.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure that menus met the nutritional needs of residents according to established guidelines, as evidenced by the kitchen staff failing to ha...
Read full inspector narrative →
Based on observation and interview, the facility failed to ensure that menus met the nutritional needs of residents according to established guidelines, as evidenced by the kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods.
This deficient practice had the potential to contribute to decreased intake, altered nutritional needs, and weight loss for the 9 residents who consumed pureed diets. 92 residents consumed foods from the kitchen.
Findings:
On 03/18/2024 at 9:50 a.m., an observation of the pureed procedure was conducted. S12Diet (Dietary) scooped 5 large unmeasured cooking spoons of macaroni noodles into the food processor, and used the same spoon to scoop 2 large spoons of melted cheese. S12Diet poured water from a large pitcher into the food processor without measuring, then poured an unmeasured portion of a white powder from a cup on the counter into the food processor. She turned the food processor on, then stopped and poured more water and white powder in the food processor and blended again.
On 03/18/2024 at 9:55 a.m., an interview was conducted with S12Diet. She stated that she had been working at the facility for 14 years. S12Diet stated that she prepared the pureed macaroni for 9 residents. She further stated that she had never used a recipe to prepare pureed foods for the residents, and was never informed that she had to use one.
On 03/18/2024 at 9:56 a.m., an interview was conducted with S5DietarySup (Dietary Supervisor). S5DietarySup stated that she did not have pureed recipes for foods prepared in the kitchen for residents. S5DietarySup further stated that she had never received pureed recipes to use for pureed menus.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintaine...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to:
1.
Discard expired foods from the kitchen refrigerator, freezer, and dry storage area;
2.
Label opened foods with the date they were opened;
3.
Remove compromised cans from the dry storage area;
4.
Clean the inside of oven and outside of refrigerator and freezer; and
5.
Ensure staff wore hair restraints in the kitchen.
This deficient practice had the potential to affect the 92 residents who consumed food from the kitchen from a census of 93 Residents.,
Findings:
On 03/18/2024 at 3:00 p.m., a review was conducted of the facility's policy titled, Storage of Refrigerated Food with a revision date of 01/25/2024. This Policy read in part, The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure .5. All non-hazardous, opened foods are labeled with name of food, date stored .11. Food shall be stored base on use-by expiration date .
On 03/18/2024 at 3:00 p.m., a review was conducted of the facility's policy titled Storage of Frozen Food with a revision date of 01/25/2024. This Policy read in part, The facility ensures the quality and safety of frozen food through accepted storage practices. Procedure: Frozen foods are used or discarded on or before the use-by expiration date .
On 03/18/2024 at 3:00 p.m., a review was conducted of the facility's policy titled Storage of Canned and Dry Food with a revision date of 09/2023. The policy read in part, Procedure .8. Opened packages are stored in tightly covered containers or zipped plastic bag . If stored in a container other than how they were received, the items name and date it was received or opened must be visible or written on the new storage container.
On 03/18/2024 at 3:00 p.m., a review was conducted of the facility's policy titled Persons Allowed in The Food Service Department with a revision date of 01/25/2024. The policy read in part, Procedure .5.All employees and non-employees entering the food service department must wear hair restraints, including beard restraint as applicable.
On 03/18/24 at 8:38 a.m., a tour of the facility's kitchen was conducted with S5DietarySup (Dietary Supervisor). She stated that she was responsible for the day-to-day management of the kitchen.
An observation of the walk-in refrigerator with S5DietarySup revealed the following items were opened but not labeled with the date and time they were opened:
1-gallon bottle of myonnaise
1-gallon bottle of mustard
1 bag of dinner rolls
2-gallon bottles of milk
1-quart box of milk
3 bags of sliced bread
S5DietarySup confirmed the items were opened, and not labeled with the date and time, and stated they should have been labeled with the date and time they were opened.
The following items did not have a date they were made or a use-by date:
9 pre-made fruit cups covered with plastic.
S5DietarySup confirmed that the pre-made fruit cups should have been labeled with the date and time they were made and placed in the refrigerator.
The following items were observed without labeling to specify what they were and when they were prepared or when to be discarded. S5DietarySup identified the contents of the following unlabeled items as:
1 pitcher of brown liquid with tea
1 pitcher of red liquid with punch
S5DietarySup confirmed the items had no label to specify the contents and when they were prepared. She further confirmed the items should have been labeled to specify the contents and when they were prepared.
Further observations revealed the following items were expired:
31 loaves of sliced bread dated 10/26/2023; 1 dated 10/25/2023; 2 dated 10/28/2023
S5DietarySup confirmed the items were expired and should have been discarded.
An observation of the walk-in freezer revealed the following items were expired or opened with no date or time:
Hot dog buns: 1 bag dated 06/13/2023; 1 bag dated 01/13/2023; 2 bags hot dog buns dated 08/09/23
29 hamburger buns dated 10/11/2023
An open bag of poboy buns with 6 remaining.
S5DietarySup confirmed that the items were expired and should have been discarded on the date they expired. She also confirmed that the poboys buns should have the date and time the bag was opened.
An observation of the dry storage room revealed the following items were expired:
1 plastic gallon-bag with rice cereal dated 02/13/2024
3 packs citrus gelatin dated 10/18/2023
1 plastic gallon bag with cheerios dated 3/17/2024 and another dated 02/29/2024
1 plastic gallon - bag with Raisin Bran dated 03/11/2024
1 plastic gallon-bag with cornflakes dated 02/13/2024
1 gallon-bag with frosted flakes dated 01/09/2024
5 packages cornbread mix dated 09/28/2023
2 packs brownie mix dated 06/27/2023
4 packs brownie mix dated 12/15/2023
The following items were opened but had no opened date:
1 two way white cake mix and 2 bags bacon bits.
The following items were compromised:
1 can tomato soup with yellow build-up on the outside of the can, and 3 dented cans.
Further observation of the dry storage room revealed the floor underneath the rolling shelfs had loose cereal on the floor and moderate dust build-up in the corners.
S5DietarySup confirmed the items in the dry storage area were expired, opened, and had no date to tell when they were opened. She also confirmed the compromised can and the dirty floor. S5DietarySup stated that the items should have been discarded and the floor cleaned.
An observation of the inside of the baking oven revealed a white dry build up on the bottom, and moderate amount of brown splatters on the inside of bilateral oven doors. Debris was noted underneath the oven doors when they were opened. S5DietarySup confirmed the findings and stated the oven should have been cleaned but was not.
An observation of the outside of the walk-in refrigerator and walk-in freezer revealed a green moist build-up around the bottom of the doors. S5DietarySup confirmed the green moist build-up and stated that it should have been cleaned.
On 03/18/2024 at 9:54 a.m., an observation was made of S13Maint (Maintenance) walking in the kitchen as surveyor stood by the counter observing the pureed process. Further observation revealed S13Maint had a full beard which was uncovered.
On 03/18/2024 at 12:24 a.m., an interview was conducted with S13Maint. He confirmed that he walked through the kitchen with his beard uncovered and stated that he should have worn a beard covering.
On 03/28/2024 at 11:03 a.m., an observation was conducted of S11AD (Activities Director) walking into the kitchen with no hair covering.
On 03/18/2024 at 1:10 p.m., an interview was conducted with S11AD. S11AD stated that she walked into the kitchen without hair covering to check a schedule in the kitchen, and stated that she should have worn a hair net but had not.
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
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observations, record review and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects and rodents. The deficien...
Read full inspector narrative →
Based on observations, record review and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects and rodents. The deficient practice had the potential to affect 87 residents who resided in the facility.
Findings:
Review of the facility's policy Pest Control, read in part a pest management program is used to prevent pests from entering . Procedure 1 . c. Gaps and cracks in doorframes and thresholds are sealed with weather stripping .
Review of resident #2's Grievance/Complaint form dated 6/29/2023 revealed the resident complained that she had bugs in her room. The summary of pertinent findings or conclusions revealed the fields surrounding the facility were recently cut and the bugs from outside were drawn to the inside light. Insects were entering the door on the hall where the resident resides. The corrective action taken revealed that on 6/29/2023 maintenance sealed the door where the insects were likely coming inside. On 6/30/2023, resident #2 stated the bugs were still coming inside.
Review of resident #3's Grievance/Complaint form dated 8/21/2023 revealed the resident reported to staff that she saw a mouse in her room.
Review of the facility's Incident Log revealed that there was documentation Resident #1 had an insect bite/sting in her room on 9/19/2023. Review of Resident #1's progress notes dated 9/19/2023 at 12:26 pm revealed, .Resident noted having scattered red raised areas to left arm . Review of Resident #1's Incident Investigation report dated 9/19/2023 revealed the red, raised areas were intact pustules around the top of the resident's left arm.
On 10/23/2023 at 11:18 a.m., an interview was conducted with Resident #3. Resident #3 was observed sitting up in bed, watching television. Awake and alert. The resident stated she saw a mouse in her room for 2 nights, a few weeks ago. She stated on the first night, the little gray mouse ran from the bathroom, to her door, and down the hallway. The following night, she saw the mouse again running towards her bathroom. The resident stated she has seen big tree roaches in the area where she plays bingo.
On 10/23/2023 at 12:00 pm, an interview was conducted with Resident #2. Resident #2 stated that there were bugs in her room that came from outside the facility. The resident stated that she reported the bug problem to S1AIT (Administrator in Training).
On 10/23/2023 at 1:55 pm, an interview was conducted with S3CNA (Certified Nursing Assistant). She stated that she worked on the A hall. S3CNA stated that she saw a mouse in the facility about 4 months ago when the fields around the facility were being cut.
On 10/23/2023 at 2:10 pm, an interview was conducted with S4LPN (Licensed Practical Nurse). She stated that she has seen bugs in the facility and heard that there were mice in the facility. S4LPN stated that she saw 2 or 3 bugs by the door when she was coming in for work this morning.
On 10/23/2023 at 2:15 pm, an interview was conducted with S5FT (Floor Tech). He stated that a few months ago the facility had problems with bugs. S5FT stated the bugs came from the fields surrounding the facility when the fields were being cut.
On 10/23/2023 at 2:30 pm, an interview was conducted with S1DON (Director of Nurses) and S1MS (Maintenance Supervisor). S1DON confirmed that Resident #1 had been bitten by ants on 9/19/2023. S6MS stated that he checked for ant mounds around the facility every week. S6MS stated that there were problems with bugs and insects because there were bean and rice fields all around the facility. He stated that when the fields were cut that was when the facility had problems with bugs. S1MS stated that the plan the facility had in place was to spray around the facility every week and he weather stripped the facility over the summer.
Review of the invoices for extermination services for pest control were dated 9/13/2023, 9/20/2023, and 10/17/2023. Review of the invoice dated 9/20/2023 revealed, Call back ants (Resident #1's room) (B Hall courtyard)
On 10/23/2023 at 3:00 pm, an interview was conducted with S1AIT. He stated the exterminator came out every month and that the exterminator had to come back in September on 9/20/2023 to take care of ants.
On 10/24/2023 at 8:45 am, an interview was conducted with S7CNA. She stated that residents had complained about mice on the C Hall.
On 10/24/2023 at 10:00 am, a tour of the facility was conducted with S6MS and S1AIT. An observation was made of the exit door on C Hall. During the observation, sunlight was observed shining through the bottom right of the exit door. The exit door was not properly sealed. S1MS confirmed that the door was not properly sealed and that there was a hole in the seal to the bottom right of the exit door on C Hall. S1MS stated that it was possible for insects and rodents to enter the facility through the hole in the seal of the exit door.
On 10/24/2023 at 10:07 am, an observation was made of a large squashed bug on the dining room floor. The residents were observed playing bingo in the dining room during this observation. S8CNA was observed passing through the dining room and was asked what was on the floor. She looked down on the floor and stated that it looked like a grasshopper and she kept walking.
On 10/24/2023 at 10:10 am, S9LPN was observed walking through the dining room. She was asked what was on the floor and she stated that it looked like a cricket and she took a paper towel and picked it up off the floor and disposed of it in the garbage can.
Aug 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain a clean and homelike environment as evidenc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain a clean and homelike environment as evidenced by the presence of cobwebs, sediment observed on the wall, and stained privacy curtain for 1 (#3) of 6 (#1, #2, #3, #4, #5 and R1) sampled residents.
Findings:
Review of facility's policy titled, Resident Environment, revealed: It is the policy of this facility to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his/her personal belongings to the extent possible.
Review of form titled, Housekeeping Hall Job Duties, revealed in part: Task to be completed each shift .Clean spider webs .When cleaning rooms please make sure you are moving everything and cleaning behind them .
Review of form titled, Detail Cleaning Checklist, revealed in part .Disinfect corners .Spot clean walls .Conduct final inspection .
Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Quadriplegia, Anxiety Disorder, Neuromuscular Dysfunction of Bladder and Dysuria.
Review of Resident #3's significant change MDS (Minimum Data Set) assessment dated [DATE] revealed that the resident had moderately impaired vision and a BIMS (Brief Interview for Mental Status) score of 9, indicating the resident's cognition was moderately impaired.
On 08/17/2023 at 4:25 p.m., an observation was made of Resident #3's bed facing an empty bed across from him and to his left of his bed, in the corner of the ceiling, was a large cobweb. At the foot of the resident's bed, was his privacy curtain with scattered dark brown and black colored stains and a quarter sized yellow stain. An additional observation was made of the wall. To the right of the resident's head of bed, was a dark brown colored splatter pattern noted on the lower portion of the wall, between the telephone outlet and air vent.
On 08/21/2023 at 9:20 a.m., a follow up observation was conducted of Resident #3's room. In the corner of the ceiling, to the left of resident's head of bed, was the large cobweb that remained. At the foot of the resident's bed, was his privacy curtain with scattered dark brown and black colored stains and a quarter sized yellow stain. An additional observation was made of the wall. The dark brown colored splatter pattern remained,on the lower portion of the wall, between the telephone outlet and air vent.
On 08/22/2023 at 8:58 a.m., an interview was conducted with S6HskSUP (Housekeeping Supervisor) who stated all housekeepers had a checklist of daily duties that was kept on each housekeeper's cart, and once a month, each room had a designated date for detailed cleaning to be done as listed on the detail cleaning checklist.
On 08/22/2023 at 9:09 a.m., S6HskSUP accompanied surveyor to Resident #3's room and confirmed the presence of a large cobweb on the ceiling to the left of the resident's head of bed, the dark brown colored splatter pattern noted on the wall to the right of the resident's head of bed and the multiple stains on the privacy curtain at the foot of the resident's bed. S6HskSUP confirmed the cobweb, dark brown splatter on the wall, and stains on the privacy curtain should have been cleaned. S6HskSup was unable to recall the date for August 2023 of Resident #3's detail cleaning and stated she had to obtain the calendar.
On 08/22/2023 at 10:00 a.m., S6HskSUP provided the August 2023 calendar of detail cleaning schedule which revealed Resident #3's room was supposed to have a detail cleaning on 08/21/2023 and did not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that service was provided as outlined in the comprehensive p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that service was provided as outlined in the comprehensive plan of care for 1 (#2) of 6 sampled residents (#1, #2, #3, #4, #5, and R1) by failing to ensure that weekly body audits were conducted for Resident #2.
Findings:
Review of the facility's policy titled, Weekly Body Audit revealed in part: Policy: To be completed weekly for all residents to identify any new alterations in skin integrity .1. On designated day of the week, per facility schedule as developed by the DON, a body audit will be performed .5. The Licensed nurse completes a head to toe inspection of the skin with notation of no new problem or new problem noted .
Resident #2 was admitted to the facility on [DATE] with diagnoses in part: Pressure Ulcer of Sacral Region, Unspecified Protein-Calorie Nutrition, Spinal Stenosis.
A review of the Resident #1's care plan revealed that he had a pressure ulcer, with an intervention for weekly body audits.
A review of the resident's July and August 2023 eMAR (Electronic Medical Record) revealed that no record of body audits were conducted.
On 08/21/2023 at 12:45 p.m., an interview and review of Resident #2's eMAR was conducted with S4LPN. S4LPN stated she was responsible for performing body audits on the resident during her shift. S4LPN confirmed that she had not been conducting body audits on the resident and should have.
On 08/22/2023 at 8:47 a.m., an interview and review of Resident #2's eMAR was conducted with S2ADON. S2ADON confirmed that Resident #2 had no weekly body audits documented in his eMAR and that weekly body audits were not being conducted by staff and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice to meet the highest practicable physical well-being of residents when the facility failed to have the required size of a curved tip urinary catheter available to replace the resident's current catheter when it had become occluded and was causing pain for 1 (#3) of 3 (#2,#3 and #R1) residents with urinary catheters out of a total 6 (#1, #2, #3, #4, #5 and #R1) sampled residents.
Findings:
Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Quadriplegia, Anxiety Disorder, Major Depressive Disorder- Recurrent, Moderate, Neuromuscular Dysfunction of Bladder, Dysuria and Other Specified Rheumatoid Arthritis, Multiple Sites.
Review of Resident #3's significant change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating the resident's cognition was moderately impaired. Resident #3 required total staff assistance for toilet use and had functional limitation in range of motion on both sides of upper and lower extremities. Further review of Resident #3's significant change MDS assessment dated [DATE] revealed the resident had an indwelling urinary catheter.
Review of August 2023 physician's orders revealed the following:
-Dated 03/07/23- Indwelling Coude' (curved tip or slightly angled tube) Catheter (#14 FR (French), 10 cc (cubic centimeters) balloon for urinary retention, change every month & as needed for malfunction, occlusion, or leakage.
Review of July 2023 eMAR (electronic Medication Administration Record) revealed indwelling coude' catheter: #14 FR, 10 cc balloon for urinary retention, change every month was completed on 07/01/2023.
Review of Resident #3's current care plan revealed the resident had a dx (diagnosis) of Neurogenic (nerve damage to the urinary system causing lack of bladder control) Bladder and indwelling catheter with a problem onset date of 08/04/2021. Interventions read in part .change cath (catheter) every month and prn (as needed); irrigate cath as ordered; notify MD (Medical Doctor) of any decreased urine output; and observe for effectiveness of medications.
Review of nursing progress notes revealed the following entries:
-Dated 08/17/2023 at 7:52 p.m. per S4LPN revealed 08/17/2023 at 1715 (5:15 p.m.) Staff treatment nurse made this nurse aware of notifying S7NP of difficulties with flushing foley (urinary) catheter, unable to successfully flush, or change catheter. New order given by S7NP to send to ER for evaluate and treat foley catheter.
-Dated 08/17/2023 at 7:54 p.m. per S4LPN revealed at 1800 (6:00 p.m.) the resident transferred via ambulance to ER for evaluation at this time.
-Dated 08/18/2023 at 3:19 a.m. per S10LPN revealed, in part, Received report from ER at 1910 (7:10 p.m.) Foley removed. 15-20 stones came out. Resident placed in brief and instructed to place condom cath on arrival .Unable to obtain condom cath .Resident to remain in brief overnight.
-Dated 08/18/2023 at 8:17 a.m. per S5TxLPN revealed, in part, Late Entry: 08/17/2023 at 1615 (4:15 p.m.) Called to Resident #3 room, per S9Activities, for resident complaints of discomfort regarding foley catheter. Upon entering, resident AAOx4 (awake, alert, oriented to person, place, time and event), resident c/o discomfort 8/10 on pain scale .Catheter assessed, urine not noted to line of gravity bag at this time, LLQ (Left Lower Quadrant) and RLQ (Right Lower Quadrant) tender to palpation. Attempt to flush catheter per MD order unsuccessful. Resident made aware. He verbalized understanding. S7NP notified of acute changes. Order obtained to transfer to ER for evaluation and treatment of foley catheter. Resident made aware of new order at bedside. He verbalized understanding .
Review of ER (emergency room) progress notes dated 08/17/2023 revealed Resident #3 arrived via ambulance on 08/17/2023 at 7:01 p.m. for c/o (complaint of) pain to urinary catheter site .no urine drainage after facility was unable to flush or remove the catheter.
Further review of ER notes dated 8/17/2023 revealed S8NP (Nurse Practitioner) removed catheter at 7:07 p.m. after 12 cc of sterile water was removed from the balloon. Multiple stones, probably 15-20 at least, expelled from the urethra after catheter removal. Discussed with facility to leave catheter out until the resident was able to follow up with Urology.
Review of the medical supply stock count dated 07/18/2023 to 08/17/2023 revealed the facility did not have a 14 French coude' catheter that the resident required in stock.
On 08/17/2023 at 4:05 p.m., an interview was conducted with Resident #3 who was observed in bed complaining of pain and discomfort to his bladder. Resident #3 stated he had used his call bell to call for assistance ten minutes prior to 4:00 p.m. and spoke to the ward clerk to let S5TxLPN (Treatment Licensed Practical Nurse) know that he requested her to come assess his catheter. Resident was observed grimacing while he stated how much discomfort he was in. His face turned dark red as he squeezed his eyes tightly and winced in pain.
On 08/17/2023 at 4:13 p.m., S9Activities entered resident's room and the surveyor asked if she could find out if S5TxLPN was coming to see Resident #3. S9Activities stated she was not sure but would find out and exited the room.
On 08/17/2023 at 4:15 p.m., the surveyor remained with Resident #3 who was observed to grimace and state how much discomfort he was having. Resident #3 stated that he felt like his catheter was not draining. Resident #3 continued to squeeze his eyes shut and his face continued to be dark red.
On 08/17/2023 at 4:25 p.m., S5TxLPN entered resident's room and informed the resident that she would attempt to flush his catheter. Resident #3 then informed her that he felt a lot of pressure and believed his catheter was not draining. The surveyor observed S5TxLPN attempt to flush the catheter but she was unable to push down on the syringe of flush. S5TxLPN then informed the resident that she would change his catheter and walked out to get her supplies. The resident grunted, his face reddened, and he continued to squeeze his eyes shut while he vocalized the discomfort he was in.
On 08/17/2023 at 4:40 p.m., S5TxLPN re-entered Resident #3's room with her supplies to change his catheter. This surveyor observed S5TxLPN open her supplies and then she stated This is a 16 French, I need a 14 French. She apologized to the resident and exited the room to get the correct catheter. The surveyor remained with Resident #3 who continued to wince and grimace in pain and his face was observed getting darker red.
On 08/17/2023 at 4:55 p.m., S5TxLPN re-entered and informed Resident #3 that she had notified S7NP who gave orders to send the resident to the ER to have his catheter evaluated. Resident continued grimacing in pain and stated The ER is going to take forever. S5TxLPN exited the resident's room. The resident's catheter remained in place.
On 08/17/2023 at 6:40 p.m., a phone interview was conducted with S8NP at the ER Resident #3 was transported to via ambulance. S8NP stated he removed Resident #3's catheter and after removal, approximately 15-20 stones came out which caused the resident to experience immediate relief.
On 08/22/2023 at 9:18 a.m., a phone interview was conducted with S7NP who confirmed that on 08/17/2023 she was notified by S5TxLPN that Resident #3's catheter would not flush and that the resident needed a 14 French coude' catheter and the facility only had a 16 French coude' catheter in stock so she gave S5TxLPN orders to send the resident out to ER for evaluation.
On 08/22/2023 at 12:44 p.m., S1DON (Director of Nursing) and S5TxLPN were interviewed. S5TxLPN stated if the correct sized coude' catheter had been available on 08/17/2023, she could have removed Resident #3's catheter in order to replace it. S1DON confirmed the facility failed to ensure a 14 French coude' catheter was in stock from 07/06/2023 thru 08/18/2023.
Jun 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for ADLs (Act...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident dependent on staff for ADLs (Activities of Daily Living) received the necessary services to maintain grooming and personal hygiene. The facility failed to provide a bath to 1 (#2) of 5 (#1, #2, #3, #4, #5) residents sampled for ADLs.
Findings:
Review of the facility's job qualifications for CNA's (Certified Nursing Assistant) revealed in part: The CNA provides care to assist with keeping the resident well-groomed and clean . Responsibilities . 16. Follows bath and whirlpool schedules as outlined for each resident.
Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Pressure Ulcer of Sacral Region, Peripheral Vascular Disease, Chronic Systolic Heart Failure, Acute Respiratory Failure with Hypoxia, Urinary Incontinence, Type 2 Diabetes Mellitus, and Bilateral Primary Osteoarthritis of Knee.
Review of Resident #2's Significant Change (SC) Minimum Data Set (MDS) dated [DATE], Section G: Functional Status revealed for bathing resident is coded as 4 for total dependence with 1 or 2 person assist.
Review of Resident #2's comprehensive care plan revealed the resident was dependent with ADLs.
Review of the facility's Grievance/Complaint Report dated 04/17/2023 for Resident #2, revealed in part, Resident's daughter states that resident was not bathed on 04/17/2023.
Review of the facility's bath schedule revealed Resident #2 should receive baths every Monday, Wednesday and Friday.
On 06/27/2023 at 8:20 a.m., an interview was conducted with Resident #2's daughter. Resident #2's daughter stated that her mother did not receive a bed bath on Monday 06/26/2023. She stated Resident #2 is scheduled to receive a bed bath every Monday, Wednesday, and Friday according to the facility's bath schedule
On 06/27/2023 at 8:25 a.m., an interview was conducted with S4ShowerCNA (Certified Nursing Assistant). S4CNA confirmed Resident #2 was to receive a bath every Monday, Wednesday, Friday per the bath schedule. S4CNA stated Resident #2 was to receive a bed bath by S3CNA on Monday 06/26/2023.
On 06/27/2023 at 8:30 a.m., an interview was conducted with S3CNA. S3CNA stated that she was assigned to Resident #2 on 06/26/2023. She further stated that the resident was supposed to receive a bed bath on Monday, Wednesday and Friday. S3CNA confirmed she did not give Resident #2 a bath on Monday 06/26/2023. S3CNA stated I did not give her a bath because I didn't have time. S3CNA confirmed she did not notify S2CNASUP (Certified Nursing Assistant Supervisor) that she did not give Resident #2 a bath on her scheduled day.
On 06/27/2023 at 8:35 a.m., an interview was conducted with S2CNASUP. S2CNASUP confirmed that Resident #2 was to receive a bed bath by the assigned CNA on Monday, Wednesday, and Friday. S2CNASUP confirmed that she was not notified that S3CNA did not give Resident #2 a bed bath on Monday 06/26/2023.
On 06/27/2023 at 9:30 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed that Resident #2 was to receive a bed bath Monday, Wednesday and Friday. S1DON confirmed that she was not notified Resident #2 did not receive a bed bath on Monday 06/26/2023. S1DON confirmed the CNAs should follow the facility's bath schedule.
Feb 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 encode and transmit a Quarterly MDS (Minimum Data Set) Assessment w...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to encode and transmit a Quarterly MDS (Minimum Data Set) Assessment within the required time frame and failed to submit within 14 days of completion for 1 Resident (#1) of 1 sampled Resident with MDS record over 120 days old. The total sample size was 42.
Findings:
Review of the clinical record for Resident #70 revealed the Resident was admitted to the facility on [DATE] with diagnoses which included: Primary Osteoarthritis, Dysphasia, Alzheimer's disease, Cognitive Communication Deficit, Hyperlipidemia and Essential Primary Hypertension.
Review of the Resident #70's Quarterly MDS Assessment with an ARD 01/05/2023 was completed on 01/19/2023.
Review of the MDS Transmission Results Summary report revealed Resident #70's Quarterly MDS Assessment was due to be transmitted by 02/02/2023. Review of the MDS Assessment revealed it was transmitted on 2/10/2023 at 5:24 a.m.
An interview conducted on 2/14/2023 at 1:30 p.m. with S3 LPN revealed that she and S4 LPN were responsible for completing Resident #70's MDS Assessment. S3 LPN stated that Resident #70's Quarterly MDS Assessment with an ARD of 01/05/2023 was not transmitted until 02/10/2023. S3 LPN stated that the reason for the late transmission of Resident #70's MDS was that she and S4 LPN were both out ill with COVID-19 and S5 RN was hired at the end of December 2022 and was not familiar with MDS transmission. S3 LPN confirmed that the MDS Assessment for Resident #70 was transmitted late and should have been transmitted within 14 days of the completion of the Assessment.
Interview on 2/15/2023 at 2:39 p.m. with S2 DON revealed she was aware of Resident #70's MDS being transmitted late. S2 DON revealed that both of the MDS Assessment nurses were out sick with COVID-19 and the S5 RN was a new hire to do MDS Assessments during that time. S2 DON confirmed that Resident #70's Quarterly Assessment should have been transmitted within 14 days of the completion of the assessment and was not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on review of Payroll Based Journal staffing report for Fiscal Year Quarter 4 2022 (July 1 - September 30) the facility failed to provide adequate weekend staffing for that quarter.
Findings:
Rev...
Read full inspector narrative →
Based on review of Payroll Based Journal staffing report for Fiscal Year Quarter 4 2022 (July 1 - September 30) the facility failed to provide adequate weekend staffing for that quarter.
Findings:
Review of the PBJ staffing report for Fiscal Year Quarter 4 2022 (July 1-September 30) revealed excessively low weekend staffing was triggered as a concern on this staffing data report.
Interview on 02/15/2023 at 3:23 p.m. with S1 Administrator revealed PBJ staffing data report information is submitted by the facility's corporate office.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Louisiana facilities.
Concerns
- • 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (35/100). Below average facility with significant concerns.
- • 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Landmark Of Rayne's CMS Rating?
CMS assigns LANDMARK OF RAYNE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Landmark Of Rayne Staffed?
CMS rates LANDMARK OF RAYNE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 66%, which is 20 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 75%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Landmark Of Rayne?
State health inspectors documented 26 deficiencies at LANDMARK OF RAYNE during 2023 to 2025. These included: 26 with potential for harm.
Who Owns and Operates Landmark Of Rayne?
LANDMARK OF RAYNE 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 THE BEEBE FAMILY, a chain that manages multiple nursing homes. With 130 certified beds and approximately 96 residents (about 74% occupancy), it is a mid-sized facility located in RAYNE, Louisiana.
How Does Landmark Of Rayne Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, LANDMARK OF RAYNE's overall rating (1 stars) is below the state average of 2.4, staff turnover (66%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Landmark Of Rayne?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Landmark Of Rayne Safe?
Based on CMS inspection data, LANDMARK OF RAYNE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Landmark Of Rayne Stick Around?
Staff turnover at LANDMARK OF RAYNE is high. At 66%, the facility is 20 percentage points above the Louisiana average of 46%. Registered Nurse turnover is particularly concerning at 75%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Landmark Of Rayne Ever Fined?
LANDMARK OF RAYNE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Landmark Of Rayne on Any Federal Watch List?
LANDMARK OF RAYNE 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.