PLANTATION OAKS NURSING & REHABILITATION CENTER
For profit - Individual
76 Beds
CENTRAL MANAGEMENT COMPANY
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
16/100
#149 of 264 in LA
Photo by Plantation Oaks Nursing & Rehabilitation Center, LLC
Photo by Plantation Oaks Nursing & Rehabilitation Center, LLC
Photo by Plantation Oaks Nursing & Rehabilitation Center, LLC
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Plantation Oaks Nursing & Rehabilitation Center received a Trust Grade of F, indicating significant concerns about the facility's care and oversight. Ranking #149 out of 264 facilities in Louisiana places it in the bottom half, and it is the lowest-ranked option in Franklin County. The facility's trend is worsening, with issues increasing from 3 in 2023 to 13 in 2024. While staffing is a relative strength, with a turnover rate of 32% that is better than the state average, it still has troubling incidents, including a critical finding of physical abuse by a CNA against a resident that went unreported for several weeks. Additionally, the facility has incurred fines totaling $128,001, which is concerning as it is higher than 92% of Louisiana facilities, indicating ongoing compliance problems.
- Trust Score
- F
- In Louisiana
- #149/264
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 32% turnover. Near Louisiana's 48% average. Typical for the industry.
- Penalties ○ Average
- $128,001 in fines. Higher than 56% of Louisiana facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
16/100
Bottom 44%
Review needed
3 → 13 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 3 issues
2024: 13 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (32%)
16 points below Louisiana average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 32%
14pts below Louisiana avg (46%)
Typical for the industry
Federal Fines: $128,001
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: CENTRAL MANAGEMENT COMPANY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 19 deficiencies on record
2 life-threatening
Sept 2024
11 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure the most recent state inspection results since the last annual survey were available for resident review.
Findings:
An observation on ...
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Based on observation and interview, the facility failed to ensure the most recent state inspection results since the last annual survey were available for resident review.
Findings:
An observation on 09/09/2024 at 7:35 a.m. revealed the results of the last annual survey results 10/04/2023 posted by the front entrance, but the last complaint survey dated 07/08/2024 was not posted.
An interview with S1Administrator on 09/10/2024 at 12:45 p.m. confirmed the most recent state inspection results from 07/08/2024 were not posted for resident review.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
On 09/09/2024 at 9:30 a.m., an observation of resident #46`s bathroom revealed there was feces on the toilet seat with brown splatter stains on the walls. Observation of the air conditioner unit in re...
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On 09/09/2024 at 9:30 a.m., an observation of resident #46`s bathroom revealed there was feces on the toilet seat with brown splatter stains on the walls. Observation of the air conditioner unit in resident #46`s room revealed there was a black mold and dirt around the perimeter of the air conditioning unit.
On 09/10/2024 at 10:00 a.m., an observation of resident #46`s bathroom revealed there was feces on the toilet seat with brown splatter stains on the walls. Observation of the air conditioner unit in resident #46`s room revealed there was a black mold and dirt around the perimeter of the air conditioning unit.
On 09/10/2024 at 1:13 p.m., an observation of the laundry room revealed there was black mold on the wall behind the washing machine and cleaning supplies were being stored directly on the floor.
On 09/10/2024 at 1:25 p.m., an observation/interview was conducted with S1Administrator. S1Administrator confirmed the above listed rooms were in need of cleaning. S1Administrator also confirmed the laundry room was in need of cleaning and the cleaning supplies should not have been stored directly on the floor.
Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#7, #22, #46 and #55) of 8 (#1, #2, #7, #12, #22, #46, #51 and #55) resident rooms/bathrooms observed. The failed practice was evidenced by the resident rooms/bathrooms listed above being in need of cleaning along with the laundry room being in need of cleaning with cleaning supplies being stored directly on the floor of the laundry room.
Findings:
Resident #7
On 09/09/2024 at 2:12 p.m., and 09/10/2024 at 1:35 p.m., observations of resident #7's room revealed a wash cloth was in between the air vents and the air conditioner vents contained dirt and grime.
Resident #22
On 09/09/2024 at 10:16 a.m., an observation of resident #22's room revealed the air conditioner vents contained grime and debris and had a paper towel in between the vents. On 09/10/2024 at 1:40 p.m., observation of resident #22's room revealed the air conditioner vents contained a black substance.
Resident #55
On 09/09/2024 at 3:27 p.m., an observation of resident #55's room revealed the air conditioner vents contained grime and debris noted in the vents, and a black substance was on the inside of the bathroom door frame.
On 09/10/2024 at 1:45 p.m., an observation of resident #55's room revealed the air conditioner vents contained grime and debris.
On 09/10/2024 at 1:25 p.m., an observation/interview was conducted with S1Administrator. S1Administrator confirmed the above listed rooms were in need of cleaning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to ensure the resident`s plan of care was implemented for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to ensure the resident`s plan of care was implemented for 1 (#11) of 1 (#11) resident reviewed for urinary catheters. The failed practice was evidenced by resident #11 not having his urinary catheter bag covered in a privacy bag when outside of his room.
Findings:
Record review revealed resident #11 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia, epilepsy, traumatic brain dysfunction, fractures and other multiple trauma, cognitive communication deficit, lack of coordination, cerebral infarction, and depression. The record review revealed resident #11 had a suprapubic urinary catheter upon admission. Further review of the record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. The cognitive pattern section of the MDS data recorded a Brief Interview of Mental Status score (BIMS) of 15 which indicated resident #11 had no cognitive impairment.
Review of active orders for September 2024 revealed the following:
24 French/10 cubic centimeter (cc) suprapubic catheter.
The facility`s undated policy and procedure related to catheter drainage bag covers revealed in part:
Catheter drainage bags will be covered at all times when resident is out of his/her room.
On 09/09/2024 at 11:25 a.m., resident #11 was observed propelling himself down the hall in his wheelchair with his catheter bag exposed (not stored in a privacy bag) while hanging underneath his wheelchair.
On 09/09/2024 at 2:15 p.m., resident #11 was observed propelling himself down the hall in his wheelchair with his catheter bag exposed (not stored in a privacy bag) while hanging underneath his wheelchair.
On 09/10/2024 at 2:17 p.m., an interview with S2Director of Nursing (DON) confirmed resident #11 should have a privacy bag covering his urinary catheter bag while in a wheelchair out of his room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident with limited mobility receives appropriate services...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 (#53) of 3 (#33, #44, and #53) residents reviewed for limited range of motion.
Findings:
Review of resident #53's record revealed an admission date of 11/23/2023 with diagnoses including Alzheimer's disease, abrasion to the right knee, urinary tract infection, dysphagia, history of falling, aphasia, bilateral primary osteoarthritis of the knee, cognitive communication deficit, pneumonia, and anorexia.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident requires assistance with all Activities of Daily Living.
An observation of resident #53 on 09/09/2024 at 9:15 a.m. revealed the resident was sitting up in a high back wheelchair with both of her feet dangling and not touching the floor.
An observation of resident #53 on 09/10/2024 at 1:40 p.m. revealed the resident was sitting up in high back wheelchair with both of her feet dangling, not touching the floor.
An interview on 09/10/2024 at 1:56 p.m. with S2Director of Nursing (DON) confirmed resident #53's feet were dangling while up in her high back wheelchair. S2DON further confirmed that resident #53 was not properly positioned while up in her wheelchair.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents who require colostomy services rece...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents who require colostomy services received care consistent with the comprehensive person-centered care plan. The failed practice was evidenced by 1 (#11) of 1 (#11) resident reviewed for colostomy care by not having colostomy bags available in accordance with his plan of care.
Findings:
Record review revealed resident #11 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia, epilepsy, traumatic brain dysfunction, fractures and other multiple trauma, cog communication deficit, lack of coordination, cerebral infarction, and depression.
The record review revealed resident #11 had a colostomy to his left side upon admission. Further review of the record revealed a quarterly Minimum Data Set (MDS) dated [DATE]. The cognitive pattern section of the MDS data recorded a brief interview of mental status score (BIMS) of 15 which indicated resident #11 had no cognitive impairment.
Review of active orders for September 2024 revealed the following:
Clean ostomy area with soap and water, pat dry, apply skin prep to skin surrounding ostomy site and apply new colostomy bag as needed for fullness or detachment.
Review of resident #11`s care plans revealed an active care plan related to ostomy care that required a new colostomy bag to be applied daily.
On 09/09/2024 at 10:23 a.m., an observation of resident #11 revealed he had colostomy with a gallon sized plastic storage bag secured with tape covering the ostomy site. Resident #11 reported the facility did not have the correct size colostomy bags available for over a week. Resident #11 reported the facility had been using the same bag over a week so he made his own colostomy bag and it was working fine.
On 09/10/2024 at 2:17 p.m., an interview with S2Director of Nursing (DON) confirmed resident #11 did not have new colostomy bags available at the facility for the past week.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44
Review of resident #44's record revealed an admission date of 01/13/2022 with diagnoses including aphasia following...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44
Review of resident #44's record revealed an admission date of 01/13/2022 with diagnoses including aphasia following cerebral infarction, vascular dementia, functional quadriplegia, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
Review of the September 2024 Physician's Orders revealed an order dated 08/01/2024 for resident #44 to have 2 assist bars at all times for bed mobility.
Review of resident #44's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed resident required extensive to total assistance with 2 person physical assistance with activities of daily living.
Review of resident #44's care plan dated 01/13/2022 revealed late loss activity of daily living deficit with potential for decline, and interventions included vanderlift for all transfers with 2 person assist and manual transfer with 2 person physical assistance.
Review of the September 2024 MAR revealed the documented evidence that resident #44 had 2 assist bars at all times for bed mobility every shift.
Observations of resident #44 on 09/09/2024 at 9:50 a.m., 09/10/2024 at 10:10 a.m., and 09/16/2024 at 10:55 a.m. revealed resident was lying in bed with 2 assist bars in the raised position.
Review of the medical record revealed no documented evidence the facility assessed resident #44 for the risk of entrapment from bed rails prior to installation, and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
On 09/16/2024 at 1:30 p.m. an interview with S2DON confirmed the facility did not have an assessment to address the risk for entrapment from bed rails, did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 (#7, and #44) of 2 (#7, and #44) residents reviewed for accident hazards.
Findings:
Resident #7
Review of the medical record for resident #7 revealed an admission date of 05/07/2024 with diagnoses including spinal stenosis, cerebral infarction, muscle wasting and atrophy, heart disease, cardiomegaly, spondylosis without myelopathy, and cognitive communication deficit.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #7 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment for daily decision making.
Review of the September 2024 physician's orders revealed an order date of 07/16/2024 with a start date of 08/01/2024 revealed assist bar to the left side of bed to aide in bed mobility every shift.
Review of the care plan dated 07/31/2024 for resident #7 revealed activities of daily living (ADL) deficit for decline with bed mobility and transfers revealed assist bar to the left side of bed to aid in mobility.
Review of the September 2024 Medication Administration Record (MAR) revealed the documented evidence that resident #7 had an assist bar to the left side of the bed to aide in bed mobility every shift.
Observations of resident #7's room on 09/09/2024 at 12:45 p.m., 09/10/2024 at 3:00 p.m. and on 09/16/2024 at 11:05 a.m. revealed one assist bar was in the raised position on the left side of the bed.
Review of the medical record revealed no documented evidence the facility assessed resident #1 for the risk of entrapment from bed rails prior to installation, and reviewed the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
On 09/16/2024 at 1:30 p.m. an interview with S2Director of Nursing (DON) confirmed the facility did not have an assessment to address the risk for entrapment from bed rails, did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services. The f...
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Based on record review and interviews, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services. The facility had extremely low weekend staff from April 1, 2024 through June 30, 2024.
Findings:
Review of the Payroll-Based Journal (PB&J) Staffing Data Report for the facility triggered extremely low weekend staff for Quarter 3 from April 1, 2024-June 30, 2024.
An Interview with S4Business Office Manager (BOM) on 09/16/2024 at 12:15 p.m. confirmed the facility had low staffing during April 1, 2024 - June 30 2024.
Review of the facility's April 2024 weekend staffing pattern and timesheets revealed insufficient staff for the following dates: 04/06/2024, 04/07/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, and 04/28/2024.
Review of May 2024 weekend staffing pattern and timesheets revealed insufficient staff for the the following dates:
05/12/2024 and 05/26/2024.
Review of June 2024 weekend staffing pattern and timesheets revealed insufficient staff for 06/02/2024.
An interview with S4BOM on 09/16/2024 at 12:15 p.m. confirmed the facility had low staffing for the dates listed above that did not meet the required staffing hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure nurse staffing data requirements was posted daily in a prominent location readily accessible to residents and visitors. This deficient...
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Based on observation and interview, the facility failed to ensure nurse staffing data requirements was posted daily in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 58 residents residing in the facility.
Findings:
On 09/09/2024 at 8:00 a.m., an observation of the facility revealed the surveyor was unable to locate the daily staffing posted in a visible area for residents and visitors.
On 09/09/2024 at 11:00 a.m., an interview with S2Director of Nursing (DON) revealed the daily staffing form was located behind the nurses' station in a binder.
On 09/09/2024 at 11:05 a.m., an observation of the nurses' station revealed the daily staffing data form was located in a black binder behind the nurses' station and not accessible to residents or visitors.
On 09/16/2024 at 2:10 p.m., S2DON revealed the staffing data should have been posted in an area visible to residents and visitors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
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 pharmacist failed to identify and report irregularities to the attending physician and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#4) of 5 (#4, #12, #21, #32, and #46) sampled residents reviewed for unnecessary medications.
Findings:
Review of resident #4's record revealed an admission date of 02/29/2024 with diagnoses including chronic kidney disease, orthostatic hypotension, fibromyalgia, type 2 diabetes mellitus, chronic atrial fibrillation, and hypertension.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact.
Review of resident #4's September Physician's Orders revealed an order dated 08/01/2024 for Midodrine Hydrochoride (HCL) 10 milligrams (mg) tablet give 1 tablet by mouth (po) 3 times a day for orthostatic hypertension, if systolic blood pressure is above 120- do not administer.
Review of the August 2024 Medication Administration Record (MAR) revealed Midodrine was documented as administered as follows: (outside of the parameters-systolic blood pressure was above 120 indicating to hold medication)-
1 time on 8:00 a.m. dose;
2 times on noon dose; and
12 times on 8:00 p.m. dose.
Review of the September 2024 MAR for resident #4 revealed Midodrine was documented as administered as follows: (outside of the parameters systolic blood pressure was above 120 indicating to hold medication)-
1 time on 8:00 a.m. dose;
1 time on noon dose; and
2 times on the 8:00 p.m. dose.
Review of the Consultant Pharmacist Monthly Report revealed the pharmacist performed a Medication Regimen Review (MRR) for resident #4 on 09/02/2024. There was no documented evidence that the pharmacist identified any issues with the administration of Midodrine outside of the parameters for resident #4 for August 2024.
An interview on 09/16/2024 at 9:30 a.m. with S2Director of Nursing (DON) confirmed the facility's pharmacy consultant did not identify an irregularity with the administration of Midodrine outside of the parameters for resident #4 in August 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
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 each resident's drug regimen must be free from unnecessary d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 (#4) of 5 (#4, #12, #21, #32, and #46) residents reviewed for unnecessary medications.
Findings:
Review of resident #4's record revealed an admission date of 02/29/2024 with diagnoses including chronic kidney disease, orthostatic hypotension, fibromyalgia, type 2 diabetes mellitus, chronic atrial fibrillation, and hypertension.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact.
Review of resident #4's September Physician's Orders revealed an order dated 08/01/2024 for Midodrine Hydrochoride (HCL) 10 milligrams (mg) tablet give 1 tablet by mouth (po) 3 times a day for orthostatic hypertension, if systolic blood pressure is above 120- do not administer.
Review of the August 2024 Medication Administration Record (MAR) revealed Midodrine was documented as administered as follows: (outside of the parameters-systolic blood pressure was above 120 indicating to hold medication)-
1 time on 8:00 a.m. dose;
2 times on noon dose; and
12 times on 8:00 p.m. dose.
Review of the September 2024 MAR for resident #4 revealed Midodrine was documented as administered as follows: (outside of the parameters-systolic blood pressure was above 120 indicating to hold medication)-
1 time on 8:00 a.m. dose;
1 time on noon dose; and
2 times on the 8:00 p.m. dose.
An interview on 09/16/2024 at 9:30 a.m. with S2Director of Nursing (DON) revealed Midodrine was administered to resident #4 on the above dates for August and September 2024. S2DON confirmed Midodrine should not have been administered on the above dates related to being outside of the parameters for administration.
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, interview, and record review, the facility failed to ensure it prepared food in accordance with professional standards by using hot water to thaw frozen meat.
Findings:
On 09/16...
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Based on observation, interview, and record review, the facility failed to ensure it prepared food in accordance with professional standards by using hot water to thaw frozen meat.
Findings:
On 09/16/2024 at 9:30 a.m., observation in the kitchen revealed S3Dietary was thawing frozen sausage in a sink with hot running water. Interview with S3Dietary confirmed she was using hot water to thaw the sausage.
On 09/16/2024 at 11:30 a.m., an interview with S1Administrator confirmed the staff should not have thawed meat using hot water.
According to the United Stated Department of Agriculture (USDA) Safe Defrosting Methods dated 2013 revealed there are three safe ways to thaw food: in the refrigerator, in cold water, and in the microwave. The USDA also instructed perishable foods should never be thawed on the counter, or in hot water.
Jul 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's right to be free from physical abuse by staff ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's right to be free from physical abuse by staff CNA (Certified Nursing Assistant) for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse.
The Immediate Jeopardy situation began on 06/08/2024, around approximately 3:40 p.m., when S4CNA physically abused resident #1. S4CNA and S5CNA were providing care to resident #1 when resident #1 hollered and pointed his finger at S4CNA. S4CNA bent resident #1's finger on left hand back, bent his left foot back, and slapped resident in the chest. S6Licensed Practical Nurse (LPN) entered resident #1's room and observed resident #1 and S4CNA arguing. She then witnessed when the resident pointed his finger at S4CNA and S4CNA grabbed both of the resident's hands and held them down on the bed. After the abuse incident occurred on 06/08/2024, S4CNA continued to work her shift on 06/08/2024 and also worked double shifts on 06/09/2024 and 06/10/2024. The facility did not initiate quality assurance or performance improvement (QAPI) for ongoing monitoring for abuse after the incident was discovered on 06/11/2024 and the facility did not interview other residents to ensure there were no other reports of suspected abuse. The continuation of abuse had the likelihood to affect the other 58 residents in the facility.
S1Administrator and S2Director of Nursing (DON) were notified of the Immediate Jeopardy on 07/02/2024 at 5:53 p.m.
The Immediate Jeopardy was removed on 07/03/2024 at 1:19 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Review of the Abuse/Neglect Prevention Program Investigation with revision date of 09/08/2021 revealed, in part:
Policy Statement:
Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals, and
Abuse/Neglect Investigation, Protection, and Reporting:
1.
Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately, and
2.
The facility representative receiving the report of abuse shall generate an incident report. If the person accused of the alleged violation is an employee and is still on the premises of facility when the allegation is brought to the attention of the supervising staff member, the employee will be suspended immediately until such time that the facility investigation for that employee is complete. If the allegation occurs after routine office hours, the night or weekend staff must not wait for the Administrator or Director of Nursing to address the incident the following day. The supervising staff must ask the employee to leave the premises immediately.
Review of the record for resident #1 revealed an admission date of 09/10/2021 with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, type 2 diabetes mellitus with diabetic polyneuropathy, heart failure, other schizoaffective disorder, major depressive disorder, mood disorder, and other cerebrovascular disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment.
Review of resident #1's current care plan, dated 01/09/2023, revealed resident had been resistant to daily care. Interventions included when resident became combative, leave and try to approach the resident later.
Review of the state reported incident dated 06/11/2024 revealed resident #1 was physically abused by S4CNA. The facility investigated the incident that occurred on 06/08/2024 by interviewing resident #1, S4CNA, S5CNA, and S6LPN and obtaining statements from each. The facility determined S5CNA witnessed S4CNA bend back resident #1's finger on his left hand, bend back resident's left foot, and slap the resident in the chest. S5CNA used the call light to call for help and S6LPN entered the resident's room and observed resident #1 and S4CNA arguing. Resident #1 pointed at S4CNA and S4CNA grabbed resident's finger and pushed both of the resident's hands down on the bed. S6LPN told S4CNA to leave the room, and had to block the door to keep S4CNA from reentering the resident's room. S4CNA was terminated on 06/11/2024 because the allegation of physical abuse was substantiated. S5CNA and S6LPN were counselled regarding witnessing abuse to resident #1 by S4CNA and not reporting incident immediately to S1Administrator or S2DON.
Review of the facility's Incident Report for resident #1 dated 06/11/2024 at 7:00 a.m., revealed S5CNA reported to S3Assistant Director of Nursing (ADON) that during care for resident #1 on 06/08/2024, resident became combative, cursed, and pointed his finger in S4CNA's face. S4CNA pushed resident #1's finger back and resident kicked S4CNA twice in the stomach. S4CNA then slapped resident in the chest, slapped resident in his right eye, and bent his toes back. Purple bruising around the right eye of resident #1 was identified on 06/11/2024.
Review of the Personnel Action form dated 06/11/2024 revealed S4CNA was terminated on 06/11/2024.
An interview on 07/01/2024 at 1:05 p.m. with resident #1 revealed on 06/08/2024 he was lying in his bed sleeping when S5CNA came into his room with S4CNA. He heard staff talking to one another and he pointed at S4CNA and told her to leave his room. Resident #1 reported S4CNA bent his finger back and started hitting him in the chest and his eye and his foot. Resident reported S6LPN came into the room and made S4CNA leave the room. Resident reported S4CNA had not been back in his room and she was fired.
An interview on 07/01/2024 at 1:20 p.m. with S2DON revealed she was notified on 06/11/2024 by S3ADON of the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S2DON was unsure if S4CNA had been sent home after the incident on 06/08/2024.
An interview on 07/01/2024 at 1:30 p.m. with S3ADON revealed S5CNA notified her on 06/11/2024 about the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S3ADON reported she assessed the resident and found a purplish bruise to the resident's right eye on 06/11/2024.
During a telephone interview on 07/01/2024 at 1:50 p.m., S4CNA reported that on 06/08/2024 she went into resident #1's room with S5CNA to provide care and S5CNA was discussing with the resident that he needed to try to go to the bathroom, instead of using his brief. S4CNA reported resident #1 started cursing and pointing at her and told her to get out of his room. S4CNA reported resident #1 kicked her in the stomach and in the breast, and she reported she grabbed the resident's hands to calm him down. S4CNA reported S5CNA used the call light to call for help and S6LPN came into the room. S4CNA told S6LPN that resident #1 kicked her for no reason because he didn't like her. S4CNA reported she was told to leave the room, and reported she did not slap the resident in the chest, grab his finger, or hit/bend his toes. S4CNA confirmed she worked the rest of her shift on 06/08/2024 and also worked double shifts on 06/09/2024 and 06/10/2024, and confirmed she was terminated on 06/11/2024.
During a telephone interview on 07/01/2024 at 3:10 p.m., with S5CNA revealed that on 06/08/2024 she and S4CNA went to resident #1's room to provide care. She reported she told the resident he needed to start getting up to use the bathroom since he has been going to therapy, and S4CNA repeated the need for resident #1 to get up to use the bathroom. S5CNA reported resident #1 became very upset and cursed, hollered and pointed his finger at S4CNA telling her to get out of his room. S5CNA reported S4CNA bent the resident's finger back, and resident #1 kicked S4CNA in the stomach 2 times, then S4CNA bent resident's foot back and slapped the resident in the chest. S5CNA reported she used the call light to call for help. S5CNA reported S6LPN came into the room and resident #1 and S4CNA were still arguing. S5CNA reported she notified S6LPN regarding S4CNA bending resident's finger back, slapping him in the chest, and bending back resident's foot.
During a telephone interview, on 07/01/2024 at 2:10 p.m., with S6LPN revealed that S5CNA called her to resident #1's room on 06/08/2024. S6LPN reported when she entered resident #1's room, S4CNA and resident #1 were arguing and resident #1 pointed his finger at S4CNA and S4CNA grabbed the resident's finger and pushed both of his hands down on the bed. S6LPN reported she made S4CNA leave the resident's room, then she asked resident #1 and S5CNA what had happened. S6LPN reported that resident #1 and S5CNA notified her that S4CNA had bent resident #1's finger back, slapped him in the chest, and bent his toes back. S6LPN reported S4CNA was very upset and she tried to get back into the resident's room. S6LPN reported she spoke with S4CNA later in the hall and S4CNA reported the resident kicked her twice for no reason. S6LPN confirmed she did not notify S1Administrator or S2DON about the physical abuse that occurred between resident #1 and S4CNA. S6LPN confirmed she did not send S4CNA home, but let her work on another hall for the rest of her shift on 06/08/2024.
An interview on 07/01/2024 at 4:05 p.m. with S7CNA revealed she heard the commotion going on in resident #1's room on 06/08/2024 and went to see what had happened. S7CNA reported she did not witness any abuse, but she assisted with pulling S4CNA out of the resident #1's room.
An interview on 07/02/2024 at 8:15 a.m. with S2DON reported the facility did not initiate QAPI for ongoing monitoring for abuse after the incident was discovered on 06/11/2024. S2DON further reported the facility did not interview other residents in the facility to ensure there were no other reports of suspected abuse.
Review of the Employee Timecard for S4CNA revealed she was clocked in and out for the remainder of the weekend, as follows:
-06/08/2024 in at 3:27 p.m. and out at 4:25 a.m.
-06/09/2024 in at 3:16 p.m. and out at 5:36 a.m.
-06/10/2024 in at 3:22 p.m. and out at 11:34 p.m.
Surveyor alerted S2DON on 07/02/2024 at 8:15 a.m. that S4CNA was not sent home on [DATE] after the incident occurred, and S4CNA also worked on 06/09/2024 and 06/10/2024 per review of S4CNA's timecard. S2DON confirmed S4CNA should have been sent home immediately per the facility's policy on abuse/neglect, and should not have been allowed to work on 06/09/2024 and 06/10/2024. S2DON confirmed S4CNA was terminated on 06/11/2024 for physical abuse to resident #1.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure staff reported physical abuse of a resident to administrat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure staff reported physical abuse of a resident to administration immediately and failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to one or more law enforcement entities for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for abuse.
The Immediate Jeopardy situation began on 06/08/2024, around approximately 3:40 p.m., as a result of resident #1 being physically abused on 06/08/2024 by S4Certified Nursing Assistant (CNA) and witnessed by S5CNA and S6LPN (Licensed Practical Nurse). The physical abuse of resident #1 was not reported immediately to S1Administration or S2Director of Nursing (DON) on 06/08/2024 by S4CNA, S5CNA or S6LPN.
S1Administrator and S2DON were notified of the Immediate Jeopardy on 07/02/2024 at 5:53 p.m.
The Immediate Jeopardy was removed on 07/03/2024 at 1:19 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit.
Findings:
Review of the Abuse/Neglect Prevention Program Investigation with revision date of 09/08/2021 revealed, in part:
Abuse/Neglect Investigation, Protection, and Reporting:
1.
Any person who witnesses or has knowledge of any act or suspected act of abuse/neglect, mistreatment, exploitation, or identifies an injury of unknown source will notify his/her supervisor immediately, and
2.
The facility representative receiving the report of abuse shall generate an incident report. If the person accused of the alleged violation is an employee and is still on the premises of facility when the allegation is brought to the attention of the supervising staff member, the employee will be suspended immediately until such time that the facility investigation for that employee is complete. If the allegation occurs after routine office hours, the night or weekend staff must not wait for the Administrator or Director of Nursing to address the incident the following day. The supervising staff must ask the employee to leave the premises immediately.
Guidance for Mandated Reporting for Allegations of Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Reportable Incidents:
II. Additional Incidents:
J. The Nursing Facility is responsible for reporting suspicious or actual criminal activity against a resident both to Health Standards Section and one or more law enforcement entities in which the facility is located.
Review of the record for resident #1 revealed an admission date of 09/10/2021 with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, type 2 diabetes mellitus with diabetic polyneuropathy, heart failure, other schizoaffective disorder, major depressive disorder, mood disorder, other cerebrovascular disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment.
Review of resident #1's current care plan dated 01/09/2023 revealed resident had been resistant to daily care. Interventions included when resident became combative, leave and try to approach the resident later.
Review of the facility's Incident Report for resident #1 dated 06/11/2024 at 7:00 a.m. revealed S5CNA reported to S3Assistant Director of Nursing (ADON) that during care for resident #1 on 06/08/2024, resident became combative, cursed, and pointed his finger in S4CNA's face. S4CNA pushed resident's finger back and resident #1 kicked S4CNA twice in the stomach. S4CNA then slapped resident in the chest, slapped resident in his right eye, and bent his toes back. Purple bruising around the right eye of resident #1 was identified on 06/11/2024.
An interview on 07/01/2024 at 1:05 p.m. with resident #1 revealed on 06/08/2024 he was lying in his bed sleeping when S5CNA came into his room with S4CNA. He heard staff talking to one another and he pointed at S4CNA and told her to leave his room. Resident #1 reported S4CNA bent his finger back and started hitting him in the chest and his eye and his foot. Resident reported S6LPN came into the room and made S4CNA leave the room. Resident reported S4CNA had not been back in his room and she was fired.
An interview on 07/01/2024 at 1:20 p.m. with S2DON revealed she was notified on 06/11/2024 by S3ADON of the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S2DON was unsure if S4CNA had been sent home on [DATE].
An interview on 07/01/2024 at 1:30 p.m. with S3ADON revealed S5CNA notified her on 06/11/2024 about the incident that occurred on 06/08/2024 between resident #1 and S4CNA. S3ADON reported she assessed the resident and found a purplish bruise to the resident's right eye on 06/11/2024.
During a telephone interview on 07/01/2024 at 1:50 p.m., S4CNA reported on 06/08/2024 she went into resident #1's room with S5CNA to provide care and S5CNA was discussing with the resident that he needed to try to go to the bathroom, instead of using his brief. S4CNA reported resident #1 started cursing and pointing at her and told her to get out of his room. S4CNA reported resident #1 kicked her in the stomach and in the breast, and she reported she grabbed the resident's hands to calm him down. S4CNA reported S5CNA used the call light to call for help and S6LPN came into the room. S4CNA told S6LPN resident #1 kicked her for no reason because he didn't like her. S4CNA reported she was told to leave the room, and reported she did not slap the resident in the chest, grab his finger, or hit/bend his toes. S4CNA confirmed she worked the rest of her shift on 06/08/2024 and also worked double shifts on 06/09/2024 and 06/10/2024, and confirmed she was terminated on 06/11/2024. S4CNA confirmed she did not notify S1Administrator or S2DON immediately when she was accused of physical abuse to resident #1 on 06/08/2024.
During a telephone interview on 07/01/2024 at 3:10 p.m., S5CNA revealed on 06/08/2024 she and S4CNA went to resident #1's room to provide care. She reported she told the resident he needed to start getting up to use the bathroom since he has been going to therapy. S4CNA repeated the need for resident #1 to get up to use the bathroom also. S5CNA reported resident #1 became very upset and cursed, hollered and pointed his finger at S4CNA telling her to get out of his room. S5CNA reported S4CNA bent the resident's finger back, and resident #1 kicked S4CNA in the stomach 2 times. S4CNA then bent resident #1's foot back and slapped the resident in the chest. S5CNA reported she used the call light to call for help. S5CNA reported S6LPN came into the room and resident #1 and S4CNA were still arguing.
During a telephone interview on 07/01/2024 at 2:10 p.m., S6LPN revealed that S5CNA called her to resident #1's room on 06/08/2024. S6LPN reported when she entered resident #1's room, S4CNA and resident #1 were arguing and resident #1 pointed his finger at S4CNA and S4CNA grabbed the resident's finger and pushed both of his hands down on the bed. S6LPN reported she made S4CNA leave the resident's room, then she asked resident #1 and S5CNA what had happened. S6LPN reported that resident #1 and S5CNA notified her that S4CNA had bent resident #1's finger back, slapped him in the chest, and bent his toes back. S6LPN reported S4CNA was very upset and she tried to get back into the resident's room. S6LPN reported she spoke with S4CNA later in the hall and S4CNA reported the resident kicked her twice for no reason. S6LPN confirmed she did not notify S1Administrator or S2DON about the physical abuse that occurred between resident #1 and S4CNA. S6LPN confirmed she did not send S4CNA home, but let her work on another hall for the rest of her shift on 06/08/2024. S6LPN confirmed she was counselled on 06/11/2024 for not notifying S2DON or S1Administrator on 06/08/2024 when resident #1 was physically abused by S4CNA.
An interview on 07/02/2024 at 11:55 a.m. with S5CNA confirmed she did not notify S2DON or S1Administrator of physical abuse of resident #1 on 06/08/2024 by S4CNA.
Review of the Employee Timecard for S4CNA revealed she was clocked in and out for the remainder of the weekend, as follows:
-06/08/2024 in at 3:27 p.m. and out at 4:25 a.m.
-06/09/2024 in at 3:16 p.m. and out at 5:36 a.m.
-06/10/2024 in at 3:22 p.m. and out at 11:34 p.m.
Surveyor alerted S2DON on 07/02/2024 at 8:15 a.m. that S4CNA was not sent home on [DATE] after the incident occurred, and S4CNA also worked on 06/09/2024 and 06/10/2024 per review of S4CNA's timecard. S2DON confirmed S4CNA should have been sent home immediately per the facility's policy on abuse, and should not have been allowed to work on 06/09/2024 or 06/10/2024. S2DON confirmed S4CNA was terminated on 06/11/2024 for physical abuse to resident #1. S2DON confirmed that S4CNA, S5CNA, and S6LPN failed to follow the facility's abuse policy and procedure by not reporting abuse immediately to S2DON or S1Administrator on 06/08/2024 when S4CNA physically abused resident #1.
An interview on 07/08/2024 at 1:00 p.m. with S1Administrator confirmed the facility did not notify a law enforcement entity within 24 hours of becoming aware of the physical abuse of resident #1 by S4CNA that occurred on 06/08/2024.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care to assist resident safety and maintain the highest practical physical, mental and psychological well-being of each resident for 1 (#1) of 3 (#1, #2, #3) residents investigated for accidents.
The facility failed practice was evidenced by two Certified Nurse Aide (CNA)'s and a Licensed Practical Nurse (LPN) failed to follow the facilities Accident/Incident policy and procedure when Resident #1 was found on the floor twice on 10/24/2023.
Review of the facilities Accident/Incident Reports: Resident in-part
Policy: When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An accident/incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes an accident/incident should be immediately directed to the Director of Nursing or the shift supervisor.
Review of the facility's Procedure included the following as referenced, in part:
1. Do not move the resident until a licensed nurse evaluates the condition;
2. Notify the nurse in charge;
3. Licensed Nurse - Administer any necessary first aid. If severe injury has occurred, call an ambulance immediately and notify the physician Complete a thorough head to toe assessment of the resident for possible injury, include range of motion;
4. Take complete vital signs (temperature, pulse, respirations, blood pressure); and,
7. Notify the resident's physician - receive orders for follow-through.
8. Notify Family.
9. Complete an accident incident report.
Findings:
Review of medical records revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to the following: metabolic encephalopathy, vascular dementia severe with other behavioral disturbance, aphasic, and neurocognitive disorder with Lewy bodies, essential hypertension, insomnia, pseudobulbar affect, impulse disorder, depression, restlessness and agitation.
On 11/16/2023 at 10:45 a.m., S4CNA reported she had worked the day shift on 10/24/2023 shift from 7:00 a.m. to 3:00 p.m. and had provided care for Resident #1. She further reported at approximately 7:15 a.m., while making her rounds, she (S4CNA) found Resident #1 in his room and on the floor. Further interview revealed that she (S4CNA and S5CNA) assisted Resident #1 from the floor and into his bed. S4CNA reported that Resident #1 had a second fall the same day (10/24/2023), around lunch time. She reported that S3LPN had called her to Resident #'1 room to assist S3LPN with getting up from the floor. S4CNA revealed that upon her arrival to the room, Resident #1 was lying on the on his right side and propped up on his elbow.
On 11/16/2023 at 11:47 a.m., during a telephone interview, S3LPN reported that she had worked on the date of 10/24/2024 from 5:00 a.m. to 5:00 p.m. and had provided care for Resident #1. She further reported that at approximately 6:30 a.m., S6CNA and S7CNA had informed her (S3LPN) that Resident #1 was on the floor, in his room. She further reported that she went to the resident's room and found Resident #1 sitting by his bed with his buttocks on the floor. S3LPN reported that at approximately 7:15 a.m., S4CNA had informed her that Resident #1 was again found on the floor, in his room. S3LPN revealed they had assisted Resident #1 up off the floor and into his chair. Further interview revealed that S3LPN did not complete an incident report and did not notify the Director of Nursing (DON) or Assistant Director of Nursing (ADON) of either incident when Resident #1 was found on the floor on the date of 10/24/2023.
Review of Resident #1's medical record revealed no documented evidence of a nurse's note and accident incident report being completed on the date of 10/24/2023 regarding Resident #1 being found on the floor.
On 11/20/2023 at 3:50 p.m., an interview with S2DON revealed Resident #1 was found on the floor in his room by staff twice on 10/24/2023. S2DON reported that S4CNA and S5CNA had found Resident #1 in his room, sitting with his buttocks on the floor. S2DON confirmed that S3LPN had not completed an incident report after she had found Resident #1 on the floor at two different occasions on the date of 10/24/2023, there was no documented evidence of Resident #1's family, the physician, DON, and /or ADON being notified of the incidents involving Resident #1 being found on the floor, in accordance with the facility's accident/incident policy and procedures.
Oct 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the pharmacist must report any irregularities to the attendi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 1 (#38) of 5 (#3, #17, #28, #38 and #43) residents reviewed for unnecessary medications. The pharmacist failed to address the facility did not follow parameters for the administration of a blood pressure medication.
Findings:
Review of the medical record for resident #38 revealed an admission date of 08/27/2021 with diagnoses of anxiety, chronic obstructive pulmonary disease, insomnia, vascular dementia, Alzheimer's disease, hypertension, hyperlipidemia and depression.
Review of the care plan dated 08/27/2021 revealed a plan for potential for altered cardiac status related to diagnoses of essential primary hypertension and mixed hyperlipidemia. Further review of the care plan revealed interventions to administer medications as ordered, and to monitor blood pressure and pulse as ordered.
Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate impaired cognition for daily decision making and required supervision with setup help with activities of daily living.
Review of the August 2023 physician orders revealed an order dated 07/27/2022 for Metoprolol Succinate Extended Release (ER) 50 milligrams (mg), administer one every day and hold if the pulse is less than 70.
Review of the August 2023 Medication Administration Record (MAR) revealed six times during the month resident #38 received Metoprolol Succinate ER 50 mg and the resident's pulse was less than 70.
Review of the Monthly Medication Review dated 09/04/2023 revealed the pharmacist did not address that the nurses administered Metoprolol Succinate ER to resident #38 when the parameter for the pulse was out of range.
On 10/04/2023 at 10:00 a.m. interview with S2Director of Nursing (DON) revealed the pharmacist did not address the Metoprolol Succinate ER 50 mg was given when resident #38's pulse was less than 70 on the September 2023 Medication Regimen Review.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
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 that resident's drug regimen was free from unnecessary drugs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 1 ((#38) of 5 (#3, #17, #28, #38 and #43) residents reviewed for unnecessary medications. The facility failed to follow parameters for the administration of a blood pressure medication to resident #38.
Findings:
Review of the medical record for resident #38 revealed an admission date of 08/27/2021 with diagnoses of anxiety, chronic obstructive pulmonary disease, insomnia, vascular dementia, Alzheimer's disease, hypertension, hyperlipidemia, aphasia, depression, and dysphagia.
Review of the care plan dated 08/27/2021 revealed a plan for potential for altered cardiac status related to diagnoses of essential primary hypertension and mixed hyperlipidemia. Further review of the care plan revealed interventions to administer medications as ordered, and to monitor blood pressure and pulse as ordered.
Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate impaired cognition for daily decision making and required supervision with setup help with activities of daily living.
Review of the August 2023 and September 2023 physician orders revealed an order dated 07/27/2022 for Metoprolol Succinate Extended Release (ER) 50 milligrams (mg), administer one every day and hold if the pulse is less than 70.
Review of the August 2023 Medication Administration Record (MAR) revealed six times during the month resident #38 received Metoprolol Succinate ER 50 mg and the resident's pulse was less than 70.
Review of the September 2023 MAR revealed one time during the month resident #38 received Metoprolol Succinate ER 50 mg and the resident's pulse was less than 70.
On 10/04/2023 at 10:00 a.m. interview with S2Director of Nursing (DON) revealed the nurses should not have administered Metoprolol Succinate ER 50 mg to resident #38 when her pulse was less than 70.
Sept 2022
3 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide services with reasonable accommodation of nee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide services with reasonable accommodation of needs for 1 (#20) of 1 sampled resident reviewed for accommodation of needs. The facility failed to initiate an alternate call light for resident #20.
Findings:
Review of the medical record for resident #20 revealed the resident was admited on 09/01/2021 with diagnoses of hemiplegia affecting right dominant side, dehydration, diabetes, mild protein-calorie malnutrition, right and left hand contracture, aphasia, dementia with behavioral disturbance, schizoaffective disorder, and depressive disorder.
Review of the Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required two person extensive assistance with bed mobility and two person total assistance with toilet use. The resident required one person total assistance with dressing, eating, and personal hygiene. The resident was incontinent of bowel and bladder. The resident had range of motion impairment on both sides of his upper extremities.
Observation on 09/12/2022 at 10:00AM revealed the resident had moved down in the bed and he wanted someone to pull him back up in bed. When asked if he could use his call light, the resident reported he could not use the call light. Observation revealed both of his hands were contracted. Further observation revealed the resident could move his arms.
An interview with S4CNA (Certified Nursing Assistant) and S5CNA on 09/12/2022 at 10:05AM reported they have not seen the resident use his call light and they have not seen him with a different kind of call light. Further interview revealed the resident could move his arms and bend his elbows.
An interview on 09/14/2022 at 9:45AM with S6LPN (Licensed Practical Nurse) revealed the resident did not use his call light.
An interview on 09/14/2022 at 10:00AM with S2DON (Director of Nursing) confirmed the resident was unable to use his current call light. S2DON further confirmed they have not attempted an alternate call light for resident #20.
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 record review, observation, and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personne...
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Based on record review, observation, and interview, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys by leaving a storage room door propped open and unattended. The storage room contained the facility's over the counter medications.
Findings:
Review of the Medication Storage in the Facility Procedure revealed:
2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.
Observation on 09/13/2022 at 8:50AM revealed a storage room door propped open and there was no staff present. Further observation revealed the storage room contained the facility's over the counter medications. Further observation revealed a sign on the door stating, Do not prop this door open, we have wanderers who may get in room and find something to injure them.
An interview on 09/13/2022 at 9:03AM with S2DON (Director of Nursing) confirmed the door should not be open unless a staff member is present. S2DON confirmed the door should be locked.
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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 follow proper sanitation when using the 3 compartment sink by having a black substance on the inside of the plastic tubing that dispensed the ...
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Based on observation and interview the facility failed to follow proper sanitation when using the 3 compartment sink by having a black substance on the inside of the plastic tubing that dispensed the sanitizer. According to S3Dietary Manager revealed 49 residents are served meals from the kitchen.
Findings:
On 09/12/2022 at 9:45AM observation of the kitchen revealed the 3 compartment sink that was used for sanitizing the dishes had 3 serving utensils in the water. Further observation of the 3 compartment sink revealed the tubing that dispensed the sanitizer had a black substance on the inside of the tube.
On 09/12/2022 at 9:50AM interview with S3Dietary Manager revealed the 3 compartment sink sanitizer dispenser tubing had a black substance on the inside of the tubing.
On 09/12/2022 at 10:30AM S1Administrator was notified of the black substance on the inside of the plastic tubing that dispensed the sanitizer for the three compartment sink.
On 09/14/2022 at 12:00PM an interview with S3Dietary Manager revealed 49 resident receive meals from the kitchen.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 32% turnover. Below Louisiana's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), $128,001 in fines. Review inspection reports carefully.
- • 19 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $128,001 in fines. Extremely high, among the most fined facilities in Louisiana. Major compliance failures.
- • Grade F (16/100). Below average facility with significant concerns.
Bottom line: Trust Score of 16/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Plantation Oaks Nursing & Rehabilitation Center's CMS Rating?
CMS assigns PLANTATION OAKS NURSING & REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Plantation Oaks Nursing & Rehabilitation Center Staffed?
CMS rates PLANTATION OAKS NURSING & REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 32%, compared to the Louisiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Plantation Oaks Nursing & Rehabilitation Center?
State health inspectors documented 19 deficiencies at PLANTATION OAKS NURSING & REHABILITATION CENTER during 2022 to 2024. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 17 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Plantation Oaks Nursing & Rehabilitation Center?
PLANTATION OAKS NURSING & REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CENTRAL MANAGEMENT COMPANY, a chain that manages multiple nursing homes. With 76 certified beds and approximately 54 residents (about 71% occupancy), it is a smaller facility located in WISNER, Louisiana.
How Does Plantation Oaks Nursing & Rehabilitation Center Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, PLANTATION OAKS NURSING & REHABILITATION CENTER's overall rating (2 stars) is below the state average of 2.4, staff turnover (32%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Plantation Oaks Nursing & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Plantation Oaks Nursing & Rehabilitation Center Safe?
Based on CMS inspection data, PLANTATION OAKS NURSING & REHABILITATION CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Plantation Oaks Nursing & Rehabilitation Center Stick Around?
PLANTATION OAKS NURSING & REHABILITATION CENTER has a staff turnover rate of 32%, which is about average for Louisiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Plantation Oaks Nursing & Rehabilitation Center Ever Fined?
PLANTATION OAKS NURSING & REHABILITATION CENTER has been fined $128,001 across 1 penalty action. This is 3.7x the Louisiana average of $34,359. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Plantation Oaks Nursing & Rehabilitation Center on Any Federal Watch List?
PLANTATION OAKS NURSING & REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.