THE ELLINGTON
For profit - Corporation
120 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#165 of 264 in LA
Photo by The Ellington of Rayne
Photo by The Ellington of Rayne
Photo by The Ellington of Rayne
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Ellington nursing home in Rayne, Louisiana, has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #165 out of 264 facilities in Louisiana, placing it in the bottom half of the state, and #3 out of 5 in Acadia County, meaning only two local options are better. The facility's trend is worsening, with issues increasing from 8 in 2023 to 12 in 2024. Staffing is average, with a 3/5 star rating and a turnover rate of 53%, which is close to the state average. However, there are serious concerns, including a critical incident where a cognitively impaired resident managed to leave the facility unsupervised, and another incident where a resident suffered a fracture due to improper transfer procedures, highlighting the need for improved safety measures.
- Trust Score
- F
- In Louisiana
- #165/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 53% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $29,007 in fines. Lower than most Louisiana facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 38%
Review needed
8 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 8 issues
2024: 12 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 53%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $29,007
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 24 deficiencies on record
1 life-threatening 1 actual harm
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 nursing services were provided to meet standards of qua...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that nursing services were provided to meet standards of quality as evidenced by failing to ensure nurses conducted a fall risk assessment after each time a resident had a fall, and accurately assessed a resident's fall risk status for 1 (#3) out of 4 (#1, #2, #3, and #4) resident's investigated for falls.
Findings:
Review of the facility's Fall Assessment and Prevention policy (no date) revealed in part . Purpose: To ensure the safety of the resident residing in the facility. Procedure: 1. Resident will be assessed using the Fall Risk Assessment Form upon admission, re-admission, at the time of the MDS/Care Plan review, and prn (as needed) .4. If a resident has a fall the Fall Assessment Form should be completed. 5. Attempt should be made to determine the cause of the fall document findings.
Review of Resident #3's records revealed she was admitted to the facility on [DATE]. Her diagnoses included in part, Age-related Osteoporosis without current Pathological Fracture, Restless Leg Syndrome, History of Falls (02/28/2024), Lack of Coordination, Unsteadiness on Feet, Multiple Fracture of Pelvis with stable disruption of pelvis ring subsequent encounter for fracture, Other specified Disorder of Bone Density and Structure, multiple sites.
Review of Resident #3's care plan revealed she had a fall on 05/10/2024, 05/13/2024, and 6/15/2024, 07/28/2024, 08/01/2024, 09/08/2024, 09/13/2024, 09/15/2024, 10/03/2024, and 10/25/2024.
Review of the resident's Fall Risk Assessments revealed the facility completed an assessment on 07/03/2024, 08/20/2024 and 10/31/2024, which was at the time of the resident's quarterly Minimum Data Set/Care Plan review.
Further review of Resident #3's electronic record revealed there was no fall risk assessment conducted after each of the above falls.
Review of the Fall Risk Assessments completed on 07/03/2024 revealed a fall risk score of 9. Under Section A. #2., no falls in past 3 months was selected.
On 11/6/2024 at 1:15 p.m., an interview and review of the facility's Fall Assessment and Prevention policy was conducted with S1DON (Director of Nursing). She stated that fall risk assessments were to be completed when a resident was admitted , re-admitted and at the time of the Minimum Data Set /Care Plan review. S1DON confirmed a fall risk assessment was not conducted for Resident #3 after each fall.
On 11/6/2024 at 1:51 p.m., an interview and review of Resident #3's Fall Risk assessment dated [DATE] was conducted with S1DON. She confirmed that the resident had a fall on 05/10/2024, 05/13/2024 and 6/15/2024, which was prior to the assessment on 07/03/2024. She reviewed the fall risk assessment and stated that Section A . #2 was selected, which indicated that the resident had no falls in the past 3 months prior to the assessment. She stated that the staff should have selected that the resident had 3 or more falls. She confirmed this was an inaccurate assessment of the resident's fall status.
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 record review and interview, the facility failed to ensure the residents received all care and treatment in accordance ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance with professional standards of practice as evidenced by nurses failing to assess the resident after receiving reports of bruising, swelling, and pain to the resident's right leg for 1 (#4) out of 4 (#1, #2 #3, #4) sampled residents.
Findings:
Review of Resident #4's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebrovascular Disease, Aphasia, and Displaced Oblique Fracture of Shaft of Right Femur (10/30/2024).
Review of the resident's annual MDS (Minimum Data Set) dated 08/06/2024 revealed the resident was coded 3 for being severely impaired for cognition. The resident was coded requiring extensive assistance with 2 plus person assist for bed mobility, and coded requiring total dependence with 2 plus person assist for transfers.
Review of the resident's nurse's note dated 10/23/2024 at 9:48 a.m. revealed, Resident c/o (complain of) right hip and leg pain when CNA (Certified Nursing Assistant) changing her under pad and brief this am (morning). (Medical Doctor) notified and ordered Right hip x-ray .
Review of the resident's right hip x-ray report dated 10/23/2024 revealed, . Negative for fracture or lytic lesion .
There was no x-ray report or order for evaluation of the resident's right leg.
Review of the resident's nurse's note dated 10/30/2024 at 8:15 p.m., revealed Late entry---4pm Resident continues to c/o pain to Rt (Right) leg with no effectiveness from pain medicine. Resident also c/o hallucinating and states she feels like she is going to die. Family at bedside and request to go to ER (Emergency Room). MD (Medical Doctor) . notified with new order noted to send to ER to eval (evaluate) and tx (treat) .
Review of the nurse's note dated 10/30/2024 at 8:23 p.m. revealed, Resident admitted to (hospital) with Rt leg Fracture.
On 11/06/2024 at 11:55 a.m., an interview was conducted with S2CNA (Certified Nursing Assistant). S2CNA stated that she worked with the resident the week of 10/21/2024 to 10/25/2024. S2CNA stated that she was assisting another CNA with changing and repositioning the resident in the bed. S2CNA stated that she remembered the resident complaining of pain to the whole right side of her body. S2CNA could not recall the exact date the resident complained of pain. S2CNA stated that she did not know if the resident was complaining of pain to her right arm or right leg because the resident did not communicate verbally and could only gesture that the pain was on the right side from the arm down to her right leg. S2CNA stated the resident's complaint of pain to her right side was reported to the nurse multiple times.
On 11/06/2024 at 12:28 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated the resident was nonverbal. S3LPN stated that on 10/23/2024 the CNA reported to her the resident was complaining of pain to her right hip and leg. S3LPN was asked if she asked the resident where the pain was. S3LPN demonstrated on her body how the resident moved her hands from her right hip area down to her right leg was where her pain was. S3LPN stated that she notified the physician and the physician ordered an x-ray of the right hip. S3LPN was asked if she communicated to the physician that the resident's complaint of pain was not related to just the hip, but rather extended down the resident's right leg due to the way the resident demonstrated the location of the pain which would also require an x-ray of the resident's right leg. S3LPN stated she did not ask the physician about getting an x-ray of the right leg because she did not see any swelling to the resident's right leg.
On 11/06/2024 at 2:30 p.m., a telephone interview was conducted with S4CNA. S4CNA stated that on 10/23/2024 she assisted S5CNA with changing the resident in bed. S4CNA stated the resident was complaining of pain in her right leg. S4CNA stated that it was reported to the nurse.
On 11/06/2024 at 2:40 p.m., an interview was conducted with S5CNA. S5CNA stated the resident was nonverbal. S5CNA stated that on 10/23/2024 she was going to change the resident and the resident was complaining of pain. S5CNA stated the resident pointed to her right side. S5CNA stated that she went to get S4CNA to help her change the resident. S5CNA stated the resident started hollering out in pain while changing her. S5CNA stated the resident complained of pain to the right leg. S5CNA stated the resident's right leg was swollen, and she noticed a bruise to the side of the resident's right leg. S5CNA stated she reported the pain and the bruise to the nurse. S5CNA stated that she worked with the resident again on 10/24/2024. S5CNA stated the swelling to the resident's right leg had increased in size and that the bruise was larger in size from the previous day she worked with the resident. S5CNA stated that she reported the swelling and the bruise to the nurse again on 10/24/2024.
Another review of the resident's nurse's notes revealed no evidence the nursing staff assessed the resident's right leg from 10/24/2024 to 10/26/2024 based on the reports of the resident's condition from the CNAs.
On 11/06/2024 at 4:46 p.m., an interview and record review was conducted with S1DON (Director of Nursing). S1DON stated that reviewing internal investigations including resident #4's fracture were her responsibility. S1DON confirmed that she reviewed S5CNA's written statement from the investigation conducted regarding the resident's fractured right leg. S1DON confirmed that S5CNA documented she reported that the resident's right leg was swollen and bruised to the nurse on 10/24/2024. S1DON confirmed that there was no evidence the nurse documented an assessment of the resident's right leg in the clinical record from 10/24/2024 to 10/26/2024. S1DON stated that she did not expect her nursing staff to document daily assessments if there were no changes in the resident's status. S1DON stated that she trusted her licensed staff assessments and observations over what the CNAs report to the licensed staff.
On 11/06/2024 at 5:15 p.m., an interview was conducted with S6LPN regarding Resident #4's leg for the dates 10/24/2024-10/26/2024. S6LPN stated S5CNA did report the bruising and swelling to the resident's right leg. S6LPN stated that she went in the resident's room to assess the resident's right leg. S6LPN stated the resident did not have any new swelling and that the bruise was an old bruise. S6LPN could not recall the date of the old bruise was first identified. She confirmed that she did not document an assessment of the resident's leg in the resident's clinical record. S6LPN stated that she should have documented the assessment in the resident's clinical record.
Review of the resident's medical records and assessments from September 2024 - present revealed no evidence of the resident having a bruise prior to 10/24/2024.
Sept 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to implement care plan interventions and provide adeq...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to implement care plan interventions and provide adequate supervision to ensure a cognitively impaired resident, who had a history of wandering did not elope for 1 (Resident #1) out of 3 sampled resident (Resident #1, #2, and #3).
This deficient practice resulted in an Immediate Jeopardy on 08/23/2024 at 6:51 p.m. when Resident #1, a severely cognitively impaired resident, was unsupervised and eloped from the facility. On 08/23/2024 beginning at 5:10 p.m., Resident #1 was observed by multiple staff members repeatedly attempting to open several doors throughout the facility before exiting the facility's front entrance door undetected by staff at 6:51 p.m. On 08/23/2024 at 7:03 p.m., the facility received a call from a citizen that observed the resident in a residential area approximately 300 feet away from the facility. Resident #1 was brought back to the facility by staff at 7:10 p.m. Resident #1 was transferred to another facility with a secured unit on 08/28/2024.
This deficient practice placed one resident that remained in the facility, who had been assessed as having wandering behaviors, at risk for undetected elopement.
S1ADM (Administrator), S2DON (Director of Nursing), and S3ADON (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 09/04/2024 at 2:00 p.m.
The Immediate Jeopardy was removed on 09/04/2024 at 5:30 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia with Other Behavioral Disturbance, Bipolar Disorder, Repeated Falls, Unsteadiness on Feet, and Other Lack of Coordination.
Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 07/17/2024 revealed the BIMS (Brief Interview for Mental Status) of 5, indicating his cognition was severely impaired. Under Section P: Restraints and Alarms revealed the resident had a wander/elopement alarms used daily.
Review of Resident Resident #1's current comprehensive plan of care with a target date of 05/21/2024, revealed Resident #1 was an elopement risk/wanderer; initiated on 05/21/2024. Interventions created on 05/21/2024 included in part . Distract resident from wandering . by offering pleasant diversions, structured activities, food, conversation, television, book . Identify pattern of wandering prn: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor locations as needed.
Review of Resident #1's physician's orders revealed an order with a start date of 06/24/2024 read in part, Monitor elopement alarm bracelet to right ankle every shift.
Review of Resident #1's Elopement Evaluation dated 06/24/2024 revealed in part:
Elopement Score: 1.0 (At Risk)
BIMS Score: 5
Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Yes
Abnormalities: Verbally expressed desire to go home, packed belongings to go home or stayed near an exit door
Clinical Suggestions: Apply personal safety alarm device, Monitor location frequently, and Notify staff of elopement risk.
Review of Resident #1's Progress Notes revealed the following:
07/03/2024 at 12:15 p.m., by S4LPN (Licensed Practical Nurse), .Resident trying to open door to leave to go meet his wife .
07/15/2024 at 10:13 a.m., by S4LPN, .Resident away from station pushing on the door.
07/30/2024 at 6:39 a.m., by S4LPN, .Resident ask to open the door so he can go home multiple times. Explained to resident multiple times I cannot open the door and he lives here now. Resident says no and pushes on the door. Unable to redirect resident .
Review Resident #1's Incident Report completed on 08/23/2024 at 9:23 p.m. by S5LPN, read in part . 7:02 pm received a call from neighbors across the street from the facility stating that resident was down .street. This nurse as well as all staff members around when the call came in rushed outside the facility. Resident was down (street) near the house before the intersection . were able to get the resident back into the facility, elopement alarm bracelet present on resident . Predisposing Situation Factors: active exit seeker and wanderer were checked .
Review of Witness Statement completed on 08/23/2024 by S6LPN, revealed the following . Last time I seen Resident #1 he was wandering the hallways of Hall W going to Hall W's west side back door trying to open it, when it didn't open he turned around and went another direction.
Review of Witness Statement completed on 08/23/2024 by S6LPN, revealed the following . Last time I saw resident was at the door by the nurse's station trying to get out. Then when another resident told him the doors were locked; he went down the hall toward the dining room.
Review of Witness Statement completed on 08/23/2024 by S7Laun (Laundry Staff), read in part .Last time was when the medicine man was here Resident #1 was at the back door, I told the man to hide on the side of the breakroom until Resident #1 passes then Resident #1 left .
Review of the facility's video surveillance on 09/03/024 at 1:15 p.m. with S2DON, revealed on 08/23/2024 at 5:10 p.m., Resident #1 was sitting in his wheelchair pushing on the exit door in the dining room. On 08/23/2024 between 5:13 p.m. - 6:32 p.m. Resident #1 was observed pushing on three different exit doors on Hall W. He was observed pushing on each door more than once every few minutes. Multiple staff members were visible in the facility's video surveillance who observed Resident #1 push on different exit doors on the Hall W. No staff members on video surveillance approached the resident to redirect or distract the resident from pushing on the doors. On 08/23/2024 at 6:36 p.m., Resident #1 was seen pushing on the back entrance door. Between 6:37 p.m. - 6:46 p.m. Resident #1 was observed going back and forth between the front lobby entrance door and back entrance door every few minutes. At 6:48 p.m. Resident #1 was seen on video surveillance pushing on the back entrance door. During this time, S7Laun came out of the laundry room and watched the resident push on the back entrance door. On the video surveillance, S7Laun had not approached the resident and was seen going back into the laundry room. At 6:51:05 p.m., Resident #1 was seen at the front lobby door attempting to push on the door with his hands and ramming his wheelchair into the door. At 6:51:23, the front lobby door opened and Resident #1 eloped from the facility. On the facility's video surveillance, no staff was observed near the front lobby door during any of the times Resident #1 was seen pushing on the door.
On 09/03/2024 at 11:00 a.m., an interview was conducted with S6LPN. S6LPN stated she worked on the Hall W the evening Resident #1 eloped from the facility. She stated she observed him at approximately 6:15 p.m. trying to push open the exit doors several times on the Hall W and wander around the facility. She confirmed she never attempted to intervene by redirecting or distracting the resident when he was pushing on the exit doors and had not notified S5LPN, his assigned nurse, of the exit seeking behaviors Resident #1 had displayed. She confirmed she had not any heard alarm the evening of 08/23/2024 when Resident #1 eloped from the facility.
Multiple attempts were made to contact S5LPN via phone on 09/03/2024 at 11:17 a.m., at 11:48 a.m., 12:25 p.m. and at 2:14 p.m. S5LPN failed to return any phone calls and was unable to be interviewed.
On 09/04/2024 at 2:29 p.m., an interview was conducted with S7Laun. She stated on the evening of 08/23/2024 she worked in the laundry room which was on the same hall as the back entrance door. She confirmed that she had observed Resident #1 at the back entrance door trying to push it open and had not approached the resident to try to redirect him and had not notified his nurse.
On 09/03/2024 at 3:17 p.m., an elopement alarm bracelet was tested at the front lobby door with S2DON. The alarm activated when the elopement alarm bracelet was approximately 10 feet away from the front lobby door and upon demonstration the front lobby door alarm's volume was very faint.
On 09/03/2024 at 4:10 p.m., an interview was conducted with S2DON. S2DON stated that in June 2024 an elopement alarm bracelet was applied on the resident due to exit seeking behavior such as Resident #1 telling multiple staff members that he wanted to go home. She stated that in July 2024 he had multiple exit seeking behaviors by pushing on the exit doors several times throughout the day. She stated on 08/23/2024, when the resident was displaying exit seeking behaviors on the Hall W, the staff could have redirected him. However, he would have went back to repeating the same behavior because that was normal for him. She stated the facility relied on all the elopement alarm and locking mechanism located on the front lobby door and back entrance door that activated when a resident with an elopement alarm bracelet was nearby. She stated there was no explanation or reasoning of why Resident #1 eloped from the facility other than the front lobby door possibly glitched when Resident #1 pushed on the door and pushed his wheelchair in the door which caused it to open.
On 09/04/2024 beginning at 8:33 a.m., the elopement alarm bracelet volume was tested near the front lobby door:
1.
On 09/04/2024 at 8:33 a.m., an interview was conducted with S6LPN on Hall W's nurse's station approximately 100 feet away from the front lobby door. The front lobby door alarm was activated. S6LPN confirmed that she could not hear the alarm.
2.
On 09/04/2024 at 8:35 a.m. the front lobby door alarm was activated. Observation made of S2DON sitting in her office with the office door open. Her office was located approximately 90 feet away from the front lobby door. S2DON did not respond to the elopement alarm bracelet.
3.
On 09/04/2024 at 8:38 a.m., an interview was conducted with S8CNACoor (Certified Nursing Assistant Coordinator) on Hall X's nurse's station located approximately 111 feet away from the front lobby door. The front lobby door alarm was activated. S8CNACoor confirmed that she could not hear the alarm.
4.
On 09/04/2024 at 9:31 a.m., an interview was conducted with S1ADM near an exit door on Hall W located approximately 130 feet away from the front lobby door. The front lobby door alarm was activated. S1ADM confirmed that he could not hear the alarm.
5.
On 09/04/2024 at 9:35 p.m. the front lobby door alarm was activated. The farthest the alarm could be heard was approximately 53 feet away near the beauty salon.
On 09/04/2024 at 10:52 a.m., an interview was conducted with S9LaunSup (Laundry Supervisor). She stated the laundry room was on the same hall as the back entrance door and if a resident with an elopement alarm bracelet goes near the door the alarm activated and she expected laundry staff to check on the alarm and respond. She stated if the alarm was activated due to a resident with an elopement alarm bracelet being near the back door then laundry staff should have checked on the resident, persuaded them to turn around away from the door, and bring the resident to their nurse and notify them of what their resident was doing.
On 09/04/2024 at 4:33 p.m., an interview was conducted with S1ADM. S1Admin stated Resident #1 was readmitted back to the facility in May 2024 and throughout his stay he could tell that the resident did not want to be here. The resident always walked around the facility and showed exit seeking behavior such as telling the staff he wanted to go home to his wife. An elopement alarm bracelet was applied after the resident displayed these behaviors. S1ADM stated he had observed Resident #1 pushing on exit doors numerous times. S1ADM confirmed that nursing staff should have attempted to redirect Resident #1 when they saw him pushing on the exit doors down the Hall W several times on 08/23/2024. He confirmed when laundry staff observed Resident #1 pushing on the back entrance door she should have intervened and got that resident's LPN. He stated staff relied on the elopement alarm bracelet lock mechanism on doors to prevent elopement. He confirmed Resident #1 left the building and the facility's premises undetected by staff. He confirmed the front lobby door was not monitored by staff to prevent Resident #1's elopement.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure resident's remained free from accidents for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure resident's remained free from accidents for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) investigated for falls. The facility failed to ensure:
1. night staff got resident out of bed during last rounds, and
2. the resident's wheel chair alarm was properly working.
Findings:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Repeated Falls, Cognitive Communication Deficit, and Unsteadiness on Feet.
Review of Resident #1's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/29/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 05, indicating he had severe cognitive impairment. Section GG Functional Abilities and Goals revealed he used a walker and required supervision for toilet transfer, sit to stand, chair/bed-to-chair transfer and walking 10 feet. Further review of Resident #1's MDS revealed he had a history of falls in the last 2 - 6 months.
Review of Resident #1's care plan revealed the following focus areas and interventions:
Increased risk for falls (initiated 05/21/2024) related to diagnosis of dementia, confusion, psychoactive drug use, unaware of safety needs, wandering and unsteady gait. Interventions included but not limited to, be sure the resident's call light is within reach (dated 05/21/2024 and revised on 06/24/2024) and encourage the resident to use it for assistance as needed (dated 05/21/2024 and revised on 06/24/2024). He was also care planned for having actual falls initiated on 06/24/2024 with revision on 07/09/2024. Interventions for the actual falls included in part, staff to redirect as needed (initiated 06/24/2024 with revision on 06/27/2024); staff to remind resident to allow them to assist with needs and encourage resident to call for assistance initiated 06/24/2024 with revision on 06/27/2024);
Further review of Resident #1's care plan revealed special instructions on only the first page of the 43 page care plan that included: Wanderguard (elopement prevention bracelet), Bed mobility=Supervision, Transfers=Supervision, Toileting=Supervision, Eating=Supervision, Bed/Chair Alarm, Fall Mats x 2 (times two), and night shift to get resident up around 05:00 a.m. There were no dates next to the items listed in the special instructions. Per facility incident report reviews, night shift to get resident up around 05:00 a.m. was on initiated 07/01/2024.
Resident #1's facility incident investigation reports revealed the following:
07/01/2024 at 7:00 a.m., Unwitnessed Fall. Resident found on floor in his room with bed alarm sounding. Resident confused per usual. No injuries observed post incident. Post fall interventions: Continue Physical Therapy and Physical Therapy evaluation, increase supervision due to frequent falls, night shift advised to get resident out of bed on 5:00 a.m. rounds if he is awake.
07/04/2024 at 05:05 a.m., Unwitnessed Fall. Resident found sitting on floor on floor mat next to bed with no injuries. Bed alarm was sounding. Confused per his usual. Post fall interventions: Physical Therapy evaluation and provided urinal at bedside.
07/06/2024 at 06:00 a.m., Unwitnessed Fall. Resident found lying on floor on floor mat beside bed. Bed alarm activated. Confused per his usual. No injuries observed post incident. Post fall interventions: Physical Therapy evaluation, collect Urine Analysis, in-service night shift that resident needs to be assisted out of bed and into wheelchair on last rounds.
07/06/2024 at 03:56 p.m., Witnessed fall. Resident fell trying to go from wheelchair to regular chair in lounge room. Confused per his usual. There were no new injuries. Post fall interventions: Physical Therapy evaluation and staff in-serviced to assist resident with all transfers due to increased weakness.
Review of an in-service dated 07/01/2024 (with no time listed) revealed the summary of subject was to provide increased supervision and assist with all transfers for Resident #1 due to increased pain and weakness. The summary of subject for the in-service did not include to get the resident out of bed on 5:00 am rounds which was listed as an intervention in response to the fall he had on 07/01/2024 at 7:00 a.m.
Review of an in-service dated 07/08/2024 revealed the summary of subject was that the night shift needed to get Resident #1 up into wheelchair during last rounds. The in-service occurred after the resident sustained 3 falls in his room on 07/01/2024, 7/4/2024, and on 7/06/2024 between the hours of 5:05 a.m. and 7:00 a.m. (night shift).
On 07/10/2024 at 10:39 a.m., a phone interview was conducted with S6ACNA (Agency Certified Nursing Assistant) whom was working the morning of 07/04/2024 at 5:05 a.m. when Resident #1 had an unwitnessed fall in his room. She stated that Resident #1 was trying to go to the bathroom. She stated that she was not aware that Resident #1 was supposed to be gotten up on her last rounds of the night shift. S6ACNA stated that it had not been reported to her.
On 07/10/2024 at 1:28 p.m., surveyor observed Resident #1 in his room lying face down on the floor next to his roommate's bed. His wheelchair was at the foot of the roommate's bed with his chair alarm attached. There was no audible sound coming from the alarm. Resident #1 was saying Help me up. Surveyor then pressed the resident's call light to summon help. S3LPN and S4LPN reported to the resident's room to assist the resident. S3LPN confirmed that the resident's alarm was not functioning and removed the resident's chair alarm.
On 07/10/2024 at 2:31 p.m., an interview was conducted with S3LPN. She confirmed that Resident #1's wheelchair alarm did not produce a sound when he fell out of his wheelchair. She stated when she opened the alarm, there were no batteries in the chair alarm for it to sound.
On 07/10/2024 at 2:55 p.m., a phone interview was conducted with S4LPN. She confirmed that Resident #1's chair alarm was not working when he fell.
On 07/10/2024 at 4:16 p.m., an interview was conducted with S2ADON. A review was conducted of all incident investigations regarding Resident #1's falls. She stated an in-service had been conducted on 07/08/2024 for night shift getting Resident #1 up into his wheelchair on their last rounds because she did not believe that they were getting the resident up due to having two more falls in the early morning hours. She confirmed that Resident #1 had fell today and that his wheelchair alarm did not have any batteries.
Jun 2024
6 deficiencies
CONCERN
(D)
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 and interview, the facility failed to maintain and clean, comfortable, and homelike environment by failing...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to maintain and clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#46) out of 2 (#24 and #46) residents investigated for homelike environment.
Findings:
On 06/26/2024, a review of the facility's policy titled Bed Making - Unoccupied Bed with a last reviewed date of 04/29/2024 read in part . Purpose: To provide a clean and comfortable bed for the residents . Essential Points . Change any soiled or dirty linen .
Review of Resident #46's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Muscle Wasting and Atrophy, Lack of Coordination, and Spondylosis without Myelopathy.
On 06/24/2024 at 12:15 p.m. an observation was made of Resident #46's room. Resident #46 was sitting in his wheelchair. The bed was observed not made and the resident's pillow case revealed a medium size yellow stain, and multiple areas of small light brown stains on the resident's bed linen.
On 06/24/2024 at 2:19 p.m. a second observation was made of Resident #46's bed. The bed was observed and was made. The resident's pillow case revealed a medium size yellow stain, and multiple areas of small light brown stains on the resident's bed linen.
On 06/24/2024 at 2:22 p.m. an interview and observation of Resident #46's room was conducted with S3LPN (Licensed Practical Nurse). She confirmed that Resident #46's bed was made. S3LPN confirmed the stains on pillow case and bed linens and she confirmed there should not be any stains on linen and it should have been changed before the bed was made.
On 06/26/2024 at 2:24 p.m. an interview was conducted with S1DON (Director of Nursing). S1DON confirmed bed linens should be clean at all times and if stains are noted on linens they should be changed.
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 observations, interviews, and record review, the facility failed to follow a physician's order and care plan for 1 (#95...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow a physician's order and care plan for 1 (#95) of 40 sampled residents by failing to ensure the resident's TED (Thrombo-Embolic Deterrent) hoses were applied as ordered.
Findings:
Resident #95 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Chronic Obstructive Pulmonary Disease, Essential Primary Hypertension, and Unspecified Atrial Fibrillation.
A review of quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/26/2024, revealed Resident #95 had a BIMS (Brief Interview of Mental Status) score of 15, indicating her cognition was intact.
A review of Resident #95's physician orders revealed an order written on 03/01/2024 to apply TED hose in the AM (morning) and remove at night.
A review of Resident #95's June 2024 care plan revealed she had Hypertension r/t (related to) dx (diagnosis) of Essential Primary Hypertension and Atrial Fibrillation with a goal to remain free of complications related to Hypertension. Interventions in part .Compression stockings on in the AM, off in PM (afternoon).
On 06/24/2024 at 12:23 p.m., an observation was made of Resident #95 in her room. The resident was sitting in her reclining chair. Further observation revealed she was wearing black slippers with no TED hoses on.
On 06/25/2024 at 9:04 a.m., an observation and interview was conducted with Resident #95. She was sitting in her chair and no TED hoses were on her legs. When asked, Resident #95 stated that the nurse did not offer to put her TED hose on yesterday (06/24/2024) or today (06/25/2024).
On 06/25/2024 at 9:09 a.m., an observation and interview of Resident #95 was conducted with S4LPN (Licensed Practical Nurse). She confirmed that the resident was not wearing her TED hoses and stated that she did not put them on the resident yesterday (06/24/2024) or today (06/25/2024).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored appropriately when...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored appropriately when not in use for 1 (Resident #97) out of 2 (Resident #83, Resident #97) sampled residents reviewed for respiratory care.
Findings:
Review of Resident #97's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, and COVID-19.
Review of Resident #97's June 2024 physician's orders revealed an order dated 04/08/2024 for O2 (oxygen) at 2L/MIN/NC (liters per minute per Nasal Cannula) PRN (as needed) to relieve hypoxia.
Review of Resident #97's care plan read in part .Resident has oxygen therapy as needed for SOB (shortness of breath). Interventions included: Oxygen Settings: 02 at 2L per nasal cannula as needed.
On 06/24/2024 at 12:04 p.m., an observation was made of Resident #97's room. An oxygen concentrator was observed near the resident's wall 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 06/24/2024 at 12:11 p.m., S3LPN (Licensed Practical Nurse) was asked to enter Resident #97's room. S3LPN observed the oxygen concentrator machine and confirmed the nasal cannula tubing was open to air and not stored appropriately. S3LPN stated the nursing staff was responsible for storing nasal cannula tubing in a bag when not in use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
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 the nursing staff demonstrated specific comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#95) of 40 sampled residents. This was evidenced by S4LPN (Licensed Practical Nurse) leaving Resident #95's medication at the bedside.
Findings:
On 06/25/2024, a review of the facility's policy titled Medication Administration - Oral with a revision date of 04/29/2024 read in part, It is the policy of the _____ to administer medications in a safe manner .The person administering medication must remain with the resident until all medication has been swallowed.
Resident #95 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Chronic Obstructive Pulmonary Disease, Essential Primary Hypertension, and Unspecified Atrial Fibrillation.
A review of Resident #95's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/26/2024, a BIMS (Brief Interview of Mental Status) score of 15 indicating her cognition was intact, but the resident had no documents in her medical records that she was able to self administer her medications.
A review of Resident #95's physician orders revealed the following orders:
-1/19/2024 Pantropazole Sodium Oral Tablet Delayed Release 40 mg (milligram) give 1 tablet by mouth 2 times a day
-1/19/2024 Venlafaxine HCL (Hydrochloride) Oral Tablet 25 mg give 1 tablet by mouth three times a day.
-1/20/2024 Allopurinol Oral tablet 100 mg give 1 tablet by mouth one time a day.
-1/20/2024 Amiodarone HCL oral tablet 200 mg give 1 tablet by mouth one time a day.
-1/20/2024 Icar-C Oral Tablet 100-250 mg give 1 tablet by mouth one time day.
-1/20/2024 Levothyroxine Sodium Oral Tablet 75 MCG (Microgram) give 1 tablet by mouth one time a day.
-1/20/2024 Metoprolol Succinate ER Oral Tablet Extended release 24 hour 25 mg give 0.5 tablet by mouth one time a day.
-1/20/2024 Multivitamin Oral Tablet give 1 tablet by mouth one time a day.
-1/21/2024 Prednisone oral tablet 5 mg give 1 tablet by mouth one time a day every other day.
-6/08/2024 Folic Acid Oral Tablet Give 1 mg by mouth one time a day related to anemia
-6/10/2024 by Lasix Oral Tablet 20 mg (Furosemide) Give 20 mg by mouth one time a day.
A review of Resident #95's Medication Audit Report revealed the following medications were administered by S4LPN (Licensed Practical Nurse) on 06/25/2024 at 6:29 a.m.:
-Levothyroxine Sodium Oral Tablet 75 MCG. Give 1 tablet by mouth one time a day.
-Metoprolol Succinate ER Oral Tablet Extended Release 24 hour 25 MG. Give 0.5 tablet by mouth one time a day.
-Allopurinol Oral Tablet 100 MG Give one tablet by mouth one time a day.
-Pantoprazole Sodium Oral Tablet Delayed Release 40 mg. Give 1 tablet by mouth two times a day.
-Icar-C Oral Tablet 100-250 MG Give 1 tablet by mouth one time a day.
-Multivitamin Oral tablet. Give 1 tablet by mouth one time a day.
-Venlafaxine HCL Oral tablet 25 MG Give 1 tablet by mouth 3 times a day.
-Folic Acid Oral Tablet. Give 1 MG by mouth one time a day.
-Lasix Oral Tablet 20 mg. Give 20 MG by mouth one time a day.
-Amiodarone HCL Oral Tablet 200 MG. Give one tablet by mouth one time a day.
-Prednisone Oral Tablet 5 MG. Give 1 tablet by mouth one time a day every other day.
On 06/25/2024 at 9:04 a.m., an observation was conducted of Resident #95 in her room. A clear plastic medicine cup containing 11 pills was observed on the resident's over bed table.
On 06/25/2024 at 9:09 a.m., an observation was made of Resident #95's room with S4LPN (Licensed Practical Nurse) followed by an interview. She confirmed that she left the medications in the clear plastic cup at the resident's bedside.
On 06/25/2024 9:45 a.m., an interview was conducted with S1DON (Director of Nursing). She stated according to the facility's policy that nurses are not supposed to leave medications at residents' bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations and interview, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food ha...
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Based on observations and interview, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by:
1. Two opened packages of hamburger buns not labeled with the date.
2. Food storage:
A. Cooler:
1. One opened Liquid Protein container not labeled with the date.
2. One opened Chocolate Desert Topping not labeled with the date and an expiration date of 03/31/2024.
B. Walk-in freezer:
1. One opened bag of garlic bread not labeled with the date.
2. One opened bag of sweet potato fries not labeled with the date.
The total amount of residents that ate out of the kitchen was 112 residents.
Findings:
On 06/24/2024 at 9:50 a.m., an initial tour of the facility's kitchen was conducted with S5DC (Dietary Cook). S5DC confirmed the two opened packages of hamburger buns were not labeled with the date.
On 06/24/2024 at 9:57 a.m., an interview and observation was conducted with S2DM (Dietary Manager). S2DM confirmed the above findings were opened and not labeled and should have been. She also stated the expired item should not be in the cooler.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to maintain accurately documented medical record in accordance with accepted professional standards and practices. The facility failed to acc...
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Based on interviews and record review, the facility failed to maintain accurately documented medical record in accordance with accepted professional standards and practices. The facility failed to accurately document on the TAR (Treatment Administration Record) for 1 (#98) out of 1(#98) sampled resident reviewed for urinary catheter or UTI (Urinary tract infection) in a final sample of 40 residents.
Findings:
Review of Resident #98's April 2024 Treatment Administration Record (TAR) revealed the nursing staff failed to initial suprapubic catheter site care and treatment on the resident's left toe and malleolus were performed on the following dates: 04/07/2024, 04/09-04/10-2024, 04/12/2024, 04/15-04/16/2024 and 04/21/2024.
Review of Resident #98's May 2024 Treatment Administration Record (TAR) revealed the nursing staff failed to initial that treatment on the resident's left toe were performed on the following dates: 05/01/2024, 05/04-05/05/2024, 05/11-05/12/2024.
Further review of the May 2024 TAR revealed the nursing staff failed to initial that suprapubic catheter care was performed every shift on the following dates:
Day shift: 05/04-05/05/2024, 05/11-05/12/2024, 05/18-05/19/2024, and 05/25-05/26/2024;
Evening shift: 05/06-05/07/2024, 05/11-05/14/24, 05/20-05/21/2024, and 05/25-05/28/2024;
Night shift: 05/01/2024, 05/07/2024, 05/11-05/12/2024, and 05/25/2024.
Review of Resident #98's June 2024 Treatment Administration Record (TAR) revealed the nursing staff failed to initial that suprapubic catheter care was performed every shift on the following dates:
Day shift: 06/01-06/02/2024, 06/07-06/08/2024, and 06/21-06/22/2024;
Evening shift: 06/01-06/04/2024, 06/07/2024, 06/09-06/11/2024, 06/15/2024, 06/17-06/18/2024, and 06/23-06/24/2024;
Night shift: 06/06/2024, 06/20-06/21/2024, and 06/24-06/25/2024.
On 06/27/2024 at 2:09 p.m., an interview and review of the resident's April, May and June 2024 TARs was conducted with S1DON (Director of Nursing). She confirmed there were multiple days on the April, May and June 2024 TARs that were not initialed by the nursing staff. She stated that the treatment nurse and/or the nurse should initial the TAR when they conduct a treatment.
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 and record review the facility failed to ensure that a resident's person-centered plan of care was implemente...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring adverse reactions of Plavix and Aspirin for 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents.
Findings:
Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Occlusion and Stenosis of Unspecified Carotid Artery, Heart Failure, and Chronic Pulmonary Edema.
Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 04/17/2024 revealed the Brief Interview for Mental Status (BIMS) of 8, indicating her cognition was moderately impaired. Under Section N: Medications revealed the resident received antiplatelets.
Review of Resident #2's physician's orders revealed an order entry with a start date of 05/01/2020 read in part, Aspirin EC (enteric coated) tablet delated release 81 mg (milligram) give 1 tablet by mouth one time a day related to Occlusion and Stenosis of Unspecified Carotid Artery. Further review of Resident #2's physician's orders, revealed an order with a started date of 05/01/2020 of Plavix Tablet 75 mg (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day related to Occlusion and Stenosis of Unspecified Carotid Artery.
Review of Resident #2's person-centered plan of care, revealed in part, a focus of Resident #2 is on Plavix and Aspirin r/t (related to) occlusion and stenosis of carotid artery with an intervention to monitor/document/report PRN (as needed) adverse reactions of therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changed in mental status, significant or sudden changes in v/s (vital signs).
Review of Resident #2's MAR (Medication Administration Record) and TAR (Treatment Administration Record) from March, April, and May 2024 did not reveal documentation of monitoring for adverse reactions of Aspirin or Plavix as ordered on the person-centered plan of care.
On 05/28/2024 at 3:10 p.m., an interview was conducted with S1DON (Director of Nursing) who confirmed that Resident #2 was taking Aspirin 81 mg and Plavix 75 mg as ordered. S1DON reviewed Resident #2's person-centered plan of care and confirmed the order of monitoring and documented adverse reactions of Plavix and Aspirin. S1DON also reviewed Resident #2's MAR and TAR from March, April, and May 2024 and confirmed there was no monitoring of adverse reactions of Aspirin and Plavix that was done by nursing staff. S1DON confirmed that monitoring of adverse reaction of Aspirin and Plavix should have been done and documented on the MAR/TAR every shift as ordered on the person-centered plan of care and was not.
Apr 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a chair to bed transfer for 1 (#1) of 4 (#1, #2, #3, and #R1) sampled residents.
This deficient practice resulted in actual harm for Resident #1 on 03/25/2024 at 5:37 p.m. when S5CNA (Certified Nursing Assistant) transferred the resident from chair to bed without assistance of another person and without the use of a mechanical lifter as required by his plan of care. On 03/26/2024 at 10:30 a.m., S3ADONWC observed Resident #1's right lower leg as discolored and painful upon movement. X-ray of the resident's right lower leg, dated 03/26/2024, revealed a tibia (shin bone) fracture. On 03/29/2024 at 11:26 a.m., S9MD (Medical Doctor) observed swelling and discoloration to the resident's left lower leg and ordered an x-ray. X-ray of the resident's left lower leg, dated 03/29/2024, revealed a fracture of the distal tibial metaphysis (lower part of the shin bone). Resident #1 was on hospice services and received treatment for the fractures in the facility.
The facility implemented a corrective action plan on 03/26/2024 which was prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
A review of the medical records for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Age-related Osteoporosis, Pain, and Paranoid Schizophrenia. The resident was on hospice care.
Review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/12/2024, revealed the following, in part:
BIMS (Brief Interview for Mental Status) of 11, which indicated the resident, had moderate cognitive impairment.
Bed mobility - dependent (staff does all the effort); Sit to stand - Not attempted due to medical condition or safety concerns; Chair/bed to chair transfer (ability to transfer to and from a bed to a chair or wheelchair) - dependent.
Review of Resident #1's current care plan revealed the following, in part: The resident has an ADL (activity of Daily Living) self-care performance deficit r/t (related to) End stage Parkinson's disease, impaired mobility .Osteoporosis, Osteogenesis Imperfecta. Interventions: The resident requires total assistance by two staff with the use of a mechanical lifter to move between surfaces.
Review of Resident #1's nursing notes revealed the following, in part:
03/26/2024 at 10:38 a.m., S6LPN (Licensed Practical Nurse) was called to the resident's room by S3ADONWC (Assistant Director of Nursing/Wound Care Nurse). S3ADONWC stated that while performing the resident's treatments she discovered discoloration to his right lower extremity (RLE) and the resident complained of pain when moved. The resident was unable to say what happened. She notified the hospice RN (Registered nurse). Vital signs: Bp (Blood pressure)-115/58, P (Pulse) - 93, R (Respirations) - 18, T (Temperature) - 98.3. Further review revealed the resident's doctor ordered X-ray of RLE at 11:00 a.m.
04/01/2024, a late entry by S2DON (Director of Nursing) for 03/26/2024 at 2:19 p.m., revealed that she received the X-ray results of fracture to the right tibia. She notified the resident's doctor and responsible party.
03/29/2024 at 11:26 a.m., S6LPN wrote that the resident's doctor placed a splint to the RLE and ordered an X-ray for his left foot and ankle d/t (due to) swelling and discoloration .
03/29/2024 at 4:40 p.m., S2DON wrote that she received a call from the x-ray facility stating that the resident had a fracture to his left ankle. She notified the resident's doctor and responsible party.
Review of Resident #1's x-ray results revealed:
03/26/2024 - X-ray of right knee, tibia and fibula revealed a non-displaced acute fracture of the proximal tibia.
03/29/2024 - X-ray of left ankle and foot revealed an acute mildly displaced fracture, distal tibial metaphysis.
Review of the facility's investigative report revealed the following, in part: On 03/26/2024 at 10:19 a.m., S3ADONWC called S6LPN to Resident #1's room. S3ADONWC informed S6LPN that while she was performing the resident's treatments, she observed discoloration to his RLE and the resident complained of pain when she moved him. The resident was unable to state what happened. Video surveillance by the facility on 3/25/2024 revealed that S5CNA entered the resident's room to put him to bed at 5:37 p.m., alone and without a lifter. When questioned she S5CNA stated that she transferred the resident using a pivot method, placing one leg in between the resident's legs and lifting him up under his arms and pivoting him into his bed. She stated the resident did not complain of pain until her last round at 9:00 p.m. Based on witness statements, review of training records and a signed probation form, S5CNA understood the procedures involved for properly transferring the resident. The facility suspended S5CNA during the investigation, performed employee counseling and re-training, and she was placed on 90 days probation. S5CNA failed to secure a second person and a lifter to transfer the resident. A finding of neglect is substantiated, as this aide failed to follow the resident's care plan.
On 04/09/2024 at 8:16 a.m., an observation was made of Resident #1 with S3ADONWC of the resident in his room. S3ADONWC removed the resident's covers and revealed a clean soft splint to his right leg with ace wrap up to his knee. The resident has a knee high black boot splint to his left leg. The resident stated he was experiencing no pain when asked.
On 04/09/2024 at 8:08 a.m., an interview was conducted with S3ADONWC who stated that she discovered the resident's first injury on 3/26/2024. S3ADONWC stated that on 3/25/2024, S4CNA and the shower aide showered the resident and used the lifter to put him back in bed. She stated she changed the resident's dressing and did not notice any bruising or swelling in his legs, and the resident did not complain of pain. S3ADONWC stated that the next day she went into the resident's room for wound care and assessment. When she pulled back the resident's covers, she noticed his right lower leg was swollen and bruised and the resident complained of pain. S3ADONWC stated she asked the resident what happened and he said, That girl hurt my leg. S3ADONWC stated that she called S6LPN to see if she knew anything and she said she did not. S3ADONWC stated she finished the resident's dressing change while S6LPN called the hospice nurse and doctor to report the findings. S3ADONWC stated his doctor ordered an x-ray which revealed a fracture.
On 04/09/2024 at 8:25 a.m., an interview was conducted with S4CNA who stated that she has been working at the facility for about two years and is familiar with the resident. She stated that the resident is transferred with two people and a lifter. S4CNA stated that on 03/25/2024, she got the resident up for his shower with the lifter and assistance from the shower aide. She stated they got him back in bed then went to get S3ADONWC to do his skin assessment and dressing. S4CNA stated that the resident had no bruising or swelling on his legs and did not complain of any pain. She stated that the next day S2DON and S6LPN asked her if she had noticed any bruising, swelling, on the resident's legs when she cared for him the previous day and she told them she had not.
On 04/09/2024 at 10:05 a.m., an interview was conducted with S2DON. She stated that she started the investigation into the incident immediately after it was discovered on 03/26/2024. She stated that video surveillance identified S5CNA going into the resident's room on 03/25/2024 at 5:37 p.m., with the resident in his Geri-chair. She stated S5CNA was alone and did not come out to get help or a lifter. S2DON stated S5CNA confessed to transferring the resident by herself without a lifter and assistance from other staff, and was suspended during investigations. She stated that after three days suspension she was counseled and is currently on 90 days of probation that ends in July 2024. S2DON further stated that S1AsstADM (Assistant Administrator) started a QAPI (Quality Assessment and Improvement) project.
On 04/09/2024 at 10:13 a.m., an interview and review of the facility's plan of correction was conducted with S1AsstADM. S1AssitADM stated that after S2DON investigated the incident, they agreed there was a problem, and a QAPI was started on 03/26/2024. She stated that in-services began on 03/26/2024 and monitoring began the following day. S1AsstADM was asked when the plan of correction will be completed and she stated that on the last week of monitoring the committee will determine if compliance was achieved and whether they need to end or extend the monitoring.
On 04/16/24 at 09:10 a.m., a phone interview was conducted with S5CNA. She did not normally work on Resident #1's hall and in the past he was always in bed when she saw him. She was not used to seeing him in a chair. When she put him back in the bed on 03/25/2024, she did so by herself using a pivot method. She stated that she should have looked in his care plan before she transferred him. She stated when she returned to work she was in-serviced on 2 person transfers using a lift and on checking the chart for direction on what type of transfer assistance the resident required before providing caring to any resident. During the training, a demonstration was provided and she performed a return demonstration on lift transfers and checking the care plan. She stated that S2DON and S10CNASup randomly monitor transfers and they are usually the ones that watched her when she was transferring residents.
On 04/16/2024 at 9:45 a.m., during an interview with S2DON, she stated that S5CNA's first day back at work was 04/06/24. She was in-serviced prior to providing care to residents and continues to be monitored for transfers and for using the care plan to determine how residents are to be transferred. She stated that S5CNA told her there was no lifter pad under the resident when she went to transfer but that when they reviewed the video footage, they could clearly see the big blue lifter pad under the resident as she brought him into the resident's room.```
Multiple staff members were interviewed regarding transfer of residents and how to find the instructions for each resident they care for. All staff members stated they were trained on hire and had yearly competency checks on using mechanical lifts. They were also knowledgeable on where to find care instructions in the kiosk for each resident.
Observations were made on 04/08/2024 and 04/09/2024 of nursing staff transferring residents using mechanical lifts. No concerns noted.
The facility has implemented the following actions to correct the deficient practice:
03/26/2024- Clinical/Administrative Corrective Action Plan:
1. S5CNA, who improperly transferred resident, was suspended immediately.
2. Employee Counseling on 03/28/2024 and signing of probation after suspension on 04/06/2024.
3. Staff in-serviced to follow care plan on 03/26/2024
4. Building wide in-service on following the care plan and looking at special instructions in grey area of chart on 03/26/2024.
5. Proper Transfer Use Monitoring Tool started on 03/27/2024. This will be checked 5 times each week for 2 weeks, 2 times each week for 2 weeks and 1 time a week for 1 week by administration staff.
6. Review of the monitoring 03/27/2024 through 04/11/2024 revealed it was being conducted as care planned. No issues with transfers noted. Review of a separate monitoring sheet revealed S5CNA was monitored to ensure residents were transferred according to their care plan on 04/06/2024, 04/08/2024, 04/10/2024, and 04/14/2024. Monitoring was conducted by S2DON and S10CNASup.
Dec 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident's person-centered compreh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident's person-centered comprehensive care plan was implemented for 1 (#2) of 3 (#1, #2 and #3) sampled residents by failing to ensure Resident #2 had a working call light and received prompt response when the resident requested assistance.
Findings:
Resident #2's electronic medical record was reviewed and revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Cerebrovascular Accident (CVA/Stroke), Other Speech Language Deficits following Cerebral Infarction, Cognitive Communication Deficit, Unsteadiness on Feet, Difficulty in Walking and Anxiety Disorder.
Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 indicating the resident's cognition was moderately impaired. Under Section GG, Resident #2 was assessed as having impairment on one side of her upper and lower extremities that interfered with daily functions. Resident #2 was also assessed as requiring substantial/maximal assistance when moving from standing position to sitting, transferring from bed to wheelchair, maintaining toileting hygiene and dressing/undressing below the waist.
Review of Resident #2's current care plan revealed the resident was identified as a high risk for falls r/t (related to) impaired mobility, unsteady on feet and hx (history) of CVA with the following pertinent interventions: The resident needs prompt response to all requests for assistance. The resident needs a safe environment .a working and reachable call light .
Review of the facility's I/A (Incidents/Accident) logs from 10/01/2023 thru 12/18/2023 revealed Resident #2 had an unwitnessed fall on 12/05/2023 at 2:30 a.m.
Review of Resident #2's I/A investigation revealed the report was prepared by S7LPN (Licensed Practical Nurse) on 12/05/2023 at 2:30 a.m. and included the nursing description that read: Called to resd (resident) room per CNA (Certified Nursing Assistant), Resd noted to be sitting on the floor on buttocks. Head to Toe Assessment done. 0 injuries/discolorations noted. Immediate Actions Taken read: Head to toe assessment, Encouraged to call for assistance by using call bell.
On 12/19/2023 at 9:09 a.m., a phone interview was conducted with S7LPN. S7LPN stated she worked the night shift (10 p.m.- 6 a.m.) on 12/04/2023 and was the nurse caring for Resident #2. S7LPN further confirmed that the immediate actions taken were not appropriate because the resident's call system was not working properly.
On 12/19/2023 at 12:30 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing) who stated she investigated and reviewed all I/A reports. S3ADON confirmed that her investigation revealed staff were not made aware of Resident #2's call bell on the morning of 12/05/2023.
On 12/19/2023 at 3:32 p.m., a phone interview was conducted with S9CNA. S9CNA confirmed she was working on Hall C, the night shift on 12/04/2023. S9CNA stated around 2:30 a.m., S7LPN instructed her to go to Resident #2's room because S7LPN observed the resident's light above her room door flickering. S9CNA stated when she opened the resident's door, the resident's bed alarm was beeping and the resident was observed on the floor mat.
On 12/19/2023 at 4:42 p.m., a joint interview was conducted with S3ADON and S4AADM/QA (Assistant Administrator and Quality Assurance Nurse). S3ADON confirmed Resident #2's call light was activated on the morning of 12/05/2023 because S7LPN observed the light above the resident's door flickering. S3ADON was unable to verify the timing that the resident's call bell was activated. S4AADM/QA confirmed the resident call system was not working properly on 12/04/2023 and 12/05/2023.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and observations, the facility failed to ensure the residents call system was functioning pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and observations, the facility failed to ensure the residents call system was functioning properly for 2 (Hall B and Hall C) of 3 halls (Hall A, Hall B and Hall C). The deficient practice was evidenced when:
1. Resident #2's RP (responsible party) filed a grievance regarding Resident #2 pressing her call bell, and staff failing to assist the resident because the call system was not functioning properly and
2. A bed alarm was tested on site in Room A and immediately after bed alarm was deactivated, the resident call system for 2 halls (Hall B and Hall C) began malfunctioning.
Findings:
Review of the facility's policy titled, Call Light System, revealed in part:
Purpose: to respond to resident's request and needs.
Equipment: Functioning call bell system
Procedure: 1. Answer call system promptly .7. If call system is defective, report to maintenance .Essential Points .Should call system malfunction hand bells will be distributed to every resident.
1. Resident #2's electronic medical record was reviewed and revealed the resident was admitted to the facility on [DATE].
Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 indicating the resident's cognition was moderately impaired. Under Section GG, Resident #2 was assessed as having impairment on one side of her upper and lower extremities that interfered with daily functions. Resident #2 was also assessed as requiring substantial/maximal assistance when moving from standing position to sitting, transferring from bed to wheelchair, maintaining toileting hygiene and dressing/undressing below the waist.
Review of facility's grievance logs from 10/01/2023 thru 12/18/2023 revealed Resident #2's RP filed a grievance on 12/05/2023.
Review of Resident #2's filed grievance revealed the resident's RP voiced concerns after reviewing the resident's in room video surveillance on 12/05/2023. The RP discovered that the resident fell and was on the floor for an hour before someone found her. Review of the Investigation findings of the filed grievance revealed the call light system on Hall C was malfunctioning.
Review of the facility's I/A (Incidents/Accident) logs from 10/01/2023 thru 12/18/2023 revealed Resident #2 had an unwitnessed fall on 12/05/2023 at 2:30 a.m.
Review of Resident #2's I/A investigation revealed the report was prepared by S7LPN (Licensed Practical Nurse) on 12/05/2023 at 2:30 a.m. and included the nursing description that read: Called to resd (resident) room per CNA (Certified Nursing Assistant), Resd noted to be sitting on the floor on buttocks. Head to Toe Assessment done. 0 injuries/discolorations noted.
Further review of Resident #2's I/A investigation revealed on 12/06/2023 a note entered by S3ADON (Assistant Director of Nursing) that read in part .Per RP, resident had pressed the call bell but no one came to the room. Issues were happening with the call bell system on Hall C and staff were under the impression that those problems had resolved but they had not, therefore staff was not alerted of the call bell .
Resident #2 was unable to be interviewed because she was admitted to the hospital.
On 12/18/2023 at 9:33 a.m., a phone interview was conducted with Resident #2's RP. He confirmed that he filed a complaint with the facility about the resident falling after calling for assistance on the early morning of 12/05/2023. Resident #2's RP stated he had reviewed the resident's in room video footage and discovered the resident had pressed her call bell button at 1:34 a.m. and after approximately 30 minutes of not receiving assistance, the resident attempted to get out of bed on her own at 2:02 a.m. and fell on the floor mat on the side of her bed. Resident #2's RP further stated, the resident remained on the floor mat until 2:37 a.m. when S9CNA entered the resident's room. He stated he was informed by S3ADON via phone that the facility's resident call system was down.
On 12/18/2023 at 3:50 p.m., an interview was conducted with S5MAINT (Maintenance). S5MAINT stated the nurses on Halls B and C had notified him on the day of 12/04/2023 that the resident call system's boxes located at the nurses stations were making a constant noise with the lights flickering. He then contacted the call system company and stated that later in the evening of 12/04/2023 someone came out and he thought the issue was fixed. S5MAINT stated he was notified the next morning by S3ADON that the resident call system was not working properly on Halls B and C.
On 12/19/2023 at 9:09 a.m., a phone interview was conducted with S7LPN. S7LPN stated she worked the night shift (10 p.m.- 6 a.m.) on 12/04/2023 and was the nurse caring for Resident #2. S7LPN confirmed the resident call system was not working properly and explained the main call system box at the nurse's station was not sounding and only the lights would [NAME] if a call light was pressed by a resident. S7LPN denied informing maintenance about the resident call system not working properly and assumed S6LPN had notified maintenance.
On 12/19/2023 at 10:28 a.m., an interview was conducted with S6LPN. S6LPN stated she had worked a double shift on 12/04/2023 from 6 a.m.- 10 p.m. on Hall B and confirmed the resident call system was not working properly. S6LPN explained the main call system box at the nurse's station was making a constant beeping noise and the lights on the box would [NAME]. S6LPN stated someone came out and fixed the resident call system by the time she finished her shift on 12/04/2023.
On 12/19/2023 at 10:42 a.m., an interview was conducted with S8LPN. S8LPN stated she worked the day shift (6 a.m- 2 p.m.) on Monday 12/04/2023 and Tuesday 12/05/2023. S8LPN stated the resident call system was not working properly on 12/04/2023 and that the main call system box at the nurse's station was making a loud noise that was constant and all the lights on the box would blink very fast. S8LPN stated on 12/04/2023 she notified S5MAINT via text message of the resident call system not working properly and he had contacted the call system company to reset the call system.
2. On 12/19/2023 at 2:45 p.m., a bed alarm was tested in Room A on Hall C with S10CNA. Upon exiting Room A, the dome light located above the outside of the door was observed flickering and S3ADON and S5MAINT were observed at the nurse's station for Hall C. S3ADON stated Room A always acts up and that S5MAINT notified the resident call system company to have a technician come out to the facility to identify the problem.
On 12/19/2023 at 3:00 p.m., S3ADON confirmed S5MAINT notified the resident call system company and reported the call system not working properly. S5MAINT then walked up and stated he was waiting for the resident call system commpany to call him back with a time of when a technician could come to the facility.
On 12/19/2023 at 3:32 p.m., a phone interview was conducted with S9CNA. S9CNA confirmed she was working on Hall C, the night shift on 12/04/2023. S9CNA stated around 2:30 a.m., S7LPN instructed her to go to Resident #2's room after S7LPN observed the resident's light located above the resident's door was flickering. S9CNA confirmed there was no noise alarming from the resident call system. When she opened the door to the resident's room, she heard the resident's bed alarm alarming and observed the resident on the floor mat near her bed.
On 12/19/2023 at 4:42 p.m., a joint interview was conducted with S3ADON and S4AADM/QA (Assistant Administrator and Quality Assurance Nurse). S3ADON confirmed she investigated an incident that happened on 12/05/2023 involving Resident #2 and identified that the resident call system was not working properly. S3ADON stated a technician came to the facility on [DATE] to repair the resident call system and alternative hand held bells were provided to be kept at the nurse's station on 12/06/2023. S3ADON confirmed it was identified after the surveyors tested a bed alarm in Room A on Hall C that the resident call system was not working properly. S4AADM/QA stated she had opened a corrective action plan on 12/05/2023 that identified the call light system problem on Hall C and implemented monitoring of the resident call system on 12/06/2023 that was currently ongoing. Review of the monitoring revealed from 12/06/2023 thru 12/19/2023, revealed Room A had not been monitored.
On 12/19/2023 at 5:10 p.m., an interview was conducted with S11Technician and S1ADM (Administrator). S11Technician explained the resident call system first began not working properly on 12/04/2023 involving Hall C which was on a connected network with Hall B. He confirmed the resident call system was a wired system and that Room A has been triggering the malfunctions that started on 12/04/2023. S11Technician stated he has had to come to the facility four additional times from 12/04/2023 thru 12/19/2023 because of the faulty resident call system affecting Halls B and C. S11Technician confirmed each time he has been onsite at the facility, the error involves Room A. S1ADM confirmed the resident call system was not working properly beginning on 12/04/2023 thru present.
Jul 2023
5 deficiencies
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 observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was compl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#11) out of 38 sampled residents. The facility had a census of 109 residents.
Review of the resident's #11's electronic clinical record revealed Resident #11 was admitted to facility on 01/17/2023 with diagnosis not limited to: Right femur fracture, Unsteady Gait, Major Depression, Visual Hallucination, Abnormal weight loss and Macular Degeneration.
Review of the physician's orders revealed an order dated 03/20/2023 - Admit to Amedisys Hospice.
Review of the resident's significant change MDS (Minimum Data Set) dated 03/27/2023 revealed the resident was not coded for having hospice services.
On 07/11/2023 at 1:50 p.m., an interview was conducted with S7LPN (Licensed Practical Nurse) who confirmed the resident is on Hospice services.
On 07/11/2023 at 3:35 p.m., during an interview S5MDS reviewed Resident #11's significant change MDS dated [DATE] and confirmed the resident was not coded for having hospice services. S5MDS confirmed the significant change MDS assessment was inaccurate because the resident was receiving hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure that Resident #61 who was admitted to the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure that Resident #61 who was admitted to the facility with the diagnoses of Bipolar Disorder and Major Depressive Disorder had a Level I PASARR (Preadmission Screening and Resident Review) screening for 1 (#61) out of 2 (#43, #61) resident investigated for PASARR.
Findings:
Resident #61 was admitted to the facility on [DATE] with diagnosis not limited to Parkinson's Disease, Unspecified Dementia, Bipolar Disorder and Major Depressive Disorder
Review of the physician orders dated 09/15/2022 revealed the resident was prescribed a medication for Bipolar Disorder which was Depakote tab delayed release 500mg (milligrams) give 1 tablet by mouth two times a day.
Review of Minimum Data Set (MDS) dated [DATE] read in part: Active Diagnoses - Bipolar Disorder, Anxiety Disorder and Depression.
Review of The Level 1 pre-screening dated 04/20/2022 was reviewed and revealed - Under Section III: Mental Illness the following was noted - 1. Has the applicant ever been diagnosed as having a serious mental illness? Include mental disorder that may lead to chronic disability. If yes to mental illness, please check the diagnosis below. A check was indicated for other mental health diagnosis/disorder that may lead to chronic disability (specify): Depression. The yes box was checked.
Section V read in part: Complete this section of any item was checked yes in section III or IV and applicant meets the criteria for one of the conditions described below. If any item is selected, this page must be signed by the attending physician and supporting documentation must be attached. The section was not completed and no physician signature.
On 07/11/2023 at 2:25 p.m., an interview was conducted with S6SSD, she reported she is not responsible for completing or review a PASARR I.
On 07/11/2023 at 2:30 p.m., an interview was conducted with S3RN, treatment nurse, she reported she does not review the PASARR I when a resident is admitted from the hospital. She stated the resident was admitted from the hospital and the hospital completed the PASARR I. She stated she only ensured the resident had a form 142, to be accepted to the facility.
On 07/11/2023 at 2:35 p.m., an interview was conducted with S4LPNCP, she confirmed she puts the resident diagnosis in the computer when the resident is admitted , but, does not ensure the mental illness diagnosis was identified on the PASARR I.
On 07/11/2023 at 2:45 p.m., an interview was conducted with S2ADON, she confirmed Resident #61's PASARR I did not contain the resident's diagnosis of Bipolar and Major Depressive Disorder. She stated the PASARR I was completed by the hospital staff, prior to admit to the facility, and the hospital should have put the diagnosis of Bipolar and Major Depressive Disorder on the PASARR I before submitting. She confirmed when the resident was admitted to the facility and the facility identified the diagnosis Bipolar Disorder and Major Depressive Disorder, the PASARR I should have been resubmitted for review for a PASARR II and the PASARR I was not resubmitted for evaluation of a level II PASARR. She confirmed there is not a facility designee to review resident's diagnoses, to determine if request for PASARR II should be requested.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to help prevent the development and transmission of comm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to help prevent the development and transmission of communicable diseases and infections. Staff failed to perform hand hygiene after changing gloves during wound care for 1 (#16) of 1 (#16) residents investigated for pressure ulcers out of 3 residents with pressure ulcers according to the Resident Census and Conditions of Residents Report (CMS-672).
Findings:
Review of the facility's Standard Precautions Policy statement read: Standard precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and mucous membranes. Policy Interpretation and Implementation: 1. Hand washing a. wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn.
Review of electronic medical record for Resident #16 revealed he was admitted to the facility on [DATE]. Resident's pertinent medical conditions read in part, Parkinson's Disease, Unspecified Severe Protein Calorie Malnutrition, Obstructive and Reflux Uropathy, Retention of Urine, Heart Failure, Dysphagia, Urinary Tract Infection Site not specified, Dermatitis, Hypertension, Type 2 Diabetes Mellitus, Pain Unspecified, Chronic Obstructive Pulmonary Disease, Cerebral Infarction.
Review of current physician orders revealed the following: left 2nd toe infectious lesion- apply betadine every other day, sporadic scabbed lesions on feet-apply betadine every other day.
On 07/11/2023 at 09:20 a.m., an observation was conducted of Resident #16's wound care administered by S3RN (Registered Nurse) with positioning assistance from S8CNA (Certified Nursing Assistant). S3RN prepped for the resident's wound treatment and applied clean gloves. S3RN raised her glasses with her gloved index finger then proceeded with the resident's wound treatment. She did not perform hand hygiene or apply clean gloves after touching her glasses. S3RN proceeded to apply betadine on the resident's left 2nd toe and scabbed lesions on his right foot. She discarded the betadine, removed her contaminated gloves then reapplied new gloves. S3RN did not perform hand hygiene before applying the new gloves.
On 07/11/2023 at 09:43 a.m., an interview was conducted with S3RN. She confirmed she lifted her glasses with her gloved hand and did not change her gloves after she touched her glasses. She also stated she did not perform hand hygiene between each of the glove changes while performing wound care to both of the resident's lower extremities.
On 07/11/2023 at 01:46 p.m., an interview was conducted with S1AADM/IP. She stated S3RN should have changed gloves after touched her glasses to lift them up, and should have performed hand hygiene in between glove changes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #105
Records review revealed that Resident #105 was admitted on [DATE] with diagnoses that included Major Depressive Di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #105
Records review revealed that Resident #105 was admitted on [DATE] with diagnoses that included Major Depressive Disorder.
A review of Resident #105's Physician's Orders revealed an order dated 05/19/2023 for Lexapro 10mg (a medications used to treat depression) give 1 tablet via PEG (percutaneous endoscopic gastrostomy) tube one time a day related to Major Depressive Disorder.
A review of Resident #105's Care Plan revealed, in part, an intervention to address Resident #105's antidepressant use to monitor/document/report adverse reactions and behaviors to antidepressant therapy.
A review of Resident #105's EMAR (Electronic Medication Administration Record) dated for July 2023 revealed the resident received Lexapro 10mg daily as ordered. There was no documentation of adverse reactions/side effects and behavior monitoring for July 2023.
On 07/11/2023 at 4:05 p.m., an interview was conducted with S12LPN. S12LPN confirmed that behavior and adverse reaction/side effect monitoring is documented on the EMAR every shift for medications, including antidepressants.
On 7/11/2023 at 4:10 p.m., an interview was conducted with S4LPNCP. S4LPNCP confirmed that resident #105 was currently prescribed and taking an antidepressant. She confirmed that an intervention on the residents Care Plan for the use of antidepressant medication required staff to monitor/document/report adverse reactions and behaviors to antidepressant therapy. S4LPNCP confirmed there was no documentation of behavior or adverse reaction monitoring on the EMAR. S4LPNCP stated that the nursing staff should be monitoring for these behaviors and adverse reactions/side effects every shift and this monitoring would be located on the EMAR.
On 07/12/2023 at 9:22 a.m., an interview was conducted with S11RNDON. S11RNDON confirmed that documentation for behavior monitoring and adverse reaction monitoring for antidepressants would be located on the EMAR. S11RNDON confirmed that Resident #105 was taking an antidepressant and that Resident #105 had no behavior or adverse reaction monitoring for an antidepressant.
Based on observation, interviews, and record reviews, the facility failed to implement the residents' plan of care by not following physician orders and the care plan for 2 (#16, #105) out of a finalized sample of 38 residents as evidenced by:
1.
Failing to ensure catheter tubing was secured by using a leg strap for resident #16,
2.
Failing to monitor and document behaviors and adverse reactions to an antidepressant for resident #105.
This deficient practice had the potential to affect a total census of 109 residents.
Findings:
Resident #16
Records review revealed that Resident #16 was admitted on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, Retention of Urine, Urinary Tract Infection Site not specified.
A review of Resident #16's Physician's Orders revealed an order dated 02/06/2023 foley leg strap to release tension from foley.
A review of Resident #16's Care Plan revealed, in part, indwelling foley catheter related to obstructive and reflux uropathy, interventions leg straps as ordered to keep tension off of catheter.
On 07/10/2023 at 10:15 am., an observation of Resident #16, lying in bed asleep. His foley bag was noted with dark urine and no foley leg strap inplace.
On 07/10/23 at 12:03 p.m., another observation was conducted of the Resident #16 with no foley leg strap inplace. An interview was conducted with S14LPN (Licensed Practical Nurse). She confirmed the Resident had no foley leg strap inplace, and should have had a leg strap inplace as per the physician orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to meet the food preferences of 1 (#48) resident out of 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to meet the food preferences of 1 (#48) resident out of 3 (#44, #48, #54) residents investigated for food in a final sample of 38 residents.
Findings:
Review of Facility's Policy titled, Food Likes and Dislikes read in part, the food likes and dislikes of each resident are determined through a dietary assessment .2. A written record shall be maintained (Nutritional Data List) of the resident's likes and dislikes. Such record will include how the resident prefers his/her food to be served (i.e., cut, chopped, or ground) .3. Residents shall be visited periodically to determine if any changes need to be made in order to meet the resident's needs.
Review of Resident #48's clinical record revealed she was admitted on [DATE] with Diagnoses that included Chronic Kidney Disease, Major Depressive Disorder, Hypertension, Acute on Chronic Diastolic Heart Failure and Age Related Osteoporosis.
Review of Resident #48's Quarterly MDS (Minimum Data Set) dated 05/01/2023 revealed a BIMS (Brief Interview for Mental Status) of 13, indicating she was cognitively intact.
In an interview with Resident #48 on 07/10/2023 at 12:05 p.m., the resident stated They keep putting that I do not like tomatoes on my meal ticket. The resident further stated that she likes tomatoes and keeps asking for them but they never give it to her. At this time, it was observed on Resident #48's meal ticket that tomato products and fresh tomatoes were listed as dislikes. It was also noted that there was a meal note stating no tomato or dairy products on her meal ticket.
Review of Resident #48's Dietary History and assessment dated [DATE] revealed dislikes milk, tomato sauce, and green beans. It included her likes as eggs, ham, chicken salad, and egg salad. Fresh tomatoes was not included in her list of likes.
Review of the resident's record revealed a dietary note dated 09/08/2021 that read in part, Resident #48 requested tomatoes, meal card has been updated to reflect.
On 07/11/2023 at 01:40 p.m., an interview was conducted with S13DM (Dietary Manager), she confirmed that Resident #48's meal ticket included a dislike for tomato products and fresh tomatoes and also a meal note stating no tomato or dairy products She also confirmed that she was aware the resident liked fresh tomatoes and that the meal ticket had not been updated.
On 07/12/2023 at 01:30 p.m., a follow-up interview was conducted with S13DM. She verified that she completed the resident's dietary assessment on 06/09/2021 and quarterly re-assessments to review resident's likes and dislikes. A dietary note is entered and the meal card should be updated when there are changes in the resident's food preferences. S13DM stated that Resident #48 told her that she liked fresh tomatoes and did not like tomato sauce. She stated that Resident #48's preference card did not accurately reflect the resident's likes/dislikes because it was not entered correctly on 06/09/2021. She further stated that the resident had not been receiving fresh tomatoes because the meal ticket had not been changed.
Apr 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to timely notify the resident's physician of a decrease in blood pressure readings until he became unresponsive for 1 (#2) of 5 (#1, #2, #3, #...
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Based on interview and record review, the facility failed to timely notify the resident's physician of a decrease in blood pressure readings until he became unresponsive for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents.
The facility had a census of 113 residents.
Findings:
Review of facility's policy titled Change in Condition read in part: All staff members shall communicate any information about resident change to appropriate licensed personnel immediately upon observation. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or mental condition. The following list of some significant changes of condition: #4, Drop or elevation in blood pressure of significant value.
Resident #2 was admitted to the nursing facility on 08/04/2006 with diagnoses that included in part the following: Essential Hypertension, Heart Failure, Retention of Urine, Shortness of Breath, Type 2 Diabetes Mellitus, Cerebral Infarction, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Dysphagia, Major Depressive Disorder, and Paroxysmal Atrial Fibrillation.
Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 02/20/2023 revealed in part: BIMS (Brief Interview for Mental Status) 11 indicating moderately impaired cognition.
Review of Resident #2's care plan revealed in part: He was care planned for Hypertension related to diagnosis Essential Primary Hypertension. (Date Initiated: 06/09/2020, Revision: 08/20/2020). He was also care planned for Heart Failure which included in part interventions to monitor vital signs per protocol, MD (medical doctor) orders and as needed, notify MD of significant abnormalities. (Date Initiated: 12/05/2022, Revision: 01/10/2023. He was also care planned for Hypotension related to use/side effects of medication, recent change in condition which also included in part an intervention to monitor vital signs per protocol, MD order and as needed. Notify MD of significant abnormalities. (Date Initiated: 12/21/2022, Revision: 04/17/2023).
Review of emergency department provider notes dated 03/24/2023 revealed in part that Resident #2 was brought in by ambulance from a local nursing home with declining mental status, and low blood pressures reportedly 70 systolic (top blood pressure number) at the nursing home. Reportedly the nursing home staff stated that the patient is always generally fairly talkative but has had a decline over the last 1 to 2 days, has been refusing to eat or drink. Critical care was necessary to treat for Metabolic Crisis, Dehydration and Sepsis.
Review of Resident #2's blood pressures revealed in part the following:
03/17/2023 at 211:01 p.m. 127/82, lying left arm.
03/18/2023 at 09:16 a.m. 138/75, lying right arm.
03/19/2023 at 11:01 p.m. 117/75, lying left arm.
03/20/2023 at 11:22 p.m. 110/70, lying left arm.
03/21/2023 at 8:29 p.m. 108/71, lying right arm.
03/22/2023 at 8:23 p.m. 123/82, lying right arm.
03/23/2023 at 11:18 p.m. 109/50, lying left arm.
03/24/2023 at 10:26 a.m. 88/54, sitting right arm.
03/24/2023 at 4:30 p.m. 86/57, sitting right arm.
03/24/2023 at 6:50 p.m. 76/54, lying right arm.
Review of Resident #2's physician orders revealed there were no orders for 3/24/2023 that addressed Resident #2's low blood pressure.
Review of nurse's notes by S3LPN revealed the following: 03/24/2023 at 4:30 p.m. Notified by CNA (certified nursing assistant) of resident's BP (blood pressure) 86/57, P (pulse) 74, O2 (oxygen saturation) 97 room air. Resident sitting up in wheelchair. NADN (no acute distress noted). Resident is able to make needs known. Resident is alert, oriented. Administered 480 ml (milliliter) of oral fluids. Will continue to monitor.
Review of nurse's notes by S3LPN on 03/24/2023 at 6:50 p.m. revealed Resident in bed. Resident alert, awake, oriented. NADN. BP 76/54 P 72 O2 94 room air. HOB (head of bed) elevated. Administered 720 ml of oral fluids.
Review of nurse's notes by S3LPN on 03/24/2023 at 07:30 p.m. revealed Rounding on patient after medicine pass, resident not easily aroused, skin cool and pale. BP 96/68 P 75 O2 98 at 2L (liters) NC (nasal cannula).
Review of nurse's notes by S3LPN on 03/24/2023 at 07:41 p.m. revealed doctor made aware of resident's condition. Resident in lethargic state. Skin cool and pale. New orders to send resident to hospital.
Review of nurse's notes by S3LPN on 03/24/2023 at 07:54 p.m. revealed Resident transported out of NH (nursing home).
On 04/17/2023 at 02:15 p.m., Resident #2 was observed lying in bed with oxygen in place per nasal cannula. The resident was awake and oriented to person. He spoke about random things and did not respond appropriately to interview questions.
04/17/2023 at 02:30 p.m., an interview was conducted with S3LPN. She stated that she was the resident's evening shift nurse on 03/24/2023 and that she had not reported the low BP of 86/54 to the doctor. She explained that she used her nursing judgement and gave him 480 ml (approximately 2 cups) of fluid by mouth. She stated that she checked it again later and it was 76/54 and he was still asymptomatic so she gave him an additional 720ml (approximately 3 cups) fluids by mouth. She stated that she later checked on resident and he was unresponsive, cool and clammy and notified the doctor at that time. She stated that she was unsure what a low blood pressure was, however, she knew that normal blood pressure is 120/80. She stated that she was unaware of any protocols for abnormal blood pressure for the resident or for the facility.
On 04/18/2023 at 12:30 p.m., an interview was conducted with S5MD (Medical Doctor). When asked about his expectations of being called for abnormal low blood pressure, he stated that he would expect to be called if a resident had a consistently low blood pressure. He could not recall if he had been notified of the resident's low blood pressures obtained on 03/24/2023.
On 04/18/2023 at 02:40 p.m., an interview was conducted with S2DON. She stated that the facility did not have standing orders for the resident that addressed abnormal blood pressure readings. She stated that when the nurse received the blood pressure result of 86/57, she should have rechecked it in a different location such as the other arm. She agreed that when the nurse gave 480 ml of oral fluids to Resident #2, she should have followed up 15-30 minutes later and rechecked his blood pressure. She stated that with a blood pressure of 86/57 and 76/54, the nurse should have notified physician. She also confirmed that a follow-up should have been done with a recheck of blood pressure once she provided an intervention of giving oral fluids in 15-30 minutes and not wait to do so for over 2 hours.
Dec 2022
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and policy reviews, the facility failed to:
1. properly log temperatures daily for 1 (B) of 3 (A, B, C) nourishment refrigerators and:
2. failed to properly date and...
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Based on observations, interviews, and policy reviews, the facility failed to:
1. properly log temperatures daily for 1 (B) of 3 (A, B, C) nourishment refrigerators and:
2. failed to properly date and label food items in 3 of 3 (A, B, C) nourishment refrigerators to prevent the
potential for foodborne illness.
Finding:
Review of the facility's Food Storage policy revealed the following, in part:
8) The Dietary Manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. Records of such information are maintained by the Dietary Manager. 10) Food may be brought to residents by family and visitors. Such foods must be stored in a safe and sanitary manner for consumption. They are to be kept in sealed, dated containers along with resident's name. Those foods that are to be kept cold are to be placed in the refrigerators in resident's room or nurse's station. Food that is expired or thought to be spoiled will be discarded by staff.
On 12/19/22 at 1:06 p.m., an observation was made of the nutrition refrigerator on B hall that revealed the following items without a name or date: 1) a Subway box, 2) two individually wrapped croissants, 3) bottle water half full, 4) Individually wrapped Uncrustable, 5) opened package of chocolate individual size candies, 6) an individually wrapped hot pocket, 7) a can of Monster drink open on bottom shelf. Review of the Refrigerator Temperature Log labeled December 2022 that did not include temperatures for the following dates: 12/7/22, 12/8/22, 12/9/22, 12/10/22, 12/11/22, 12/13/22, 12/14/22, 12/15/22, 12/16/22, 12/17/22, 12/18/22, and 12/19/22.
On 12/19/22 at 1:24 p.m. an observation was made of the nutrition refrigerator on A hall that contained a partially empty Coca-Cola bottle and partially empty water bottle that was also not labeled or dated.
On 12/19/22 at 2:38 p.m. an observation was made of C hall nutrition refrigerator that revealed the following with no label, name, or date: 1) open monster energy drink, 2) supreme pizza, 3) banquet frozen meal, 4)Supplement (2CalHN supplement) open no date, 5) a partially empty bottle of water, 6) an open Hawaiian punch drink.
On 12/19/22 at 1:11 p.m. an interview was conducted with S3CNA. S3CNA confirmed the nutrition refrigerator on B hall did not have dates or labels on above named items.
On 12/19/22 at 1:16 p.m. an interview was conducted with S4LPN that confirmed the nutrition refrigerator on B hall contained the items listed above that did not have a label, name or dates. S4LPN confirmed Refrigerator Temperature Log was incomplete with missing temperatures for the above named dates.
On 12/19/22 at 1:27 p.m. an interview was conducted with S2HSK revealed housekeeping was responsible for logging the temperatures for nutrition refrigerators.
On 12/19/22 at 1:28 p.m. an interview was conducted with S5LPN who confirmed nutrition refrigerator on A hall contained the above listed items without a label, name, or dates.
On 12/19/22 at 2:22 p.m. an interview was conducted with S1DM who stated that housekeeping and nursing staff were responsible for removing expired items the from nutrition refrigerators on the halls.
On 12/19/22 at 2:33 p.m. an interview with S7HSK revealed housekeeping was assigned to check temperatures on the nutrition refrigerators and record the temperatures on the log. S7HSK stated housekeeping is responsible for cleaning and removing expired items and items not labeled/dated in nutritional refrigerators
On 12/19/22 at 2:40 p.m. an interview was conducted with S7LPN. S7LPN confirmed items noted above were in the nutrition refrigerator on C hall were not labeled or dated.
Jun 2022
3 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide bed hold notices upon hospital transfer to the resident and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide bed hold notices upon hospital transfer to the resident and the resident's representative for 4 (#11, #50, #61, #65) out of 4 (#11, #50, #61, #65) residents investigated for hospitalization. This deficient practice had the potential to affect a census of 107 residents.
Findings:
Resident #11: Review of the facility's Emergency Transfer Logs revealed that the resident was sent to the hospital on [DATE], 2/1/22, and 3/6/22.
Review of Resident #11's nursing progress note dated 6/17/22 at 11:50 am revealed ambulance transport arrived to transfer the resident to the hospital.
Review of Resident #11's medical record revealed no evidence of bed hold notices at the time of the resident's hospitalizations.
Resident #50: Review of Resident #50's medical record/nurse's notes revealed the resident was sent out to the hospital on [DATE] at 18:35 (6:35 p.m.) and did not return until 04/19/2022 at 16:23 (4:23 p.m.).
Review of the facility's Emergency Transfer Log for April 2022 revealed Resident #50 was included on the list with a transfer dated 04/16/2022.
Further review of the medical record revealed no evidence of bed hold notices at the time of the resident's hospitalizations.
Resident #61: Review of the facility' Emergency Transfer Log revealed that the resident was sent to the hospital on 5/11/22, 5/20/22, 5/22/22 and 6/3/22.
Review of Resident # 61's medical record revealed no documented evidence of bed hold notices at the time of the resident's hospitalizations.
Resident #65: Review of the facility's Emergency Transfer Log revealed that the resident was sent to the hospital on 5/10/22 and 5/27/22.
Review of Resident # 65's medical record revealed no documented evidence of bed hold notices at the time of the resident's hospitalizations.
Review of the facility's bed hold policy revealed, in part, the following: .Upon admission and when leaving the facility, the resident and/or the agent or legal representative will be given instructions of the times allowed out of the facility for hospitalization and/or therapeutic leave .Formal notification will be made to the responsible party upon hospitalization.
06/21/22 at 4:00 p.m., an interview was conducted with S1ADM after requesting bed hold notices for the resident transfers to the hospital. He stated that the all residents are notified of the bed hold policy upon admission. He confirmed that no bed hold notices were sent at the time of hospital transfer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to serve food in a sanitary manner as evidenced by a staff member preparing meal trays with contaminated gloves. This deficient practice had t...
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Based on observations and interviews, the facility failed to serve food in a sanitary manner as evidenced by a staff member preparing meal trays with contaminated gloves. This deficient practice had the potential to affect 105 residents who consumed meals from the kitchen.
Findings:
On 6/20/22 at 10:38 am, an observation made of S4KS preparing meal trays from the steam table line with gloved hands. She touched meal trays, plates, serving utensils, and the warmer door handle. As she prepared the meal trays, she opened the warmer and grabbed rolls with the same gloved hands. She then placed the rolls on meal trays. S4KS was not observed changing her gloves or washing her hands throughout the meal service.
On 6/20/22 at 11:12 am, during an interview with S3DM, she stated that staff should use tongs or utensils to handle rolls. She confirmed the S4KS did not use tongs and handled rolls after she touched other items without changing her gloves.
On 6/20/22 at 11:14, am interview was conducted with S4KS. She stated tongs should be used to handle rolls and not gloved hands. She confirmed she did not use tongs to handle the rolls or change her gloves. During the interview, S4KS reached into her pocket to retrieve her name tag, then returned her name tag to her pocket, with gloved hands. She continued to prepare the meal trays without changing her gloves upon the conclusion of the interview.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help to prevent and co...
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Based on record review and interview, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help to prevent and control the spread of infectious communicable disease, COVID-19, by failing to ensure staff appropriately screened visitors prior to them entering the facility. This deficient practice has the potential to affect 107 residents who reside in the facility.
Findings:
Review of the facility document titled COVID-19 Visitation Policy And Procedure read in part .Visitor Screening .2. All visitors must be screened, except for emergency services personnel entering the facility 3. Visitor screenings must be documented in a log, which must include the following:
a.
Name of each person screened
b.
Date and time of the screening
c.
Resident being visited
d.
Signs and symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea.
e.
Contact in the last 14 days with someone who has a confirmed diagnosis of COVID-19, is under investigation for COVID-19, or is ill with a respiratory illness, unless the visitor is seeking entry to provide critical assistance .
On 06/20/22 at 08:09 a.m., an observation was made of the signage on the front door which read in part, Everyone will be screened for COVID-19 signs and symptoms.
On 6/20/22 at 9:00 a.m., an interview and observation was made of the visitor's screening logs with S6GR. S6GR stated he was responsible for monitoring the front entrance and visitor screening. He stated that screening consisted of taking the temperature, documenting it on the log and ensuring that all the COVID-19 screening questions were answered appropriately before visitors were allowed into the facility. He stated that staff were responsible for completing the screening questionnaire and he took their temperature to ensure that temperatures were monitored. He informed the Administrator daily of the number of visitors. S6GR stated, once the logs were full, he put them in the top drawer of a cabinet located in the front lobby. He stated that he was unaware of who was responsible for reviewing the log sheets after he put them in the cabinet drawer. At that time, S6GR removed the visitors log sheet from the cabinet drawer.
A review of the May and June 2022 visitor's logs was conducted with S6GR which revealed incomplete screening on 6/4/22, 6/6/22, 6/7/22, 6/12/22, 6/15/22 and 6/16/22. There was missing documentation of temperatures, dates and answers to screening questions. S6GR stated that the person responsible for screening the visitors is supposed to make sure that all screening information was is documented on the log.
On 06/20/22 at 10:39 a.m., after review of May and June 2022 visitor's logs, S1ADM stated I see what you mean. Yes, they should have completely filled out the questionnaire and documented the temperatures. S1ADM confirmed that the staff assigned to screening visitors and staff should ensure temperatures are documented and all screening questions are answered to ensure appropriate screening was conducted.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $29,007 in fines. Review inspection reports carefully.
- • 24 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $29,007 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Ellington's CMS Rating?
CMS assigns THE ELLINGTON an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Ellington Staffed?
CMS rates THE ELLINGTON's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 53%, compared to the Louisiana average of 46%.
What Have Inspectors Found at The Ellington?
State health inspectors documented 24 deficiencies at THE ELLINGTON during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 22 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Ellington?
THE ELLINGTON is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 111 residents (about 92% occupancy), it is a mid-sized facility located in RAYNE, Louisiana.
How Does The Ellington Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, THE ELLINGTON's overall rating (2 stars) is below the state average of 2.4, staff turnover (53%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting The Ellington?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is The Ellington Safe?
Based on CMS inspection data, THE ELLINGTON has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Ellington Stick Around?
THE ELLINGTON has a staff turnover rate of 53%, which is 7 percentage points above the Louisiana average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Ellington Ever Fined?
THE ELLINGTON has been fined $29,007 across 2 penalty actions. This is below the Louisiana average of $33,369. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Ellington on Any Federal Watch List?
THE ELLINGTON 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.