SHREVEPORT MANOR SKILLED NURSING & REHABILITATION
For profit - Partnership
127 Beds
PRIORITY MANAGEMENT
Data: November 2025
Trust Grade
48/100
#157 of 264 in LA
Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Shreveport Manor Skilled Nursing & Rehabilitation has a Trust Grade of D, indicating below average performance with several concerns. They rank #157 out of 264 facilities in Louisiana, placing them in the bottom half, and #14 out of 22 in Caddo County, meaning only a few local options are better. The facility is seeing an improving trend, with issues decreasing from 12 in 2024 to 11 in 2025, but staffing remains a significant concern, rated at 1 out of 5 stars with a 54% turnover rate, which is average for the state. There are also concerning findings, such as residents' call lights being out of reach, lack of communication regarding personal funds, and failure to provide a safe environment for residents at risk of falls. While they have an average health inspection score of 3 out of 5 and average fines of $10,567, the lack of sufficient RN coverage, being lower than 88% of Louisiana facilities, is a notable weakness.
- Trust Score
- D
- In Louisiana
- #157/264
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $10,567 in fines. Higher than 59% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 41%
No red flags
12 → 11 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 11 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: 54%
Near Louisiana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $10,567
Below median ($33,413)
Minor penalties assessed
Chain: PRIORITY MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
Aug 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0575
(Tag F0575)
Could have caused harm · This affected 1 resident
Based on interviews and observations, the facility failed to post the correct telephone number of pertinent state agencies in a form and manner accessible and understandable to residents/resident repr...
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Based on interviews and observations, the facility failed to post the correct telephone number of pertinent state agencies in a form and manner accessible and understandable to residents/resident representatives. Findings:During an interview on 08/26/2025 at 3:01 p.m. S1 DON (Director of Nursing) reported the state complaint hotline number for nursing homes was posted on the main hallway bulletin board.Observation on 08/26/2025 at 3:02 p.m. with S2 Corporate Nurse failed revealed to reveal the correct number to file a complaint with the state survey agency was posted. During an interview on 08/26/2025 at 3:02 p.m. S2 Corporate Nurse verified the number was incorrect by calling the posted number, on speaker, in the presence of surveyors.Observation on 08/27/2025 at 11:30 a.m. revealed hand written state complaint hotline number for nursing homes was only posted on main dining room hallway bulletin board and was above eye level while standing.During an interview on 08/27/2025 at 11:32 a.m. S3 Human Resources reported the state complaint hotline number for nursing homes was only posted on main dining room hallway bulletin board, should have been posted in other places, and was above eye level while standing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement an individualized care plan for 1 (#52) out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement an individualized care plan for 1 (#52) out of 29 total sampled residents reviewed. The facility failed to develop Resident #52's care plan for dependent assistance with activities of daily living (ADL) and refusal to wear socks and shoes.Findings:Review of Resident #52's medical records revealed an admit date of 07/11/2025 with the following diagnoses, including in part: other impulse disorders, other disorders of psychological development, developmental disorder of scholastic skills unspecified and other specified anxiety disorders.Review of Resident #52's MDS (Minimum Data Set) assessment dated [DATE] revealed a functional status of dependent with eating, toileting hygiene, shower/bathe, upper and lower body dressing, putting on/taking off footwear and personal hygiene.Review of Resident #52's comprehensive care plan revealed the following problem and approach for ADL self-care performance deficit .(initiated 7/11/25) - dressing: Resident is independent with dressing. No assistance required. Eating: Resident is independent with eating. No assistance required. Personal hygiene: Resident is independent with personal hygiene. No assistance required. Toilet use: Resident is independent in toilet use. Bathing: Resident is independent in bathing. Dressing: Resident is independent in dressing. Observation on 08/25/2025 at 10:30 a.m. revealed Resident #52 sitting in wheelchair in common area with no socks or shoes on and feet touching the floor.Observation on 08/26/2025 at 8:25 a.m. revealed Resident #52 sitting in wheelchair in common area with no socks or shoes on and feet touching the floor.During an interview on 08/26/2025 at 3:12 p.m. S12 CNA (Certified Nursing Assistant) reported Resident #52 would take off his socks if you put them on and most times would not let you put shoes or socks on him. During an interview on 08/27/2025 at 8:22 a.m. S11 LPN (Licensed Practical Nurse) reported Resident #52 would not wear shoes or socks and would throw the shoes across the room.During an interview on 08/27/2025 at 8:35 a.m. S10 LPN Care Plan Nurse acknowledged Resident #52 was dependent for all ADLs and the care plan was incorrect. S10 LPN Care Plan Nurse further reported she was unaware Resident #52 refused to wear socks and shoes and should have been care planned for this.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on record review, observations, and interviews the facility failed to accommodate the needs of 2 (#37 and #48) of 4 (#6, #37, #48, and #78) residents reviewed for environment. The facility faile...
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Based on record review, observations, and interviews the facility failed to accommodate the needs of 2 (#37 and #48) of 4 (#6, #37, #48, and #78) residents reviewed for environment. The facility failed to ensure the residents' call lights remained in reach. Findings:Review of Resident Call Light System revised 06/2023 revealed:PurposeThe purpose of this procedure is to respond to the resident's requests and needs.Policy implementationA call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities.General Guidelines3. Return demonstration may be utilized to ensure the resident can operate the system.4. Ensure that the call light is easily reachable by the resident.Resident #37Observation on 08/27/2025 at 7:50 a.m. revealed Resident #37 was in bed and call light on the floor and not in reach.Observation on 08/27/2025 at 10:05 a.m. revealed Resident #37's was in bed and call light on the floor and not in reach.Observation on 08/27/2025 at 10:10 a.m. with S6 LPN (Licensed Practical Nurse) revealed Resident #37 was in bed and call light was on the floor and not in reach.During an interview on 08/27/2025 at 10:10 a.m. S6 LPN confirmed Resident #37 was in bed and call light was on the floor and not in reach.Resident #48Observation on 08/25/2025 at 8:35 a.m. revealed Resident #48 was in bed and call light was not plugged into the wall.Observation on 08/25/2025 at 11:28 a.m. revealed Resident #48 was in bed and call light was not plugged into wall.Observation on 08/25/2025 at 11:30 a.m. with S7 LPN revealed Resident #48 was in bed and call light was not plugged into wall.During an interview on 08/25/2025 at 11:30 a.m. S7 LPN confirmed Resident #48 was in bed, call light was not plugged in, and should have been accessible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure quarterly statements for residents' personal funds entrusted...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure quarterly statements for residents' personal funds entrusted to the facility were provided for 1 (#41) of 1 resident reviewed for personal funds. The facility failed to provide quarterly statements to Resident #41. Findings: Review of admission packet documents provided to residents revealed a Resident Funds Letter which included:Dear Resident:Our facility provides each resident with an opportunity to deposit his/her personal funds into a resident's trust fund account.Should you elect to deposit funds into the resident's trust fund: .You or your legal representative will receive a confidential quarterly statement of funds. Review of Resident #41's medical record revealed Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's 06/12/2025 Quarterly Minimum Data Set (MDS) revealed Resident #41 had a BIMS (Brief Interview Mental Status) score of 15, which indicated intact cognition. During an interview on 08/25/2025 at 2:43 p.m. Resident #41 reported the facility holds money for her and would not communicate how much money the facility was holding for her. During an interview on 08/26/2025 at 3:30 p.m. S5 Business Office Manager (BOM) reported she had worked at the facility for 3 years and residents with personal funds trust accounts had not been receiving quarterly statements.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on record reviews, observations and interviews the facility failed to ensure a resident that was cognitively impaired and at risk for falls had an environment free of accidents hazards for 1 (#4...
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Based on record reviews, observations and interviews the facility failed to ensure a resident that was cognitively impaired and at risk for falls had an environment free of accidents hazards for 1 (#48) of 2 (#31, #48) residents reviewed for accidents. Findings: Review of facility's Managing Falls and Fall Risk policy (Revised November 14, 2024) revealed:Policy StatementBased on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Review of Resident #48's face sheet revealed an admission date of 07/31/2023 with the following diagnoses but not limited to sequelae of cerebral infarction, generalized muscle weakness, unspecified lack of coordination, unspecified psychosis not due to a substance or known physiological condition, muscle wasting and atrophy to multiple sites, dementia, mood disturbance, anxiety, insomnia, pain, restless legs syndrome, and Alzheimer's disease. Review of Annual MDS (Minimum Data Set) dated 07/03/2025 revealed a BIMS (Brief Interview of Mental Status) of 03 indicating severely impaired cognition. Review of Resident #48's Incident Report dated 05/31/2025 revealed interventions: staff will continue to ensure bed is in lowest position and mats will remain at bedside. Staff will continue to monitor and will assist as needed. An observation on 08/25/2025 at 8:35 a.m. revealed Resident #48 resting in bed and fall mat was leaning against the wall. An observation on 08/25/2025 at 11:29 a.m. revealed Resident #48 resting in bed and fall mat was leaning against the wall. During an interview on 08/25/2025 at 11:30 a.m. S7 LPN (Licensed Practical Nurse) acknowledged Resident #48's fall mat was positioned against wall and should have been on floor next to the bed while Resident #48 was in bed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on record review, observations and interviews the facility failed to provide appropriate infection control practices for 1(#37) of 1 resident reviewed for urinary catheter/ UTI (Urinary Tract In...
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Based on record review, observations and interviews the facility failed to provide appropriate infection control practices for 1(#37) of 1 resident reviewed for urinary catheter/ UTI (Urinary Tract Infection). The facility failed to ensure a resident with a supra pubic catheter received the appropriate care and services to prevent urinary tract infections by failing to ensure (1) the suprapubic catheter was properly secured in a manner to promote drainage and (2) the catheter tubing and bag did not come in contact with the floor. Findings: Review of Resident #37's face sheet revealed an admission date of 03/12/2024 with the following diagnoses but not limited to history of urinary tract infection, chronic, bladder-neck obstruction, benign neoplasm of prostate, obstructive and reflux uropathy, and benign prostatic hyperplasia without lower urinary tract symptomsReview of Resident #37's August 2025 EMAR (Electronic Medication Administration Record) revealed:03/14/2025: Catheter: urinary catheter ensure tubing anchor and privacy bag is intact and secure every shiftReview of Resident #37's care plan revealed indwelling suprapubic catheter with interventions include to position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks while providing care and each shift. Review of Resident #37's Quarterly MDS (Minimum Data Sets) dated 08/08/2025 revealed a BIMS (Brief Interview of Mental Status) of 12 indicating moderately impaired cognition. Further review of MDS revealed Resident #37 had an indwelling catheter.Observation on 08/27/2025 at 7:50 a.m. revealed Resident #37 resting in bed in lowest position with tubing and catheter bag on the floor. Observation on 08/27/2025 at 10:05 a.m. revealed Resident #37 resting in bed in lowest position with tubing and catheter bag on the floor.Observation on 08/27/2025 at 10:10 a.m. with S6 LPN (Licensed Practical Nurse) revealed Resident #37's tubing and catheter bag was on the floor. Further observation failed to reveal Resident #37's catheter tubing was secured to thigh. During an interview on 08/27/2025 at 10:10 a.m. S6 LPN confirmed Resident #37's catheter tubing should have been secured to thigh and was not. S6 LPN confirmed Resident #37's catheter tubing and bag was on the floor and should not have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on record reviews and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure...
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Based on record reviews and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the low temperature dishwasher met wash cycle temperature recommendations. The deficient practice had the potential to affect the 70 residents who received meals from the kitchen as per S4 Housekeeping/Dietary Manager.Findings: Review of Policy: Mechanical Cleaning and Sanitizing of Utensils and Portable EquipmentDate approved: October 1, 2018Policy: The facility will follow the cleaning and sanitizing requirements of the state and US (United States) Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.Procedure: .If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120 degrees F (Fahrenheit). Observation on 08/27/2025 at 09:15 a.m. revealed a sticker on the front of the kitchen dishwasher which read ____________ Dishwasher Operating Requirements 1. Water temp. 120 degrees F minimum, 2. Chlorine Residual 50 PPM (parts per million) min. (minimum), 3. Min. Wash 56 sec. (seconds) rinse 24 sec. Review of completed August 1, 2025 to August 25, 2025 Dishwasher Temperature/Chemical Record revealed daily dishwasher wash temperature checks for breakfast, lunch, and dinner were below the required 120 degrees and each wash temperature was documented at 110 degrees. Review of completed July 2025 Dishwasher Temperature/Chemical Record revealed daily dishwasher wash temperature checks for breakfast, lunch, and dinner were below the required 120 degrees for the following:-Breakfast wash temperature was recorded as 100 degrees on 07/01/2025 to 07/07/2025, 07/09/2025 to 07/19/2025 and 07/21/2025; and recorded as 50 degrees F on 07/08/2025, 07/20/2025, and 07/22/2024 to 07/25/2025.-Lunch wash temperature was recorded as 100 degrees on 07/01/2025 to 07/29/2025 and recorded as 50 degrees on 07/30/2025 and 07/31/2025.-Dinner wash temperature was recorded as 100 degrees on 07/01/2025 to 07/17/2025 and 07/24/2025 to 07/29/2025; and was recorded as 50 degrees on 07/30/2024 and 07/31/2024. During an interview on 08/27/2025 at 8:40 a.m. S4 Housekeeping/Dietary Manager reported the July 2025 and August 2025 dishwasher temp logs included wash temperatures which were below 120 degrees Fahrenheit and dishwasher wash temperature should be at least 120 degrees Fahrenheit.
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 reviews, observations and interviews, the facility failed to ensure staff practices were consistent with current infection control principles and practices to prevent infection and cro...
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Based on record reviews, observations and interviews, the facility failed to ensure staff practices were consistent with current infection control principles and practices to prevent infection and cross contamination. The facility failed to ensure:(1) PPE (Personal Protective Equipment) was used during contact with contaminated medical equipment and hand hygiene performed, and(2) Proper cleaning and disinfection of medical equipment Findings:Review of facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy revised 10/2018 revealed: Policy Interpretation and Implementation2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.Review of facility's Handwashing/Hand Hygiene policy revised 12/22/2023 revealed: This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.8. Hand hygiene is the final step after removing and disposing of personal protective equipment.9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.10. Single-use disposable gloves should be used:b. When anticipating contact with blood or body fluids.Review of facility's Personal Protective Equipment - Using Gloves policy revised 11/2010 revealed: Objectives1. To prevent the spread of infection;3. To protect hands from potentially infectious material. Equipment and Supplies4. Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces.5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.)When to Use Gloves1. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin;4. When cleaning potentially contaminated items. Hall A An observation on 08/25/2025 at 1:08 p.m. revealed Hall A gray shower chair had brown, hard, and dried residue in holes and blue chair had brown, hard, and dried residue on inside and outside of chair. An observation on 08/25/2025 at 2:45 p.m. S7 LPN (Licensed Practical Nurse) reported shower chairs should be cleaned between resident use. S7 LPN acknowledged Hall A shower gray and blue chairs had brown residue and should have been cleaned. Hall BAn observation on 08/25/2025 at 2:35 p.m. revealed Hall B white shower chair had brown, hard, and dried residue on top of chair and in holes. During an interview on 08/25/2025 at 2:36 p.m. S8 Housekeeping confirmed Hall B white shower chair had brown residue. S8 reported he cleaned Hall B chair yesterday and it should be cleaned again. S8 Housekeeping reported housekeeping is responsible for cleaning shower chairs. An observation on 08/25/2025 at 2:36 p.m. revealed S8 Housekeeping cleaned chair with foaming cleaner and a rag. S8 Housekeeping did not use gloves and did not use hand hygiene after cleaning.During an interview on 08/25/2025 at 2:36 p.m. S8 Housekeeping reported he should have worn gloves while cleaning Hall B shower chair and performed hand hygiene after cleaning.During an interview on 08/25/2025 at 2:40 p.m. S9 CNA (Certified Nursing Assistant) reported housekeeping is responsible for cleaning shower chairs. S9 CNA will contact housekeeping for cleaning between resident showers. During an interview on 08/26/2025 at 2:30 p.m. S4 Housekeeping/Dietary Manager reported S8 had multiple discussions concerning hand hygiene and infection control practices. S4 Housekeeping/Dietary Manager reported S8 Housekeeping should have worn gloves while cleaning and performed hang hygiene after cleaning Hall B shower chair.During an interview on 08/25/2025 at 2:30 p.m. S10 Care Plan Nurse reported CNAs are responsible for cleaning chairs between residents.
Apr 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility failed to accommodate the needs of 1 (#1) of 3 (#1, #2, and #3)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility failed to accommodate the needs of 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure resident #1's call light was within reach.
Findings:
The facility's Resident Call Light System policy/procedure (revised date 06/2023) presented by the S1 Corporate Nurse revealed in part:
Purpose: The purpose of this procedure is to respond to the resident's requests and needs.
Policy Implementations: A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need. Residents can communicate with the Nurse's Station from their room and/or bathing and toileting facilities.
General Guidelines: 4. Ensure that the call light is easily reachable by the resident.
Resident #1 was admitted to this facility 07/14/2022. Diagnoses included rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints
Review of resident #1's most recent quarterly MDS (Minimum Data Set) dated 12/20/2024 revealed resident #1 had a BIMS (brief interview for mental status) score of 13 indicating moderate cognitive impairment. Further review of quarterly MDS dated [DATE] revealed resident #1 required two plus persons for physical assist with bed mobility and toileting use.
Observation on 04/07/2025 at 12:30 p.m. revealed resident #1 sitting at the bedside in a wheelchair. Further observation revealed resident #1's call light hanging on the head of the bed on the opposite side of the bed from resident #1 and was out of resident #1's reach.
During an interview on 04/07/2025 at 12:30 p.m. resident #1 reported she was unable to reach her call light.
During an interview on 04/07/2025 at 12:40 p.m. S2 CNA (Certified Nursing Assistant) entered the room and was asked if resident #1 could reach the call light. S2 CNA agreed resident #1 would not be able to reach the call light from where it was placed. S2 CNA reported maybe she or therapy had placed the call light there this morning.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 (#1) of 3 (#1, #2 and #3) sampled residents wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure 1 (#1) of 3 (#1, #2 and #3) sampled residents who were unable to carry out ADL (activities of daily living) received the necessary services to maintain good grooming and personal hygiene.
Findings:
Review of resident #1's medical record revealed an admission date of 07/14/2022 and diagnoses which included, in part, rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints.
Review of resident #1's most recent quarterly MDS (Minimum Data Set) dated 12/20/2024 revealed resident #1 had a BIMS (brief interview for mental status) score of 13 indicating moderate cognitive impairment. Further review of quarterly MDS dated [DATE] revealed resident #1 required two plus persons for physical assist with bed mobility and toileting use.
Observation on 04/07/2025 at 12:30 p.m. revealed resident #1's fingernails were jagged, uneven, long, and extended well over the tip of her fingers. Further observation revealed resident #1's fingernails had a brown substance underneath the nails.
During an interview on 04/07/2025 at 12:30 p.m. resident #1 reported she had asked for her fingernails to be trimmed but so far no one had trimmed them.
Review of resident #1's current Physician orders revealed an order dated 08/26/2024 trim fingernails every two weeks.
Review of resident #1's care plan revealed an identified problem of self-care performance deficit related to impaired mobility due to generalized weakness to upper and lower extremities. Interventions included extensive assist with all ADL's. Resident #1 is totally dependent in bathing, bed mobility, dressing and personal hygiene.
Review of resident #1's March 2025 and April 2025 TAR (Treatment Administration Record) failed to reveal any documentation her fingernails had been trimmed every two weeks as ordered by the physician.
During an interview 04/08/2025 at 8:30 a.m. S3 LPN (Licensed Practical Nurse) observed resident #1 fingernails and agreed they needed trimming. S3 LPN reported resident #1's fingernails should have been trimmed by the floor nurse every two weeks.
During an interview on 04/08/2025 at 12:39 p.m. S4 Nurse Auditor reviewed resident #1's TARs and confirmed there was not documentation resident #1's fingernails had been trimmed every two weeks. S4 Nurse Auditor confirmed resident #1's fingernails should have been trimmed as ordered.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on record review and interview the facility failed to ensure nurses had the appropriate competencies and skilled sets to provide nursing and related services necessary to care for resident's nee...
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Based on record review and interview the facility failed to ensure nurses had the appropriate competencies and skilled sets to provide nursing and related services necessary to care for resident's needs. The facility failed to ensure lab blood work had been completed as order for 1 (#1) of 3 (#1, #2 and #3) sample residents.
Findings:
Review of resident #1's medical record revealed an admission date of 07/14/2022 and diagnoses which included, in part, iron deficiency anemia, rheumatoid arthritis, muscle weakness (generalized), need for assistance with personal care, other lack coordination, bilateral primary osteoarthritis of first carpometacarpal joints.
Review of resident #1's current Physician orders revealed the following active orders:
Order date 07/26/2022 CBC (complete blood count) every month
Order date 08/16/2022 Lipid Panel yearly in August
Review of resident #1's medical record revealed the results of a CBC dated 12/22/2024 which had been completed during a hospitalization stay. Review of resident #1's medical record failed to reveal a CBC had been completed for the months of January, February, and March 2025.
Further review of resident #1's medical record revealed no monthly CBCs and no annual lipid panel had been completed by the facility in August 2024 as ordered.
During an interview on 4/8/2025 at 10:03 a.m. S4 Nurse Auditor reported the monthly CBC or yearly lipid panel had not been completed as ordered. S4 Nurse Auditor agreed the physician orders for lab work remained active and should have been completed.
Jul 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to ensure a resident was cared for with respect and dignity by failing to provide a privacy covering for a urinary catheter ba...
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Based on observations, interviews, and record review, the facility failed to ensure a resident was cared for with respect and dignity by failing to provide a privacy covering for a urinary catheter bag for 1 resident (#221) out of 4 (#35, #38, #42, #221) residents reviewed for dignity out of a total of 31 sampled residents.
Findings:
Review of resident #221's medical record revealed an admit date of 03/12/2024 with a diagnoses of, but not limited to, unspecified conversion disorder with seizures, bladder-neck obstruction, urinary tract infection and schizoaffective disorder bipolar type.
Review of resident #221's Quarterly MDS (Minimum Data Set) dated 01/14/2024 revealed resident #221 had a BIMS (Brief Interview Mental Status) score of 10 indicating moderately impaired cognition.
Review of resident #221's July Physician's Orders revealed an order for: Catheter: Urinary Catheter ensure tubing anchor and privacy bag is intact and secure every shift.
Observation on 07/28/2024 at 8:00 a.m. revealed resident #221 was up in his room in the wheelchair. Resident #221's door was open and resident #221's catheter bag did not have a privacy cover over it.
Observation on 07/28/2024 at 11:49 a.m. with S6 CNA (certified nursing assistant) revealed resident #221's catheter bag did not have a privacy cover over it.
During an interview on 07/28/2024 at 11:45 a.m. resident #221 reported, I don't know why I don't have a blue cover over the bag, I get embarrassed especially when I am up front with the other people.
During an interview on 07/28/2024 at 11:49 a.m. S5 LPN (licensed practical nurse) confirmed resident #221 should have a privacy cover on his catheter bag.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations and interview the facility failed to accommodate the needs of 1 (#57) resident out of 4 (#20, #55, #57, #67) residents reviewed for environment. The facility failed to ensure res...
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Based on observations and interview the facility failed to accommodate the needs of 1 (#57) resident out of 4 (#20, #55, #57, #67) residents reviewed for environment. The facility failed to ensure resident #57's call device was within reach.
Findings:
Review of resident #57's medical record revealed an admit date of 10/25/2023 with a diagnoses of, but not limited to, Alzheimer's disease, unspecified need for assistance with personal care, essential hypertension, Parkinson's disease and anxiety disorder.
Review of resident #57's quarterly MDS (minimum data set) dated 05/07/2024 revealed resident #57 did not have a BIMS (brief interveiw mental status) score because resident #57 was rarely or never understood.
Review of resident #57's comprehensive plan of care revealed resident #57 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene.
Observation on 07/28/2024 at 7:45 a.m. revealed resident #57 in bed with his breakfast tray in front of him. Further observation revealed resident #57's call device was on the floor underneath his bed out of resident #57's reach.
Observation with S5 LPN (licensed practical nurse) on 07/28/2024 at 7:45 a.m. revealed resident #57's call device was on the floor underneath his bed and out of resident #57's reach.
During an interview on 07/28/2024 at 7:45 a.m. S5 LPN confirmed resident #57's call device should have been placed within resident #57's reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observations and interview the facility failed to ensure the most current survey results were posted in a place readily accessible to the residents, family members or anyone to review.
Findi...
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Based on observations and interview the facility failed to ensure the most current survey results were posted in a place readily accessible to the residents, family members or anyone to review.
Findings:
Observation on 07/28/2024 at 11:45 a.m. failed to reveal the most recent survey results were posted in a place that was readily accessible for review.
Observation on 07/28/2024 at 11:45 a.m. with S1 Administrator revealed the most recent survey results were not posted in a place that was readily available for review.
During an interview on 07/28/2024 at 11:45 a.m. S1 Administrator confirmed the most recent survey results should have been posted for residents, family and anyone to review.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observations, record reviews and interviews the facility failed to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or ...
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Based on observations, record reviews and interviews the facility failed to ensure residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#35) of 2 (#5, #35) residents reviewed for position and mobility. The facility failed to ensure Resident #35's splint was in place to treat a contracture.
Findings:
Review of Resident #35's medical record revealed an admit date of 09/20/2019 with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, direct infection of unspecified hand in infectious and parasitic diseases classified elsewhere, need for assistance with personal care, contracture/right hand and unspecified lack of coordination.
Review of Resident #35's comprehensive care plan revealed at risk for complications due to right hand decreased strengthening and positioning - 06/26/2024 right palm pressure ulcer treat as ordered per medical director.
Review of Resident #35's physician's orders revealed an order dated 07/10/2024 - May use/wear right hand orthotic daily as tolerated every shift r/t (related to) contracture right hand .every day as tolerated.
Review of Resident #35's Nurse Practitioner's progress note dated 07/01/2024 revealed chief complaint of right hand wound infection .New finding of right palm wound likely 2/2 (secondary to) contracture
Observation on 07/28/2024 at 8:55 a.m. failed to reveal a splint in Resident #35's right hand.
Observation on 07/28/2024 at 2:30 p.m. failed to reveal a splint in Resident #35's right hand.
Observation on 07/29/2024 at 11:00 a.m. failed to reveal a splint in Resident #35's right hand.
Observation on 07/29/2024 at 3:30 p.m. failed to reveal a splint in Resident #35's right hand.
During an interview on 07/29/2024 at 8:15 a.m. S4 LPN (Licensed Practical Nurse) reported Resident #35 should have a splint in her right hand. S4 LPN confirmed a splint should have been placed in Resident #35's right hand and was not.
During an interview on 07/29/2024 at 10:20 a.m. S7 OT (Occupational Therapy) reported Resident #35 had a splint that was to be placed in her right hand for a contracture. S7 OT further reported her right hand was in a tight fist and her nails dug into her palm.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to ensure residents who were unable to carry out activ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (#53, #57, #221) of 4 (#5, #53, #57, #221) residents reviewed for ADLs (activities of daily living). The facility failed to ensure nail care was provided.
Findings:
Resident #53
Review of resident #53's medical record revealed an admit date of 11/03/2023 with a diagnoses of, but not limited to, unspecified dementia, major depressive disorder, recurrent, severe with psychotic symptoms, unspecified dementia, mild, with mood disturbance, unsteadiness on feet, and cognitive communication deficit.
Review of resident #53's quarterly MDS (minimum data set) dated 05/10/2024 revealed a BIMS (brief interview mental status) of 4 indicating severely impaired cognition.
Review of resident #53's comprehensive plan of care revealed resident #53 had a self-care deficit, was totally dependent and required assistance with bathing and personal hygiene.
Observation on 07/28/2024 7:45 a.m. with S5 LPN (licensed practical nurse) revealed resident #53's fingernails protruded past nailbeds and had not been trimmed.
During an interview on 07/28/2024 at 7:35 a.m. S5 LPN confirmed resident #53's fingernails should have been trimmed.
Resident #57
Review of resident #57's medical record revealed an admit date of 10/25/2023 with a diagnoses of, but not limited, to Alzheimer's disease, unspecified need for assistance with personal care, essential hypertension, Parkinson's disease and anxiety disorder.
Review of resident #57's quarterly MDS (minimum data set) dated 05/07/2024 revealed resident #57 did not have a BIMS (brief interview mental status) because resident #57 was rarely or never understood.
Review or resident #57's comprehensive plan of care revealed resident #57 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene.
Observation on 07/28/2024 at 7:55 a.m. with S5 LPN revealed resident #57's fingernails on both hands had not been trimmed and protruded past the nailbeds.
During an interview on 07/28/2024 at 7:55 a.m. S5 LPN confirmed resident #57's fingernails should have been trimmed.
Resident #221
Review of resident #221's medical record revealed an admit date [DATE] with a diagnoses of, but not limited, muscle wasting and atrophy, lack of coordination, unspecified conversion disorder with seizures or convulsions, schizoaffective disorder, bipolar type, chronic hepatitis, and essential hypertension.
Review of resident #221's quarterly MDS (minimum data set) dated 05/14/2024 revealed resident #221 had BIMS (brief interview mental status) score of 10, indicating moderately impaired cognition.
Review of resident #221's comprehensive plan of care revealed resident #221 had a self-care deficit and required assistance with bathing, bed mobility, dressing, eating, transferring and personal hygiene.
Observation on 07/28/2024 at 8:00 a.m. revealed resident #221 had fingernails that protruded past his nailbeds on both hands.
During an interview on 07/28/2024 at 8:00 a.m. S5 LPN confirmed resident #221's fingernails should have been trimmed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observations and interview the facility failed to ensure residents' environment remained free of accident hazards on the locked memory unit by failing to ensure all rooms had a door handle. T...
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Based on observations and interview the facility failed to ensure residents' environment remained free of accident hazards on the locked memory unit by failing to ensure all rooms had a door handle. This had the potential to effect 14 residents residing on the memory care unit.
Findings:
Observation on 07/28/2024 at 8:00 a.m. on the locked memory unit revealed room A failed to have a door handle in place, exposing a sharp edge.
Observation on 07/29/2024 at 8:15 a.m. with S8 Maintenance Supervisor on the memory unit revealed room A failed to have a door handle in place, exposing a sharp edge.
During an interview on 07/29/2024 at 8:15 a.m. S8 Maintenance Supervisor reported the door handle to room A had been off since the unit was established and confirmed the door handle should have been repaired.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observations, record reviews and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for...
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Based on observations, record reviews and interview, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 2 (#20, #67) of 2 (#20, #67) residents reviewed for respiratory services. The facility failed to ensure resident's hand held nebulizer (HHN) masks and tubing were dated and stored in a plastic bag.
Findings:
Review of the facility's Departmental Respiratory Therapy Policy (revised November 2021) revealed: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection control considerations related to medication nebulizers/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses.
Resident #20
Review of Resident #20's medical record revealed an admit date of 06/15/2021 with the following diagnoses, in part: chronic obstructive pulmonary disease/unspecified, acute and chronic respiratory failure with hypoxia, panlobular emphysema, and encounter for attention to tracheostomy.
Review of Resident #20's physician's orders revealed an order dated 04/26/2022 for Acetylcysteine Inhalation Solution 20% 3 ml (milliliter) inhale orally three times a day related to acute and chronic respiratory failure with hypoxia.
Observation on 07/28/2024 at 8:40 a.m. revealed Resident #20's HHN on bedside table. Further observation revealed mask and tubing sitting on top of the machine with no date and not stored in a plastic bag.
Resident #67
Review of Resident #67's medical records revealed an admit of 06/19/2024 with the following diagnoses, in part: Alzheimer's disease/unspecified, chronic obstructive pulmonary disease/unspecified, and acute and chronic respiratory failure with hypoxia.
Review of Resident #67's physician's orders revealed orders dated 07/19/2024 for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT (microgram/actuation) (Ipratropium- Albuterol) 1 puff inhale orally every 6 hours as needed for wheezing and Fluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 MCG/DOSE 1 inhalation inhale orally every 12 hours for wheezing.
Observation on 07/28/2024 at 9:15 a.m. revealed Resident #67's HHN on bedside table. Further observation revealed mask and tubing sitting on top of the machine with no date and not stored in a plastic bag.
During an interview on 07/28/2024 at 9:20 a.m. S4 LPN (Licensed Practical Nurse) acknowledged Resident #20 and Resident #67's HHN mask and tubing should be dated and stored in a plastic bag.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter...
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Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31).
Findings:
Review of the facility Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 2 2024 (January 1 - March 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing.
Review of the facility's weekend staffing pattern forms for FY Quarter 2 2024 revealed hours of direct care provided exceeded the hours of care required.
During an interview on 07/29/2024 at 8:05 a.m. S3 Director of Nursing reported she did not understand why the facility triggered for low staffing and did not know why the data entered would be incorrect because the facility always overstaffs.
During an interview on 07/30/2024 at 10:45 a.m. S2 Corporate Nurse reported she did not know why the PBJ Staffing Data Report for FY Quarter 2 2024 to CMS shows low weekend staffing.
Jul 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to maintain a clean, comfortable, homelike environment ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to maintain a clean, comfortable, homelike environment for 1 (#4) of 4 (#1, #2, #3, #4) sampled residents investigated for resident rights. This deficient practice had the potential to affect all the residents residing in the facility. The facility's census was 73.
Findings:
Review of Resident #4's clinical record revealed an initial admission dated of 11/17/2023.
Review of Resident #4's Quarterly MDS (Minimum Data Set) dated 04/19/2024 revealed the following diagnoses: Heart failure, unsteady on feet, abnormalities of gait and mobility, inflammatory disease of prostate, muscle wasting and atrophy.
Review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating resident's cognition was mildly impaired.
An observation on 07/01/2024 at 11:56 a.m. revealed a soiled gown at the door opening of the Resident #4's room. Resident #4 was out of his bed and in his wheelchair and a strong urine odor was noted upon entry into his room. Further observation revealed Resident #4's bed was not made and the fitted sheet was exposed with a large yellow stain.
During an interview on 07/01/2024 at 11:56 a.m., Resident #4 reported he had been changing his own gown and bed linens because he gets tired of waiting on a CNA (Certified Nursing Assistant) to change them. Resident #4 further reported the CNA's tell him to put the dirty linen under the chair in his room, but the soiled linens lay there for a long time and make the room smell which he does not like. Resident #4 reported the fitted sheet on his bed had been soiled since early this morning and was almost dry now. Resident #4 continued to report his Lasix (diuretic medication) makes him go to the bathroom and he had accidents frequently. When asked about the gown in the doorway, Resident #4 reported, he changed his gown this morning because it was soiled and he laid it by the door waiting on a CNA to pick it up. Resident #4 reported he did not like to change his bed linens or placing his soiled linens under a chair on the floor in his room. Resident #4 reported when he had visitors, they would help him get the soiled linens out of his room. Resident #4 reported he did not want to change his own linens, but CNA's did not tell him he did not have to change them.
During an interview on 07/01/2024 at 12:24 p.m., S2 CNA confirmed the smell coming from Resident #4's room was from urine and the soiled fitted sheet needed to be changed. S2 CNA further reported, in front of Resident #4, he changes his own linens.
During an interview on 07/01/2024 at 12:40 p.m. S3 DON (Director of Nursing) and S1 Corporate Nurse were informed of the above finding and acknowledged the linens should be changed by the CNA.
During an interview on 07/01/2024 at 1:00 p.m. S1 Corporate Nurse reported Resident #4's room smelled of urine and he did not willingly want to change his own linens.
May 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's Physician/Physician's Representative and Respo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's Physician/Physician's Representative and Responsible Party (RP) were notified after a fall for 1 (Resident #3) of 3 (Resident #1, #2, and #3) sampled residents.
Findings:
Review of facility's Assessing Falls and Their Causes policy with a revision date of March 2018 revealed in part:
The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.
After a fall:
5. Notify the resident's attending physician and family in an appropriate time frame.
a. When a fall occurs, or when the fall results in a significant injury or condition change, prompt notification of the physician by phone is indicated.
Documentation:
When a resident falls, the following information should be recorded in the resident's electronic medical record:
4. Notification of physician and family.
Resident #3 was admitted to the facility on [DATE] with diagnoses including in part, severe dementia with other behavioral disturbances, persistent mood disorders, major depressive disorder, schizoaffective disorder, and Alzheimer's disease.
Review of Resident #3's MDS (Minimum Data Set) dated 01/30/2024 revealed in part, Resident #3 had a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. Resident #3 required extensive assistance with bed mobility, transfers, and toilet use.
Review of Resident #3's Medical Record revealed a nurse's note written by S6LPN (Licensed Practical Nurse) dated 04/20/2024 at 10:55 p.m., which read in part, S5CNA (Certified Nursing Assistant) came and told me (S6LPN) that Resident #3 was on the floor and that Resident #3 had fallen on the mat beside his bed.
Further review of Resident #3's Medical Record failed to reveal Resident #3's Physician/Physician's Representative and RP had been notified of Resident #3's unwitnessed fall on 04/20/2024.
During a telephone interview on 05/07/2024 at 11:45 a.m., Resident #3's RP reported facility never notified me of Resident #3's fall on 04/20/2024.
During an interview on 05/09/2024 at 8:50 a.m., S2Corporate Nurse acknowledged Resident #3's Physician and RP had not been notified of the fall on 04/20/2024 and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video footage review, and interviews the facility failed to ensure the nursing staff possessed the compe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video footage review, and interviews the facility failed to ensure the nursing staff possessed the competency to assess a resident after an unwitnessed fall and complete an internal report in a timely manner for 1 (Resident #3) of 3 (Resident #1, #2, and #3) sampled residents.
Findings:
Review of facility's Assessing Falls and Their Causes policy with a revision date of March 2018 revealed in part:
The purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.
After a fall:
1. If a resident has just fallen, or is on the floor without a witness to the event, evaluate for possible injuries to the head, neck spine and extremities.
5. b. All unwitnessed falls regardless of orientation will require neurological checks using the approved neurological check forms.
7. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings.
8. Complete an Incident Report for resident falls after the fall occurs. The Incident Report form should be completed by the Nursing Staff on duty at the time and submitted to the Director of Nursing.
Documentation:
When a resident falls, the following information should be recorded in the resident's electronic medical record:
1. The condition in which the resident was found .
2. Assessment data, including vital signs and any obvious injuries.
Resident #3 was admitted to the facility on [DATE] with diagnoses including in part, severe dementia with other behavioral disturbances, persistent mood disorders, major depressive disorder, schizoaffective disorder, and Alzheimer's disease.
Review of Resident #3's MDS (Minimum Data Set) dated 01/30/2024 revealed in part, Resident #3 had a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. Resident #3 required extensive assistance with bed mobility, transfers, and toilet use.
Review of Resident #3's Medical Record revealed a nurse's note written by S6LPN (Licensed Practical Nurse) dated 04/20/2024 at 10:55 p.m., which read in part, S5CNA (Certified Nursing Assistant) came and told me (S6LPN) that Resident #3 was on the floor and that Resident #3 had fallen on the mat beside his bed. When writer (S6LPN) arrived to room, Resident #3 was sitting on the floor next to the bed, looking up at the ceiling. Resident #3 denies any pain when asked, but began to say Ow when we picked Resident #3 up to put him back to bed.
Further review of Resident #3's Medical Record failed to reveal a thorough head to toe assessment, vital signs and neurological checks had been completed by nursing staff after Resident #3's unwitnessed fall on 04/20/2024.
Review of Resident #3's Hospice binder revealed a visit summary note written by S8Hospice Nurse dated 04/21/2024 at 4:00 pm, which read in part, Resident #3 had a fall from bed on 04/20/2024. Resident #3 was observed laying in the bed with head of bed at 30 degrees sleeping. Resident #3 does have his right leg drawn up/bent at the knee. Resident #3's right lower leg is leaned across the left leg above the left knee. Resident #3 has the right hip flexed also. When you go to move the right leg, Resident #3 does grimace and moan out like he is in pain. Resident #3 is rating a 5 out of 10 on a pain scale.
Review of Resident #3's x-ray report dated 04/21/2024 revealed in part Resident #3 had a mildly displaced right great trochanter fracture.
Review of internal incident report revealed in part Resident #3's unwitnessed fall on 04/20/2024 was not completed by S6LPN until 04/21/2024.
Review of surveillance video footage provided by Resident #3's RP (Responsible Party) on 05/07/2024 at 2:00 p.m. revealed in part, motion activated video clips with a duration of 20 seconds each, as follows:
04/20/2024 at 10:39:17 p.m., Resident #3 was observed to be sitting on the floor. Resident #3 attempted to reach over and grab the end of his bed when both legs moved into an upward motion and caused Resident #3 to roll over backwards and onto his right side.
During a telephone interview on 05/08/2024 at 5:45 p.m., S9LPN reported Resident #3 was noted to be grimacing with pain when staff attempted to change him on 04/21/2024 around lunchtime. S9LPN reported Resident #3 hollered out in pain when she examined his right leg. S9LPN reported she then telephoned S8Hospice Nurse to report findings.
During a telephone interview on 05/08/2024 at 5:00 p.m., S8Hospice Nurse reported she was telephoned on 04/21/2024 by S9LPN who stated Resident #3 was in pain and she could not figure out what was wrong. S8Hospice Nurse reported when she arrived to facility, she assessed Resident #3 who grimaced in pain when his right leg was examined. S8Hospice Nurse reported she called Resident #3's RP while she was still in the room and Resident #3's RP went to look at the video footage. S8Hospice Nurse further reported while on the phone, Resident #3's RP informed her she saw where Resident #3 had a fall the night before. S8Hospice Nurse reported an x-ray was ordered and the result of right hip fracture came back on 04/22/2024.
During an interview on 05/09/2024 at 8:45 a.m., S3ADON (Assistant Director of Nursing) acknowledged a thorough head to toe assessment, vital signs and neurological checks had not been performed by the nurse after Resident #3's unwitnessed fall on 04/20/2024 and should have been.
During an interview on 05/09/2024 at 8:50 a.m., S2Corporate Nurse, acknowledged a thorough assessment to include vital signs and neurological checks had not been completed by the nurse after Resident #3's unwitnessed fall on 04/20/2024 and should have been. S2Corporate Nurse reported S6LPN did not complete the internal incident report for Resident #3 until the next day, 04/21/2024, after Resident #3's injury had been discovered, and should have been completed at the time of incident.
During a telephone interview on 05/09/2024 at 10:10 a.m., S6LPN reported she was called to Resident #3's room on 04/20/2024 by S5CNA who told her she found Resident #3 on the floor. S6LPN reported when she entered the room, Resident #3 was sitting on the floor and she (S6LPN) and S5CNA assisted Resident #3 back into bed. S6LPN acknowledged Resident #3 voiced pain when moved back into bed and could not provide documentation of vital signs or neurological checks.
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 F0836
(Tag F0836)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video footage review and interviews, the facility failed to ensure it operated and provided services in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, video footage review and interviews, the facility failed to ensure it operated and provided services in compliance with Federal, State, and local laws by not ensuring a resident's RP (Responsible Party) installed surveillance camera was not hampered with and/or obstructed for 1 (Resident #3) of 3 (Resident #1, #2, and #3) sampled residents.
Findings:
The current Nursing Home Virtual Visitation Act 596 revealed in part:
Prohibited Acts Under the Nursing Home Virtual Visitation Act:
2. No person shall intentionally hamper, obstruct, tamper with, or destroy a monitoring device or a recording made by a monitoring device installed in a nursing home; this does not apply to the resident.
Resident #3 was admitted to the facility on [DATE] with diagnoses including in part, severe dementia with other behavioral disturbances, persistent mood disorders, major depressive disorder, schizoaffective disorder, and Alzheimer's disease.
Review of Resident #3's MDS (Minimum Data Set) dated 01/30/2024 revealed in part, Resident #3 had a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. Resident #3 required extensive assistance with bed mobility, transfers, and toilet use.
Review of Resident #3's Medical Record revealed a nurse's note written by S6LPN (Licensed Practical Nurse) dated 04/20/2024 at 10:55 p.m., which read in part, S5CNA (Certified Nursing Assistant) came and told me (S6LPN) that Resident #3 was on the floor and that Resident #3 had fallen on the mat beside his bed. When writer (S6LPN) arrived to room, Resident #3 was sitting on the floor next to the bed, looking up at the ceiling. Resident #3 denies any pain when asked, but began to say Ow when we picked Resident #3 up to put him back to bed.
Review of surveillance video footage provided by Resident #3's RP on 05/07/2024 at 2:00 p.m. revealed in part, motion activated video clips with a duration of 20 seconds each, as follows:
04/20/2024 at 10:39:17 p.m. Resident #3 was observed to be sitting on the floor at the foot of his bed. Resident #3 attempted to reach over and grab the end of his bed when both legs moved into an upward motion and Resident #3 rolled over backwards and onto his right side.
04/20/2024 at 10:55:58 p.m. Resident #3 was observed in semi-sitting position supported by his right arm on the floor at the foot of his bed with left knee in a bent position and right leg in an extended position. S5CNA and S7CNA entered Resident #3's room. S7CNA approached Resident #3 and stated, Resident #3, hey, what you doing? Why are you down here? S5CNA was observed turning the video surveillance camera towards the wall and further view of Resident #3 was blocked.
04/20/2024 at 11:04:48 p.m. Resident #3's video surveillance camera was observed to be turned back around in view of Resident #3 by an unidentifiable staff. Resident #3 was observed lying in bed and covered with a blanket.
Upon completion of the review of video clips provided by Resident #3's RP, the care provided by staff after Resident #3 was found on the floor on 04/20/2024 was unable to be documented due to the obstructed view.
Review of Resident #3's x-ray report dated 04/21/2024 revealed in part Resident #3 had a mildly displaced right great trochanter fracture.
During an interview with S4Care Plan Nurse on 05/09/2024 at 9:00 a.m., S4Care Plan Nurse viewed the video clip dated 04/20/2024 at 10:55:58 p.m. and identified S5CNA as the staff who turned Resident #3's surveillance camera around. S4Care Plan Nurse acknowledged Resident #3's camera should not have been hampered with and view of Resident #3's care after a fall had been obstructed.
During an interview on 05/09/2024 at 10:20 a.m., S2Corporate Nurse reported it was the family's right to have video surveillance without interruption from staff and S5CNA should not have hampered with the surveillance camera.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
Concerns
- • 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $10,567 in fines. Above average for Louisiana. Some compliance problems on record.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Shreveport Manor Skilled Nursing & Rehabilitation's CMS Rating?
CMS assigns SHREVEPORT MANOR SKILLED NURSING & REHABILITATION 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 Shreveport Manor Skilled Nursing & Rehabilitation Staffed?
CMS rates SHREVEPORT MANOR SKILLED NURSING & REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the Louisiana average of 46%.
What Have Inspectors Found at Shreveport Manor Skilled Nursing & Rehabilitation?
State health inspectors documented 23 deficiencies at SHREVEPORT MANOR SKILLED NURSING & REHABILITATION during 2024 to 2025. These included: 23 with potential for harm.
Who Owns and Operates Shreveport Manor Skilled Nursing & Rehabilitation?
SHREVEPORT MANOR SKILLED NURSING & REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PRIORITY MANAGEMENT, a chain that manages multiple nursing homes. With 127 certified beds and approximately 66 residents (about 52% occupancy), it is a mid-sized facility located in SHREVEPORT, Louisiana.
How Does Shreveport Manor Skilled Nursing & Rehabilitation Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, SHREVEPORT MANOR SKILLED NURSING & REHABILITATION's overall rating (2 stars) is below the state average of 2.4, staff turnover (54%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Shreveport Manor Skilled Nursing & Rehabilitation?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Shreveport Manor Skilled Nursing & Rehabilitation Safe?
Based on CMS inspection data, SHREVEPORT MANOR SKILLED NURSING & REHABILITATION has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Shreveport Manor Skilled Nursing & Rehabilitation Stick Around?
SHREVEPORT MANOR SKILLED NURSING & REHABILITATION has a staff turnover rate of 54%, which is 8 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 Shreveport Manor Skilled Nursing & Rehabilitation Ever Fined?
SHREVEPORT MANOR SKILLED NURSING & REHABILITATION has been fined $10,567 across 1 penalty action. This is below the Louisiana average of $33,185. 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 Shreveport Manor Skilled Nursing & Rehabilitation on Any Federal Watch List?
SHREVEPORT MANOR SKILLED NURSING & REHABILITATION 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.