What is Winnfield Nursing and Rehabilitation Center, LLC's CMS rating?

Winnfield Nursing and Rehabilitation Center, LLC has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does Winnfield Nursing and Rehabilitation Center, LLC have?

Winnfield Nursing and Rehabilitation Center, LLC has 30 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Winnfield Nursing and Rehabilitation Center, LLC?

Winnfield Nursing and Rehabilitation Center, LLC has a four-star staffing rating from CMS with 0.38 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

How many beds does Winnfield Nursing and Rehabilitation Center, LLC have?

Winnfield Nursing and Rehabilitation Center, LLC has 124 certified beds.

Who owns Winnfield Nursing and Rehabilitation Center, LLC?

Winnfield Nursing and Rehabilitation Center, LLC is a for profit - limited liability company facility and is part of the NORBERT BENNETT & DONALD DENZ chain.

Was Winnfield Nursing and Rehabilitation Center, LLC ever fined?

No, Winnfield Nursing and Rehabilitation Center, LLC has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is Winnfield Nursing and Rehabilitation Center, LLC on any federal watch list?

No, Winnfield Nursing and Rehabilitation Center, LLC is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at Winnfield Nursing and Rehabilitation Center, LLC?

Medicare inspectors have found 30 deficiencies at Winnfield Nursing and Rehabilitation Center, LLC: 30 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Winnfield Nursing and Rehabilitation Center, LLC?

Families visiting Winnfield Nursing and Rehabilitation Center, LLC should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Winnfield Nursing and Rehabilitation Center, LLC compare to other nursing homes?

Winnfield Nursing and Rehabilitation Center, LLC has a 2-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

Winnfield Nursing and Rehabilitation Center, LLC | 50/100 (Grade C)

Sept 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a resident's discharge was documented in the resident's medical record for 2 (Resident #1, Resident #R1) of 3 (Resident #1, Resident...

Read full inspector narrative →

Based on record review and interview, the facility failed to ensure a resident's discharge was documented in the resident's medical record for 2 (Resident #1, Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The facility failed to:1. Ensure documentation in the medical record included the basis for discharge for Resident #1 and Resident #R1;2. Ensure documentation in the medical record included that written discharge instructions were given to and discussed with the Resident/Responsible Party for Resident #1 and Resident #R1; and3. Ensure documentation in the medical record included discharge planning that addressed caregiver support and referrals to local contact agencies for Resident #1.Findings:On 09/03/2025, a review of the facility's policy titled Discharge Plan/Summary last revised 04/2025 revealed in part.6. If the resident is discharging to a private home, social work should meet with the person accepting responsibility for the resident. Referrals needed should be made to home health, DHS, or others based upon the needs of the resident.11. Nursing should meet with the person responsible for the resident at home and provide instruction to that person as appropriate in regard to medication and treatments to be continued at home. Referrals should be ensured for home care as needed, and coordinate same with Social Services. Any unused medications that are currently ordered after discharge may be sent with the resident prior to discharge.17. There should be documentation in the Nurses Notes regarding resident status at the time of discharge.Resident #1Review of Resident #1's medical record revealed an admission date of 02/19/2025 with diagnoses including, in part.Other Fracture of Shaft of Right Tibia, Subsequent Encounter for Closed Fracture with Delayed Healing; Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site; Diabetes Mellitus due to Underlying Condition with Unspecified Complication; Personal History of Other Venous Thrombosis and Embolism.Review of Resident #1's Quarterly MDS with an ARD of 05/28/2025 revealed a BIMS Score of 15, indicating intact cognition. The resident was noted to be independent for ADLs and used assistive devices of a wheelchair and walker for mobility. Resident #1 was noted to be incontinent of bowel and bladder. Resident #1 participated in the assessment and goal setting. Resident #1 did not want to be a long-term resident and wanted to return to her home.Review of Resident #1's electronic and paper health record revealed that the resident did not have a documented discharge plan in place prior to her discharge. According to an interview on 09/03/2025 at 9:19 am with S6 SSD, on 08/01/2025, S4 BOM and S6 SSD went together to tell Resident #1 that her insurance had ended on 07/31/2025.In an interview with S6 BOM on 09/02/2025 at 10:57 a.m., she stated that she gave Resident #1 the fax confirmation of the resident's insurance coverage ending. S6 BOM stated the resident was given the choice to pay out of pocket to stay, but this amount and the resident's refusal were not documented by the facility in the resident's record. S4 BOM stated she gave the resident the amount she would be charged to stay, but couldn't verbalize the cost given to Resident #1.A review of Resident #1's closed record revealed that a discharge form was partially completed by S6 SSD and signed by Resident #1. No other discharge documentation, such as the basis for discharge, referrals, medication reconciliation, instructions for discharge, or coordination of care, was documented by the facility in Resident #1's record.An interview with S1 Administrator on 09/03/2025 at 9:25 a.m. confirmed that S6 SSD was responsible for discharge planning and documentation. In an interview on 09/03/2025 at 2:52 p.m., S2 DON stated Social Services was responsible for initiating the Discharge Summary and completing their part. S2 DON stated the nurse had a part to complete, also. S2 DON acknowledged Resident #1's medical record did not contain the reason for her discharge, nor any documentation that written instructions were given to or discussed with the resident regarding her medications at discharge. Resident #R1Review of Resident #R1's medical record revealed an admit date of 03/18/2025 and a discharge date of 06/10/2025. Resident #R1's diagnoses included Alzheimer's disease, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction.Review of Resident #R1's 5 day MDS with an ARD of 03/25/2025 revealed a BIMS score of 15, which indicated intact cognition.Review of Resident #R1's medical record revealed no documentation stating why the resident was discharged . Further review revealed no documentation of the medications provided to the resident at discharge or any instructions given to the resident.Review of Resident #R1's progress notes revealed the following:6/10/2025 at 12:23 p.m. Nurses Note by S8 LPN: Note Text: 12:20 p.m. Resident is discharged out of facility with medications.6/10/2025 at 10:54 a.m. Discharge Summary by S6 SSD: Resident sitting up in wheelchair waiting for family to arrive so that he can discharge home with fiancee. He is alert and oriented to self. His speech is clear. His hearing is adequate. He understands and is understood. No behaviors noted nor observed. He has a diagnosis of Alzheimer's Disease, Cerebral Infarction, HTN, and Type 2 Diabetes. He is incontinent of bowel and bladder. He is aware of activities and will attend those that interest him. Resident's main mode of transportation is wheelchair. Resident has to be encouraged to socialize with other residents. He prefers to stay in room and isolate to his room. His family is active in his care and attentive to his needs. He is capable of voicing his preference regarding his care. He is a full code, no living will, no POA, non-smoker, and not at risk for elopement. Resident discharges home 6/10/25. LTPCS will evaluate resident on 6/23/25 to see what services that he can receive at home.In an interview on 09/03/2025 at 2:45 p.m., S3 LPN stated Resident #R1 was here for short term therapy after having a stroke. S3 LPN stated Resident #R1 wanted to go home after receiving therapy.In an interview on 09/03/2025 at 2:52 p.m., S2 DON stated Social Services was responsible for initiating the Discharge Summary and completing their part. S2 DON stated the nurse had a part to complete, also. S2 DON acknowledged Resident #R1's medical record did not contain the reason for his discharge nor any documentation that written instructions were given to or discussed with the resident regarding his medications at discharge.

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 F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to have a discharge summary that included the required information for 2 (Resident #1 and Resident #R1) of 3 (Resident #1, Resident #R1, and R...

Read full inspector narrative →

Based on record review and interview, the facility failed to have a discharge summary that included the required information for 2 (Resident #1 and Resident #R1) of 3 (Resident #1, Resident #R1, and Resident #R2) residents reviewed for discharge. The discharge summaries for Resident #1 and Resident #R1 failed to include:1. A recapitulation of the residents' stay that included diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results;2. A final summary of the residents' status at the time of the discharge; and3. Reconciliation of all pre-discharge medications with the residents' post-discharge medications (both prescribed and over-the-counter).Findings:On 09/03/2025, a review of the facility's policy titled, Discharge Plan/Summary last revised 04/2025 revealed in part.12. The Discharge Summary form should be completed with care needs identified and documented as appropriate.14. Guidelines for completion of the Discharge Summary: Nursing: Identifies continuing nursing needs. Specifies level of nursing care needed. Verifies resident/family understanding of orders including all medications prescribed by physician. Detailed nursing care plan, special problems, teaching steps and level of progress and further teaching as appropriate. Social Services: May identify resident's personal, financial and social needs in relation to medical and psychological problems.15. A copy of the summary is given to resident/family upon discharge when resident is going home. 16. The original is placed in the resident Medical Record. 17. There should be documentation in the Nurses Notes regarding resident status at the time of discharge.Resident #1Review of Resident #1's medical record revealed an admit date of 02/19/2025 with diagnoses that included in part Other Fracture of Shaft of Right Tibia, Subsequent Encounter for Closed Fracture with Delayed Healing; Methicillin Resistant Staphylococcus Aureus Infection, Unspecified Site; Diabetes Mellitus due to Underlying Condition with Unspecified Complication; Personal History of Other Venous Thrombosis and Embolism. Further review revealed a discharge date of 08/01/2025.Review of Resident #1's Quarterly MDS with an ARD of 05/28/2025 revealed a BIMS Score of 15, which indicated intact cognition. Resident #1 was noted to be independent for ADLs and used assistive devices of a wheelchair and walker for mobility. Review of Resident #1's electronic record revealed there was no documented discharge summary, which should have included a recapitulation of Resident #1's stay, a final summary of the Resident #1's status, and a reconciliation of Resident #1's medications.Review of Resident #1's paper medical record revealed a partially completed document titled, Discharge Summary/Instructions, dated 08/01/2025 signed by S6 SSD and Resident #1.Interview with S6 SSD on 09/03/2025 at 9:19 a.m. confirmed the partially completed document titled, Discharge Summary/Instructions, dated 08/01/2025 was provided to Resident #1 at the time of discharge.Interview with S1 Administrator on 09/03/2025 at 9:25 a.m. revealed she did not provide any documentation to Resident #1 upon discharge and S6 SSD was responsible for discharge documentation.Interview with S2 DON on 09/03/2025 at 2:52 p.m. confirmed Resident #1's medical record did not contain a completed discharge summary and should have.Resident #R1Review of Resident #R1's medical record revealed an admit date of 03/18/2025 and a discharge date of 06/10/2025. Resident #R1's diagnoses included Alzheimer's disease, Paroxysmal Atrial Fibrillation, Atherosclerotic Heart Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction.Review of Resident #R1's progress notes revealed the following:06/10/2025 at 10:54 a.m.: Discharge Summary by S6 SSD: Resident sitting up in wheelchair waiting for family to arrive so that he can discharge home with fiance. He is alert and oriented to self. His speech is clear. His hearing is adequate. He understands and is understood. No behaviors noted nor observed. He has a diagnosis of Alzheimer's disease, cerebral infarction, HTN, and type 2 diabetes. He is incontinent of bowel and bladder. He is aware of activities and will attend those that interest him. Resident's main mode of transportation is wheelchair. Resident has to be encouraged to socialize with other residents. He prefers to stay in room and isolate to his room. His family is active in his care and attentive to his needs. He is capable of voicing his preference regarding his care. He is a full code, no living will, no POA, non-smoker, and not at risk for elopement. Resident discharges home 6/10/25. LTPCS will evaluate resident on 6/23/25 to see what services that he can receive at home.06/10/2025 at 12:23 p.m.: Nurses Note by S8 LPN: Note Text: 12:20 p.m. Resident is discharged out of facility with medications.Review of Resident #R1's medical record revealed no documentation stating why Resident #R1 was discharged , no documentation of the medications provided to Resident #R1 at discharge, or any instructions given to the resident. Review of Resident #R1's Discharge Summary/Instructions form dated 06/10/2025 revealed no documentation of Resident #R1's diagnoses, course of illness/treatment, or therapy received and no medication reconciliation or summary of Resident #R1's status at the time of discharge. The Discharge Summary was not signed by Resident #R1.Interview with S2 DON on 09/03/2025 at 2:52 p.m. revealed Social Services was responsible for initiating the Discharge Summary and completing their part of the form and the nurse also had a part to complete. S2 DON confirmed Resident #R1's Discharge Summary and medical record did not contain a list of medications provided to Resident #R1 or documentation of written or verbal instructions provided to or discussed with Resident #R1 regarding his medications at discharge. S2 DON acknowledged Resident #R1's Discharge Summary did not contain a recapitulation of Resident #R1's stay or Resident #R1's status at time of discharge and should have.

Jun 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on interviews and record review, the facility failed to ensure the admission and Quarterly MDS assessments accurately reflected a resident's status for 1 (Resident #1) of 5 sampled residents. Fi...

Read full inspector narrative →

Based on interviews and record review, the facility failed to ensure the admission and Quarterly MDS assessments accurately reflected a resident's status for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled MDS Assessment, revised 06/2023, revealed, in part .these assessments provide information on the resident's condition and facilitate development of an individualized plan of care. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with admission diagnoses which included, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's Quarterly MDS with ARD of 04/22/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Further review of the MDS revealed Resident #1's history of suicidal behaviors, suicidal ideations, and substance use/abuse were not listed. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in part .a BIMS Score 0f 15, which indicated intact cognition. Resident #1 did not have PTSD. Further review of the MDS revealed Resident #1's history of suicidal behaviors, suicidal ideations, and substance use/abuse were not listed. Review of Resident #1's Psychiatric Initial Evaluation dated 02/13/2025 revealed, in part .Resident #1 was positive for methamphetamine upon arrival to the facility. Review of Resident #1's social services progress note dated 01/21/2025 revealed, in part .Resident #1 had a diagnosis of PTSD and a history of substance abuse. Interview with S6SSD on 06/10/2025 at 8:22 a.m. confirmed Resident #1's Social Services History and Initial Assessment completed on 01/21/2025 identified a diagnosis of PTSD, increased anxiety, and a history of substance use/abuse. Interview with S1ADM on 06/12/2025 at 12:50 p.m. confirmed Resident #1's admission and Quarterly MDS assessments did not include diagnosis of PTSD and substance use/abuse, SI, or History of Suicidal Behavior, but should have.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care that met pro...

Read full inspector narrative →

Based on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care that met professional standards of quality care for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .a baseline care plan is the initial plan of care to be used upon admission, until the comprehensive care plan is completed. The baseline care plan is to be developed within 48 hours. A resident-centered goal is to be developed for each problem. Staff approaches are to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's medical record revealed Resident #1 did not have a baseline care plan. Interview with S2DON on 06/12/2025 at 4:59 p.m. revealed she was unable to provide a baseline care plan for Resident #1. S2DON confirmed a baseline care plan was not developed for Resident #1, but 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facilit...

Read full inspector narrative →

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 5 sampled residents. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A resident-centered goal is to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's comprehensive care planned revealed Resident #1 was not care-planned for Suicidal Ideations, History of Suicidal Behavior, PTSD, or Substance Use/Abuse. Interview with S1ADM on 06/12/2025 at 12:50 p.m. confirmed Resident #1 was not care-planned for Suicidal Ideations, History of Suicidal Behavior, PTSD, or Substance Use/Abuse, but should have been. Interview with S7MDS on 06/12/2025 at 1:08 p.m. confirmed Resident #1 was not care planned for Substance Use/Abuse, but 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 F0658 (Tag F0658)

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 provide mental health services as dictated by accepted standards of...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide mental health services as dictated by accepted standards of quality for a resident admitted with multiple mental health diagnoses for 1 (Resident #1) of 5 sampled residents. The facility failed to: 1. Provide a timely referral for mental health services, and 2. Ensure mental health services were provided on a continual basis. Findings: Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in part .a BIMS Score 0f 15, which indicated intact cognition. Resident #1 was taking antipsychotic and antidepressant medications on a routine basis. Review of Resident #1's Urine Drug Screen dated 01/22/2025 at 5:00 p.m. revealed Resident #1 was positive for methamphetamine. Review of Resident #1's orders revealed an order to refer to the Psychiatric MP for evaluation of medication management and increased anxiety, dated 02/03/2025. Review of Resident #1's progress notes revealed an Initial Psychiatric Evaluation was conducted on 02/13/2025. Psychiatric Follow-Up Evaluations were conducted on 02/27/2025 and 03/27/2025. No additional mental health encounters were noted. 1. Interview with S6SSD on 06/10/2025 at 8:22 a.m. confirmed Resident #1's Social Services History and Initial Assessment completed on 01/21/2025 identified PTSD, increased anxiety, a history of substance abuse, and previous inpatient psychiatric treatment. S6SSD confirmed Resident #1 should have been referred for mental health services following the assessment, but was not. Interview with S9NP on 06/10/2025 at 11:10 a.m. revealed residents who are admitted with a mental health diagnoses are automatically referred for mental health services. S9NP confirmed Resident #1 should have been referred for mental health services upon admission, but was not. 1.& 2. Interview with S10MHNP on 06/10/2025 at 11:46 a.m. revealed Resident #1 was admitted to the facility on [DATE]. S10MHNP confirmed Resident #1 should have been referred for mental health services upon admission, but was not. S10MHNP revealed residents taking antipsychotics are seen by the MHNP at least monthly. S10MHNP confirmed Resident #1 had not been seen by the MHNP after 03/27/2025, but should have been.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected multiple residents

Based on interviews and record reviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocia...

Read full inspector narrative →

Based on interviews and record reviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents sampled with behavioral health diagnoses by failing to: 1. Develop and implement a person-centered plan of care that addressed Resident #1's history of Substance Use/Abuse; 2. Ensure concerns identified in the provider's progress notes regarding drug diversion were addressed; and 3. Perform monthly UDS as ordered. Findings: Review of the facility's policy entitled Comprehensive Person Centered Care Plans, revised 01/2025, revealed, in part .each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. A resident-centered goal is to be developed for each problem. Staff approaches are to be developed for each problem. Review of Resident #1's medical record revealed an admission date of 01/17/2025 with diagnoses including, in part .Adverse Effect of Methamphetamines, Cannabis Abuse with Intoxication, Suicidal Ideations, History of Suicidal Behavior, PTSD, GAD, Bipolar Disorder, and MDD. Review of Resident #1's admission MDS with ARD of 01/24/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Substance use/abuse was not indicated. Review of Resident #1's Quarterly MDS with ARD of 04/22/2025 revealed, in part .a BIMS Score of 15, which indicated intact cognition. Resident #1 did not have PTSD. Substance use/abuse was not indicated. 1. Review of Resident #1's comprehensive care plan revealed, in part .resident was not care-planned for History of Substance Use/Abuse. Interview with S1ADM on 06/09/2025 at 2:36 p.m. revealed Resident #1 had been discharged from another facility due to abuse of methamphetamine. S1ADM confirmed Resident #1 was not care-planned for a History of Substance Use/Abuse, but should have been Interview with S11MDS on 06/12/2025 at 1:08 p.m. confirmed Resident #1 was not care planned for Substance Use/Abuse, but should have been. 2. Review of Resident #1's provider progress note dated 04/08/2025 revealed, in part .it was brought to the provider's attention that the resident had been diverting scheduled medications and taking medications that were not prescribed to him. Review of Resident #1's provider progress note dated 04/22/2025 revealed, in part .the resident was seen for active substance use. Resident #1 reported he had been actively abusing medications since being admitted to the facility. Review of Resident #1's provider progress note dated 04/29/2025 revealed, in part .klonopin, an antianxiety medication, had recently been discontinued due to active substance abuse. Interview with S9NP on 06/10/2025 at 11:10 a.m. revealed Resident #1 had been actively abusing drugs when admitted to the facility and was positive for methamphetamine on 01/22/2025. S9NP confirmed on 04/08/2025 she documented Resident #1 had been diverting scheduled medications and taking pain medications that were not prescribed to him since admission to the facility. S9NP stated Resident #1 stated he had been pocketing his klonopin and had been trading his medication. S9NP confirmed on 04/22/2025 she documented Resident #1 was seen for active substance abuse within the facility. S9NP confirmed her 04/29/2025 progress note for Resident #1 recorded active substance abuse. Interview with S1ADM on 06/10/2025 at 2:43 p.m. confirmed at the time of Resident #1's death she was unaware of S9NP's progress notes indicating Resident #1 had active substance abuse, had been diverting scheduled medications and taking pain medications that were not prescribed to him since admission to the facility, had been pocketing his klonopin, and trading his medication. S1ADM confirmed no actions had been taken to address these concerns. Interview with S9NP on 06/10/2025 at 7:58 p.m. revealed someone from the facility had called her and made her aware of Resident #1's drug diversion in the facility. S9NP declined to answer the surveyor when asked whom from the facility she had been notified by. 3. Review of Resident #1's orders revealed, in part .monthly UDS, dated 02/21/2025. Review of Resident #1's laboratory reports revealed a UDS collected on 01/22/2025 was positive for methamphetamine. Resident #1 had no UDS dated 02/21/2025 through 05/14/2025. Interview with S1ADM on 06/09/202025 at 4:13 p.m. revealed Resident #1 was ordered a monthly UDS on 02/21/2025. Interview with S1ADM on 06/10/2025 at 9:02 a.m. confirmed a monthly UDS was not performed, as ordered, for Resident #1, but should have been. Interview with S8LPN on 06/10/202025 at 9:18 a.m. revealed she entered the order for monthly UDS on 02/21/2025 at 1:01 p.m. S8LPN confirmed Resident #1 should have had a UDS on 02/21/2025, and then monthly thereafter, but did not.

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse, for 1 (#3...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's rights to be free from physical abuse, for 1 (#3) of 3 (#2, #3, and #5) residents reviewed for abuse. The facility failed to protect Resident #3 from physical abuse by Resident #5. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's undated policy on 02/05/2025, titled Abuse Prevention, read in part . The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consults, volunteers, staff from other agencies, family members, legal guardian, or any other individual. Resident #3 Review of Resident #3's medical record revealed an admit date of 01/05/2024, with diagnoses that included: Schizoaffective Disorder Bipolar type, Anxiety Disorder, Major Depressive Disorder, Depression, Glaucoma, Legal Blindness, and Cognitive Communication Deficit. Review of Resident #3's Quarterly MDS with an ARD of 11/14/2024, revealed a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident #3's Care plan with a review date of 01/31/2025, read in part . Altered Mood State related to the following diagnoses: Depression, Anxiety, Schizoaffective disorder, bipolar type. 01/29/2025: Resident to Resident: Victim. Interventions: Care in pairs due to history of making false allegations against staff; ongoing evaluation of the effectiveness of current psychotropic medications to target behaviors; and resident moved off behavior unit on 01/29/2025. Resident #5 Review of Resident #5's medical record revealed an admit date of 08/04/2022, with diagnoses that included: Schizoaffective Disorder, Depressive type, Anxiety Disorder, Diffuse Traumatic Brain Injury, and Cognitive Social or Emotional Deficit following Cerebrovascular Disease. Review of Resident #5's Quarterly MDS with an ARD of 01/20/2025, revealed a BIMS of 12, indicating moderate cognitive impairment. Review of Resident #5's Care Plan with a target date of 02/10/2025, read in part .At risk for Psychosocial Well-being and Behavioral Symptoms, and Altered Mood State: 01/29/2025 - Resident to Resident - aggressor. Review of a facility incident report dated 01/29/2025, revealed Resident #3 and Resident #5 were eating breakfast in the dining room on Hall X, when S3 CNA and S4 CNA heard Resident #3 yell and tell Resident #5 to give her back her milk. S3 CNA and S4 CNA stated they observed Resident #5 made contact with her fist to Resident #3's face. Review of a witness statement written by S4 CNA on 01/29/2025 at 8:15 a.m. read . I was passing out trays when I heard Resident #3 say 'don't take my milk', then I observed Resident #5 make contact with Resident #3's face. Interview on 02/05/2025 at 1:11 p.m. with S3 CNA revealed she was passing breakfast trays on Hall X and heard Resident #3 say hey, you took my milk. S3 CNA stated while walking over to Resident #3, she observed Resident #5 hit Resident #3 in the mouth with her fist. S3 CNA stated Resident #3 and Resident #5 were immediately separated, and S2 DON was notified. Interview on 02/05/2025 at 2:14 p.m. with S2 DON, revealed she was notified of the incident immediately after it occurred on 01/29/2025. S2 DON stated she assessed Resident #3's face, and observed a discoloration to her upper lip. S2 DON revealed Resident #5 was immediately placed on 1:1 supervision until she was sent to a behavioral hospital on [DATE]. Interview on 02/05/2025 2:50 p.m. with S1 Executive Director revealed after the incident occurred with Resident #3 and Resident #5 on 01/29/2025, the following was put into place: Resident #3 and Resident #5 were immediately separated, Resident #5 was put on 1:1 supervision until sent out to a behavioral hospital, an in-service was initiated for all staff on abuse, and body audits/life safety rounds were completed for all residents on Hall X. S1 Executive Director stated per family wishes, Resident #5 was accepted to another facility that would better suit her needs. The facility has implemented the following actions to correct the deficient practice: 1. Resident #3 and Resident #5 were separated, and Resident #5 was placed on 1:1 monitoring immediately. 2. Each resident's physician and responsible party were notified regarding the incident. 3. Resident #3 had discoloration observed to upper lip after the incident that was resolved the following day, and had no other injuries. No new physician orders. 4. New orders from Resident #5's physician for an inpatient psychiatric evaluation. Resident #5 continued 1:1 supervision until he was admitted to an inpatient behavioral hospital on [DATE]. 5. Life satisfaction rounds were made on all cognitive residents who resided on Hall X, with no issues noted. 6. Body audits were conducted for all residents with low cognition who resided on Hall X, with no issues noted. 7. On 01/29/2025, S2 DON initiated an In-service/training, reviewed the facility's abuse policy with staff, and educated staff on Residents with combative behaviors. All in services/training completed for facility staff as of 01/31/2025. 7. Resident #5 was transferred to another nursing facility after discharge from the behavioral hospital per family request. Facility correction date of 01/31/2025.

Oct 2024 6 deficiencies

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 observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (#30) of 1 (#30) re...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (#30) of 1 (#30) resident reviewed for environment. The facility failed to ensure Resident #30 had a call light in reach in order to call for assistance. The total sample size was 23. Findings: Review of Resident #30's medical record revealed an admit date of 01/05/2024 with diagnoses that included: Legal Blindness, Major Depressive Disorder, Schizoaffective Disorder, Major Depressive disorder, and Cognitive Communication Deficit. Review of Resident #30's Minimum Data Set (MDS) with an ARD of 08/15/2024 revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Review of Resident #30's Care Plan with review date of 04/25/2024 revealed in part . Sensory/Perception Altered: Vision related to legal blindness. Resident #30 is at risk for falls and injuries. Keep call light within reach while in room. Interview on 09/30/2024 at 10:50 a.m. with Resident #30 revealed she was blind and does not know how to find the call bell at night to ask for help. Observation on 10/01/2024 at 10:35 a.m. revealed Resident #30 lying in bed asleep with the call bell on a nightstand across the room, out of reach of the resident. Observation on 10/01/2024 at 2:10 p.m. of Resident #30 lying in bed asleep with no call bell nearby. Resident #30's call bell was plugged into a wall across the room, sitting on her roommate's nightstand. Interview on 10/01/2024 at 2:15 p.m. with S7 CNA revealed Resident #30 was not using a call bell at this time because of the position of the bed in to room would cause the call light cord to lay across her roommates bed and walkway path. S7 CNA revealed Resident #30 usually yelled out when she wanted to make her needs known. Interview on 10/02/2024 at 10:40 a.m. with S8 RN confirmed that Resident #30's call bell was not within reach because the facility was waiting on an extension cord, but should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physi...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (#76) of 2 ( #68 and #76) residents reviewed for abuse. The facility failed to ensure Resident #76 was not physically abused by Resident #68. Findings: Review of the facility's policy titled Abuse Prevention, on 10/02/2024, with a review date of 10/2022, revealed in part .The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual. Abuse defined: Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. Resident #76 Review of Resident #76's medical records revealed an admit date of 02/01/2024, with diagnoses that included: Bipolar Disorder, Unspecified Psychosis, Unspecified Dementia, Major Depressive Disorder, Schizophrenia, and Anxiety Disorder. Review of Resident #76's Quarterly MDS with an ARD of 08/08/2024, revealed a BIMS score of 99, indicating the resident was unable to complete the interview. The MDS revealed Resident #76 required partial to moderate assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. Resident #76 was coded as independent with transfers. Review of Resident #76's care plan with a review date on 11/12/2024, revealed in part . Alterations in psychosocial well-being with interventions for behavior monitoring. Review of Resident #76's nurses' notes dated 08/11/2024 at 7:17 p.m., by S10 LPN, read as follows in part . S7 CNA reported that another resident pulled this resident down on the floor and started kicking her in the back. Residents separated at this time. Small red area noted to left mid back area, no other injuries noted at this time. Resident #68 Review of Resident #68's medical records revealed an admit date of 08/04/2022, with diagnoses that include: Traumatic Subarachnoid Hemorrhage, Persistent Mood Disorder, Cerebrovascular Disease, Paranoid Schizophrenia, Diffuse Traumatic brain injury with loss of consciousness, and Schizoaffective Disorder. Review of Resident #68's Annual MDS with an ARD of 07/26/2024, revealed a BIMS score of 9, indicating moderate cognitive impairment. The MDS revealed Resident #68 was coded as independent with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene. Review of Resident #68's Care Plan with a review date of 11/24/2024, read in part Resident #68 is at risk for psychosocial wellbeing and behavioral symptoms, altered mood state related to a diagnosis of Paranoid Schizophrenia with interventions for behavior monitoring. Review of a facility's Incident Report documented by S1 Administrator, revealed on 08/11/2024 at 5:00 p.m., S9 CNA reported that while passing out snacks in the special care unit's common area, Resident #76 tapped Resident #68 on the shoulder. Resident #68 became frightened and made physical contact with Resident #76 by grabbing her hair. S9 CNA reported while on the way to separate the residents, Resident #76 fell onto the ground. Resident #68 and Resident #76 were immediately separated. Resident #68 was placed on 1:1 supervision until she was sent to a behavioral hospital on [DATE]. Interview on 10/01/2024 2:15 p.m. with S7 CNA, revealed she was on duty on the behavioral unit when the incident occurred. S7 CNA stated she heard S9 CNA yell out, so she ran into the behavioral unit's common area, and observed Resident #76 on the ground in front of Resident #68's wheelchair. S7 CNA denied seeing Resident #68 kicking Resident #76. S7 CNA revealed that Resident #68 was sent to her room with 1:1 supervision, and Resident #76 stayed in the common area. Interview on 10/02/2024 at 3:37 p.m. with S1 Administrator, revealed Resident #68 had a history of resident to resident altercations. S1 Administrator confirmed the Resident to Resident altercation between Resident #68 and Resident #76 occurred on 08/11/2024.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

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 conduct a thorough investigation of an incident of abuse for 1 (#76...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a thorough investigation of an incident of abuse for 1 (#76) of 2 (Resident #68 and Resident #76) residents sampled for abuse in a total sample of 23. Findings: Review of the facility's policy dated 10/2022, and titled Abuse Prevention on 10/02/2024, read in part . Investigation: The facility will initiate at the time of any finding of potential abuse or neglect, an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation. Review of a facility's Incident Report documented by S1 Administrator, revealed on 08/11/2024 at 5:00 p.m., S9 CNA reported that while she was passing out snacks in the special care unit's common area, Resident #76 tapped Resident #68 on the shoulder. Resident #68 became frightened and made physical contact with Resident #76 by grabbing her hair. S9 CNA reported while on the way to separate the residents, Resident #76 fell onto the ground. Resident #68 and Resident #76 were immediately separated. Resident #68 was placed on 1:1 supervision until she was sent to a behavioral hospital on [DATE]. Review of the Investigation revealed witness statements were not obtained from S9 CNA, S10 LPN, or the Registered Nurse on duty at the time of the incident. Interviews with S9 CNA, S10 LPN, and the RN that was on duty at the time of the incident, were not successful. Interview on 10/02/2024 at 3:37 p.m. with S1 Administrator, revealed Resident #68 had a history of resident to resident altercations. S1 Administrator confirmed the Resident to Resident altercation between Resident #68 and Resident #76 occurred on 08/11/2024. S1 Administrator confirmed the facility had not completed the investigation, and failed to complete body audits and safety rounds on all residents who resided on the behavioral unit. S1 Administrator confirmed that the facility failed to obtain witness statements for all staff that were on duty and witnessed the resident to resident abuse between Resident #68 and Resident #76 on 08/11/202, but should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight ...

Read full inspector narrative →

Based on record review, observation, and interview, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, by failing to implement appropriate interventions for weight loss for 1 (#56) of 2 (#32 & #56) residents reviewed for nutrition. The facility failed to: 1. Ensure Resident #56's meal intake was documented for each meal, as care planned, and 2. Provide one on one assistance to Resident #56 with all meals, as care planned. Findings: Review of Resident #56's medical record revealed an admit date of 03/31/2021 with diagnoses that included in part .Major Depressive Disorder, Unspecified Dementia, Cellulitis, and Hypertension. Review of Resident #56's Quarterly MDS with an ARD of 09/19/2024 revealed a BIMS could not be completed because the resident was rarely or never understood. Review of the MDS revealed Resident #56 required supervision or touching assistance with eating and was independent with sit to stand and chair/bed to chair transfers. Review of Resident #56's Care Plan with a target date of 01/01/2025 revealed the resident was care planned for Need to maintain adequate nutritional intake related to Dementia, Depression . Interventions included in part .1 on 1 Dependent Diner, Supplements as ordered, Encourage resident to allow staff to obtain weights, Dietician to evaluate and follow up as needed, and Monitor food intake at each meal and record. Report any decline to physician and dietician. Review of Resident #56's medical record revealed the following weights which indicated a 17.15% weight loss over the past six months: 09/10/2024-97.6 pounds 08/09/2024-106.3 pounds 06/07/2024-112.8 pounds 03/08/2024-117.8 pounds Review of Resident #56's current physician's orders revealed the following: 03/31/2021-Regular diet 03/21/2023-House supplement-offer if resident eats less than 50% of meals and monitor percentage taken In an observation on 10/01/2024 at 12:21 p.m., Resident #56 was observed in her room standing at the table, eating spaghetti and vegetables with her hands. No staff was observed in her room during meal. At 12:25 p.m., S5 CNA went in the resident's room and took the tray out of her room while Resident #56 was still standing near it. When S5 CNA exited the room, this surveyor entered and found Resident #56 stuffing a wad of plastic wrap in her mouth. This surveyor called S6 LPN who came and took the plastic wrap away from the resident. S6 LPN asked Resident #56 if she was still hungry and the resident nodded yes. S6 LPN left and returned shortly with a fudge round, took it out of the wrapper, and gave it to the resident who began eating it. When S5 CNA returned, she stated Resident #56 had eaten about 50% of her tray. Review of the Meal Report (documentation of meal intake) on 10/02/2024 revealed the following: 09/30/24-no documentation of intake at breakfast or lunch 09/29/24-no documentation of intake at breakfast or lunch 09/28/24-no documentation of intake at breakfast or lunch 09/27/24-no documentation of intake at breakfast, lunch, or dinner 09/26/24-no documentation of intake at breakfast or lunch 09/25/24-no documentation of intake at breakfast or lunch 09/24/24-no documentation of intake at breakfast or lunch 09/23/24-no documentation of intake at breakfast or lunch 09/22/24-no meal intake documented for breakfast, lunch, or dinner 09/21/24-no meal intake documented for breakfast, lunch, or dinner 09/19/24-no meal intake documented for breakfast or lunch 09/18/24-no meal intake documented for breakfast, lunch, or dinner 09/17/24-no documentation of intake at breakfast or lunch 09/16/24-no documentation of intake at dinner In an interview on 10/02/2024 at 2:21 p.m., S2 DON acknowledged staff were not documenting Resident #56's food intake at each meal and should have been. S2 DON acknowledged Resident #56 was observed eating lunch on 10/01/2024 without staff assistance. S2 DON confirmed Resident #56 was care planned for one on one assistance with dining.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation and interview the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard t...

Read full inspector narrative →

Based on observation and interview the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure the nutritional adequacy of the meal for all residents who received a regular diet prepared by the facility kitchen. Findings: Review of Production Sheet Main Menu S/S 2024 provided by the facility revealed Baked Chicken portion size was 3 oz. Observation of lunch preparation on 09/30/2024 at 11:40 a.m. revealed improper serving sizes for six residents. Plates were served to 5 residents on a regular diet with one small chicken leg and two small chicken legs served as a double portion for 1 resident. Interview with S3 Dietary Manager and S4 Regional Director of Nutritional Services on 09/30/2024 at 12:43 p.m. confirmed one chicken leg without the bone was only approximately 2 oz. and that residents should have been served two chicken legs to meet the 3 oz. portion size on the menu and that two small chicken legs were not considered a double portion.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation and interview the facility failed to store food in accordance with Professional standards for food safety. The facility failed to properly store dry food items in the kitchen as e...

Read full inspector narrative →

Based on observation and interview the facility failed to store food in accordance with Professional standards for food safety. The facility failed to properly store dry food items in the kitchen as evidenced by one loaf of bread with mold present; two packages of hot dog buns that expired on 08/19/2024; one opened box of cornstarch that was undated and one used pad of butter in the refrigerator, unsealed and undated. This deficient practice had the potential to affect any resident who consumed meals served from the facility's kitchen. Findings: Kitchen observation of the dry food storage area with S3 Dietary Manager on 09/30/2024 at 09:04 a.m. revealed one loaf of bread with mold present; two packages of hot dog buns that expired on 08/19/2024 and one box of cornstarch opened and undated. Observation of the walk-in refrigerator with the S3 Dietary Manager revealed one used pad of butter, unsealed and undated.

Jul 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on record review, observation, and interview, the facility failed to ensure that each resident was treated with respect and dignity and cared for in an environment that promoted maintenance or e...

Read full inspector narrative →

Based on record review, observation, and interview, the facility failed to ensure that each resident was treated with respect and dignity and cared for in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (#2) of 3 (#1, #2, & #3) sampled residents by failing to ensure she was free of facial hair. Findings: Review of Resident #2's medical record revealed an admit date of 03/15/2024 with diagnoses that included in part .Pneumonia, Urinary Tract Infection, Major Depressive Disorder, Dementia, Down's Syndrome, Type 2 Diabetes Mellitus, and Moderate Intellectual Disabilities. Review of Resident #2's MDS with an ARD of 05/07/2024 revealed a BIMS was not conducted the resident was rarely or never understood. Review of the MDS revealed the resident required set up or clean up assistance with eating, substantial or maximal assistance with toileting hygiene and showering or bathing self, and partial to moderate assistance with personal hygiene. Review of Resident #2's current care plan revealed the resident was at risk for decline in ADLs with a problem onset of 03/15/2024 related to Down 's syndrome, unspecified mood disorder, and psychotropic medication usage. Interventions in the care plan included in part .Requires one person assist with ADLs, continent of bowel and bladder, wears pull ups for episodes of incontinence, and call light within reach while in room. In an observation on 07/09/2024 at 12:10 p.m., Resident #2 was sitting at a dining room table in her wheelchair. Resident #2 was noted to have many long, curly chin hairs. The chin hairs were noted to be about an inch long and were covering her entire chin. In an interview on 07/09/2024 at 3:20 p.m., S2 CNA reported staff bathed Resident #2 in the shower on the hall on the unit and that Resident #2 was bathed yesterday. S2 CNA reported Resident #2 does not refuse showers and doesn't have any behaviors. S2 CNA was notified of Resident #2's many long chin hairs. S2 CNA replied that she would shave her and confirmed Resident #2 doesn't refuse to be shaved. In an observation on 07/10/2024 at 7:15 a.m., Resident #2 was observed sitting in a wheelchair in the hallway with other residents and staff. Resident #2 was noted to have multiple long, curly chin hairs. In an interview at that time, S3 CNA acknowledged Resident #2's long chin hairs and resplied she would shave the resident. In an observation and interview at 07/10/2024 at 7:25 a.m., S4 LPN observed Resident #2 and confirmed observing Resident #2's long chin hairs and said She needs to be shaved. In an interview on 07/10/2024 at 11:05 a.m., S1 DON acknowledged that Resident #2 had been observed over the past three days with multiple long chin hairs that needed to be shaved by staff.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to implement the plan of care to meet the needs of 2 (#1 & #2) of 3 (#1, #2, & #3) sampled residents. The facility failed to monitor and record...

Read full inspector narrative →

Based on record review and interview the facility failed to implement the plan of care to meet the needs of 2 (#1 & #2) of 3 (#1, #2, & #3) sampled residents. The facility failed to monitor and record food intake at each meal as directed in the residents' care plans. Findings: Resident #1 Review of Resident #1's medical record revealed an admit date of 03/05/2024 with diagnoses that included in part .Unspecified Dementia, Major Depressive Disorder, History of falling, Anxiety Disorder, and Insomnia. Review of Resident #1's Quarterly MDS with an ARD of 04/24/2024 revealed a BIMS score of 4 indicating severe cognitive impairment. Review of the MDS revealed Resident #1 required supervision or touching assistance with eating. Review of Resident #1's current care plan revealed a potential for weight loss with a problem onset of 03/05/2024. Interventions in the care plan included in part .Dietician to evaluate and follow up as needed, determine food preferences, downgrade diet to mechanical soft with chopped meats, house supplement 8 ounces twice daily between meals, monitor food intake at each meal and record and report any decline to physician and dietician. Review of Resident #1's Meal Report from 06/01/2024 through 07/09/2024 revealed food intake at each meal was not recorded on 36 of the 39 days. Review of Resident #1's medical record revealed the following weights which represented a significant weight loss of 17% over a 3 month period: 06/07/2024-105.8 pounds 05/10/2024-108.2 pounds 04/10/2024-111.2 pounds 03/29/2024-117.1 pounds 03/22/2024-120.4 pounds 03/15/2024-127.1 pounds 03/05/2024-128 pounds In an interview on 07/10/2024 at 11:00 a.m., S1 DON acknowledged staff were not documenting meal intake after each meal for Resident #1, as instructed in Resident #1's care plan, and should have been. Resident #2 Review of Resident #2's medical record revealed an admit date of 03/15/2024 with diagnoses that included in part .Pneumonia, Urinary Tract Infection, Major Depressive Disorder, Dementia, Down's Syndrome, Type 2 Diabetes Mellitus, and Moderate Intellectual Disabilities. Review of Resident #2's QM5 MDS with an ARD of 05/07/2024 revealed a BIMS was not conducted as resident was rarely or never understood. Review of the MDS revealed the resident required set up or clean up assistance with eating, substantial or maximal assistance with toileting hygiene and showering or bathing self, and partial to moderate assistance with personal hygiene. Review of Resident #2's current care plan revealed a potential for weight loss with a problem onset of 03/15/2024. Interventions in the care plan included in part .Dietician to evaluate and follow up as needed, determine food preferences, monitor food intake at each meal and record, and report any decline to physician and dietician. Review of Resident #2's Meal Report from 06/01/2024 through 07/09/2024 revealed food intake at each meal was not recorded on 32 of the 39 days. Review of Resident #2's medical record revealed the following weights which represented a significant weight loss of 12% over a 4 month period: 07/05/2024-68.6 pounds 06/07/2024-77.8 pounds 03/15/2024-78.4 pounds In an interview on 07/10/2024 at 11:00 a.m., S1 DON acknowledged staff were not documenting meal intake after each meal for Resident #2, as instructed in Resident #2's care plan, and should have been.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of Resident #3's clinical record revealed an admit date of 07/07/2022 with diagnoses which included: Hypertension, Unspecified sequelae of other Cerebrovascular Disease, Type 2 Diabetes Mellitus, and Insomnia. Review of Resident #3's Quarterly MDS with an ARD of 12/28/2023 revealed a BIMS score of 11, indicating moderate cognitive impairment. Review of the MDS revealed Resident #3 had impairments to both sides of his lower extremities, and was dependent with chair/bed to chair transfers and independent with wheeling a manual wheelchair. Review of Resident #3's Care Plan with a Target of 04/2024 revealed a problem of impaired mobility and at risk for decline in ADLs related to diagnoses of: CVA, Depression, and Bilateral AKAs. Interventions included: A self-release belt while up in wheelchair due to poor safety awareness due to bilateral AKAs (non-restraint); Check every 30 minutes; and release and reposition every 2 hours. Observation on 03/22/2024 at 9:49 a.m. revealed Resident #3's wheelchair next to his bed with a self-release belt that had a broken buckle. Interview on 03/22/2024 at 9:49 a.m. with Resident #3 revealed the self-release belt buckle on his wheelchair was broken and had been broken for a few days. Resident #3 reported he told a nurse but cannot recall which nurse. Observation on 03/25/2024 at 10:55 a.m. revealed Resident #3's wheelchair next to his bed with a self-release belt that had a broken buckle. Observation on 03/25/2024 at 11:00 a.m. accompanied by S2 LPN revealed the self-release belt buckle was broken on Resident #3's wheelchair. Interview with S2 LPN revealed Resident #3 was in bed that morning so she had not looked at the self-release belt on his wheelchair until then. S2 LPN confirmed his self-release belt buckle was broken, but should not have been. S2 LPN reported the nursing staff are to monitor the self-release belt routinely. Interview on 03/25/2024 at 11:22 a.m. with S1 ADM confirmed the self-releasing belt buckle was broken, but should not have been.

Sept 2023 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #80) of 1 sampled resident reviewed for resident ...

Read full inspector narrative →

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (Resident #80) of 1 sampled resident reviewed for resident assessments. Findings: Review of the clinical record for Resident #80, revealed an admission date of 09/06/2022, and diagnoses that included: Anxiety Disorder, Anemia, UTI, Unspecified Dementia, Unspecified Severity with other Behavioral Disturbances, and Unspecified psychosis. Review of the facility's MDS transmission report revealed Resident #80's Quarterly MDS with an ARD (Assessment Reference Date) of 06/15/2023, was not transmitted until 07/07/2023. Interview on 09/07/2023 at 9:47 a.m. with S2 DON confirmed Resident #80's MDS assessment was completed late on 07/07/2023. S2 DON confirmed the assessment should have been transmitted timely within 14 days after completed, and was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review, the Facility failed to have an appropriate person-centered care plan for Resident #61 by failing to have interventions care planned when Resident #61 refused ADL ...

Read full inspector narrative →

Based on interview and record review, the Facility failed to have an appropriate person-centered care plan for Resident #61 by failing to have interventions care planned when Resident #61 refused ADL (Activities of Daily Living) care or refused to allow staff to change his bed linen. Total sample size was 20. Findings: Review of Resident #61's medical record revealed a date of 03/16/2023, with diagnoses which included: Major Depressive Disorder, Unspecified Dementia, Conversion Disorder with Seizure or Convulsions, and Acute Hepatitis C. Review of Resident #61's Quarterly MDS with an ARD of 06/08/2023 revealed a BIMS score of 12 (indicating mildly impaired cognition). The MDS revealed Resident #61 required supervision with set-up help only for bed mobility, dressing, eating, toilet use and personal hygiene; Resident #61 was coded as independent with transfers, and no ROM impairment to upper and lower extremities. Review of Resident #61's Care Plan with a review date of 05/22/2023 revealed he is at risk for decline in ADL's (Activities of Daily Living) related to Diagnoses of Chronic Pain, Seizures, Dementia and Depression. Often refuses ADL care and to allow staff to change his sheets. The care plan did not identify nursing interventions or measures that addressed Resident #61's behavior of refusal of ADL care, and not allowing staff to change his sheets. Observation and interview on 09/05/2023 at 10:32 p.m. revealed Resident #61 lying in bed fully clothed. Resident #61 did not have a pillowcase on his pillow and his bottom bed sheet was dirty with yellow stains. Urinal at bedside with approximately 300-400 cc's of yellow urine in it. Resident stated he did not know why he didn't have a pillowcase. Observation on 09/06/2023 at 2:10 p.m. revealed Resident #61 lying in bed fully clothed. Resident #61 did not have a pillowcase on his pillow, and his bottom bed sheet was dirty with yellow stains. Urinal at bedside was full with approximately 600cc's of yellow urine in it. Resident #61 revealed it had been a while since his sheets had been changed, or since he had a pillowcase. Resident #61 stated he would have liked his sheets changed, and a pillowcase for his pillow. Observation and interview on 09/26/2023 at 2:14 p.m. with S6 Corporate Nurse revealed Resident #61 lying in bed fully clothed. Resident #61 did not have a pillowcase on his pillow and his bottom bed sheet was dirty with yellow stains. Urinal at bedside was full with approximately 600cc's of yellow urine in it. S6 Corporate Nurse confirmed Resident #61's bed linen was dirty with yellow stains, and it should not have been. S6 Corporate Nurse confirmed Resident #61's pillow should have had a pillowcase, and it did not. Interview on 09/06/2023 at 2:42 p.m. with S7 CNA revealed she provided care for Resident #61. S7 CNA stated she had not offered to change Resident #61's bed linen, or offer him a pillowcase for his pillow because she thought he did it himself. Interview on 09/06/2023 at 3:40 p.m. with S1 Administrator revealed if Resident #61 refused ADL care, or did not allow staff to change his bed linen, his plan of care interventions should have been to keep trying to assist Resident #61, and to reach out to a family member for help. Interview on 09/07/2023 at 10:03 with S6 Corporate Nurse confirmed Resident #61 did not have any interventions care planned for his refusal of ADL care, and refusal to allow staff to change his bed linen, and he should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0773 (Tag F0773)

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 promptly notify the ordering physician of the results of a urine cu...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the ordering physician of the results of a urine culture resulting in a delay of treatment for 1 (Resident #16) of 20 sampled residents. Findings: Review of the facility's policy titled Notification of a change in a resident's status read in part . Policy: The attending physician/physician extender and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Procedure: 1. Guideline for notification of physician/responsible party: f. Abnormal lab findings. 2. Document in the Interdisciplinary Team (IDT) notes: b. Physician/Physician extender notification. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part .Neuromuscular Dysfunction of the Bladder, Type 2 Diabetes Mellitus, and Urinary Tract Infection. Review of Resident #16's Quarterly MDS with ARD of 07/06/2023 revealed Resident #16 had a BIMS of 15 (cognitively intact). Resident #16 required extensive 1 person physical assistance with toileting. Resident #16 had an indwelling catheter. Review of Resident #16's Comprehensive Person Centered Care Plan revealed Resident had a potential for urinary tract infection related to the presence of an indwelling catheter. Interventions included: Observe and report to MD signs and symptoms of urinary infection. Review of Resident #16's 08/2023 and 09/2023 Physician Orders revealed the following in part .Urinalysis, Culture and Sensitivity for diagnosis of dysuria and chronic suprapubic catheter. Order date: 08/16/2023 Ceftin (Antibiotic) 500mg by mouth twice daily for 14 days for diagnosis of Urinary Tract Infection. Order date: 09/06/2023 Review of Resident #16's medical record revealed a lab result sheet that revealed in part . a Urinalysis and Urine Culture and Sensitivity was collected on 08/16/2023, with results dated 08/16/2023 for Urinalysis and results dated 08/20/2023 for Urine Culture and Sensitivity. The results of Urinalysis revealed critical findings that the lab reported to S4 LPN on 08/16/2023 at 5:08 p.m. The results of the Urine Culture and Sensitivity revealed Resident #16 had Providencia Stuartii and Proteus Mirabilis (bacteria) reported on 08/20/2023. The lab results sheet was signed by nursing on 09/05/2023, with documentation that it was faxed to the physician and awaiting a return call. Review of Resident #16's Electronic Departmental Notes revealed the following entries in part . 08/16/2023 at 5:29 p.m. by S4 LPN: 2:25 p.m. UA collected and packaged of lab. 08/16/2023 at 5:30 p.m. by S4 LPN: 4:15 p.m. UA delivered to lab per transportation driver. 08/30/2023 at 12:58 p.m. by S4 LPN: 10:00 a.m. Resident complains of Bladder Pain and catheter is flushed as per nursing protocol. Flushes well at this time. Resident requested prn pain pill. Administered as requested and monitoring for effectiveness. 09/06/2023 at 9:08 a.m. by S8 LPN: Late Entry for 09/05/2023- Called for UA results- lab faxed over results with abnormal ranges noted. Call placed to MD office and message left for MD to call back with orders pertaining to results. Labs faxed over also. No orders noted at this time, will call back with any new orders from MD. 09/06/2023 at 9:08 a.m. by S8 LPN: 9:06 a.m. MD office called back with a verbal order for Ceftin 500mg twice daily for 14 days. After antibiotic therapy repeat UA. Pharmacy faxed and resident and RP notified. Interview on 09/07/23 at 1:23 p.m. with S2 DON revealed she was unsure why Resident #16's lab results from 08/16/2023 was not followed up on, or reported to MD until 09/05/2023, but she would interview staff and provide surveyor an update. Interview on 09/07/2023 at 1:35 p.m. with S2 DON revealed she spoke with S4 LPN who received the critical lab results on 08/16/2023, and S4 LPN informed S2 DON she had hand wrote a note on 08/16/2023 stating she notified MD of results, and the MD chose not to treat Resident #16. S2 DON stated a staff member had noticed on 09/05/2023 that the lab results from 08/16/2023 were not on Resident #16's chart, so the facility called for the lab to fax the results. Telephone interview on 09/07/2023 at 2:07 p.m. with Resident #16's physician revealed he recalled ordering the UA on 08/16/2023. The physician stated he was not notified by facility of the UA results until 09/05/2023. The physician stated he would have ordered antibiotics to treat Resident #16 after reviewing urine culture results, but he was not notified by the facility of the urine culture results until 09/05/2023. Interview on 09/07/2023 at 3:25 p.m. with S2 DON confirmed the UA results for Resident #16 on 08/16/2023 and Urine Culture results on 08/20/2023 must have been missed by her, and the physician should have been notified of Resident #16's Urine Culture results and complaints of urinary symptoms prior to 09/05/2023, but had not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

Based on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly. Findings: Observation on 09/05/2023 at 9:05 a.m. of the outside kitchen area accompanied...

Read full inspector narrative →

Based on observation and interview the Facility failed to ensure garbage and refuse were disposed of properly. Findings: Observation on 09/05/2023 at 9:05 a.m. of the outside kitchen area accompanied by S5 Dietary Manager revealed 1 large blue dumpster located within a fenced in area, and 1 large black open topped roll away dumpster located outside of the fenced in area. There were multiple trash cans, and bags of trash observed spilling over the trash cans. There was a large amount of trash and debris on the ground that littered the area. Interview with S5 Dietary Manager at time of observation revealed the blue compact dumpster within the fenced in area had been broken for several weeks, and the facility brought in the roll away dumpster on yesterday 09/04/2023. S5 Dietary Manager confirmed there was a large amount of uncontained trash and debris on the ground, and there should not have been.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure medications were stored under proper temperature controls for 2 (Hall A medication refrigerator and Hall B medication ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure medications were stored under proper temperature controls for 2 (Hall A medication refrigerator and Hall B medication refrigerator) of 2 medication refrigerators. Findings: Review of the facility's policy titled Medication Storage revealed in part . All drugs, treatments, and biologicals must be stored securely, and following the manufacturer's labeled recommendations. Review of the facility's procedure titled Medication Storage revealed in part . Medications requiring refrigeration must be stored between 36 degrees F and 46 degrees F in a refrigerator. A thermometer must be used for frequent monitoring. Medications that require storing in a cool place are to be refrigerated unless otherwise labeled. Review of the Hall B Medication Storage Refrigerator/ Equipment Temperature Log on 09/06/2023 at 11:50 a.m. with S4 LPN, revealed the refrigerator temperatures were not checked daily. Interview with S4 LPN revealed the medication refrigerator should be checked daily by the night shift nurses. S4 LPN confirmed there was missed documentation of refrigerator temperatures on the following dates: 07/06/2023, 07/07/2023, 07/08/2023, 07/10/2023, 07/11/2023, 07/14/2023, 07/15/2023, 07/16/2023, 07/18/2023, 07/31/2023, 08/01/2023 and 08/27/2023. S4 LPN confirmed the refrigerator temperatures were not checked daily, and should have been. Review of Hall A Medication Storage Refrigerator/Equipment Temperature Log on 09/06/2023 at 12:20 p.m. with S3 LPN, revealed the refrigerator temperatures were not checked daily. Interview with S3 LPN at that time revealed the medication refrigerator should be daily by the night shift nurses. S3 LPN confirmed there was missed documentation of refrigerator temperatures on the following dates: 07/05/2023, 07/062023, 07/12/2023, 07/21/2023, 07/30/2023, 07/31/2023, 08/01/2023, 08/02/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/14/2023, 08/20/2023, 08/24/2023, 08/28/2023 and 08/29/2023. S3 LPN confirmed the refrigerator temperatures were not checked daily, and should have been. Interview on 09/06/2023 at 12:39 p.m. with S2 DON revealed the night shift nurses are responsible for checking the medication refrigerator temperatures, and they are to document the temperatures on the log every day. S2 DON stated the night shift nurses should have checked the medication temperatures, and documented the temperatures on the log daily in July and August 2023, for Hall A and Hall B Medication Storage Refrigerators, and they did not.

Aug 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on interview and record review, the Facility failed to provide pharmaceutical services that assured the accurate reconciliation of controlled medications to meet the needs of each Resident, by f...

Read full inspector narrative →

Based on interview and record review, the Facility failed to provide pharmaceutical services that assured the accurate reconciliation of controlled medications to meet the needs of each Resident, by failing to ensure a physical inventory of controlled medications were conducted by two licensed clinicians at each shift change. Findings: Review of the Facility's policy and procedure on controlled medications read in part . (8). At each shift change, a physical inventory of controlled medications is conducted by two licensed clinicians. By signing the Controlled Substance Tracking Form each nurse is agreeing that the number of controlled medications units (tabs, patches, etc.), and the number of Controlled Substance Records (sign-out sheet) matches the number of medication units on the Controlled Drug Record for each medication order. Review of an Incident Report dated 07/14/2023 by S1 Administrator at approximately 8:00 a.m., read in part . S3 LPN reported to S2 DON that there was an issue with the narcotic count, specifically the Fentanyl patches. S3 LPN showed S2 DON two boxes of Fentanyl patches for Resident #3, both were opened. The box with 1 of 2 written on it contained (4) 25MCG patches. The box with 2 of 2 written on it contained (3) 25MCG patches. Review of the Controlled Drug Record showed S4 LPN signed in (10) patches on 07/04/2023. The only entry on the Controlled Drug Record was on 07/12/2023 at 9:00 a.m., when S4 LPN signed out (1) 25MCG Fentanyl patch indicating there were (9) 25MCG Fentanyl patches left. S4 LPN confirmed she counted with S5 LPN at 7:00 p.m. on 07/12/2023 and on 07/13/2023. Interview on 08/02/2023 at 11:30 a.m. with S6 Consultant Pharmacist revealed he visited the facility at least twice monthly, and randomly checked narcotics. S6 Consultant Pharmacist stated during the random checks, he found missed signatures on the narcotic sign-out sheets. Telephone Interview on 08/02/2023 at 2:00 p.m. with S4 LPN revealed on 07/12/2023 at 9:00 a.m., she applied a 25 MCG Fentanyl patch on Resident #3, and did not count the number of Fentanyl patches when she opened the box. S4 LPN stated she did not count the Fentanyl patches until the end of her shift at 7:00 p.m. with S5 oncoming nurse, and the count was correct, (9) Fentanyl patches. Interview on 08/02/2023 at 3:01 p.m. with S3 LPN revealed she was running late for work for the 7:00 a.m. - 7:00 p.m. shift on 07/14/2023, so she texted S7 LPN and asked her to reconcile narcotics with S8 LPN, and S3 LPN agreed. S3 LPN confirmed this was not good practice, and stated she was responsible for reconciling her narcotics at the beginning and at the end of shift change. Telephone interview on 08/03/2023 at 9:27 a.m. with S9 LPN revealed she was running late for work for the 07/13/2023 7:00 a.m. - 7:00 p.m. shift on 07/13/2023, and when she arrived to work, the night shift nurse was leaving and informed her S10 LPN had the keys to her medication cart. S9 LPN confirmed she retrieved her keys from S10 LPN, but did not reconcile any narcotics at that time, and she should have. Interview on 08/03/2023 at 10:13 a.m. with S1 Administrator revealed she was not aware of the nurses being late for work and asking other nurses to reconcile their narcotics. S1 Administrator confirmed the nurses should not have taken the medication cart keys without reconciling narcotics.

Jul 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a physician's order was implemented as required in the person centered plan of care for 1 (Resident #4) of 5 (Resident #1, Resident ...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure a physician's order was implemented as required in the person centered plan of care for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of the facility's policy titled Ordering and Receiving Medications from Pharmacy revealed in part . Policy: Medications are ordered and received from the pharmacy in a timely manner. The facility maintains accurate records of medications ordered and their receipt. 3. New medications, except for emergency and/or stat medications prior to next scheduled delivery are ordered as follows: A. If needed before the next regular delivery, phone the medication order to the pharmacy. Inform pharmacy of the need for delivery prior to next scheduled delivery. Use the emergency/stat kit drugs when the resident needs a medication prior to pharmacy delivery, if available. Review of Resident #4's Medical Record revealed an admit date of 02/02/2023 with diagnoses that included: Muscle Spasm, Cough, and Chronic Viral Hepatitis. Review of Resident #4's Quarterly MDS with an ARD of 05/11/2023 revealed a BIMS score of 15, indicating intact cognition. Section I revealed Resident #4 had Active Diagnoses of Pneumonia and Idiopathic Pulmonary Fibrosis. Review of Resident #4's Care Plan revealed a problem of infection/fever related to respiratory tract infection and possible pneumonia with an onset date of 06/29/2023 with interventions that included: Levaquin 750 mg daily x 5 days, Doxycycline 100 mg PO BID x 10 days, encourage PO fluids, and temperature check while on antibiotics. Resident #4 had a problem of infection/fever/Flu with an onset date of 07/06/2023 with interventions that included: administer medications as ordered, monitor vital signs, and precautions: isolation. Review of Resident#4's Physician Orders revealed the following orders in part . Order Date 06/29/2023 - Doxycycline 100 mg 1 PO BID x 10 days and Levaquin 750 mg 1 PO daily x 5 days Order Date 07/06/2023 - Tamiflu 75 mg PO BID x 7 days Review of Resident #4's Progress Notes revealed in part . 06/29/2023 2:55 p.m. - 11:30 a.m. NP notified of results of chest X-Ray of previous day - possible pneumonia - new orders noted 1) Doxycycline 100 mg PO BID x 10 days 2) Levaquin 750 mg PO daily x 5 days. 07/06/2023 7:34 p.m. New order Tamiflu 75 given PO BID x 7 days. 07/08/2023 8:49 a.m. - Late entry for 07/07/2023 at 9:00 a.m. ID of Tamiflu 75 mg administered at this time. Pulled ID from E-Kit and faxed to pharmacy. Review of Resident #4's 06/2023 and 07/2023 MAR revealed Doxycycline 100 mg PO BID x 10 days was not administered on 06/29/2023 and Resident #4 received 9 days of Doxycycline BID at 9:00 a.m. and 9:00 p.m. from 06/30/2023 through 07/08/2023. Resident #4 did not receive Levaquin 750 mg PO daily x 5 days on 06/29/2023 or 06/30/2023 at 9:00 p.m. and received Levaquin BID on 07/01/2023 and 07/02/2023 at 9:00 a.m. and 9:00 p.m. Resident #4 did not receive Tamiflu 75 mg PO BID on 07/06/2023, 07/07/2023, and 07/08/2023 at 9:00 p.m. Review of the facility's Emergency Drug Kit Oral Medications list revealed Doxycycline Hyclate 100 mg, Levofloxacin (Levaquin) 250 mg, and Oseltamivir (Tamiflu) 75 mg were available in the emergency kit. Interview on 07/14/2023 at 12:38 p.m. with S1 DON revealed Tamiflu 75 mg is available in the Emergency Drug Kit, along with Doxycycline 100 mg and Levaquin 250 mg. Interview on 07/14/2023 at 1:48 p.m. with Resident #4 revealed he could not remember what his medications looked like to be able to tell if he received all of his antibiotics for pneumonia or medication for the flu. Review of the Emergency Drug Kit Slips with S1 DON on 07/14/2023 at 2:15 p.m. revealed no receipts for Doxycycline or Levaquin for Resident #4. A receipt was noted for Tamiflu on 07/07/2023 for the 9:00 a.m. dose. Interview on 07/14/2023 at 2:15 p.m. with S1 DON revealed orders for antibiotics and antivirals should be faxed to the pharmacy and then taken from the Emergency Drug Kit, if available, for administration on the same day. S1 DON confirmed Doxycycline 100 mg PO BID x 10 days ordered on 06/29/2023 at 11:30 a.m. was not administered until 06/30/2023 at 9:00 a.m. and Resident #4 did not receive 10 days as ordered, but it should have been initiated on 06/29/2023 and administered for 10 days. S1 DON confirmed Levaquin 750 mg PO daily x 5 days ordered on 06/29/2023 at 11:30 a.m. was not administered on 06/29/2023 or 06/30/2023, but should have been initiated on 06/29/2023. S1 DON confirmed Levaquin 750 mg PO daily x 5 days was administered to Resident #4 twice a day on 07/01/2023 and 07/02/2023, but should not have been as the order was for daily. S1 DON confirmed Resident #4 did not receive the initial dose of Tamiflu on 07/06/2023 at 9:00 p.m. and the 9:00 p.m. doses on 07/07/2023 and 07/08/2023 as ordered, but should have. Interview on 07/14/2023 at 2:33 p.m. with S1 DON revealed the facility did not have a specific policy on the time frame in which an antibiotic or antiviral should be administered, but it is standard nursing practice to start it as soon as possible the same day because the resident requires it for their care.

Mar 2023 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to ensure the plan of care had been developed or prepared by an interdisciplinary team that included the participation of the resident and the ...

Read full inspector narrative →

Based on record review and interview the facility failed to ensure the plan of care had been developed or prepared by an interdisciplinary team that included the participation of the resident and the resident's responsible party for 2 (Resident #56 and Resident #57) out of a total sample of 25 Residents. The facility failed to reveal any documentation or reasons in the medical records of why the resident or their responsible party did not participate in the development of the Care Plan. The facility's total census was 89 residents. Findings: Review of the facility policy titled: Interdisciplinary Care Plan Meeting, revealed in part . 1. The Social Service staff will notify the resident and if applicable the resident representative prior to each ICP (Interdisciplinary Care Plan) meeting and encourage them to attend the meeting and solicit their input. 2. If the resident/resident representative does not attend or participate with care plan development documentation should be noted in the medical record including the steps taken to include the resident/resident representative. #56 Interview on 03/20/2023 at 12:00 p.m. with Resident #56 revealed he was not invited to attend care-planning meetings. Resident #56 stated he liked to keep up with his care and medicines and would attend meetings if he knew about them. Resident #56 stated his family lived in Texas so they would not be able to attend. Review of Resident #56's annual MDS Assessment with an ARD of 01/19/2023 revealed a BIMS score of 15 (cognitively intact). Review of the Interdisciplinary Care Plan Team Attendance for Resident #56 revealed meetings were held on 02/10/2022, 05/05/2022, 08/04/2022, 11/02/2022 and 02/02/2023. Review of the Attendance documents revealed Resident #56 was not in attendance for any of the meetings. Review of Resident #56's Nurses', Social Service and IDT notes revealed there was no documentation of why Resident #56 did not participate in the development of his Care Plan. Interview on 03/21/2023 at 3:00 p.m. with S7 SSD (Social Services Director) revealed Resident #56's last Care Planning meeting was on 01/19/2023. S7 SSD stated she contacted Resident #56's family member but the family member declined to attend. S7 SSD stated sometimes she (S7 SSD) asked Residents if they want to attend Care Planning meetings. S7 SSD confirmed she had not asked Resident #56 about attending his own care planning meetings. Interview on 03/22/2023 at 2:17 p.m. with S2 DON revealed she signed Residents' IDT attendance forms, but only as an attendant, not as a representative for Residents. S2 DON confirmed there was no documentation of notification of meeting dates or reasons why Resident #56 did not participate in Care Planning and there should have been. S2 DON confirmed Residents should be invited to Care Plan meetings and Resident #56 had not been. #57 Review of Resident #57's annual MDS Assessment with an ARD of 01/12/2023 revealed Resident #57 was rarely/never understood. Telephone interview on 03/20/2023 at 2:27 p.m. with Resident #57's RP (Responsible Party) revealed she was not being invited to Care Planning meetings. Review of the Interdisciplinary Care Plan Team Attendance for Resident #57 revealed meetings were held on 05/05/2022, 08/04/2022, 10/26/2022 and 01/25/2023. Review of the attendance documents revealed Resident #57's RP was not in attendance for any IDT Care Plan meetings. Review of Resident #57's Nurses', Social Service and IDT notes revealed there was no documentation of why Resident #57's RP did not participate in the development of the Care Plan. Interview on 03/21/2023 at 3:38 p.m. with S7 SSD (Social Services Director) revealed she called Resident #57's RP and notified her of upcoming Care Plan meeting dates. S7 SSD stated she did not remember if she offered Resident #57's RP the option of conducting meetings over the phone or alternative methods. S7 SSD stated she does not keep a log of calls nor does she document conversations. Interview on 03/22/2023 at 2:26 p.m. with S2 DON revealed she signed Resident #57's IDT attendance forms, but only as an attendant, not as a representative for Resident #57. S2 DON confirmed there was no documentation of the steps the facility took to include Resident #57's RP in Care Planning to include offering alternative methods and there should have been.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

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 provide an ongoing Resident centered activity program for 1 (Reside...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide an ongoing Resident centered activity program for 1 (Resident #9) of 25 sampled Residents. This failed practice had the potential to affect all 89 residents residing in the facility per the facility's Resident Census and Condition of Resident form. Findings: Review of the medical record revealed Resident # 9 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set) with ARD of 02/02/2023 revealed the resident's BIMS score (Brief Interview of Mental Status) was 15 indicating the Resident was cognitively intact. Review of Resident #9's current care plan read in part . Resident participates and attends activities of choice, needs daily reminder, enjoys having outside time, engage residents in group activities, post personal activity schedule in Resident's room, give Resident verbal reminders of activity before commencement of activity, Resident likes getting her nails done. Interview on 03/20/2023 at 10:14 a.m. with Resident # 9 revealed the Facility often fails to have activities during the week and never has activities on the weekend. Interview on 03/21/2023 at 10:20 p.m. with S6 Front Door Clerk revealed she works 7a.m.-7p.m. 2 days on and 2 days off and she sits at the front door by the dining area where most of the activities are held. She revealed activities are not done every day and were not done during the weekends she worked. Interview on 03/21/2023 at 11:45 a.m. with S5 Activity Director revealed when she asks, S6 Front Door Clerk will provide activities at times during the weekend and confirmed at times there was no one scheduled to provide activities during the weekend or during the week.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours per day for 5 of 92 days reviewed for RN staffing hours. This deficient ...

Read full inspector narrative →

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours per day for 5 of 92 days reviewed for RN staffing hours. This deficient practice had the potential to affect all of the 89 Residents residing in the facility according to the facility's Resident Census and Conditions Form (CMS 672). Findings: Review of the PBJ Staffing Data Report for Fiscal Year Quarter 1 2023 (October 1-December 31) revealed the facility had no RN coverage on 11/05/2022, 11/06/2022, 11/19/2022, 11/20/2022, and 12/28/2022. Review of the Staffing Pattern Form completed by S1 Executive Director revealed the facility had no RN coverage on 11/05/2022, 11/06/2022, 11/19/2022, 11/20/2022, and 12/28/2022. In an interview on 03/22/2023 at 8:00 a.m., S1 Executive Director acknowledged the facility did not have an RN in the facility for at least 8 consecutive hours on 11/05/2022, 11/06/2022, 11/19/2022, 11/20/2022, and 12/28/2022 and should have.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #42 Review of the medical record revealed Resident # 42 was admitted to the facility on [DATE]. Review of the MDS (Mini...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #42 Review of the medical record revealed Resident # 42 was admitted to the facility on [DATE]. Review of the MDS (Minimum Data Set) revealed the resident's BIMS score (Brief Interview of Mental Status) was 15 indicating the Resident was cognitively intact. Interview with Resident #42 on 03/21/23 at 3:09 p.m. revealed that he is his own responsible party and he completed the Facility admission paper work with S8 Director of Admissions on 02/02/2023. Resident #42 stated that he cannot recall ever going over an Arbitration Agreement during admission paperwork with S8 Director of Admissions or being given any documents about Arbitration to read. After Resident #42 reviewed his signed agreement he stated he would have never signed the agreement if he would have read or had been notified of what the agreement entailed. Based on interview and record review the facility failed to ensure the arbitration agreement was explained to the resident in a form and manner that he or she understands, including in a language the resident and his or representative understands for 2 (Resident #191 and Resident #42) of 3 (Resident #191, Resident #42 and Resident #74) sampled Residents for Arbitration. Findings: #191 Interview on 03/20/2023 at 9:30 a.m. with S1 Executive Director revealed S8 Director of Admissions was responsible for obtaining Resident Arbitration Agreements. Review of an Admission/readmission Evaluation revealed Resident #191 was blind and spoke a foreign language. Review of an Arbitration Agreement signed by Resident #191 revealed it was dated 03/14/2023. Review of Resident #191's admission MDS Assessment with an ARD of 03/21/2023 revealed Resident #191 had a BIMS score of 3 (indicating severe cognitive impairment). Telephone interview on 03/21/2023 at 2:46 p.m. with S8 Director of Admissions revealed she was responsible for explaining Arbitration Agreements to Residents and Responsible Parties. S8 Director of Admissions stated Residents are told the Arbitration Agreement was basically a contract that says they can come together with a third party to resolve any issue. S8 Director of admission stated she gives situations such as a broken window or damage on their (Residents) side. S8 Director of Admissions stated she does not read the entire agreement to Residents, but gives an overview. S8 Director of Admissions revealed she gave Resident #191 a copy of the Arbitration Agreement. S8 Director of Admissions stated she was unsure if Resident #191 was able to read the English language. Interview on 03/21/2023 at 3:30 p.m. with S1 Executive Director confirmed Resident #191 was blind and therefore would not be able to read an Arbitration Agreement. S1 Executive Director also confirmed Resident #191 was severely cognitively impaired and English was not his first language. S1 Executive Director confirmed Resident #191 was not capable of entering into a binding Arbitration Agreement. S1 Executive Director also confirmed that S8 Director of Admissions should read through the entire Arbitration Agreement with Residents and she had not.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident on dialysis maintained acceptable parameters of n...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident on dialysis maintained acceptable parameters of nutritional status by failing to provide ordered supplements for 1 (#43) resident out of 1 resident reviewed for nutrition out of a total of 25 sampled residents. Findings: Resident #43 Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus. Review of Resident #43's quarterly MDS with an ARD of 02/09/2023 revealed a BIMS score of 11, which indicated the resident had moderately impaired cognition. Review of Resident #43's physician's orders revealed the following: 12/26/2022: Nepro (a specialized nutritional drink for people on dialysis) 1 can PO daily at 10 a.m. Send with resident on dialysis days. 10/12/2017: Dialysis on Tuesday, Thursday, Saturday Review of Resident #43's MARs for February and March 2023 revealed Resident #43 was only receiving Nepro 1 can po on Tuesdays, Thursdays, and Saturdays. Review of the Tracking My Numbers for March 2023 dated 03/06/2023 from dialysis revealed: Albumin: protein in my blood that helps fight infections and aids in healing. Goal is 4 or higher. Resident #43's albumin level was 3.6, below goal. enPCR (equilibrated normalized protein catabolic rate): Suggests if I am eating enough fish, chicken, beef, eggs and other protein foods. Goal is 1.1 or higher; Resident's level was 0.8 (below goal). Your protein intake may be low. My plan for this month is: Add Nepro 1 x daily Review of the 03/07/2023 Dialysis Information Update Transfer Form revealed: Return instructions: Add Nepro 1 x daily. Signed by dialysis RN on 03/07/2023. In an interview on 03/22/2023 at 09:15 a.m., Resident #43 reported she was supposed to receive the Nepro shakes every day because she needs the protein but only gets it on the days she goes to dialysis. Resident #43 stated she asked for a Nepro this morning and was told they would see if they could find one. In an interview on 03/22/2023 at 09:22 a.m., S3 LPN confirmed she only gives Resident #43 Nepro on the days indicated on the MAR, which were Tuesday, Thursday, and Saturday. In an interview on 03/22/2023 at 09:22 a.m., S4 RN acknowledged Resident #43 should have been receiving Nepro daily, as ordered, but had only received it on the days she went to dialysis.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure Gradual Dose Reductions (GDR) for psychotropic medications ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to ensure Gradual Dose Reductions (GDR) for psychotropic medications were implemented 1 (#28) of 5 residents (#10, #14, # 28 # 57, # 68) reviewed for unnecessary medications. Findings: Review of Resident #28's medical records revealed an admit date of 05/06/2022 with diagnoses of Paranoid Schizophrenia, Other Seizures, [NAME] Systolic Heart Failure, Dementia and Primary Insomnia. Review of the MDS (Minimum Data Set) with ARD of 01/12/2023 revealed the resident's BIMS score (Brief Interview of Mental Status) was 15, indicating Resident #28 was cognitively intact. Review of Resident #28's medical record revealed a Consultant Pharmacist Communication to Physician dated 11/28/2022 which requested a GDR on Trazadone 100mg HS (used for Insomnia) reduced to Trazadone 75mg HS. GDR was agreed upon by Facilities Nurse Practitioner on 12/10/2022. Review of the medical record revealed the facility did not decrease Resident #28's Trazadone to 75mg at HS until 03/08/2023. An interview on 03/22/2023 at 11:45 a.m. with S2 DON confirmed the GDR order on 11/28/2022 to decrease Resident #28's Trazadone from 100mg to 75mg was signed by the PCP on 12/10/22. S2 DON confirmed Resident #28's dose reduction was not implemented until 03/08/2023. S2 DON also confirmed the GDR should have been implemented on 12/10/2022 and had not been.

Winnfield Nursing and Rehabilitation Center, LLC

The Good

The Bad

The Ugly 30 deficiencies on record

Questions to Ask on Your Visit

Our Honest Assessment

About This Facility

What is Winnfield Nursing And Rehabilitation Center, Llc's CMS Rating?

How is Winnfield Nursing And Rehabilitation Center, Llc Staffed?

What Have Inspectors Found at Winnfield Nursing And Rehabilitation Center, Llc?

Who Owns and Operates Winnfield Nursing And Rehabilitation Center, Llc?

How Does Winnfield Nursing And Rehabilitation Center, Llc Compare to Other Louisiana Nursing Homes?

What Should Families Ask When Visiting Winnfield Nursing And Rehabilitation Center, Llc?

Is Winnfield Nursing And Rehabilitation Center, Llc Safe?

Do Nurses at Winnfield Nursing And Rehabilitation Center, Llc Stick Around?

Was Winnfield Nursing And Rehabilitation Center, Llc Ever Fined?

Is Winnfield Nursing And Rehabilitation Center, Llc on Any Federal Watch List?

Winnfield Nursing and Rehabilitation Center, LLC

Strengths

Concerns