Latest Medicare Health Inspections For Nursing Homes Owned by Bob Dean

Department of Health & Human Services Printed: 09/20/2021
Form Approved OMB

Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
195403 B. Wing 10/16/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2233 Eighth Street
Maison De'Ville Nursing Home of Harvey
Harvey, LA 70058
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to
receiving treatment and supports for daily living safely.
Level of Harm - Minimal harm
or potential for actual harm Based on observation and interview, the facility failed to maintain ceiling tiles in good repair in a room and
working light fixtures in a hallway. This deficient practice had the potential to affect any of the 91 residents
Residents Affected - Some who reside at the facility as documented on the facility's CMS Form-672 Resident Census and Condition of
Residents.
Findings:
The facility's Policy and Practices entitled Infection Control revealed in part, the objectives of our infection
control policies and practices are to maintain a safe, sanitary, and comfortable environment for personnel,
residents, visitors and the general public.
An observation on 10/12/2020 at 7:35AM of Room a revealed to the left of the entrance of room a two
missing ceiling tiles. Further observation of the ceiling where the ceiling tiles were missing revealed it was
open to the attic, wires were noted, and pipes were exposed. Upon further observation, Resident #72 was
sitting in his wheelchair beneath the missing tiles while waiting for breakfast.
Observation on 10/16/2020 at 09:50am with S2Director of Nursing (DON) of Room a revealed missing ceiling
tiles. In an interview on 10/16/2020 at 09:50am, S2DON acknowledged room 'a was not maintained in a
clean and sanitary/safe environment with the hole in the ceiling.
Observation on 10/16/2020 at 10:40AM with S5Maintenance Housekeeping Supervisor revealed missing

ceiling tiles in room a.
In an interview on 10/16/2020 at 10:40AM, S5Maintenance Housekeeping Supervisor he acknowledged the

tiles were not maintained and did not provide a clean and sanitary environment in room a where residents
ate their meals or took part in activities.
An observation on 10/12/2020 at 7:40AM of hallway g revealed one light fixture off of the ceiling with wires
exposed and two other light fixtures with lights not working. Further observation revealed 2 Licensed
Practical Nurses, S8LPN and S11LPN preparing medications at their carts.
In interview on 10/12/2020 at 7:40AM, S11LPN indicated she had been employed at the facility since July,
2020 and the lights have not worked since that time.
In interview on 10/12/2020 at 7:41AM, S8LPN indicated she used the light coming in from the window to
prepare the medications for administration.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 1 of 6
195403
Form Approved OMB
A. Building
195403 B. Wing 10/16/2020

2233 Eighth Street
Harvey, LA 70058

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions
that can be measured.
Level of Harm - Minimal harm or
potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few Based on observation, interview, and record review the facility failed to implement a resident's plan of care
by failing to discontinue hospice services on the care plan after the Resident (Resident #26) was discharged
from hospice, and failing to include isolation precautions on the care plan (Resident #251). This deficient
practice was identified for 2 (Resident #26 and Resident #251) of 21 sampled residents but had the potential
to affect any of the 91 residents who resided at the facility as documented on the facility's CMS Form-672
Resident Census and Condition of Residents.
Findings:
Resident #26
Review of Resident #26's clinical record revealed that he was admitted to the facility on [DATE] with
[DIAGNOSES REDACTED].
Review of Resident #26's physician's orders [REDACTED].#26 was admitted to hospice with a [DIAGNOSES
REDACTED]. Subsequently, the clinical record indicated on July 22, 2020 Resident #26 was discharged
from hospice care because he was no longer terminally ill.
Review of the care plan revealed Resident #26 was admitted to hospice with a focus on providing
collaborative care between the hospice agency and the facility with a goal of keeping the hospice facility up
to date with his plan of care through 12/24/2020. Further review revealed the care plan was updated on
4/7/2020, 6/30/2020, 7/7/2020, 7/30/2020, and 8/24/2020 with an update scheduled for12/24/2020. Further
review revealed hospice care was discontinued on 7/22/2020 and the care plan was not accurately updated
to reflect the modification of care.
In an interview on 10/14/2020 at 10:45AM, S6Licensed Practical Nurse (LPN) indicated the Resident #26
was no longer on hospice and had been discharged because he was no longer terminally ill.
In an interview on 10/15/2020 at 10:40AM, S7Certified Nursing Assistant (CNA) indicated she has not
witnessed anyone from Hospice caring for Resident #26 and that she provided him with baths/showers,
activities of daily living care and assistance as needed.
There was no documented evidence and the facility did not present any documented evidence that the care
plan had been revised to reflect the current plan of care related to hospice care for Resident #26.
Resident #251
Review of Resident #251's clinical record revealed in Resident #251 was admitted to the facility on [DATE]
with [DIAGNOSES REDACTED].
Observation on 10/12/2020 at 7:00AM of Resident #251's door revealed signage for isolation precautions.
(continued on next page)

195403
Form Approved OMB
A. Building
195403 B. Wing 10/16/2020

2233 Eighth Street
Harvey, LA 70058

F 0656 In an interview on 10/12/ at 7:00am, S12LPN indicated Resident #251 was on isolation because she was
newly admitted . She further indicated she did not know why Resident #251 was in a room with other
Level of Harm - Minimal harm or residents when Resident #251 was on isolation precautions.
potential for actual harm
Review of Resident #251's physician's orders [REDACTED].
Residents Affected - Few
Review of the policy and procedure entitled Coronavirus Disease (COVID 19) - Identification and
Management of Ill Residents dated August 2020 Procedure for Accepting Admissions from Hospitals
revealed in part:
For patients/residents who are tested prior to hospital discharge and are COVID 19 negative, ADMIT and-
a. Place resident in isolation and care for using all recommended COVID-19 PPE for 14 days;
b. Monitor resident for symptoms consistent with COVID 19 every shift; and
c. Increase monitoring of resident's vital signs (temperature twice daily, pulse ox twice daily, and blood
pressure, pulse, respirations daily) for 14 days.
In an interview on 10/15/2020 at 10:47AM, S6LPN indicated the Resident #251 was admitted to the facility
with no signs or symptoms of COVID-19 and that Resident #251 was placed on precautions for 14 days
because she was newly admitted .
In an interview on 10/15/2020 at 2:33PM, S4 Registered Nurse Corporate Nurse indicated Resident #251
never tested positive for COVID 19. S4RN Corporate Nurse further stated upon Resident #251's admission
there were no private rooms available so the facility staff put her in a room with other residents who had
previously tested positive for COVID 19. S4RN Corporate Nurse further stated that sometimes you do the
best that you can and because the residents were residing with other residents who had previously tested
positive, they thought this was the best option for this resident. S4 RN Corporate Nurse indicated this
procedure is in the plan of care for all newly admitted residents.
Review of Resident #251's care plan revealed Resident #251 was not care planned for isolation.
There was no documented evidence and the facility did not present any documented evidence that Resident
#251 was care planned to be on isolation precautions.

195403
Form Approved OMB
A. Building
195403 B. Wing 10/16/2020

2233 Eighth Street
Harvey, LA 70058

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
Level of Harm - Minimal harm or locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Some
Based on observation and interview the facility failed to ensure drugs in the medication storage room did not
have expired medications available for use. This deficient practice had the potential to affect any of the 91
residents who reside in the facility as documented on the facility's CMS Form-672 Resident Census and
Conditions of Residents.
Findings:
Observation on 10/15/2020 at 2:00 p.m., of the facility's (b) revealed the following:
1. (7) Major Fish Oil 500 mg expiration date 9/20/2020 and available for use,
2. (7) Good Sense Antacid expiration date 8/20/2020 and available for use,
3. (12) Good Sense Bisacoyl 5mg tablets expiration date 8/20/2020 and available for use,
4. (24) Geri care Thera tab Multivitamin expiration date 7/20/2020 and available for use,
5. (2) Gericare Simethacone 80mg tablets expiration date 8/20/2020, and available for
6. (24) Gericare Vitamin E 400IU capsules expiration date 7/20/2020, and available for use
7. (8)(NAME)[MEDICATION NAME] 1.5 calorie therapeutic nutrition expiration date 5/20/20 and
available for use,
8. (4) Milk of Magnesia expiration date 3/20/2020, and available for use,
9. (33)[MEDICATION NAME] therapeutic nutrition expiration date 12/18/2018 and available for use
In an interview on 10/15/2020 at 2:00pm with S5Director of Nursing (DON), S2LPN (Licensed Practical
Nurse) verified the expiration dates on the items listed above. S2LPN and S5DON further indicated and
acknowledged b had not been audited and expired medications were not discarded by the dates of expiration
listed above and available for use.

195403
Form Approved OMB
A. Building
195403 B. Wing 10/16/2020

2233 Eighth Street
Harvey, LA 70058

F 0880 Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or Based on observations, record review, and interviews, the facility failed to maintain a safe and sanitary
potential for actual harm environment by:
Residents Affected - Some 1) Failing to ensure hand soap was in the dispenser, toilet paper was available for use, (Room c);
2) Failing to ensure paper towels, toilet paper and a dead roach were not on the bathroom floor (Room d);
3) Failing to ensure a brown crusted like substance was not on the garbage bin, no chipped paint was on the
wall by the faucet, and a shower head was not laying on the floor (Room e); and
4.) Failing to ensure there were no chipped and missing tiles on the bathroom floor and no
black like substance on the air conditioner vent. (Room f)
This deficient practice had the potential to affect any of the 91 residents who reside at the facility as
documented on the facility's CMS Form-672 Resident Census and Condition of Residents.
Findings:
Review of the Facility Policy and Procedure - Infection Control revealed in part, This facility's infection control
policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and
to help prevent and manage transmission of diseases and infections. Furthermore, the objectives of our
infection control policies and practices are to:
b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general
public.
Observation on 10/12/2020 at 6:40AM of Room c revealed in the bathroom closet, mini blinds pulled half way
up at an angle with some of the blinds sticking out towards the front, with the toilet running and no toilet
tissue available. Further observation revealed no hand soap in the soap dispenser near the sink. Further
observation revealed the outer portion of the sink base was peeling and the microfiber board was exposed.
Observation above and to the left of the sink revealed a raw piece of wood nailed to the wall.
An interview on 10/12/2020 at 6:40AM with S9Licensed Practical Nurse (LPN) who stated that room c was
currently used for resident care.
An interview on 10/16/2020 at 10:00AM with S2/Director of Nursing (DON) who observed room c in disrepair
and agreed the area was not maintained and the surfaces could not be properly cleaned and sanitized.
Observation on 10/12/2020 at 6:43AM of room d revealed paper towels on the floor by the trash can, toilet
paper on the floor by the toilet and in the corner of the room upon entry. Further observation revealed a
large, dead roach on the floor in the corner near the entry of room d.

195403
Form Approved OMB
A. Building
195403 B. Wing 10/16/2020

2233 Eighth Street
Harvey, LA 70058

F 0880 An interview on 10/16/2020 at 10:00AM with S2DON who indicated the room d was used by residents and
staff.
potential for actual harm Observation on 10/12/2020 at 6:47AM of room e revealed the side of the sink base peeling off with microfiber
compressed wood exposed and not able to be properly cleaned. Further observation revealed a small plastic
Residents Affected - Some garbage bin located near the farthest wall with brown crusted substance noted up the plastic bin. Further
observation revealed the shower stall closest to the door with chipped pain where the faucet comes out of
the wall; the second shower stall with shower head hanging to the floor and not suspended from the holder in
a sanitary manner.
An interview on 10/12/2020 at 6:55AM with S10/Transportation Aide who indicated room e was currently
used for resident care.
Observation on 10/12/2020 at 7:43AM of room f revealed 15 tiles on the bathroom floor chipped or missing.
Further observation revealed there was one tile above the sink broken with a rough edge. Further
observation revealed an air conditioner vent located above the toilet missing part of the ventilator pieces and
filled with a black substance.
An interview on 10/16/2020 at 10:02AM with S2/Director of Nursing (DON) who observed the tiles broken in
room f and agreed that they could not be properly cleaned.
An interview on 10/16/2020 at 10:43AM with S5/Maintenance Housekeeping Supervisor indicated upon

observation of room f, he agreed the surface could not be properly cleaned.

195403
Form Approved OMB
A. Building
195591 B. Wing 11/21/2019

1020 Manhattan Blvd
West Jefferson Health Care Center
Harvey, LA 70058

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm Based on interview and record review, the facility failed to inform the resident or his or her legal
or potential for actual harm representative in writing that Medicare services may not be covered, and of the resident's/beneficiary's
potential liability for payment for non-covered services as evidence by failing to ensure liability notices were
Residents Affected - Few completed as required. This deficient practice was identified for 2 (Resident #52, and Resident #244) of 3
residents reviewed for beneficiary protection notification. The facility had a total census of 97 residents who
resided in the facility as documented on the facility's Resident Census and Conditions of Residents Form
CMS-672.
Findings:
Resident #52
Record review revealed Resident #52's last day of covered Part A skilled services was 05/31/19, and
Resident #52 remained in the facility. Further review of Resident #52's record revealed Resident #52's
Advance Beneficiary Notice of Non-coverage Form CMS-R-131 (ABN) was signed and dated by Resident
#52 on 05/30/19 but no option choice was selected.
Resident #244
Record review revealed Resident #244's last day of covered Part A skilled services was 11/20/19, and
Resident #244 remained in the facility. Further review of Resident #244's record revealed Resident #244's
ABN was signed and dated by Resident #244 on 11/15/19 but no option choice was selected.
In interview on 11/20/19 at 12:25pm, S8/Social Worker (SW) stated she was responsible for obtaining
Liability notices. (ABNs) for the facility. S8/SW reviewed Resident #52's and Resident #244's liability notices
with surveyor and S8/SW acknowledged no option choice was selected.
In interview on 11/20/19 at 2:55pm, S4/Regional Director of Quality confirmed no options was elected on
liability notices for Resident #52 and Resident #244.


195591
Form Approved OMB
A. Building
195591 B. Wing 11/21/2019

1020 Manhattan Blvd
Harvey, LA 70058

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent
accidents.
Residents Affected - Few Based on interviews and record reviews, the facility failed to ensure each resident had monitoring of
wanderguard device to prevent accidents. For 1(Resident #18) of 7 residents who wore a wanderguard
device out of total sample of 40 Residents in the investigation stage. This deficient practice had the potential
to affect all 97 residents residing in the facility as documented on the facility's Resident Census and
Conditions (CMS 672 Form).
Findings:
Record review revealed Resident #18 was admitted to the facility on [DATE]. Further review of Resident
#18's record revealed resident #18 had a [DIAGNOSES REDACTED].
Record review of Resident #18's Minimum Data Set revealed in part, a Brief Interview for Mental Status
(BIMS) revealed score of 6 (score of 0-7 is severe impairment). Further review of Resident #18 record
revealed he had a wander/elopement risk with an ankle alarm.
Record review of Resident #18's Physician orders [REDACTED].
Review of Resident #18's Risk of Elopement and/or Wandering Review dated 05/30/19 revealed
documentation Resident #18 was at high risk for wandering or Elopement, which required frequent
monitoring. Further review revealed Resident #18 was cognitively impaired with poor decision-making skills,
and Resident #18 was able to independently ambulate.
Review of Resident #18's Medication Administration Record [REDACTED].
In an interview on 11/21/19 at 11:24am, S1Certified Nursing Assistant (CNA) stated there was no form for
her to document Resident #18's wanderguard bracelet.
In an interview on 11/21/19 at 12:30pm, S13Licenced Practical Nurse (LPN) stated the maintenance staff
was responsible for monitoring Resident #18's wanderguard bracelet. S13LPN confirmed that she was not
monitoring Resident #18's wanderguard bracelet.
In an interview on 11/21/19 at 1:56pm, S5Corporate Registered Nurse (RN) confirmed Resident #18's
wanderguard bracelet was not being monitored. S5CorporateRN confirmed there was no documentation on
Resident #18's (MONTH) 2019 MAR indicated [REDACTED].

195591
Form Approved OMB
A. Building
195591 B. Wing 11/21/2019

1020 Manhattan Blvd
Harvey, LA 70058

F 0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
potential for actual harm Based on observation, record review, and interviews, the facility failed to ensure the steam tables were
holding food temperatures at a safe temperature. This deficient practice was identified for 1 of 1 steam table
Residents Affected - Some observed. This deficient practice had the potential to affect any of the residents in the facility who received
food from the steam table. The facility census was 97 residents as documented on the facility's Census and
Conditions of Residents Form (CMS-672).
Findings:
Observation of food temperatures on the steam tables with S7Cook on 11/21/19 at 11:00 AM revealed the
following temperatures: white cooked rice 122 degrees F, puree: pork chops 109 degrees F, rice 112
degrees F, and zucchini 103 degrees F.
In an interview on 11/21/19 at 11:00 AM, S7Cook stated the steam table is turned up to maximum heat. Food
is placed on steam table at least no greater than 45 minutes before serving.
In an interview on 11/21/19 at 11:15 AM with S1Administrator and S4Regional Director of Quality, surveyor
advised these staff members of food temperatures on steam table. S1Administrator stated the temperatures
are not correct and would have S6Dietary Supervisor address. S4Regional Director of Quality confirmed
temperatures of foods on steam table are too low except smothered pork chops and zucchini. S4Regional
Director of Quality stated would have S6Dietary Supervisor re-heat the food.
Observation and interview on 11/21/19 at 11:35 AM for the lunch meal revealed S6Dietary Supervisor
removing white rice, and pureed smothered pork chops, pureed white rice, and pureed zucchini from stove
and immediately checking temperatures and documented these temperatures on the Daily Food
Temperature Log. S6Dietary Supervisor stated he usually documents temperatures from steam tables,
except right now because of earlier low temperature readings he was documenting internal temperatures
directly from the stove. S6Dietary Supervisor acknowledged food temperatures should be monitored and
maintained in an acceptable range on steam table.
In an interview on 11/21/19 at 12:53 PM, S1Administrator acknowledged S6Dietary Supervisor recorded the
lunch internal food temperatures from the stove top and should have recorded the food temperatures from
the steam table on the on the Daily Food Temperature Log dated 11/21/19. S1Administrator confirmed
S6Dietary Supervisor did not record food temperatures appropriately.

195591
Form Approved OMB
A. Building
195591 B. Wing 11/21/2019

1020 Manhattan Blvd
Harvey, LA 70058

F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and
preferences and sufficient to maintain resident hydration.
Residents Affected - Few Based on observation, interviews and record reviews, the facility failed to ensure a resident received his diet
as ordered for 1 of 40 sample residents on the investigation stage sample. This deficient practice had the
potential to affect all 97 residents residing in the facility as documented on the facility's Resident Census and
Conditions (CMS 672 Form).
Findings:
A record review of resident #63's physician's orders [REDACTED].
A record review of the Dietary Manger Nutrition Data Note (NDN) dated 10/14/19 revealed documentation for
resident #63 to have milk with all meals.
A record review of resident #63's dietary slip revealed special instructions to add milk with all meals.
In an interview on 11/18/19 at 10:50am, resident #63's wife stated she feeds her husband every day for
lunch, and he did not get milk today on his lunch tray. Resident #63's wife further stated her husband loves
chocolate milk.
An observation on 11/18/19 at 11:50am revealed resident #63's milk was not on his lunch tray.
An observation on 11/19/19 at 12:10pm revealed resident #63's milk was not on his lunch tray.
In an interview on 11/20/19 at 11:20am, resident #63's wife stated her husband did not get his milk today on
his lunch tray.
An observation on 11/20/19 at 4:49pm revealed no milk was on resident #63's dinner tray.
In an interview on 11/21/19 at 12:05pm, resident #63's wife stated her husband did not get milk for lunch
today.
An observation on 11/21/19 at 12:05pm revealed resident #63's lunch tray without milk.
In an interview on 11/21/19 at 12:46pm, S13LPN(Licensed Practical Nurse) stated resident #63 had an order
to have milk with all meals, and it should be on his tray. S13LPN confirmed the milk was not on resident
#63's tray.

195591
Form Approved OMB
A. Building
195591 B. Wing 11/21/2019

1020 Manhattan Blvd
Harvey, LA 70058

Level of Harm - Minimal harm or Based on observation, interview, and record review the facility failed to maintain an effective infection
potential for actual harm prevention and control program by:
Residents Affected - Some I. failing to ensure staff were knowledgeable about sanitizing/disinfection procedures for the facility showers
and whirlpools (shower rooms a and b); and
II. failing to ensure a glucometer (a blood glucose monitoring device) was properly cleaned.
This deficient practice had the potential to affect any of the 97 residents currently residing in the facility as
documented on the facility's Resident Census and Conditions of Residents form (CMS-672).
Findings:
I. Observation of the shower room a on 11/21/19 at 8:35am with S15CNA (Certified Nurse Assistant)
revealed a spray bottle on labeled Shampoo/Body Wash with a purple tinted liquid noted in the spray bottle.
S15CNA confirmed she uses this liquid to bathe residents and to disinfect the shower between residents.
Observation of the shower room b on 11/21/19 at approximately 8:45am with S15CNA revealed a squeeze
bottle labeled Soothe and Cool Cleanse Shampoo and Body Wash sitting on a shelf. S15CNA demonstrated
how she squeezes the pink tinted liquid throughout therapeutic whirlpool and rinses with hot water to
disinfectant between residents. S15CNA confirmed she also uses this liquid to bathe residents.
Review of instructions on how to clean the shower/whirlpool posted on back of shower room b door revealed,
in part, utilize Neutral Disinfectant after each shower/whirlpool, let disinfectant stand for 10 minutes and rinse
surface completely.
In an interview on 11/21/19 at 9:00am, S2Director of Nurses (DON) acknowledged S15CNA was not properly
cleaning showers/whirlpools after each resident. S2DON confirmed S15CNA should be using Neutral
Disinfectant to disinfect showers/whirlpools after each resident use instead of the soap she uses to bathe
residents.
II. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment
revealed, in part, 'reusable resident care equipment will be decontaminated and/or sterilized between
residents according to manufacturers' instructions.
In an interview on 11/18/19 at 11:57am, S9LPN stated she cleans the glucometer with alcohol wipes after
resident use.
In an interview on 11/18/19 at 2:50pm, S4Regional Director of Quality stated the facility used CaviWipe
towelettes, not alcohol wipes, to disinfectant the glucometer between resident use. S2DON confirmed the
facility used Caviwipes towelettes to clean the glucometer. S2DON stated S9LPN should not have used
alcohol wipes to clean glucometer.

195591
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A. Building
195176 B. Wing 03/18/2021

535 Commerce Street
Park Place Healthcare, LLC
Gretna, LA 70056

No health deficiencies found
Level of Harm - Unknown
Residents Affected - Unknown


195176
Form Approved OMB
A. Building
195174 B. Wing 11/01/2019

1420 General Taylor
Maison Orleans Healthcare of New Orleans
New Orleans, LA 70115

or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Some Based on interview and record review, the facility failed to ensure residents or responsible party were invited
to care plan meetings for 1 (Resident #122) of 68 sampled residents but had the potential to affect any of the
180 residents as documented on the facility's Resident Census and Conditions of Residents. (CMS 672)
Findings:
Review of the Minimal Data Set ((MDS) dated [DATE] revealed Resident #122 had a Brief Interview for
Mental Status (BIMS) of 13 BIMS score which indicated Resident #122 was cognitively intact.
In an interview on 10/28/19 at 11:54am, Resident #122 indicated she had never been invited to or
participated in a care plan meeting.
In an interview on 11/01/19 at 02:35pm, S8Social Worker (SW), revealed he did not have a care plan
meeting with Resident #122 because the resident did not request one. S8SW disclosed he only had care
plan meetings with residents if the family requested them. S8SW stated he was not aware that he had to
invite all residents to their individual care plan meetings.
Interview an on 11/01/19 at 2:45pm, S6Regional Administrator, revealed the Care Plan meetings should be
done quarterly with family and or resident.


195174
Form Approved OMB
A. Building
195174 B. Wing 11/01/2019

1420 General Taylor

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards.
potential for actual harm Based on observations and interview the facility failed to store, prepare, distribute and serve food under
sanitary conditions. This deficient practice was evidenced by the facility failing to ensure
the three compartment sink was being used properly and monitored for proper functioning.
This deficient practice had the potential to affect any of the residents in the facility who received food from
the facility's kitchen.
Findings:
During initial tour of the kitchen on 10/28/19 at 9:50am S11DietaryManager and S5DietarySupervisor were
present and on observation of three compartment sink, female employee observed cleaning dirty plastic
bowls in the wash compartment and dirty pans with reddish color resembling tomato sauce color residue in
the rinse compartment. The sanitizer compartment was empty without any water present.
S5DietarySupervisor counseled female employee and S5DietarySupervisor let out the dirty water from the
rinse compartment to properly fill the sinks.
Observation on 10/31/19 at 8:40am with S11Dietary Manager present, the three compartment sink contained
dirty dishes. Observation further revealed S12Dishwasher filled the rinse compartment and sanitizer
compartment which revealed a reddish ring noted to the center of sink in the sanitizer compartment and a
reddish color noted to the suds and the edges of the sink.
In an interview 10/31/19 at 8:45am S12Dishwasher verbalized that's the color of the sanitizer and it always
had that color in it. S12Dishwasher drained the sanitizer and water out and refilled the sink with water and
sanitizer and revealed the same results of the reddish film.
In an interview 10/31/19 at 8:47am S11DietaryManager acknowledged a reddish ring in the center of the sink
that appeared to be dirt scum. S11DietaryManager further verbalized that she's never noticed any reddish
color film in the suds for a sanitizer and that the film was not normal.
In an interview 10/31/19 at 9:11am S11DietaryManager verbalized contacting Auto-Chlor Representative and

that they were sending someone out to check the line due to the reddish film not clearing out the lines
properly even after cleaning the sink of the reddish residue.

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1420 General Taylor

F 0814 Dispose of garbage and refuse properly.
Level of Harm - Minimal harm or Based on observation and interview the facility failed to ensure garbage and refuse were disposed of
potential for actual harm properly. This deficient practice had the potential to affect all 180 residents who resided in the facility as per
the facility's Resident Census and Conditions of Resident Form.
Findings:
An observation of the facility's garbage dumpsters was conducted with S13HousekeepingSupervisor on

10/28/19 at 9:42am. During the observation two large garbage dumpsters were noted and both of the
dumpster's tops were open. Further observation of the open dumpsters revealed a trash bag filled with trash
of trash on top of each dumpster lid. Further observation of the ground in between the dumpsters were at
least three trash bags of trash, soiled diapers on the ground, as well as other trash outside of the trash bags.
Both dumpsters with ample amount of room inside of dumpster whereas trash and bags could have been
properly disposed of.
On 10/28/19 at 9:45am an interview was conducted with S13HousekeepingSupervisor. During the interview
S13Housekeeping Supervisor acknowledged that the dumpster's top should have been closed and the side
doors are accessible if trash wasn't impeding walk space in between dumpsters.

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1420 General Taylor

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, record reviews and interviews, the facility failed to maintain an effective infection
Residents Affected - Some prevention and control program by failing to and ensure staff washed and/or sanitized their hands during
care of 1 (Resident #208); and failed to ensure staff followed standard precautions during administration of
dietary supplement for 1 (Resident #11) of 68 sampled residents in the investigative stage of the annual
survey. This failed practice had the potential to affect all of the residents in the facility. The total census was
180.
Findings:
Resident #208
Observation on 10/30/19 at11:45am, revealed S10Certified Nursing Assistant(CNA) was observed coming
out of a Resident #208's room with a pair of blue gloves on. S10CNA was asked if he knew that Resident
#208 was on contact precautions for ,[MEDICAL CONDITION].-Difficile ([MEDICAL CONDITION]) and if he
should have washed his hands after removing his gloves. S10CNA indicated yes.
In an interview on 10/30/19 at 12:05pm, S7Licensed Practical Nurse(LPN) was informed of S10CNA coming
out of Resident #208's room with gloves on. S7LPN stated S10CNA should not have had gloves on in the
hallway and should have removed his gloves in the room and washed his hands before leaving Resident
#208's room.
Record review of Resident #208's electronic lab report dated 10/23/19 indicated Resident #208 was positive
for ([MEDICAL CONDITION]).
In an interview on 10/30/19 at 01:15pm, S2Director of Nursing(DON) agreed S10CNA should not have come
out the room with the gloves on, and he should have washed his hands prior to leaving the room.
Resident # 11
Observation on 10/30/19 at 09:25am, revealed S9Licensed Practical Nurse(LPN) dropped the cap to the
supplement container on the floor. S9LPN picked the cap up off the floor and replaced the cap on the
supplement container.
In an interview on 10/30/19 at 10:10am, S2Director of Nursing(DON) was made aware of S9LPN dropping
the cap to a container of supplement on the floor and replacing it on the supplement container. S2DON
stated agreed that S9LPN should have discarded the container after replacing the cap on the container.

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195305 B. Wing 09/03/2020

146 E. 28th Street
South Lafourche Nursing & Rehab
Cut Off, LA 70345

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent
accidents.
Level of Harm - Immediate
jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
safety
Based on interviews, record reviews and observation, the facility failed to ensure 1 (Resident #3) of 8
Residents Affected - Few sampled residents were free from accident hazards by failing to ensure there was a system in place for
inspecting mechanical lift sling pads, used on mechanical lifts, to ensure they were free from rips, tears,
frayed edges, and/or holes prior to use.
This deficient practice resulted in an Immediate Jeopardy on 05/26/2020 at 11:21 a.m. for Resident #3, when
during a transfer from the bed to the wheelchair with the use of a mechanical lift, the lift sling pad ripped from
the seam and broke resulting in the resident falling to the floor. At the time of the resident's fall, the facility did
not have a system in place to ensure the lift sling pads were free of holes and in good repair. After the fall,
the resident complained of pain to the left stump. On 05/27/2020, after continuing to complain of pain to the
left stump area, a mobile x-ray was ordered. The x-ray results revealed the resident had a non-displaced
[MEDICAL CONDITION] left fibula.
The facility implemented actions which were completed prior to the State Agency's completion of its
investigation, thus it was determined to be a Past Noncompliance citation.
Findings:
Review of the Manufacturer's guidelines for use of the Reusable Full-Body Patient Sling used for Resident
#3 revealed, in part, sling maintenance best practices included, in part, the following:
1.) Check condition before each use. If there is any fraying or visible wear and tear, do not use;
2.) Reusable slings should be replaced every six (6) months.
Review of the facility's Policy and Procedure titled Lifting Machine, Using a Mechanical (lift) revealed the
following:
1.) Steps in Procedure - make sure that all necessary equipment (slings, hooks, chains, straps, and
supports) is on hand and in good condition.
2.) Sling Care - discard any worn, frayed, or ripped slings.


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146 E. 28th Street
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F 0689 Review of the record revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES
REDACTED].
jeopardy to resident health or Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/2020 revealed
safety Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14 (score of 13-15 indicated cognitively
intact). Resident #3 required extensive assistance with bed mobility and transfers, and had impaired mobility
Residents Affected - Few to her upper and lower extremities bilaterally. Resident #3 had one fall with major injury since her last
admit/reentry/prior assessment.
Review of Resident #3's record revealed a care plan was developed with an onset date of 10/12/2017 which
identified Resident #3 with impaired mobility related to Left and Right BKA, limited Range of Motion (ROM),
was blind, and used a mechanical lift. One approach included to evaluate the use of assistive devices for
transferring from bed to chair. Resident #3 was further identified at risk for falls with an onset date of
10/12/2017 due to impaired mobility, left and right BKA, and limited ROM. A revision was made to include a
fall with injury on 05/26/2020. Two new approaches dated 05/27/2020 were added which included x-ray
mobile care left stump, and referred to orthopedic MD and splint applied per orders.
Review of Resident #3's nurse's notes revealed, in part, the following:
05/26/2020 at 11:21am - The nurse was called to the room by the Certified Nursing Assistant (CNA). Upon
assessment, the resident was found sitting upright on the floor. The CNA stated that Resident #3 fell during
transfer with the mechanical lift. Upon assessment, the sling pad was found to have one of the clips ripped
from the seam. A small abrasion was noted to Resident #3's left limb. The site was cleansed and a bandage
was applied to the area. Resident #3 complained of pain at a level 4 on a scale of 10.
05/26/2020 at 2:10pm - Resident #3 complained of pain to her left stump.
05/27/2020 at 10:24am - Resident #3 complained of left stump pain related to yesterday's fall. Received a
verbal order for a mobile x-ray to her left stump.
05/27/2020 at 4:00pm - Received x-ray. Result is for non-displaced [MEDICAL CONDITION] left fibula.
Review of Resident #3's physician's orders [REDACTED].
Review of Resident #3's May 2020 Medication Administration Record [REDACTED]
05/26/2020 - 3 doses, times and initials illegible.

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146 E. 28th Street
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F 0689 05/31/2020 - 4 doses, times and initials illegible.
Level of Harm - Immediate Review of Resident #3's mobile x-ray results dated 05/27/2020 revealed, in part, the x-ray was indicated for
jeopardy to resident health or pain and trauma, and was positive for non-displaced [MEDICAL CONDITION] left fibula.
safety
Review of CNA in-service training record dated 05/27/2020 revealed documentation of in-service training
Residents Affected - Few regarding lift pad inspection prior to use. Training included before placing a resident on a lifter pad, assure
pad is in proper working order (no rips, holes, frayed edges or seams that are not intact). If lifter pad is not in
proper working order, discard and notify CNA Supervisor to issue a new one to the resident.
Review of a CNA monitoring tool revealed documentation of lift pad inspections which were conducted on
05/28/2020, after Resident #3's fall on 05/26/2020. Further review revealed pads were numbered one (1)
through eleven (11). Further review revealed pads nine (9) and ten (10) were identified with holes.
In an interview on 08/25/2020 at 2:00pm, Resident #3 stated she fell from the mechanical lift when a strap on
the sling pad ripped. Resident #3 was unable to recall the date of the accident. Resident #3 stated her leg
was in pain. When her pain did not diminish, Resident #3 stated they did an x-ray, and her leg was broken.
Resident #3 stated she continued to be nervous when staff used the mechanical lift. Resident #3 stated she
continued to have discomfort in her left leg. Observation at this time revealed Resident #3 lying in bed, with a
night shirt on and her lower limbs exposed. Resident #3 had BKA amputations bilaterally. No apparent signs
of trauma to Resident #3's exposed limbs.
In an interview on 08/25/2020 at 3:15pm, S6CNA Supervisor confirmed Resident #3 fell from the mechanical
lift on 05/26/2020 when the mechanical lift sling pad ripped as she was being transferred from the bed to the
wheelchair. S6CNA Supervisor stated since Resident #3's fall, she now inspected the pads monthly for rips,
tears, and frayed edges. S6CNA Supervisor further stated after Resident #3's fall on 05/26/2020, employees
were in-serviced to inspect pads for wear and tear prior to each use. S6CNA Supervisor further stated she
was unaware of the manufacturer's recommendations of replacing sling lift pads every 6 months. S6CNA
Supervisor further stated that upon inspection of the remaining sling lift pads in use on 05/28/2020, two (2)
sling lift pads, #9 and #10 were identified with holes. S6CNA Supervisor confirmed these two (2) pads, pads
numbered 9 and 10, were in circulation for use on residents between 05/26/2020 through 05/28/2020.
S6CNA Supervisor stated pads #9 and #10 were discarded on 05/28/2020. S6CNA Supervisor further stated
she was unable to inspect the mechanical lift sling pad used for Resident #3 on 05/26/2020 because it was
discarded by staff after Resident #3's fall. S6CNA Supervisor confirmed she was not inspecting mechanical
lift sling pads for rips, tears, frayed edges and/or holes monthly prior to Resident #3's fall and injury on
05/26/2020.
In an interview on 08/28/2020 at 10:30am, S3CNA stated she and S4CNA were transferring Resident #3
from her bed to her wheelchair with a mechanical lift. When they lifted her, the sling pad ripped near the
corner, and Resident #3 fell to the floor. S3CNA was shown a manufacturer's picture of the sling lift pad
which was provided to this surveyor by the facility, and pointed to an upper corner of the sling pad where it
ripped. S3CNA stated Resident #3 complained of pain to her left knee. S3CNA further stated Resident #3
complained of leg pain the following day, at which time an x-ray was done and her knee was broken. S3CNA
stated she was unsure of the manufacturer's recommendations for time frames of pad replacements. S3CNA
stated she received in-service training after Resident #3's fall, which included instructions on inspecting
mechanical lift sling pads for any defects prior to use.

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146 E. 28th Street
Cut Off, LA 70345

F 0689 In an interview on 08/31/2020 at 11:16am, S4CNA stated on 05/26/2020, she was assisting S3CNA with
transferring Resident #3 from her bed to a wheelchair using a mechanical lift. After Resident #3 was placed
Level of Harm - Immediate in the sling lift pad and lifted, they turned her to put her in the chair. One of the sling lift pad straps near
jeopardy to resident health or Residents #3's shoulder ripped, and she tumbled out of the sling onto the floor. S4CNA stated Resident #3
safety later complained of pain to her left leg. S4CNA stated they always looked at the pads prior to use, but now,
the inspection is more detailed. Any fraying, tearing, ripping, or any imperfections must be reported
Residents Affected - Few immediately, and they are not to use the sling. S4CNA stated she received in-service training regarding
inspecting lift pads after Resident #3's fall. S4CNA stated she was unsure of the manufacturer's
recommendations for time frames of pad replacements.
In an interview on 08/31/2020 at 9:41am, S1Director of Nursing (DON) stated prior to Resident #3's fall on
05/26/2020, staff were to inspect all mechanical lift sling pads prior to use for holes, frayed edges, tears
and/or rips. If any holes, tears, rips, and/or frayed edges were identified, the pad was not to be used. After
Resident #3's fall on 05/26/2020, the facility initiated a plan to inspect all mechanical sling lift pads prior to
each use, and a monthly inspection by S6CNA Supervisor for wear and tear. S1DON stated she was unable
to provide documented evidence of when the pad used on Resident #3 on 05/26/2020 was first purchased,
or put out into circulation for use. S1DON stated she was unaware of the manufacturer's recommendations
to replace sling lift pads every six (6) months.
In an interview on 08/31/2020 at 10:03am, S2Corporate Nurse stated mechanical lift sling pads were
replaced as needed. S2Corporate Nurse confirmed she was unaware of the manufacturer's
recommendations of replacing lift sling pads every six (6) months.
There was no documented evidence and the facility presented no documented evidence of systemic
processes for monitoring mechanical lift sling pads for defects and/or excessive wear and tear prior to
Resident #3's fall on 05/26/2020.
Observation of sampled Resident #4 on 08/31/2020 at 12:23pm revealed Resident #4 was observed being
transferred using a mechanical lift and mechanical lift sling pad from her wheelchair to her bed. Observation
further revealed 2 staff members inspected the pad prior to use, and it had no rips, tears, holes, or frayed
edges.
The facility has implemented the following actions to correct the deficient practice effective 05/28/2020 at
8:00am:
1.) On 05/26/2020, the lift pad used during transfer of identified Resident #3 was discarded and replaced with
a new one.
2.) On 05/27/2020, CNA staff were educated by S1DON on the importance of inspecting lifter pads before
placing a resident on the pad to assure they are in the proper working order. If not in proper working order,
CNA is to discard the pad and notify S6CNA Supervisor to issue a new pad. Staff are to always use two (2)
people when using a mechanical lift to ensure none of the other 14 residents who could potentially use
mechanical lift transfer assistance were affected.
3.) On 05/28/2020, all lifter pads in the facility were numbered. S1DON developed a monitoring tool to
ensure lifter pads are in proper working order and implemented by S6CNA Supervisor. Any pads noted with
issues were discarded. All old pads were discarded and an order was placed to increase inventory. All newly
purchased pads will be numbered upon being put into use.

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F 0689 4.) S6CNA Supervisor will conduct visual inspections of lifter pads monthly, and document findings on the
monitoring tool. Any pads noted with issues will be discarded and replaced.
jeopardy to resident health or 5.) Date of Compliance: 05/28/2020.
safety

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146 E. 28th Street
Cut Off, LA 70345

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
potential for actual harm Based on interviews and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA) used
a mechanical lift with 2 staff members as required per facility policy which resulted in a resident sustaining a
Residents Affected - Few fall.
This deficient practice was identified for 1 (Resident #4) of 5 sampled residents, and had the potential to
affect any of the 17 residents who required mechanical lift transfers. The facility census was 77 as
documented on the facility's resident census list.
Findings:
Review of the facility's Policy and Procedure titled Lifting Machine, Using a Mechanical (lift) revealed, in part,
at least two nursing assistants are needed to safely move a resident with a mechanical lift.
In an interview on 08/28/2020 at 10:20am Resident #4 stated that while on the stand up lift, she fell off of it
and the staff that did it did not know what she was doing.
Review of Resident #4 Incident Report dated 06/17/2020 at 6:30pm revealed, in part, the resident was
uninjured from a fall while on the stand up lift.
Review of a written statement by S7Certified Nursing Assistant (C.N.A) dated 06/17/2020 revealed, in part,
as S7C.N.A was lifting Resident #4 up in the lifter the Resident #4 complained of her back hurting. Resident
#4 was lowered back down at the edge of her chair and the resident slid off her chair onto the floor. The
resident's leg was pressed up against her chair and the lifter.
In an interview on 08/28/2020 at 10:15am, S6C.N.A. Supervisor stated that the stand-up lift secures the
resident with the belts so she did not see how the resident could have slipped out of the stand-up lift. She
further stated S7C.N.A did not have any training on the lift so we trained her the next day on 06/18/2020.
She further stated S6C.N.A should have had two staff present when lifting Resident #4.
In an interview on 08/31/2020 at 10:25am, S1Director of Nursing stated that the incident of the fall occurred
from the resident on a stand up lift and the C.N.A. should of have had two staff at the time and there was
only one. She stated she was not sure if the belt under the resident's arms was not attached or it was during
the time when the C.N.A. was transferring the resident over to her bed when the fall occured.
In an interview on 08/31/2020 at 2:18pm, S7C.N.A stated she was using the stand-up mechanical lift by
herself and the resident slid off the lift as she was raising the lift up.

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5301 Tullis Drive
River Palms Nursing & Rehab, L L C

or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few Based on interviews and record reviews, the facility failed to ensure a physician's order was transcribed and
implemented as required in the person centered care plan. This deficient practice was identified for 1
(Resident #124) of 58 residents reviewed in the investigation stage, and had the potential to affect any of the
173 residents who resided in the facility as documented on the Resident Census and Conditions of
Residents Form CMS-672.
Findings:
Review of the record revealed Resident #124 was admitted to the facility on [DATE] with a diagnoses, in
part, of Major [MEDICAL CONDITION] and [MEDICAL CONDITION].
Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/10/2020 revealed,
in part, Resident #124 received an antidepressant 7 of 7 days during the look back period.
Review of Resident #124's care plan with a problem onset date of 09/10/2020 revealed, in part, medication
observation for significant side effects related to need for antidepressant medications (Trazadone), with an
approach to administer medications as ordered. Further review revealed Resident #124 had impaired
thought processes related to a [DIAGNOSES REDACTED].
Review of Resident #124's record revealed a physician's order dated 10/16/2020 to increase Trazadone (an
antidepressant) to 50 milligrams (mg) by mouth at bedtime; [MEDICATION NAME] (a sleep aid) 5mg by
mouth at bedtime; Psych consult due to increased agitation and [MEDICAL CONDITION]. Further review
revealed the area on the order labeled signature of nurse receiving order, date, and time, was blank. Further
review revealed on the lower portion of the order an area titled Nurse: please initial the documentation record
as performed was also blank.
Review of Resident #124's October 2020 Medication Administration Record [REDACTED]. Further review
revealed no documentation of change in treatment to indicate Trazadone was increased to 50mg every night,
and no addition of [MEDICATION NAME] on the MAR.
Review of Resident #124's clinical record revealed no documented evidence of a Psychiatric consult as
ordered on [DATE].


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F 0656 In an interview on 10/21/2020 at 1:33pm, S4CorporateNurse reviewed Resident #124's physician's orders
dated 10/16/2020 and confirmed that the orders had not yet been transcribed and/or implemented.

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F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Residents Affected - Few Based on record review and interview the facility failed to revise a resident's care plan after a fall for 1
(Resident #20) of 58 sampled residents reviewed. This deficient practice had the potential to affect any of the
173 residents that resided in the facility as documented on the Residents Census and Conditions form
(CMS-672) Census List.
Findings:
Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses, in part, of
[MEDICAL CONDITION] Disorder and Hypertension
Review of Resident #20's Minimum Data Set (MDS) with an Assessment Reference Date dated 08/13/2020
revealed a Brief Interview for Mental Status (BIMS) score of 11 and required limited assistance with one
person physical assist for bed mobility, transfers, dressing, bathing and locomotion. Further review revealed
Resident #20 had arthritis and suffered from [MEDICAL CONDITION].
Review of the medical record revealed a care plan was not revised for Resident #20's fall that was reported
to nursing on 08/03/2020.
Review of Resident #20's nurse's notes dated 08/03/2020 at 11:00am revealed, in part, Resident #20 stated
she fell the day before out of her chair and complained of mid-ower back pain. Further review of Resident
#20's nurse's notes revealed Resident #20 was transferred to a local hospital via ambulance.
Review of Resident #20's incident report dated 08/03/2020 revealed equipment involved was a wheelchair.
Review of the physical therapy plan of care dated 08/17/2020 revealed, in part, Resident #20 was
hospitalized [DATE]-08/13/2020 for an injury that occurred while transferring from her bed to wheelchair
resulting in a left superior pubic fracture.
In an interview on 10/21/2020 at 2:28pm, Resident #20 indicated she fell while transferring from her bed to
her wheelchair, but did not report it to the nurse until the next day.
In an interview on 10/21/2020 at 2:40pm, S1Administrator stated the care plan did not reflect an updated or
revision for Resident #20 after her fall.

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F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Based on observation, record review, and interview the facility failed to ensure 1 (Resident#78) of 58
Residents Affected - Some residents reviewed in the investigation stage received showers every other day and the facility failed to
ensure 1 (Resident #139) of 58 residents reviewed in the investigation stage received nail care. This
deficient practice had the potential to affect any of the 173 residents who resided in the facility as
documented on the Resident Census and Conditions of Residents Form (CMS-672).
Findings:
Resident #78
Review of Resident #78's record revealed an admitted on 05/08/2020 with [DIAGNOSES REDACTED].
Review of Resident #78 's Minimum Data Set with an Assessment Reference Date of 08/06/2020 revealed a
Brief Interview for Mental Status score of 11 (score of 8-12 was moderately impaired) and he required one
person physical help, with transfers only, for bathing.
Review of Resident #78's Care Plan revealed in part, a problem identified for activities of daily living (ADL)
self-care deficit with personal hygiene and bathing related to disease process with approaches to report
changes in activities of daily living self-performance to nurse.
In an observation and interview on 10/19/2020 at 9:28am, Resident #78 was questioned if he gets a shower
every other day and Resident #78 stated no, he only gets a shower when he asks for one. Resident #78 was
sitting in his wheelchair with a long ungroomed beard. When surveyor asked him if he wanted a shave he
stated yes, but he had to purchase his own razors and was waiting for his check.
Review of Resident #78's Certified Nursing Assistant (CNA) ADL sheets dated September 2020 revealed
only documentation of a shower was on 09/02/2020 and the only refusals for a shower was documented on
09/01/2020, 09/03/2020, 09/10/2020, 09/12/2020. Further review of Resident #78's September 2020 CNA
ADL sheet revealed no other documentation of a shower or refusals of a shower for the month of September
2020.
Review of Resident #78's Certified Nursing Assistant (CNA) ADL sheets dated October 2020 revealed only
documentation of a shower was on 10/01/2020, 10/02/2020, 10/03/3030, 10/12/2020, 10/14/2020, and
10/17/2020. Further review of Resident #78's October 2020 CNA ADL sheet revealed no other
documentation of a shower or refusals of a shower for the month of October 2020.
In an interview on 10/20/2020 at 1:50pm, S2Director of Nursing (DON) stated a resident can have a
bath/shower every day if they want one, but all other residents receive a shower every other day. S2DON
stated the facility does not have a shower team and the CNAs working on each hall are responsible for
showering their own residents.

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5301 Tullis Drive

F 0676 In an interview on 10/21/2020 at 11:15am, S13CNA stated the even numbered rooms are showered on
Monday, Wednesday and Friday and the odd numbered rooms are showered on Tuesday, Thursday and
Level of Harm - Minimal harm or Saturday. S13CNA stated the A beds are done in the morning and the B beds are done in the evening.
potential for actual harm S13CNA stated Resident #78 would be showered in the mornings because he was in an A bed. S13CNA
stated they document showers on the ADL flowsheet.
In an interview on 10/21/2020 at 11:35am, S2DON was informed of Resident #78 stating he was not
receiving his showers at least every other day. S2DON stated she was unaware Resident #78 was not
getting his showers. After reviewing Resident #78's CNA ADL sheets dated September 2020 and October
2020, S2DON confirmed there was no documentation of Resident #78 receiving his shower every other day.
S2DON stated if a resident refused a shower/bath then the CNAs should document an R for refusal.
Resident #139
Record review revealed Resident #139 was admitted on [DATE] with diagnoses, in part, of [MEDICAL
CONDITIONS] with left side [MEDICAL CONDITION] and Diabetes.
Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/08/2020 revealed
Resident #139 had a Brief Interview for Mental Status score (BIMS) of 12 which indicated mild impairment
and required extensive assistance with one person physical assist with personal hygiene.
Review of Resident #139's medical record revealed a care plan was developed for care deficit related
[MEDICAL CONDITIONS] with a goal date to have activity of daily living (ADL) needs met every day with
appropriate assistance, groomed, dressed, bathed, fed, transferred with approaches, in part, to keep
fingernails neat and trimmed.
Observation on 10/19/2020 at 1:21pm revealed Resident #139 with long fingernails with dark substance
underneath nails on both hands.
Observation on 10/21/2020 at 3:20pm revealed Resident #139 with long fingernails with dark colored
material underneath on both hands.
In an interview on 10/21/2020 at 3:21pm, Resident #139 indicated he would like to have his fingernails
clipped and cleaned.
In an interview on 10/21/2020 at 3:29pm, S16Charge Nurse indicated the nurse was responsible for
performing nail care to a Diabetic resident.

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F 0695 Provide safe and appropriate respiratory care for a resident when needed.
Based on observations, interviews and record reviews, the facility failed to ensure a resident's oxygen
Residents Affected - Some humidifier bottle was changed and kept filled per facility policy. This deficient practice was identified for 1
(Resident #34) of 58 residents reviewed in the investigation stage, and had the potential to affect any of the
173 residents who resided in the facility as documented on the Resident Census and Conditions of
Residents Form (CMS-672).
Findings:
Review of the facility's policy titled Department (Respiratory Therapy) - Prevention of infection revealed, in
part, Check water levels of refillable Humidifier units daily. If the water level falls below the fill line: discard
residual solution. Pour a small amount of distilled water into the reservoir and swish around to rinse all
surfaces. Discard water refill with distilled water to fill line. Use distilled water for humidification per facility
protocol.
Review of Resident #34's record revealed, in part, an admitted [DATE] with [DIAGNOSES REDACTED].
Review of Resident #34's Minimum Data Set with an Assessment Reference Date of 05/7/2020 revealed, in
part a Brief Interview for Mental Status score of 15 (cognitively intact), and recieved oxygen therapy.
Review of Resident #34's Care plan revealed, in part, a problem identified for impaired breathing patterns
related to disease process; need for continuous oxygen for shortness of breath with an onset date of
05/07/2020. Further review of the care plan revealed approaches, in part, uses oxygen, and if not in use
place cannula in plastic bag, and change oxygen tubing every week.
Review of Resident #34's Physician orders [REDACTED].
Further review of Resident #34's MAR pertaining to the order to change of oxygen humidifier bottle (distilled
water) every week revealed, in part, the following: July 2020 not documented as being done; August 2020
MAR indicated [REDACTED].
Observation on 10/18/20 at 12:16pm revealed Resident #34's using the oxygen condenser per nasal
cannula, and the oxygen condenser humidifier bottle was dated 07/05/2020 and empty.
Observation on 10/19/2020 at 09:23am revealed Resident #34 was using his oxygen condenser per nasal
cannula, and the oxygen condenser humidifier bottle was dated 07/05/2020 and empty.
Observation on 10/20/2020 at 10:32am revealed Resident #34's oxygen was in use per nasal cannula, and
the oxygen condenser humidifier bottle was dated 07/05/2020 and had no distilled water for humidified
oxygen.

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F 0695 Observation 10/20/2020 at 11:30am revealed Resident #34's oxygen humidifier bottle dated 07/05/2020 was
empty and oxygen condenser was in use.
potential for actual harm In an interview on 10/20/2020 at 10:32am, Resident #34 stated no one had ever refilled his humidification
bottle nor had it been changed since 07/05/2020 as dated on the bottle.
In an interview on 10/20/2020 at 1:03pm ,S12Licensed Practical Nurse (LPN) stated she did not check
Resident #34's humidification bottle today. She stated she only checked that his oxygen was on.
In an interview on 10/20/2020 at 12:40pm, S3Corporate Nurse stated the date on the bottle was 07/05/2020
and it was empty. She further stated that the bottle should have been changed according to policy and
should not have been empty.

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Residents Affected - Some Based on observations, interviews, and record reviews, the facility failed to ensure nursing competencies as
evidenced by:
1.) Failing to ensure controlled medications were accurately counted (#41, #42, #60, #115, #131, #136, and
#148);
2.) Failing to ensure controlled medications were documented as administered (#41, #66. #115, #131, #136,
and #148); and
3.) Failing to transcribe medications correctly onto the Individual Patient's Narcotics Record (#41 and #66).
This deficient practice was identified for 8 (#41, #42, #60, #66, #115, #131, #136, and #148) of 58 residents
reviewed in the investigation stage, and had the potential to affect any of the 173 residents who resided in
the facility as documented on the Resident Census and Conditions of Residents Form CMS-672.
Findings:
An observation of medication storage of Cart B was conducted on 10/20/2020 at 3:11pm. The following
discrepancies were found:
Resident #41:
Review of Resident #41's pill punch card labeled [MEDICATION NAME]/APAP 5:325milligrams (mg) (pain
medication substituted for [MEDICATION NAME]) revealed there were 24 pills left on the card.
Review of Resident #41's Individual Patient's Narcotics Record sign out sheet revealed the page was not
labeled with the resident's name, and/or the name of the medication. Further review revealed the amount
remaining was 25 tablets. Further review revealed between 10/13/2020 and 10/19/2020, 14 doses of this
medication was signed out as dispensed to Resident #41.
Review of Resident #41's October 2020 Medication Administration Record [REDACTED].
In an interview on 10/20/2020 at 3:11pm, S14Licensed Practical Nurse (LPN) confirmed the Individual
Patient's Narcotic Record sign out sheet was for Resident #41's [MEDICATION NAME]/APAP 3:325mg pain
medication, confirmed the count was incorrect, and confirmed the doses were not documented on the
October 2020 MAR.
Resident #42:
Review of Resident #42's pill punch card labeled [MEDICATION NAME] 0.5mg (anticonvulsant substituted
for Klonopin) revealed there were 18 pills left on the card.

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F 0726 Review of Resident #42's Individual Patient's Narcotics Record sign out sheet revealed the amount
remaining was 19 tablets.
potential for actual harm Resident #60:
Residents Affected - Some Review of Resident #60's pill punch card labeled [MEDICATION NAME] tablets 100mg (anticonvulsant)
revealed there were 15 pills left on the card.
Review of Resident #60's Individual Patient's Narcotics Record sign out sheet labeled [MEDICATION NAME]
100mg revealed the amount remaining was 16 tablets.
Resident #66:
Review of Resident #66's pill punch card labeled [MEDICATION NAME] (HCL) 5mg tablet (pain medication
substituted for [MEDICATION NAME]) revealed there were 13 tablets left on the card.
Review of Resident #66's Individual Patient's Narcotics Record sign out sheet labeled [MEDICATION NAME]
5mg revealed between 10/12/2020 and 10/21/2020, there were 18 doses documented as dispensed to
Resident #66.
In an interview on 10/20/2020 at 3:11pm, S5LPN confirmed the sign out sheet labeled [MEDICATION NAME]
5mg was being used as the sign out sheet for [MEDICATION NAME] HCL 5mg tablets.
Review of Resident #66's October 2020 MAR indicated [REDACTED].
Review of Resident #66's October 2020 physician's orders [REDACTED].
In a telephone interview on 10/22/2020 at 09:01am, the facility's contracted pharmacist confirmed that
[MEDICATION NAME] is not [MEDICATION NAME], and Resident #66 was ordered [MEDICATION NAME]
5mg tablets as verified with the prescription number.
Resident #115:
Review of Resident #115's pill punch card labeled [MEDICATION NAME] 50mg tablets (pain medication
substituted for [MEDICATION NAME]) revealed there was 8 pills left on the card.
Review of Resident #115's Individual Patient's Narcotics Record sign out sheet labeled [MEDICATION
NAME] 50mg revealed the amount remaining was 9 pills. Further review revealed between 10/06/2020 and
10/18/2020, there was 21 pills signed out as dispensed to Resident #115.
Resident #131:
Review of Resident #131's pill punch card labeled [MEDICATION NAME] 300/30mg (pain medication
substituted for Tylenol with [MEDICATION NAME] #3) revealed there were 10 tablets left on the card.

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F 0726 Review of Resident #131's Individual Patient's Narcotics Record sign out sheet labeled Tylenol #3 revealed
the amount remaining was 11 pills. Further review revealed between 10/06/2020 and 10/19/2020, there were
Level of Harm - Minimal harm or 19 pills signed out as dispensed to Resident #131.
Resident #136:
Review of Resident #136's pill punch card labeled [MEDICATION NAME] 10mg tablets (used for pain relief
and to treat drug addiction) revealed there were 6 tablets left on the card.
NAME] 10mg revealed the amount remaining was 7 tablets.
Review of Resident #136's pill punch card (2 cards) labeled [MEDICATION NAME]/APAP 10-325mg tablets
revealed there were 35 tablets left on the cards.
NAME]/APAP ([MEDICATION NAME]) 10-325mg tablets revealed the amount remaining was 36 tablets.
Further review revealed between 10/18/2020 and 10/20/2020, there were 9 tablets signed out as being
dispensed to Resident #136.
Resident #148:
Review of Resident #148's pill punch card labeled [MEDICATION NAME] 1mg tablet (antianxiety) revealed
there were 5 tablets left on the card.
Upon review of Resident #148's Individual Patient's Narcotics Record sign out sheet labeled [MEDICATION
NAME] 1mg during medication storage, it was noted the amount remaining was 6 tablets. Upon receipt of the
requested copy of the sheet, it was noted that the count remaining was changed to 5 tablets. Further review
revealed between 10/17/2020 and 10/20/2020, there was 6 tablets signed out as dispensed to Resident
#148.
In an interview of 10/20/2020 at 3:30pm, S5LPN confirmed she altered the document prior to providing the
surveyor with a copy, and confirmed she administered the medication, but did not complete the count sheet
at that time.
Review of the facility's policy titled Documentation of Medication Administration revealed, in part, the facility
shall maintain a Medication Administration Record [REDACTED]. (MAR).
Administration of medication must be documented immediately after (never before) it is given.

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F 0726 In a joint interview on 10/22/2020 at 10:30am, S3Corporate Nurse and S4Corporate Nurse reviewed the
above findings with this surveyor, and confirmed the count for the controlled medications were not
Level of Harm - Minimal harm or documented accurately, confirmed incomplete and incorrect transcription of medications onto the Individual
potential for actual harm Patient's Narcotics Records sign out sheets, and confirmed medications were not documented as given on
the MARs.

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F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
Residents Affected - Some Based on observation, interview and record review the facility failed to ensure residents food preferences
were honored for 2 (Resident #67 and Resident #102) of 58 residents reviewed in the investigation stage,
and had the potential to affect any of the 173 residents, who received food from the kitchen, as documented
on the Resident Census and Conditions of Residents Form CMS-672.
Findings:
Review of the facility's policy titled Resident Food Preferences revealed in part, upon the resident's
admission the Dietitian or nursing staff will identify a resident's food preferences. When possible, staff will
interview the resident directly to determine current food preferences based on history and life patterns
related to food and mealtimes.
Resident #67
Review of Resident #67's record revealed an admitted [DATE] with [DIAGNOSES REDACTED].
Review of Resident #67's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of
08/06/2020 revealed in part, a Brief Interview for Mental Status score of 12 (score of 8-12 was moderately
impaired), and received a therapeutic diet.
Review of Resident #67's October physician's orders [REDACTED].
In an interview on 10/18/2020 at 11:07am, Resident #67 stated he told the kitchen staff that he did not like
broccoli on his tray, he requested double portions and filled out a preference paper already. Resident #67
stated the kitchen person told him they needed another order for double portions when he came back from
the hospital and Resident #67 stated nothing was done. Resident #67 stated he was not receiving double
portions with his meals as requested.
Review of Resident #67's meal ticket on 10/19/2020 at 12:42pm revealed no concentrated sweet
(NCS)/regular diet and milk with all meals. Further review of Resident #67's meal ticket revealed under
Special Notes: no oatmeal, no green beans, low fat milk at all meals, no brussels sprout, no black eye peas,
no fried food, no juice, water, and double portions.
In an interview on 10/19/2020 at 12:40pm, Resident #67 stated he told the kitchen people he did not like red
beans and that was what they were serving him for lunch.
Observation of Resident #67's meal tray on 10/19/2020 at 12:43pm revealed Resident #67 was not served
double portions as requested and red beans and rice were on his lunch meal tray.
In an interview on 10/19/2020 at 12:45pm, S9Registered Dietician looked at Resident #67's meal tray and
stated Resident #67's meal tray was a large portion and not a double portion. S9RD reviewed Resident #67's
meal ticket and confirmed there was no documentation of his preference for no broccoli and no red beans.

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F 0806 In an interview on 10/20/2020 at 11:30am, S6Dietary manager stated double portions for the lunch meal
would consist of two scoops of rice, six meatballs and two egg rolls.
potential for actual harm In an interview on 10/20/2020 at 2:30pm, Resident #67 stated for his lunch meal he had one and half scoops
of rice, three meatballs and no egg rolls on his meal tray. Resident #67 denied having double portions for his
Residents Affected - Some lunch meal on 10/20/2020.
In an interview and observation on 10/22/2020 at 8:30am, Resident #67 was sitting on the side of his bed
with his breakfast meal in front of him. His breakfast meal consisted of two strips of bacon, one biscuit, one
serving of grits and one serving of eggs and a carton of chocolate milk. Resident #67 stated he did not
receive double portions on his breakfast tray this morning or last night for his supper meal. Review of
Resident #67's breakfast meal ticket revealed in part, double portions and no chocolate milk listed.
In an interview on 10/22/2020 at 8:35am, S10Certified Nursing Assistant (CNA) stated she delivered
Resident #67's breakfast tray to him and she did not read his meal ticket before giving Resident #67 his
breakfast tray. S10CNA stated she did not read his ticket that stated no chocolate milk and she served
Resident #67 chocolate milk on his breakfast tray. S10CNA walked with the surveyor to Resident #67's room
and when S10CNA was asked if Resident #67 was served double portions on his breakfast tray, she replied
no it was not double portions.
In an interview on 10/19/2020 at 12:55pm S9Registered Dietician stated she was aware there was an issue
with resident meal preferences.
Resident #102
Review of the record revealed Resident #102 was admitted to the facility on [DATE] with [DIAGNOSES
REDACTED].
Review of Resident #102's Minimum Data Set with an Assessment Reference Date of 09/10/2020 revealed,
in part, a Brief Interview for Mental Status score of 6 (severe cognitive impairment). Impairment), required
extensive assistance with most activities of daily living and required limited assistance with eating.
Review of Resident #102's Care Plan Revealed in part, mechanical soft diet (onset 07/11/2019) with
approaches to weigh resident as scheduled and document results and monitor dietary regime compliance by
resident.
Review of Resident #102's October 2020 Physician orders [REDACTED].
06/05/2020 - pureed diet, double portions, double gravy, chocolate milk with all meals
02/26/2020 - Med pass, administer 8 ounce portion each day; and
09/10/2020 - puree with double gravy portion on meat. Change med pass to 4 ounces three times a day.
Increase Z-calorie to 80 ounce bolus 4 times a day.
Review of Resident #102's monthly weights from 4/16/2020 thru 10/07/2020 revealed, in part:

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F 0806 On 04/16/2020, the resident weighed 127.90 lbs. On 10/07/2020, the resident weighed 122.5 pounds which
is a -4.22 % Loss.
potential for actual harm On 07/03/2020, the resident weighed 124.10 lbs. On 10/07/2020, the resident weighed 122.5 pounds which
is a -1.29 % Loss.
On 09/02/2020, the resident weighed 123.60 lbs. On 10/07/2020, the resident weighed 122.50 pounds which
is a -0.89 % Loss. No significant weight loss identified.
Review of Resident #102's nutritional consult done 09/09/2020 revealed, in part: Clarify diet order to puree
with double portion gravy on meat.
An observation on 10/21/2020 at 5:30 pm revealed a plate with 2 scoops of potatoes, 1 large scoop of
pureed casserole, pudding, large serving of pureed vegetable and chocolate milk.
An observation of Resident #102's Breakfast tray on 10/22/2020 at 7:40am revealed, in part, a meal ticket
stating: Special notes: Chocolate Milk with all meals, double portion. Double butter, double gravy.
An observation of Resident #102's breakfast tray on 10/22/2020 at 7:40am revealed, in part, servings:
observed 1 bowl oatmeal, puree sausage, scramble eggs and chocolate milk.
In an interview on 10/22/2020 at 7:40am, S11Certified Nursing Assistant (CNA) stated Resident #102's meal
tray was not double portions.
In an interview on 10/22/2020 at 9:40am, S6Dietary Manager stated a double portion of this morning's
breakfast would consist of 2 scoops of scrambled eggs, 2 bowels of oatmeal, 2 puree biscuits and 2 portions
of puree sausage.She further stated Resident #102 was suppose to have a double portion tray.
In an interview on 10/22/2020 at 9:45am, Resident #102 stated he only ate some of his eggs. He stated he
did receive another plate of breakfast food, but was not hungry this morning.
In an interview on 10/22/2020 at 9:50am, S12Licensed Practical Nurse, (LPN) stated she noted Resident
#102 did not have double portions this morning for his breakfast.
In an interview on 10/22/2020 at 10:15am, S11CNA stated Resident #102 was supposed to get double
portions at meals.

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F 0809 Ensure meals and snacks are served at times in accordance with residents needs, preferences, and
requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to
Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to ensure snacks are served at times in accordance
with resident's needs, preferences and requests. The facility failed to offer snacks to residents outside of
scheduled meal service times for 2 (Resident #67 and Resident #161) of 58 residents reviewed in the
investigation stage, and had the potential to affect any of the 173 residents, capable of consuming a snack,
who resided in the facility as documented on the Resident Census and Conditions of Residents Form
(CMS-672).
Findings:
Resident #67
08/06/2020 revealed in part, a Brief Interview for Mental Status score of 12 (score of 8-12 was moderately
impaired), and received a therapeutic diet.
Review of Resident #67's October physician's orders [REDACTED].>Review of Resident #67's September
2020 Certified Nursing Assistant (CNA) Activity of Daily Living (ADL) Tracking Form revealed in part, no
documentation of a bedtime snack offered and/or accepted from 09/01/2020 through 09/11/2020 and from
09/20/2020 through 09/30/2020.
Review of Resident #67's October 2020 CNA ADL Tracking Form revealed in part, no documentation of a
snack offered on 10/14/2020, 10/16/2020, and 10/19/2020.
In an interview on 10/18/2020 at 11:07am, Resident #67 stated he had asked the kitchen staff for a night
time sandwich and he was not getting his night time sandwich. Resident #67 stated the facility was not
consistent with giving him his night time sandwich. He stated in the last few weeks the Certified Nursing
Assistants (CNAs) were not passing out his night time sandwich.
In an interview on 10/21/2020 at 10:00am, S6Dietary Manager stated the kitchen staff distributes the snacks
to each unit around 7:30pm to 8:00pm. S6Dietary Manager stated they bring out fruit, cookies, and
sandwiches to the nurses station. S6Dietary Manager stated she completes a nutrition screen for
preferences, but the preference for snacks was not on her screening tool. S6Dietary Manager stated she
does not receive a list of residents' snack preference; therefore, she was unaware if each resident was
offered their preference of snacks and did not know how many residents requested a night time sandwich.
Surveyor reviewed Resident #67's October 2020 physician's orders [REDACTED].#67's order for a night time
sandwich. S6Dietary Manager confirmed she did not know if a sandwich was offered to Resident #67 nightly.

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F 0809 In an interview on 10/21/2020 at 10:40am, Resident #67 stated he had not received his night time sandwich,
as his snack, from 10/18/2020 through 10/20/2020. During the interview, S9Registered Dietician entered
Level of Harm - Minimal harm or Resident #67's room and began questioning Resident #67 about his snack preferences.
Resident #161
Review of Resident #161's MDS with an ARD of 09/17/2020 revealed a BIMS score of 12 (moderately
impaired).
In an interview on 10/21/2020 at 11:00am, Resident #161, who was Resident #67's roommate, stated he did
not get a preference for snacks. Resident #161 stated he had to get up out of bed and go get snacks at the
nursing station, and when he gets to the nursing station all the snacks are all gone by the time he gets to the
desk. Resident #161 stated the CNA's don't come to his room to pass out snacks every evening.
In an interview on 10/21/2020 at 10:50am S9Registered Dietician confirmed the resident's should receive
their meal and snack preferences.
In an interview on 10/21/2020 at 11:30am, S2Director of Nursing (DON) was informed of Resident #67 and
Resident #161 not getting an evening snack or their snack preference. S2DON confirmed CNAs should go to
each resident and offer a snack and then document on the CNA ADL sheet whether the resident accepted or
refused the snack.

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F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards.
potential for actual harm Based on observations and interview the facility failed to store, prepare, distribute and serve food under
sanitary conditions. This deficient practice was evidenced by the facility failing to ensure:
1.) a cart for storing clean dishes was free from crumbs;
2.) a manual can opener was clean and free of food;
3.) a microwave was clean;
4.) a dusty fan was not present in the kitchen near the food steam table;
5.) a dusty blower was not present in the kitchen area;
6.) a stove was clean with no dried up grease on the back panel;
7.) oven was clean with no black particles on the inside bottom wall;
8.) food in the refrigerator was dated;
9.) rice was discarded within the proper timeframe after cooking;
10.) food temperature logs were accurate;
11.) automatic dishwasher was in working order; and
12.) sanitizer was maintained at the appropriate level for the three-compartment sink.
This deficient practice had the potential to affect any of the residents in the facility who received food from
the facility's kitchen. The facility's census was 173 as documented on the Resident Census and Conditions of
Residents Form CMS-672.
Findings:
During the initial tour of the kitchen on 10/18/2020 at 9:40am, the following was observed:
1.) a rolling cart used to store clean plates and covers had visible crumbs on the bottom of each shelf;
2.) a manual can opener had a build-up of a black substance on the sides of the can opener;
3.) a microwave had dried up food particles on the inside walls;
4.) a fan, with a buildup of dust on the inside blades and outside grill, located on top of the ice machine
located next to the food steam table;

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F 0812 5.) a blower with a buildup of dust on the outside located on a shelf under the microwave;
Level of Harm - Minimal harm or 6.) stove had dried up black particles under the top grill and dried up grease on the back panel;
7.) oven had black particles on the inside bottom wall of the oven;
In an interview on 10/18/2020 at 9:42am S6Dietary Manager stated the rolling cart needed to be cleaned and
she needed to purchase a new can opener and it needed to be cleaned. S6Dietary Manager stated the
microwave was not clean and it should be cleaned daily.
In an interview on 10/18/2020 at 9:50am, S6Dietary Manager stated there was no documentation of cleaning
equipment in the kitchen, but stated the oven should be cleaned every other day and confirmed the oven
was not clean and should have been cleaned on Friday. S6Dietary Manager confirmed the top of the stove
had dried up black particles under the top grill and dried up grease on the back panel of the stove and both
needed to be cleaned.
Review of the facility's policy titled Refrigerators and Freezers revealed in part, all food shall be appropriately
dated to ensure proper rotation by expiration dates. Use by dates will be completed with expiration dates on
all prepared food in refrigerators.
During the initial tour of the refrigerator on 10/18/2020 at 9:55am, the following was observed:
1.) an opened bag of cookie dough, an opened bag of garlic biscuits and an opened bag of bread dough with
no open date on either bag;
2.) nine styrofoam bowls with a piece of chocolate cake in each bowl with no date on the plastic covering;
3.) two bowls of cereal with no date on the plastic covering; and
4.) a metal container full of rice located on the top shelf of the refrigerator covered with plastic wrap dated
10/13.
Observation of the pantry area on 10/18/2020 at 10:05am revealed two packs of gravy mix were opened and
not dated and a pack of marshmallows were opened and not dated.
In an interview on 10/18/2020 at 10:00am S6Dietary Manager stated all items in the refrigerator and pantry
should have a date on them and confirmed there was no date on the items mentioned above. S6Dietary
Manager confirmed the container of rice should have been discarded within 24 hours after being cooked.
Review of the facility policy titled Sanitization, with a revised date of October 2018, revealed in part, manual
washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing:
a. Scrape food particles and wash using hot water and detergent;
b. Rinse with hot water to remove soap residue; and

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F 0812 c. Sanitze with hot water or chemical sanitizing solution.
Level of Harm - Minimal harm or During the kitchen observation on 10/18/2020 at 10:20am S8Dietary Staff was washing an item in the
potential for actual harm three-compartment sink with only water and suds in the wash compartment. There was no water in the rinse
compartment sink and no water in the sanitize compartment sink. There was a pan that had baked on food
Residents Affected - Some particles in the sanitize sink compartment.
In an interview on 10/18/2020 at 10:21am S8Dietary Staff stated she was washing dishes in the
three-compartment sink and S7Dietary Staff checked the sanitizer daily, but not the wash water temperature.
S8Dietary Staff confirmed there was no water in the rinse compartment sink and no water or sanitizer in the
sanitizer compartment sink.
In an interview on 10/18/2020 at 10:23am, S6Dietary Manager confirmed there was no water in the rinse
compartment sink and no water in the sanitize compartment sink and S8Dietary Staff was washing dishes.
In an interview on 10/19/2020 at 1:30pm, S9Registered Dietician (RD) stated her last inspection was on
09/08/2020 and she found some of the same things surveyor found in the kitchen. S9RD confirmed food
should be discarded after 48 hours of being cooked.
Review of the dishwashing temperature/sanitizer record dated September and October 2020 revealed a
wash temperature of 200, a rinse temperature of 120 and sanitizer was documented as 50 parts per million
(PPM) for breakfast, lunch, and supper.
Review of the facility's automatic dishwasher on 10/19/2020 at 11:54am revealed two different stickers on
the dishwasher. One sticker stated the rinse temperature needed to be at least 125 degrees and another
sticker on the dishwasher stated the rinse temperature needed to be at least 120 degrees.
Observation on 10/19/2020 at 11:55am revealed S7Dietary Staff made three attempts to run the dishwasher,
but the dishwasher did not reach a temperature of higher than 115 degrees.
In an interview on 10/19/2020 at 11:58am, S7Dietary Staff stated the water temperature of the dishwasher
has never gotten above 115 degrees and it should be 120 degrees. S7Dietary Staff stated he did not notify
anyone of the problem with the water temperature not being at least 120 degrees.
In an interview on 10/20/2020 at 3:25pm, S6Dietary Manager stated S7Dietary Staff did not inform her of any
problems with the dishwasher temperature gauge.
Review of the food temperature logs for September and October 2020 revealed at the top of the page a
heading titled Hot Foods 160 degrees-140 degrees Fahrenheit and Cold Foods 34 degrees Fahrenheit and
below. Further review of the September and October 2020 logs revealed 160 degrees documented as the
temperature on most of the food items for each day of the logs and 33 degrees documented as the
temperature for most of the cold items for each day of the logs.
In an interview on 10/20/2020 at 3:14pm, S6Dietary Manager reviewed the food temperature logs August,
September and October 2020 with surveyor and confirmed the temperature logs were not accurate because
there was no way all the food temperatures could be 160 degrees Fahrenheit for each food item daily.

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F 0812 In an interview on 10/22/2020 at 9:25am, Resident #32 stated when he gets his food it was cold all the time.
Level of Harm - Minimal harm or 07/03/2020 revealed a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact).
In an interview on 10/22/2020 at 9:30am, Resident #125 stated when he gets his food it was cold all the time.
Residents Affected - Some Review of Resident #125's MDS with an ARD of 09/10/2020 revealed a BIMS score of 15 (cognitively intact).
In an interview on 10/22/2020 at 9:35am, Resident #101 stated when she gets her food it was cold all the
time. Review of Resident #101's MDS with an ARD of 09/17/202 revealed a BIMS score of 13 (cognitively
intact).
In an interview on 10/22/2020 at 9:40am, Resident #168 stated when he gets his food it was cold all the time.
Review of Resident #168's MDS with an ARD of 10/05/2020 revealed a BIMS score of 15.
In an interview on 10/22/2020 at 9:30am, S6Dietary Manager confirmed there was a fan and a blower in the
kitchen and she was not sure who brought either of them into the kitchen. S6Dietary Manager confirmed the
fan was dusty and should not be in the kitchen. S6Dietary Manager also confirmed the blower should not be
in the kitchen and needed to be cleaned.
In an interview on 10/22/2020 at 11:00am S9Registered Dietician confirmed the temperature of each food
item could not be 160 degrees on a daily basis and stated the logs were inaccurate.

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195341 B. Wing 10/22/2020

5301 Tullis Drive

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.
Based on record review and interview, the facility failed to ensure the Quality Assurance (QA) committee
Residents Affected - Some identified quality deficiencies and failed to develop and implement an appropriate plan of action to correct the
deficient practices. The facility failed to have a system in place to ensure:
1.) A physician's orders [REDACTED].
2.) Revise a care plan after a fall;
3.) Activities of Daily Living were maintained for shower and nail care;
4.) A resident's oxygen humidifier bottle was changed per facility policy;
5.) Controlled medications were accurately counted, documented as administered and transcribed correctly
onto the Individual Patient's Narcotics Record;
6.) Food preferences are honored;
7.) Snacks were served at times in accordance with resident requests;
8.) The kitchen was kept clean and sanitary;
9.) An effective infection prevention control program was maintained;
10.) Oxygen cylinder was stored in proper location;
11.) The sanitizer was maintained in the three compartment sink.
The facility had a total census of 173 who resided in the facility as documented on the facility's Resident
Census and Conditions of Residents Form (CMS-672).
Findings:
Cross reference to F656, F657, F676, F695, F726, F806, F809, F812, F880, and F908.
In an interview on 10/22/2020 at 11:55am, S1Administrator confirmed and presented the facility's Quality
Assurance (QA) plan and stated they have corporate rounds monthly with a calendar of scheduled items for
review. If during the corporate reviews something would be identified as a concern, S1Administrator would
develop a QA at that time if necessary. S1Administrator stated during the daily morning meetings the staff
could also bring up any quality concerns that would need to be addressed.
In an interview on 10/22/2020 at 11:55am, S1Administrator confirmed the facility had not identified any of the
above mentioned findings.

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5301 Tullis Drive

Based on observation, interview, and record review the facility failed to maintain an infection prevention and
Residents Affected - Some control program to provide a safe and sanitary environment to help prevent the development and
transmission of communicable disease and infections by failing to:
1.) Ensure shower rooms were clean and in good repair for Hall A, Hall B, Hall C, and Hall D.
2.) Ensure dirty laundry was kept off the floor.
3.) Ensure respiratory equipment was maintained in a sanitary manner (Resident #54)
This practice had the potential to affect any of the 173 residents who resided in the facility as documented on
the Resident Census and Conditions of Residents Form (CMS-672).
Findings:
Observation of Hall B shower room on 10/21/2020 at 11:30am revealed the second stall to the left side of the
door with tile missing and several tile with missing grout and several chipped tile with a gray substance.
Further observation revealed the shower stall to the right of the door note with moist black substance on a 3
inch x 4 inch section of tile.
Observation of Hall C shower room on 10/21/2020 at 11:40am revealed a thick loose black/brown/white
debris behind the door; debris to the base of the Hoyer lift; multiple debris under the wooden bench to the
right of the shower room; 1st shower stall to the left of the door had a container holder mounted to the wall
which was 75% rusted and 25% blue paint and debris to the floor; the 2nd shower stall to the left of the door
revealed a bariatric chair with several areas of rust on the seat with gray residue; white chalk like residue to
the shower chair back and same rusted container holder; back section of the shower room had a thick brown
crusty substance on the floor approximately 1 foot in length by 6 inches wide; floor mats with waterproof
outer layer peeled and exposing mats; a dead roach was on the floor; and [MEDICAL CONDITION] mask on
the floor not contained.
Observation of Hall D shower room on 10/21/2020 at 11:46am revealed several loose brown streaks on the
floor; which wiped off when rubbed with the sole of surveyors shoe.
Observation of Hall A shower room on 10/21/2020 at 11:50am revealed a bag of dirty laundry on the floor
contained in bag; the 1st shower stall to the right of the door revealed a shower chair with 2 areas of broken
plastic to the shower chair seat.
During an infection control/environment rounds on 10/21/2020 at 1:02pm S1Administrator confirmed the

above findings.

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5301 Tullis Drive

F 0880 In an interview on 10/21/2020 at 1:02pm, S1Administrator stated Hall B shower room was supposed to be
redone this week, but was halted due to the survey activity stated it was part of Quality Assurance (QA) once
Level of Harm - Minimal harm or it was identified; Hall C shower room S1Administrator stated the debris needed to be cleaned; bariatric
potential for actual harm shower chair was not in use, but couldn't dispose of because the outside dumpster was filled with flooring
debris; S1Administrator stated the equipment in the back was due to be disposed of and the dead roach was
Residents Affected - Some due to pest control having sprayed Monday. S1Administrator further stated the brown substance on the floor
would be handled when floors were changed. Surveyor then asked S1Administrator if an area can be
cleaned should it be cleaned and S1Adminitrator stated if the area cannot be cleaned then the next level
would be to change the flooring which it was due to be changed. S1Administrator had a housekeeper come
to the area and an unknown floor cleaner was used on the floor and the housekeeper was able to wet mop
all the thick brown substance that was on the floor. S1Administrator stated the area was able to be cleaned
and should have been cleaned. S1Administrator confirmed the streaks on Hall D can be cleaned. She
confirmed the shower chair on the Hall A should be repaired or disposed of.
Resident #54
Review of Resident #54's record revealed an admitted [DATE] with diagnoses, in part, of Acute [MEDICAL
CONDITION] with [MEDICAL CONDITION], Obstructive sleep Apnea (adult), and [MEDICAL CONDITION].
Review of Resident #54's Minimum Data Set with an Assessment Reference Date of 07/30/2020 revealed, in
part, a Brief Interview for Mental Status of 15 (13-15 cognitively intact), required an limited assistance with a
one person assist for transfers, bed mobility, toileting, and eating.
Review of Resident #54's August, September, and October 2020 physician's orders [REDACTED].
Review of Resident #54 Care Plan revealed, in part, the following problems and interventions: [DIAGNOSES
REDACTED]. Ensure resident is using equipment appropriately, assist resident with [MEDICAL CONDITION]
equipment each night, monitor sleep patterns for adequate amounts of sleep, monitor worsening symptoms
of sleep apnea and report to physician and evaluate. Evaluate resident each morning for signs of decreased
oxygen, confusion.
An observation on 10/18/20 at 11:32am revealed Resident #54's [MEDICAL CONDITION] machine was on
his bedside table uncontained and the mask was visibly dirty.
An observation on 10/19/20 at 9:30am revealed on his bedside table uncontained and the mask was visibly
dirty.
An observation on 10/20/2020 at 9:05am revealed Resident #54's [MEDICAL CONDITION] machine was on
his bedside table uncontained and the mask was visibly dirty.
In an interview on 10/20/2020 at 9:05am, Resident #54 stated his [MEDICAL CONDITION] mask broke and
he had to super glue it back together. He stated his oxygen tubing for his [MEDICAL CONDITION] was last
replaced in December 2018.

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F 0880 In an interview on 10/20/2020 at 9:10am, S15CNA stated she had never cleaned Resident #54's [MEDICAL
CONDITION] mask or tubing.
potential for actual harm In an interview on 10/20/2020 at 12:50pm, S3Corporate Nurse stated Resident #54's mask should not be in
the condition it was.

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F 0908 Keep all essential equipment working safely.
Level of Harm - Minimal harm or Based on observation, record review and interview the facility failed to maintain the safety of oxygen
potential for actual harm cylinders, by not storing oxygen cylinders in the proper location. This deficient practice had the potential to
affect any of the 173 residents residing in the facility as documented on the facility's Resident Census and
Residents Affected - Some Conditions of Residents form (CMS-672).
Findings:
Review of facility's policy titled Fire Safety and Prevention revealed in part, store oxygen cylinders in racks
with chains, sturdy portable carts or approved stands. Never leave oxygen cylinder free standing. Do not
store oxygen cylinders in any resident room or living area.
Observation on 10/18/2020 at 10:05am, Resident #2 was lying on his bed with a nasal cannula connected to
a portable oxygen unit. Further observation revealed three oxygen cylinders were located against the wall in
Resident #2's room. One oxygen cylinder was standing up in the corner of the room not contained in a metal
holder and two oxygen cylinders were in a metal holder against the wall.
In an observation and interview on 10/19/2020 at 11:00am, Resident #2 was lying in his bed with an oxygen
cannula in his nares that was connected to a portable oxygen humidifier. Further observation revealed three
oxygen cylinders were located against the wall in Resident #2's room. Resident #2 stated he keeps his
oxygen on at all times and the three oxygen cylinders located against his wall have always been there.
Resident #2 stated he uses the oxygen cylinders when he goes out of the facility.
Observation on 10/19/2020 at 1:00pm, three oxygen cylinders remained in Resident #2's room against the
wall.
Observation on 10/20/2020 at 8:14am, three oxygen cylinders remained in Resident #2's room against the
wall.
In an interview on 10/20/2020 at 3:00pm, S2Director of Nursing (DON) stated oxygen tanks should be stored
in the oxygen room and not in a resident room.
In an interview on 10/20/2020 at 3:45pm, S2DON confirmed there were three oxygen cylinders located in
Resident #2's room and they should not have been in his room.

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195307 B. Wing 02/07/2020

107 South Hollywood Drive
Maison De'Ville Nursing Home
Houma, LA 70360

F 0646 Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Level of Harm - Minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
or potential for actual harm
Based on record review and interview the facility failed to notify the state mental health authority that a
Residents Affected - Some PASARR 2 (pre admission screening and resident review) was needed on 2 (#69, #[AGE]) of 28 sampled
residents with a mental illness. This deficient practice had the potential to affect any of the 113 residents
listed on the facility's census list.
Findings:
Resident #69
Record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses, in part, of
[MEDICAL CONDITION] and Anxiety. Resident #69 was diagnosed with [REDACTED]. Further review
revealed Resident #69 did not have a mental illness [DIAGNOSES REDACTED].
In an interview on 01/13/2020 at 2:45pm, S10Social Worker stated she did not have a Level II PASARR on
file for Resident #69.
In an interview on 01/17/2020 at 9:33am, S11Social Worker stated the facility's social services department
was responsible for notifying the Office of Behavioral Health when a resident has had a significant change
mental health [DIAGNOSES REDACTED].
In an interview on 01/17/2020 at 9:41am, S2DON confirmed there was no documentation of a Level II

PASARR for Resident #69. S2DON further agreed that Level II PASARR should have been completed when
Resident #69 was diagnosed with [REDACTED].
Resident #[AGE]
Record review revealed Resident #[AGE] was admitted to the facility on [DATE] with diagnoses, in part, of
Hypertension, Depression and back pain. Further review revealed Resident #[AGE] had a Level 1 PASARR
completed on 11/11/13.
Record review revealed Resident #[AGE] was diagnosed with [REDACTED].
In an interview on 01/13/2020 at 2:45pm, S10Social Worker stated she did not have a Level II PASARR on
file for Resident #[AGE].


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Houma, LA 70360

F 0646 In an interview on 01/17/2020 at 9:33am, S11Social Worker stated the facility's social services department
was responsible for notifying the Office of Behavioral Health that a significant change in mental health
Level of Harm - Minimal harm or [DIAGNOSES REDACTED].#[AGE] to obtain a Level II PASARR assessment.
In an interview on 01/17/2020 at 9:40am, S10Social Worker stated the process for obtaining a Level II
Residents Affected - Some PASARR on Resident #[AGE] would have been to complete a level II request and faxed to the Office of
Behavioral Health who would then send a representative out to complete an assessment.
In an interview on 01/17/2020 at 9:41am, S2DON confirmed there was no documentation of a Level II

PASARR for Resident #[AGE]. S2DON further agreed that Level II PASARR should have been completed on
Resident #[AGE] who later was diagnosed with [REDACTED].

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Residents Affected - Some Based on observation, record review, and interviews the facility failed to ensure resident's care plans were
revised with measureable interventions and time tables after a fall (Resident #64 and Resident # 81). This
deficient practice was identified for 2 (Resident #64 and Resident #81) of 3 residents reviewed for accidents
in a total investigation sample of 28 residents and had the potential to affect any of the 113 residents residing
in the facility as documented on the Resident Census and Conditions of Residents form
(C[CONDITION]-6[AGE]).
Findings:
Resident #64
Review of Resident #64's record revealed an admitted [DATE] with diagnoses, in part, of Unsteady Gait with
History of Falls, History [MEDICAL CONDITION] Therapy, and [MEDICAL CONDITION].
Review of Resident #64's Significant Change Minimum Data set (MDS) with an Assessment Reference Date
(ARD) of 10/22/2019 revealed, in part, the Brief Interview for Mental Status not completed due to resident
unable to be understood, required a one person assist for transfers, bed mobility, toileting, and activities of
daily living, was always incontinent of bowel and bladder and had one fall prior to assessment with no injury
noted.
Review of Resident #64's fall risk assessment dated [DATE] and 12/12/19 indicated Resident #64 was a high
risk for falls.
Review of facility's incident/accident log dated October 2019 and November 2019 revealed Resident #64 had
a fall on 10/31/2019 and 11/17/2019.
Review of Resident #64's care plan revealed no revision to the care plan with a measurable intervention after
Resident #64's fall on 11/17/19.
In an interview on 01/16/2020 at 12:45pm, S2DON confirmed Resident #64's care plan was not revised after
a fall on 11/17/19.
Resident #81
Review of Resident #81's MDS with ARD of 10/30/19 revealed, in part, BI[CONDITION] not assessed due to
resident severely impaired; required one person extensive assistance for bed mobility and transfers and had
one fall since prior assessment: injury (not major) and no falls with major injury.
Review of the facility's incident/accident log revealed in part, Resident #81 had a witnessed fall on 10/17/19
and unwitnessed fall on 10/28/19.

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F 0656 Review of Resident #81's care plan revealed no revision to the care plan with measurable interventions with
timetables implemented after Resident #81 falls on 10/17/19 and 10/28/19.
potential for actual harm In an interview on [DATE] at 2:54pm, S17LPN/Care plan nurse confirmed the approaches listed on Resident
#81's fall care plan after her 10/17/19 and 10/28/19 fall were not measureable interventions with timetables.
In an interview on 01/17/2020 at 9:35am, S2DON reviewed the above deficient practice and had no
additional documentation to present.

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Houma, LA 70360

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.
Based on interview and record review the facility failed to ensure residents received a shower according to
Residents Affected - Few their schedule for 1 (Resident #205) of 3 (#10, #14, #205) residents sampled for activities of daily living in an
investigation sample of 28 residents. This deficient practice had the potential affect any of the 113 residents
that resided in the facility as documented on the Residents Census and Conditions form
Findings:
Review of Resident #205's Certified Nursing Assistant (CNA) flowsheet dated January 2020 revealed in part,
documentation of a shower given on the following dates/times:
6:00am to 2:00pm shift: 01/07/2020, [DATE]20, 0[DATE]20 and on 01/13/2020, 01/14/2020, and [DATE]20.
Further review of the CNA flowsheet revealed documentation Resident #205 received a bed bath on
01/11/2020 and 01/12/2020.
Observation on 01/13/2020 at 11:38am revealed Resident #205 was sitting in her wheelchair in her room
and her hair appeared very oily, and not combed. Resident #205's stated she had not had a shower or a bed
bath since last Tuesday, 01/07/2020. Resident #205 stated she was scheduled to get a shower every other
day. Resident #205 stated she was able to get into her wheelchair and sat in the shower chair when the
CNA's took her to the shower. Resident #205's family was in the room and confirmed she did not receive a
shower since 01/07/2020.
In an interview on 01/13/2020 at 11:38am, Resident #205 stated she spoke with the Occupational Therapist
this morning and he told Resident #205 that he would make sure she received a shower today.
In an interview on [DATE]20 at 9:40am Resident #205 denied receiving a shower today and confirmed she
did not receive a shower on Monday, 01/13/2020 after surveyor interviewed her.
In an interview on 01/16/2020 at 10:20am Resident #205 stated she did not receive a shower yesterday.
In an interview on [DATE]20 at 9:55am S21CNA stated Resident #205 goes to the shower and Resident
#205 gets a shower every other day. S21CNA stated Resident #205's shower day varied because she was
in a private room. S21CNA stated she would look at the CNA flowsheet to determine if the previous day CNA
had taken Resident #205 for her shower. S21CNA stated Resident #205 was a two person assist for bathing
in the shower. S21CNA stated Resident #205 did not receive a shower today. Record review of Resident
#205's CNA flowsheet dated January 2020 with S21CNA revealed there was documentation that Resident
#205 had a shower on 01/13/2020, 01/14/2020 and [DATE]20 and her documentation for [DATE]20 was not
accurate. S21CNA confirmed Resident #205 did not receive a shower on [DATE]20.

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Houma, LA 70360

F 0677 In an interview on [DATE]20 at 10:05am, Resident #205 stated her CNA told her on Thursday, 0[DATE]20
and Saturday, 01/11/2020 that it was too cold outside for her to take a shower and have her hair washed.
Level of Harm - Minimal harm or Resident #205 confirmed she had not received a bed bath or shower since 1/07/2020.
In an interview on 01/16/2020 at 10:25am, S22Occupational Therapist (OT) stated he observed Resident
Residents Affected - Few #205 on the morning of Monday, 01/13/2020 and her hair was very oily and she had a strong body odor.
S22OT stated Resident #205 told him she had not had a shower since Tuesday, 01/07/2020. S22OT
confirmed Resident #205 was a reliable resident to interview and she was cognitively intact. S22OT stated
he told Resident #205's CNA to give Resident #205 a shower on Monday, 01/13/2020, and he assumed it
would be done.
In an interview on [DATE]20 at 10:00am, S2DON stated the CNA's on each hall are responsible for
bathing/showering their assigned residents. S2DON stated she observed Resident #205 on Monday,
01/13/2020 and her hair looked wet, so she thought Resident #205 had received her shower on 01/13/2020.
S2DON was unaware Resident #205 had not received a shower since 01/07/2020 and she did not receive a
shower on Monday, 01/13/2020. S2DON confirmed not receiving a shower in seven days was an issue and
residents should receive a shower every other day, including the weekends, if that was her preference.
Surveyor informed S2DON that the CNA flowsheets were inaccurate and the CNA documented Resident
#205 received a shower on [DATE]20, 0[DATE]20, 01/13/2020 and [DATE]20 and Resident #205 did not
receive a shower on those days, and bed baths were documented on 01/11/2020 and 01/12/202 and they
were not performed. S2DON did not present any additional information.

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Houma, LA 70360

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Residents Affected - Some Based on observations, interviews and record reviews, the facility failed to:
1. Ensure a resident's catheter was changed as ordered (Resident #13);
2. Ensure a urinalysis was collected as ordered after a new catheter was placed (Resident #13);
3. Record urinary output every shift and 24 hour total (Resident #81);
4. Ensure a urine collection leg bag was used only when resident was sitting, standing or walking (Resident
#81);
5. Revise a resident's care plan with measureable interventions with timetables after a [DIAGNOSES
REDACTED].#81); and
6. Ensure catheter care was performed according to standard infection control practices (Resident #81).
This deficient practice was identified for 2 (Resident #13 and Resident #81) of 2 residents sampled for
urinary catheter and/or urinary tract infection in an investigation sample of 28 residents. The deficient
practice had the potential to affect any of the 15 residents with indwelling catheters as documented on the
facility's Residents Census and Conditions Form (C[CONDITION]-6[AGE]).
Findings:
Resident #13
Review of Resident #13's Face Sheet revealed an admitted [DATE] with [DIAGNOSES REDACTED].
08/09/2019 revealed Resident #13 had a Brief Interview for Mental Status Score (BI[CONDITION]) of 15
(cognitively intact). Further review of the MDS revealed Resident #13 had an indwelling catheter with a
[DIAGNOSES REDACTED].
Review of Resident #13's January 2020 Physician order [REDACTED]. Further review of Resident #13's
Physician order [REDACTED].
Review of Resident #13's Care Plan revealed Resident #13 had a potential for urinary tract infections related
to the presence of a catheter. Further review of Resident #13's care plan included an intervention to change
Resident #13's catheter as ordered.
Review of Resident #13's December 2019 Medication Administration Record [REDACTED].

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Houma, LA 70360

F 0690 Review of Resident #13's January 2020 (MAR) revealed documentation of Resident #13's suprapubic
catheter was changed on 01/13/2020.
potential for actual harm In interview on [DATE]20 at 8:16am, S2Director of Nursing (DON) stated she is responsible for changing
Resident #13's catheter. She stated she changed Resident's catheter on 01/13/2020.
In interview on [DATE]20 at 9:56am, S2DON stated there was no documentation that Resident #13's
catheter was changed from [DATE] to 1/13/20. She stated without documentation, there is no way to prove
the catheter was changed.
In interview on [DATE]20 at 10:35am, Resident #13 stated the last time his suprapubic catheter was
changed was on [DATE]. He stated he kept track of the dates of his catheter changes on his computer.
In interview on 01/16/20 at 3:09pm, S2DON stated she did not obtain a urinalysis with Resident's catheter
change on 01/13/2020. S2DON further stated she was unaware Resident #13 had an order to obtain a
urinalysis with each new catheter insertion.
In interview on 01/16/20 at 3:10pm, S9Corporate Nurse denied any UAs were collected with the catheter
changes in December 2019 or January 2020.
Resident #81
Review of Resident #81's MDS with ARD of 10/30/19 revealed in part, BI[CONDITION] not assessed due to
severely impaired; required one person extensive assistance for personal hygiene and one person total
dependence for toilet use; appliance assessed under bowel and bladder section and was always incontinent
of urine and bowels.
Review of Resident #81's Physician order [REDACTED].
Review of Resident #81's Physician order [REDACTED].>Review of Resident #81's Physician order
[REDACTED].
Review of Resident #81's MAR indicated [REDACTED]
6:00am-2:00pm shift: [DATE] through 11/25/19, [DATE], [DATE] and 11/30/19;
2:00pm-10:00pm: 11/30/19.
Further review of Resident #81's November 2019 MAR indicated [REDACTED].
Review of Resident #81's intake and output record dated December 2019 revealed no documentation of
output on the following dates/times:
6:00am-2:00pm shift:

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F 0690 12/05/19, 12/06/19, 12/13/19, 12/14/19, 12/15/19, 1[DATE], [DATE], and 12/31/19;
Level of Harm - Minimal harm or 2:00pm to 10:00pm shift: 12/29/19; and

10:00pm to 6:00am shift: 12/29/19.
Further review of Resident #81's intake and output record dated December 2019 revealed no documentation
of the 24 hour totals of Resident #81's output for the month of December 2019.
Review of Resident #81's MAR indicated [REDACTED]
01/03/2020, 01/04/2020, 0[DATE]20, 01/11/2020, and 01/12/2020.
Review of Resident #81's care plan with problem onset date of 10/30/19 for foley catheter and is incontinent
of bowel with approaches in part, give perineal care when resident is incontinent, use urine collection leg bag
only when resident is sitting, standing, or walking, position urine collection bag below level of bladder,
position catheter tubing below level of bladder, and position resident so urine will drain from bladder. Further
review of Resident #81's care plan revealed in part, infection risk for recent treatment of [REDACTED].#81
diagnosed with [REDACTED].
Observation on [DATE]20 at 12:55pm, surveyor walked into Resident #81's room and Resident #81 was
lying flat in bed on her right side. Surveyor observed S15Certified Nursing Assistant (CNA) perform catheter
care on Resident #81 with S16Restorative CNA standing on the side of Resident #81's bed. Resident #81
was lying supine in her bed with foley catheter attached to a leg bag which was secured to Resident #81's
thigh with velcro straps to the top and bottom of the leg bag. Resident #81's leg bag was dated 01/15/19.
S15CNA donned gloves and went to Resident #81's bathroom and wet a wash cloth and applied
shampoo/body wash liquid to the wet wash cloth. S15CNA then took Resident #81's adult brief off and took
the wet wash cloth and cleaned Resident #81 from back to front multiple times then took the same wash
cloth and wiped the catheter tubing from insertion site down the tubing away from insertion site. S15CNA
then took a dry wash cloth and wiped Resident #81 from back to front multiple times then applied a clean
adult brief. S16CNA informed S15CNA that she did it all wrong and she should know better than to wipe
back to front. S16CNA also informed S15CNA she should rinse the soap off of the resident because the
soap can irritate her.
In an interview on [DATE]20 at 1:45pm, S2DON was informed of the break in infection control during
Resident #18's catheter care with S15CNA. S2DON stated the CNA should know how to wipe front to back.
S2DON stated an inservice on incontinence care was done on 11/21/19, but there was no monitoring or
observation of CNA staff after the inservice was given.
In an interview on 01/17/2020 at 9:35am, S2DON reviewed documentation for Resident #81's output and
confirmed there was no documentation of urinary output or 24 hour totals for the dates/times mentioned
above.
In an interview on [DATE]20 at 2:35pm, S17CNA stated she was Resident #81's CNA and she was
responsible for emptying Resident #81's foley bag. S17CNA stated Resident #81's leg bag stayed attached
to her thigh when Resident #81 was sitting up or laying down. S17CNA stated they were told to keep the leg
bag attached to Resident #81's thigh at all times.

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F 0690 On [DATE]20 at 2:40pm, S2DON confirmed with surveyor that Resident #81 was lying flat on her right side in
her bed with foley catheter attached to a leg bag secured with velcro straps to her upper thigh. S2DON
Level of Harm - Minimal harm or confirmed Resident #81's foley catheter should not be attached to a leg bag while she was lying in bed.
In a joint interview on [DATE]20 at S18LPN/Care plan (CP) and S19LPN/CP both reviewed Resident #81's
Residents Affected - Some CP and stated they assumed the urine collection bag would be changed when Resident #81 was lying in
bed. S18/LPN/CP and S19LPN/CP both confirmed the foley attached to the leg bag should not be secured to
Resident #81's leg when she was lying in bed and could have contributed to her current Urinary Tract
Infection [MEDICAL CONDITION].
In an interview on 01/16/2020 at 10:10am, S8LPN stated prior to yesterday, Resident #81 had her foley
catheter attached to a leg bag to her thigh all the time and S8LPN did not change out Resident #81's
collection bag when Resident #81 was placed in her bed.
In an interview on 01/16/2020 at 4:10pm, S20CNA Supervisor confirmed she did not monitor CNA staff with
direct observation of catheter care and/or incontinence care and only had inservices with CNA staff. S20CNA
Supervisor stated CNA staff should wipe female residents front to back.
In a joint interview on 01/17/2020 at 9:15am, S18LPN/CP and S19LPN/CP stated they are notified of UTI's
by receiving a copy of the orders daily and would revise the care plan. S18LPN/CP and S19LPN/CP
confirmed there was no revision to Resident #81's care plan with measurable interventions with time tables
for Resident #81's UTI diagnosed on [DATE] with a change in antibiotic on 09/10/19, UTI on 10/21/19 and a
change of antibiotic on 10/23/19 and new [DIAGNOSES REDACTED].

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F 0692 Provide enough food/fluids to maintain a resident's health.
Based on interviews and record reviews, the facility failed to ensure a resident with significant weight loss
Residents Affected - Few received nutritional supplement as ordered. This deficient practice was identified for 1 (Resident #81) of 4
residents reviewed for nutrition, in a investigation sample of 28 residents. There were 113 residents who
resided in the facility as documented on the facility's Resident Census and Conditions of Residents Form
Findings:
Review of Resident #81's record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].
Review of Resident #81's weights revealed the following weights:
[DATE]- 171 pounds;
11/01/19- 168 pounds;
12/01/19- 1[AGE] pounds; and
01/01/2020- 155 pounds, which was a significant weight loss of 7.74% in three months.
Review of Resident #81's Registered Dietician (RD) Progress Notes dated 10/25/19 revealed a supplement
order for Ensure one can twice a day. Further review of the RD's notes revealed no documentation of any
new orders since 10/25/19.
Review of Resident #81's signed Physician order [REDACTED]. Further review of Resident #81's December
2019 Physician orders [REDACTED].#81's December 2019 orders. Further review of Resident #81's
Physician order [REDACTED].#81's Ensure twice a day by mouth.
Review of Resident #81's Medication Administration Record (MAR) dated December 2019 revealed no
documented evidence that Resident #81 received one can of Ensure twice a day by mouth as ordered.
In an interview on 01/15/19 at 11:30am, S8Licensed Practical Nurse (LPN) reviewed Resident #81's
Physician orders [REDACTED].#81's MAR dated December 2019. S8LPN confirmed Resident #81 had an
order for [REDACTED].#81 received her Ensure for the month of December 2019. S8LPN then reviewed
Resident #81's weights with surveyor and confirmed Resident #81 had a 7.74% weight loss in three months.
In an interview on 01/16/19 at 12:25pm, S12Registered Dietician (RD) stated she makes four visits per
month at the facility and her last visit at the facility was on 01/09/19. S12RD reviewed her RD progress notes
in Resident #81's record and confirmed her last documented progress note was on 10/25/19.

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F 0692 In an interview on 01/16/19 at 1:25pm, S3Assistant Director of Nursing (ADON) stated it was a team effort to
reconcile MAR's and Physician orders [REDACTED]. S3ADON reviewed Resident #81's December 2019
Level of Harm - Minimal harm or MAR and confirmed there was no nurse signature or initials at the bottom of the MAR. S3ADON confirmed
potential for actual harm the Ensure order must have been missed because the orders were not reconciled with Resident #81's MAR
for December 2019.
In an interview on 01/17/2020 at 9:35am, S2Director of Nursing (DON) reviewed the above deficient practice
and had no other documentation to present.

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F 0697 Provide safe, appropriate pain management for a resident who requires such services.
Based on record review, interview and observation the facility failed to assess for pain and have ordered pain
Residents Affected - Some medication available for use for 1 (Resident #154) of 3 (#58, #78, #154) resident's sampled for pain
management in an investigation sample of 28 residents. The deficient practice had the potential to affect any
of the 113 residents who resided in the facility as documented on the facility's Resident Census and
Conditions of Residents Form (C[CONDITION]-6[AGE]).
Findings:
Review of Resident #154's record revealed an admitted [DATE] with a [DIAGNOSES REDACTED].
Review of Resident #154's physician progress notes [REDACTED].#154 had a Lumbar Laminectomy on
08/19/2019 with a healed incision, and had joint replacement on both hips.
Review of Resident #154's Baseline Care Plan revealed in part, a problem identified for pain with
approaches, in part, to administer pain medications as ordered; report ineffectiveness to the physician, and
monitor pain levels as appropriate.
Review of Resident #154's Medication Administration Record [REDACTED]. Further review of the MAR
indicated [REDACTED].
In an interview on 01/14/20 10:21am, Resident #154 stated she experienced pain in the neck, shoulder and
her lower back and had received [MEDICATION NAME] since her admitted in December 2019. Resident
#154 further stated about a week ago, a nurse told her the facility was out of her [MEDICATION NAME] and
was waiting for her doctor to respond.
In an interview on [DATE] 10:28am, S8 Licensed Practical Nurse (LPN) stated Resident #154 was admitted
with a fractured right clavicle and was always in pain. S8LPN stated Resident #154 was out of her
[MEDICATION NAME] and she would give Resident #154 [MED] for the pain. S8LPN confirmed there was
no [MEDICATION NAME] on the medication cart for Resident #154 and she was not sure how long Resident
#154 had been out of her [MEDICATION NAME].
Observation on [DATE] at 12:48pm, Resident #154 was observed in bed guarding her right arm, and stated
she was in bed because she was hurting.
In an interview on [DATE]20 at 12:48pm, Resident #154 stated she was in pain this morning and asked for
pain medication and was told her [MEDICATION NAME] was still not available.
Review of Resident #154's January 2020 MAR indicated [REDACTED]. S8LPN stated she faxed the doctor
on Resident #154 requiring a script for the [MEDICATION NAME] and has not received any orders.
Review of a Communication Result Report dated 0[DATE]20, 01/13/2020, and 01/14/2020 revealed the
doctor was faxed on Resident #154 requiring a script for [MEDICATION NAME].

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F 0697 Review of Resident #154's Daily Skilled Nurse's Note dated [DATE]20 through 01/14/2020 revealed no
documentation of the doctor being notified of Resident #154 being out of [MEDICATION NAME].
potential for actual harm In an interview on [DATE]20 at 3:00pm, S8LPN stated she did not find any notes of contacting the doctor and
stated the medication should be available if there was an order for [REDACTED].>In an interview on
Residents Affected - Some 01/16/20 09:46am, Resident #154 stated she was in severe pain last night and she had let the nurse know
and the nurse informed her she will let the doctor know.
In an interview 01/16/20 10:40am, S2Director of Nursing (DON) stated she was not aware of Resident #154
being out of her [MEDICATION NAME]. S2DON stated Resident #154 should have pain medication in the
facility and confirmed Resident #154 was out of her [MEDICATION NAME] since [DATE]20. S2DON stated
she was not aware Resident #154 was in pain.

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Residents Affected - Some Based on record review, and interview the facility failed to:
1). Ensure neurochecks were performed after a fall (Resident #64 and Resident #81); and
2.) Ensure a resident (Resident #102) received medication as ordered. This deficient practice was identified
for 3 (Resident #64, Resident #81, and Resident #102) of 28 residents in the investigation sample and had
the potential to affect any of the 113 residents residing in the facility as documented on the Resident Census
and Conditions of Residents form (C[CONDITION]-6[AGE]).
Findings:
Review of the facility's policy on Assessing Falls and their Causes revealed in part, After a fall: observe for
delayed complications of a fall for approximately seventy-two hours after an observed or suspected fall and
will document findings in the medical record
Resident #64
Review of Resident #64's record revealed an admitted [DATE] with diagnoses, in part, of Unsteady Gait with
History of Falls, History [MEDICAL CONDITION] Therapy, and [MEDICAL CONDITION].
Review of Resident #64's Significant Change Minimum Data set (MDS) with an Assessment Reference Date
(ARD) of 10/22/2019 revealed, in part, the Brief Interview for Mental Status not completed due to resident
unable to be understood, required a one person assist for transfers, bed mobility, toileting, and activities of
daily living, was always incontinent of bowel and bladder and had one fall prior to assessment with no injury
noted.
Review of facility's incident/accident log dated October 2019 and November 2019 revealed Resident #64 had
a fall on 10/31/2019 and 11/17/2019.
Review of Resident #64's clinical record revealed no documented evidence of neurochecks completed for
the falls of 10/31/2019 and 11/17/2019.
In an interview on 01/16/2020 at 3:05pm, S7LPN stated neuro checks were suppose to be initiated after an
unwitnessed fall or a fall when the head was struck. She further stated there was a neurocheck form that
should be completed and placed in the resident's chart.
In an interview on 01/17/20 at 10:13am, S2DON stated there was no documentation that neurochecks were
performed for Resident #64 after the falls on 10/31/2019 and 11/17/2019 and confirmed the neurochecks
should have been documented.
Resident #81

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F 0726 Review of Resident #81's MDS with ARD of 10/30/19 revealed, in part, BI[CONDITION] not assessed due to
resident severely impaired; required one person extensive assistance for bed mobility and transfers and had
Level of Harm - Minimal harm or one fall since prior assessment: injury (not major) and no falls with major injury.
Review of Resident #81's incident report dated 09/24/19 revealed in part, Resident #81 had an unwitnessed
Residents Affected - Some fall and was found on the floor next to a chair laying down.
Review of Resident #81's record revealed no documented evidence of neurochecks completed for [AGE]
hours after Resident #81's unwitnessed fall on 09/24/19.
In an interview on [DATE] at 2:45pm, S2DON stated neurochecks should be done on all unwitnessed
resident falls or falls that involved head injury.
In an interview on 01/17/2020 at 10:05am, S2DON confirmed there was no documentation of neurochecks

after Resident #81's unwitnessed fall on 09/24/19. S2DON confirmed the nurses should have documented
neuro checks for [AGE] hours after Resident #81's unwitnessed fall.
Resident #102
Review of Resident #102's record revealed an admitted [DATE] with diagnoses, in part, of Down's
Syndrome, Alzheimer's and Dementia.
Review of Resident #102's Minimum Data Set (MDS) revealed in part, with an Assessment Reference Date
(ARD) of 11/06/2019 revealed: Brief Interview for Mental Status (BI[CONDITION]) of 3 (severely cognitively
impaired). Behaviors of verbal/vocal symptoms such as yelling and shouting noted. Use of antianxiety,
antidepressant, and antipsychotic medication used 7 of 7 days prior to assessment.
Review of Resident #102 Care Plan, in part, noted a Problem of Coping Impaired, Individual mild depression
symptoms. Risk for depression, sleep troubles, trouble concentrating, easily annoyed. Approaches were:
Medication as ordered. See MAR (Medication Administration Record).
Review of Resident #102's Physicians orders dated 12/30/2019 revealed [MEDICATION NAME] (generic is
[MEDICATION NAME], an antianxiety medication) 1 milligram (mg.) tablet 3 times a day.
Review of the facility's policy on Medication orders and Receipt Record revealed, in part, Medication should
be ordered in advance, based on the dispensing pharmacy's required lead time.
Review of the facility's policy Administering Medications policy revealed, in part, medications must be
administered in accordance with the orders, including any required time frames. Medications must be
administered within 1 hour of their prescribed time, unless otherwise specified. The individual administering
the medication must initial the resident's MAR indicated [REDACTED].
Review of the Facility's policy on Medication Time Schedule revealed TID means three times a day 8AM, 12
NOON, 4 PM or 9AM, 1PM, 5PM.

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F 0726 Review of Resident #102's MAR for November 2019 and December 2019 revealed the following doses for
[MEDICATION NAME]/[MEDICATION NAME] 1 mg. were not signed out as ordered:
potential for actual harm 11/05/2019-6am,
Residents Affected - Some 1[DATE]19-1pm, 8pm,
1[DATE]19-1pm,
1[DATE]-6am,
11/16/2019-8pm,
11/18/2019-6am,
11/19/2019-6am,
1[DATE]19-6am, 1pm, 8pm,
11/25/2019-1pm,
11/26/2019-1pm,
1[DATE]19-1pm,
11/30/2019-6am, 8pm,
12/01/2019-10pm,
12/02/2019-2pm,
12/03/2019-6am,
[DATE]-6am,
12/15/2019-10pm,
[DATE]-6am,
1[DATE]19-10pm,
12/26/2019-2pm,
[DATE]19-2pm,
1[DATE]-2pm, 10pm,
12/30/2019-2pm, and

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F 0726 12/31/2019-2pm.
Level of Harm - Minimal harm or Review of Resident #102's Individual Resident's Controlled Substance Record from November 11, 2019
potential for actual harm through December 31, 2019 of [MEDICATION NAME]/Lorazapam 1 mg. revealed the following doses were
not signed out as ordered:
11/13/2019- 2pm,
11/14/2019- 2pm,
11/18/2019- 6am,
1[DATE]19- 8pm,
11/30/2019-10pm,
12/05/2019- 2pm,
12/12/2019-2pm,
1[DATE]19-2pm, 10pm,
[DATE]-6am, 2pm,
12/16/2019-2pm,
[DATE]-8pm,
1[DATE]19-10pm,
1[DATE]-10pm,
12/30/2019-8pm,
12/31/2019-2pm.
In an interview on [DATE]20 at 10:45am, Resident #102's sitter and cousin stated he had missed doses of
his prescribed [MEDICATION NAME] in the last 3 months. She further stated she was told by staff his
[MEDICATION NAME] was out and they were waiting on the doctor to send a prescription.
In an interview on [DATE]20 11:18am, S14License Practical Nurse (LPN), stated when Resident #102 has a
2-3 day supply of his [MEDICATION NAME] staff calls the MD for a refill or new prescription.
In an interview on [DATE]20 12:50pm, S2DON and S13Corporate Nurse confirmed [MEDICATION NAME] 1
mg. was not given as ordered for Resident #102.

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F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange
for the provision of hospice services.
Residents Affected - Some Based on interviews and record reviews, the facility failed to collaborate with a hospice agency to ensure a
resident had a Hospice Plan of Care for 1 resident (Resident #203) sampled for a hospice investigation in a
total investigative sample of 28 residents. The deficient practice had the potential to affect any of the 5
residents receiving hospice services as documented on the facility's Resident Census and Conditions form
Findings:
Review of Resident #203's January 2020 Physician order [REDACTED].
Review of the facility's Hospice Program Policy and Procedure revealed, in part, when a resident participates
in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family
will be developed and shall include directives for managing pain and other uncomfortable symptoms.
Review of the facility and hospice agency's Long Term Care Agreement revealed, in part, Hospice Plan of
Care means a written care plan established, maintained, reviewed and modified if necessary, at intervals
established by the Hospice Interdisciplinary group, which includes; an assessment of each Hospice patient's
needs; an identification of the Hospice Services, including Management of discomfort and symptom relief,
needed to meet such Hospice patient's needs and the related needs of the patient's family; and details of the
scope and frequency of such Hospice services. Further review of the facility and hospice agency's Long
Term Care Agreement revealed, in part, Hospice will develop a Plan of Care for each new Residential
Hospice Patient, furnishing Nursing Facility with a copy of this Plan of Care.
Review of Resident #203's hospice folder revealed no Hospice Plan of Care.
Review of Resident #203's medical record revealed no Hospice Plan of Care.
In interview on 01/17/2020 at 8:47am, S8Licensed Practical Nurse (LPN) stated the Hospice Agency should
have provided the facility with Resident #203's Hospice Plan of Care, but she was unable to locate it. She
agreed that without a Hospice Plan of Care, the facility would be unware of how to coordinate Resident
#203's care with the hospice agency.
In interview on 01/17/2020 at 9:11am, S1Director of Nursing (DON) confirmed Resident #203's Hospice Plan
of Care was not present on the medical record. She stated Resident #203 should have a Hospice Plan of
Care on his chart. She also stated the facility was unable to verify the correct coordination of Resident #203's
care was taking place without a Hospice Plan of Care.
In interview on 01/17/2020 at 10:02am, S1DON stated Resident #203's Hospice Plan of Care was never
received from the Hospice Agency because the Hospice Agency did not have the facility's email address for
correspondence. She stated the facility never asked for the Hospice Plan of Care before 01/17/2020.

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F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
potential for actual harm Based on record review and interview, the facility failed develop and implement appropriate plans of action to
correct identified quality deficiencies during the Quality Assessment and Assurance (QAA) meetings. This
Residents Affected - Some deficient practice was identified for the facility, but had the potential to affect any of the 113 residents who
resided in the facility as documented on the facilities Resident Census and Conditions of Residents form
Findings:
Review of the facility's Quality Assurance and Performance Improvement (QAPI) Committee policy revealed
in part, the primary goals of the QAPI Committee are to coordinate the development, implementation,
monitoring, and evaluation of performance improvement projects to achieve specific goals.
Further review of the QAPI committee policy revealed in part, the QAPI committee shall help various
departments/committees/disciplines/individuals develop and implement plans of correction and monitoring
approaches. These plans should include specific time frames for implementation and follow-up. The
committee shall track the progress of any active plans of corrections.
Review of facilities quarterly Quality Assurance Meeting dated 03/27/19 revealed no quarterly data
documented for the months of January 2019 and February 2019.
documented for the months of April 2019 and May 2019.
documented for the months of July 2019 and August 2019.
documented for the months of October 2019 and November 2019.
Review of the facilities identified QAPI plans in place, prior to the annual survey, revealed no documentation
of any monitoring, follow-ups or goal dates in place for any of the projects.
In an interview on 1/17/2020 at 2:36pm, S2DON confirmed the QA Committee met on a quarterly basis and
she was the QAPI Coordinator. S2DON reviewed the quarterly QA meeting information for the year 2019 and
confirmed there was incomplete and missing quarterly data for each of the quarterly meetings mentioned
above. S2DON also reviewed the current QA plans that were in place, prior to the survey, and S2DON
confirmed there was no documentation of monitoring, follow-ups and goal dates and signatures on the QA
forms reviewed. S2DON did not provide any additional documentation.

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F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm or Based on record review and interview the facility failed to ensure quality assessment and assurance
potential for actual harm committee included the medical director or his/her designee. This failed practice had the potential to affect
the 113 residents residing in the facility as documented on the facility's Resident Census and Conditions of
Residents Affected - Some Residents form (C[CONDITION]-6[AGE])
Findings:
Review of the facility's Quality Assurance (QA) Meeting sign in sheet for the year of 2019 revealed no
documented evidence of the medical director and/or his designee having attended the meetings for the
second, third and fourth quarters of 2019.
Review of Quality Assurance and Performance Improvement (QAPI) Committee policy revealed the medical
director listed as an individual who will serve on the committee.
In an interview on 01/17/2020 at 3:15pm, S2 Director of Nursing (DON) stated the medical director usually
attended the QA meetings, and wasn't sure if he was present at the 3 meetings. S2DON confirmed the
quality meeting documentation for second, third and fourth quarter did not contain the Medical Director's
signature.

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Based on observations, interviews, and record reviews, the facility failed to:
1. Ensure a toothbrush was labeled and contained in a sanitary manner (Bathroom a); and
2. Ensure respiratory equipment was changed weekly, dated and contained in a sanitary manner (Resident
#87, Resident #203 and Resident #204).
This deficient practice had the potential affect any of the 113 residents that resided in the facility as
documented on the Residents Census and Conditions form (C[CONDITION]-6[AGE]).
Findings:
Bathroom a
Observation on 01/13/2020 at 9:59am revealed an unlabeled and uncontained toothbrush on the bathroom
sink in Bathroom a.
Observation on 01/14/2020 at 9:28am revealed an unlabeled and uncontained toothbrush on bathroom sink
in Bathroom a.
Observation on [DATE]20 at 12:05pm revealed an unlabeled and uncontained toothbrush on the bathroom
sink in Bathroom a.
In an interview on [DATE]20 at 1:29pm, S5Certifed Nursing Assistant (CNA) stated toothbrushes should be
contained and stored in the resident's bedside drawer. She stated an unlabeled and uncontained toothbrush
could cause a problem with multiple residents sharing a bathroom because any resident could use the
toothbrush.
In an interview on [DATE]20 at 1:30pm, S3Assistant Director of Nursing (ADON) stated the unlabeled and
uncontained toothbrush on the bathroom sink in Bathroom a should not have been there. She stated the
toothbrush should have been labeled and contained.
Resident #87
Review of Resident #87's face sheet revealed Resident #87 had a [DIAGNOSES REDACTED].
Review of Resident #87's Physician order [REDACTED].
Observation on 01/13/20 at 9:55am revealed Resident #87's oxygen tubing was not dated. Further
observation revealed Resident #87's humidifier bottle was dated 01/04/2020.
Observation on 01/14/2020 at 10:45am revealed Resident #87's oxygen tubing was not dated. Further
observation revealed Resident #87's humidifier bottle was dated 01/04/2020.

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F 0880 In interview on 01/14/20 at 10:50am, S4Licensed Practical Nurse (LPN) stated it was night shift's
responsibility to change oxygen tubing and humidifier bottle. She confirmed the date on Resident #87's
Level of Harm - Minimal harm or humidifier bottle was 01/04/2020. She confirmed Resident #87's oxygen tubing was not dated.
In interview on 01/14/2020 at 10:58am, S3ADON stated it was night shift's responsibility to change and date
Residents Affected - Some oxygen tubing and humidifier bottle every week. She acknowledged humidifier bottle was dated 01/04/2020
and the oxygen tubing was not dated. She agreed the oxygen tubing and humidifier bottle needed to be
changed.
Resident #203
Review of Resident #203's record revealed an admitted [DATE] with diagnoses, in part, [MEDICAL
CONDITION].
Review of Resident #203's January 2020 Physician orders [REDACTED].
Observation on 01/13/2020 at 10:21am, Resident #203 had a nasal cannula in his bilateral nostrils and the
cannula was connected to a humidifier bottle located next to his bed with the oxygen tubing dated
01/01/2020 and no date on the humidifier bottle.
In an interview on 01/13/2020 at 10:25am, Resident #203 was cognitively intact and stated he keeps his
oxygen on at all times. Resident #203 confirmed with surveyor his oxygen tubing was dated 01/01/2020.
In an interview on 01/14/2020 at 10:15am, S3ADON stated oxygen tubing and respiratory equipment should
be changed every Thursday on the night shift. S3ADON stated the nurse should document on the Medication
Administration Record [REDACTED]. S3ADON reviewed Resident #203's MAR's dated November and
December 2019 and January 2020 and confirmed there was no documented evidence that Resident #203's
oxygen tubing or humidifier bottle or nebulizer mask was changed once a week.
Resident #204
Review of Resident #204's record revealed an admitted [DATE] with diagnoses, in part, of Chronic
[MEDICAL CONDITIONS], Heart failure, and [DIAGNOSES REDACTED].
Review of Resident #204's January 2020 orders revealed, in part, an order for [REDACTED].
Review of Resident #204's MAR indicated [REDACTED]. Further review of Resident #204's MAR indicated
[REDACTED].
Observation on 01/13/2020 at 10:41am revealed Resident #204's nasal cannula was lying on top of the
oxygen condenser located next to Resident #204's bed with no date on the oxygen tubing or humidifier bottle
and nasal cannula was not contained. Further observation revealed Resident #204's respiratory nebulizer
mask lying on top of Resident #204's bedside table not dated and not contained.
In an interview on 01/14/2020 at 10:20am, S3ADON reviewed Resident #204's MAR indicated [REDACTED].
S3ADON confirmed oxygen tubing and respiratory nebulizer masks should be contained in a plastic bag
when not in use.

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Form Approved OMB

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

Observation on 10/16/2020 at 10:40AM with S5Maintenance Housekeeping Supervisor revealed missing

In an interview on 10/16/2020 at 10:40AM, S5Maintenance Housekeeping Supervisor he acknowledged the

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

(continued on next page)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

available for use,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

F 0880 Provide and implement an infection prevention and control program.

black like substance on the air conditioner vent. (Room f)

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

An interview on 10/16/2020 at 10:43AM with S5/Maintenance Housekeeping Supervisor indicated upon

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

Record review of Resident #18's Physician orders [REDACTED].

Review of Resident #18's Medication Administration Record [REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

A record review of resident #63's physician's orders [REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

F 0880 Provide and implement an infection prevention and control program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

No health deficiencies found

Level of Harm - Unknown

Residents Affected - Unknown

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES

In an interview 10/31/19 at 9:11am S11DietaryManager verbalized contacting Auto-Chlor Representative and