Inspection Reports for
Evangeline Oaks Guest House
240 Arceneaux Road, Carencro, LA, 70520
Back to Facility Profile13 Reports
Inspection Report — Aug 27, 2025
Complaint Investigation CMS
Date: Aug 27, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify a resident's physician and responsible party immediately after an injury, failure to file a grievance, failure to perform timely CPR, and failure to maintain current CPR certification.
Complaint Details
The investigation was complaint-driven based on allegations that the facility failed to notify the correct physician and responsible party immediately after a resident's injury, failed to file a grievance, delayed CPR initiation during a cardiac arrest, and had staff with expired CPR certification. The complaints were substantiated as the facility confirmed these failures.
Findings
The facility failed to immediately notify the correct physician and responsible party after a resident's fall, failed to file a grievance for the incident, delayed initiation of chest compressions during a cardiac arrest, and had staff with lapsed CPR certification.
Deficiencies (4)
F 0580: The facility failed to immediately notify Resident #2's physician and responsible party after a fall incident on 06/21/2025, notifying the wrong individuals instead.
F 0585: The facility failed to file a grievance for Resident #2 regarding the fall incident and delayed notification to the resident's representative.
F 0658: The facility failed to ensure timely chest compressions were performed for Resident #5 during a cardiac arrest on 06/02/2025, with CPR initiated only upon the Director of Nursing's arrival around 8:00 a.m.
F 0678: The facility failed to maintain current CPR certification for S3LPN, whose certification expired in 05/2025 and was not renewed timely.
Report Facts
Residents sampled: 10
Residents affected: 1
Residents affected: 1
BLS certification expiration month: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Licensed Practical Nurse | Failed to notify correct physician and responsible party after Resident #2's fall |
| S1 DON | Director of Nursing | Verified notification failures and delayed CPR initiation for Resident #5 |
| S2 ADM | Administrator | Verified notification failures related to Resident #2's fall |
| S3 LPN | Licensed Practical Nurse | Delayed initiation of chest compressions during Resident #5's cardiac arrest and had lapsed CPR certification |
| S6 CNA | Certified Nursing Assistant | Reported Resident #5's unresponsive status and assisted in notification |
| S7 WC | Ward Clerk | Observed Resident #5 unresponsive and called 911 |
Inspection Report — Jul 29, 2025
Annual Inspection CMS
Date: Jul 29, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and evaluate the quality of care provided to residents.
Findings
The facility was found deficient in implementing physician-ordered laboratory testing, providing timely personal hygiene care for incontinent residents, and ensuring continuous oxygen therapy as ordered for residents.
Deficiencies (3)
F 0656: The facility failed to implement the plan of care by not following physician orders to obtain laboratory testing as ordered for one resident. Laboratory tests including Lipid panel, PSA, and urine for microalbumin were not obtained as scheduled.
F 0677: The facility failed to provide personal hygiene care per care plan for one resident unable to perform activities of daily living. The resident was not toileted every 2 hours as required and was found with soaking wet pants after over 5 hours without care.
F 0695: The facility failed to ensure continuous oxygen therapy as ordered for one resident. The resident was observed without oxygen in use and the oxygen tank was found empty despite physician orders for continuous oxygen.
Report Facts
Residents sampled: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Confirmed laboratory orders not followed, confirmed toileting and oxygen therapy deficiencies |
| S4CNA | Certified Nursing Assistant | Observed resident without oxygen and brought resident to dining room |
| S5CNA | Certified Nursing Assistant | Observed resident with soaking wet pants and confirmed lack of toileting |
| S6CNA | Certified Nursing Assistant | Observed resident with soaking wet pants and confirmed lack of toileting |
| S2LPN | Licensed Practical Nurse | Confirmed oxygen tank was empty and resident was not receiving oxygen as ordered |
| S3CNAS | Certified Nursing Assistant Supervisor | Confirmed resident was not toileted every 2 hours as required |
Inspection Report — May 8, 2025
Complaint Investigation CMS
Date: May 8, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding resident rights, care planning, environment cleanliness, dietary services, infection control, and hospice services at the facility.
Complaint Details
The visit was complaint-related, investigating multiple concerns including resident financial safeguards, care planning, environment cleanliness, dietary services, hospice services, and infection control. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to safeguard resident funds, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, inaccurate staffing information, improper food preparation, failure to provide therapeutic diets as ordered, lack of hospice recertification, and failure to maintain proper infection control practices.
Deficiencies (11)
F 0567: The facility failed to have a system to safeguard Resident #34's funds against misappropriation, with no process for handling resident funds received on weekends or after hours.
F 0584: The facility failed to ensure shower drains in Room A were free from excessive hair, compromising a safe and homelike environment.
F 0641: The facility failed to ensure Resident #45's Minimum Data Set assessment accurately reflected the use of a wander bracelet.
F 0656: The facility failed to develop and implement a comprehensive care plan and follow physician's orders for Residents #34 and #42, including failure to apply a carrot splint and update care plan for UTI.
F 0657: The facility failed to revise comprehensive care plans timely for Residents #21 and #47 to reflect accurate advance directive status and removal of floor mats.
F 0677: The facility failed to provide necessary assistance with activities of daily living to Resident #42, resulting in missed feeding and lack of encouragement to eat.
F 0732: The facility failed to post accurate and current nurse staffing information, posting previous day's data with incorrect census of 90 instead of 87.
F 0805: The facility failed to ensure recipes were used for pureed, chopped, and bite-sized meals, risking poor nutrition and dining experience for multiple residents.
F 0808: The facility failed to provide Resident #90 with foods in the appropriate pureed form as ordered, serving chopped meat instead.
F 0849: The facility failed to obtain hospice recertification for Resident #21, with the last certification expired on 04/14/2025.
F 0880: The facility failed to maintain infection prevention by not performing appropriate hand hygiene during wound care for Resident #65.
Report Facts
Residents affected: 87
Residents affected: 56
Residents affected: 15
Residents affected: 12
Residents affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6LPN | Licensed Practical Nurse | Confirmed presence of Resident #34's funds and failure to apply carrot splint |
| S12CNA | Certified Nursing Assistant | Reported handling Resident #34's funds |
| S2DON | Director of Nursing | Provided multiple confirmations regarding care plan deficiencies, staffing, and hospice documentation |
| S11AC | Administration Clerical | Responsible for residents' trust funds and staffing information |
| S7MDS | Minimum Data Set Coordinator | Confirmed MDS coding errors and care plan deficiencies |
| S13LPN | Licensed Practical Nurse | Confirmed absence of fall mats for Resident #47 |
| S16CNA | Certified Nursing Assistant | Observed not feeding Resident #42 |
| S17LPN | Licensed Practical Nurse | Confirmed Resident #42's lunch was uneaten |
| S9Cook | Cook | Observed preparing pureed meals without recipes |
| S8DS | Dietary Supervisor | Confirmed recipes should be used for pureed meals |
| S7DS | Dietary Supervisor | Confirmed pureed meat texture was incorrect |
| S5TN | Treatment Nurse | Observed failing to perform hand hygiene during wound care |
| S3IC | Infection Control Nurse | Confirmed hand hygiene training and deficiencies |
Inspection Report — Apr 29, 2025
Annual Inspection CMS
Date: Apr 29, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with healthcare regulations related to respiratory care and medical record documentation at Evangeline Oaks Guest House.
Findings
The facility failed to ensure proper storage and usage instructions for respiratory equipment for Resident #2 and failed to maintain accurate and complete medical records for Resident #1, including improper cleaning and documentation of CPAP/BIPAP equipment.
Deficiencies (2)
F 0695: The facility failed to ensure Resident #2's respiratory equipment was stored properly and failed to indicate the frequency for BIPAP use in physician orders.
F 0842: The facility failed to maintain accurate and complete medical records for Resident #1, including improper cleaning and documentation of CPAP/BIPAP mask and tubing.
Report Facts
Residents sampled for respiratory care: 3
Residents sampled for medical record review: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S1CNA) | Confirmed improper storage of oxygen nasal cannula | |
| Licensed Practical Nurse (S2LPN) | Confirmed improper storage of oxygen nasal cannula and BIPAP use at night only | |
| Infection Preventionist (S3IP) | Confirmed oxygen nasal cannulas should be stored in a storage bag when not in use | |
| Director of Nursing (S4DON) | Confirmed BIPAP should be applied anytime Resident #2 is sleeping and nurses should not document task completion prior to completion | |
| Licensed Practical Nurse (S5LPN) | Admitted to documenting CPAP mask cleaning before task completion |
Inspection Report — Mar 6, 2025
Routine CMS
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards including activities of daily living assistance and accuracy of nurse staffing information posting.
Findings
The facility failed to ensure a resident received necessary nail care and failed to maintain accurate and current nurse staffing information posted daily.
Deficiencies (2)
F 0677: The facility failed to provide care and assistance for activities of daily living by not trimming and cleaning a resident's fingernails as ordered.
F 0732: The facility failed to ensure nurse staffing information posted daily was accurate and current, with staffing data dated over two weeks old.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Confirmed nail care and staffing posting deficiencies |
Inspection Report — Feb 12, 2025
Complaint Investigation CMS
Date: Feb 12, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to immediately notify a resident's physician and responsible party after an injury, failure to write a timely telephone order and obtain wound cultures as ordered, and failure to maintain accurate medical records.
Complaint Details
The investigation was complaint-driven, focusing on notification delays, documentation failures, and untimely wound culture orders. The deficiencies were substantiated as the facility failed to meet regulatory requirements in these areas.
Findings
The facility failed to promptly notify the physician and responsible party when Resident #5 was injured, delayed wound culture collection and telephone order documentation for Resident #2, and failed to document an incident involving Resident #5 in the nurse's notes. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
F 0580: The facility failed to immediately notify Resident #5's physician and responsible party after she was hit in the head with her room door on 01/04/2025; notification occurred two days later on 01/06/2025.
F 0773: The facility failed to write a telephone order and obtain wound cultures in a timely manner for Resident #2 as ordered by the physician on 10/02/2024; cultures were collected two days later on 10/04/2024.
F 0842: The facility failed to maintain accurate medical records by not documenting the incident where Resident #5 was hit in the head with the door in the nurse's notes dated 01/04/2025.
Report Facts
Residents reviewed: 5
Incident date: Jan 4, 2025
Notification delay: 2
Wound culture order date: Oct 2, 2024
Wound culture collection date: Oct 4, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Treatment Nurse | Treatment Nurse | Named in failure to write telephone order and delay in wound culture collection for Resident #2 |
| S1 DON | Director of Nursing | Interviewed regarding notification delays and documentation failures |
| S3 LPN | Licensed Practical Nurse | Interviewed about Resident #5's complaint of headache and notification status |
| S4 ALPN | Agency Licensed Practical Nurse | Interviewed about awareness of Resident #5's head injury incident |
Inspection Report — Jun 25, 2024
CMS
Date: Jun 25, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, sanitary, and comfortable environment for residents as part of regulatory oversight.
Findings
The facility failed to maintain a safe and homelike environment as evidenced by the deteriorated condition of Resident #1's back door frame and the damaged north wall in his room.
Deficiencies (1)
F 0921: The facility failed to ensure Resident #1's back door frame was in good repair, with a section of rotten wood about one foot in height. The north wall on the left side of Resident #1's bed had two breaks in the sheetrock that were not repaired.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Confirmed the condition of Resident #1's back door frame and north wall. | |
| Administrator | Confirmed the condition of Resident #1's back door frame and north wall. |
Inspection Report — May 22, 2024
Routine CMS
Date: May 22, 2024
Visit Reason
Routine inspection of Evangeline Oaks Guest House to assess compliance with regulatory requirements including resident dignity, care planning, infection control, medication administration, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete resident council meetings, inadequate mail delivery, unsafe environment conditions, inaccurate resident assessments, incomplete care plans, insufficient activity provision, improper catheter care, medication administration errors, food safety violations, inaccurate staffing data submission, infection control breaches, and inadequate call bell accessibility.
Deficiencies (14)
F 0550: The facility failed to treat Resident #11 with dignity by staff addressing her as 'girl' instead of by her name.
F 0565: The facility failed to organize monthly resident council meetings, missing meetings in March and April 2024, potentially affecting 95 residents.
F 0576: The facility failed to ensure residents received mail on Saturdays, affecting 95 residents.
F 0584: The facility failed to provide a homelike environment for Resident #13 due to a cracked, peeling, and hanging ceiling in the resident's room.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for Residents #63 and #89, with errors in medication and restraint coding.
F 0656: The facility failed to implement care plans for Resident #198 by not repositioning her every 2 hours and not providing a communication board or notebook; also failed to monitor padding on Resident #82's bedframe.
F 0657: The facility failed to invite Resident #70 or his responsible party to care planning meetings, affecting resident participation.
F 0679: The facility failed to provide activities based on the care plan for Resident #198, who had not participated in activities since hospital return.
F 0690: The facility failed to provide appropriate catheter care for Resident #70 by not securing the catheter tubing to the thigh as ordered.
F 0759: The facility failed to maintain medication error rates below 5%, with 2 late medication administrations out of 32 opportunities (6.25% error rate).
F 0812: The facility failed to follow food safety standards by storing expired foods, not labeling opened foods with date/time, and missing temperature logs for coolers and freezer for one week.
F 0851: The facility failed to submit accurate payroll-based staffing data to CMS, missing documentation of 8 consecutive RN coverage hours on multiple weekend days.
F 0880: The facility failed infection control by allowing staff to exit Resident #12's contact isolation room wearing soiled gloves and gown.
F 0919: The facility failed to provide accessible call systems for Residents #37 and #62 by not keeping call bells within reach, and Resident #83 was unable to use the call bell due to physical limitations.
Report Facts
Residents affected: 95
Medication error rate: 6.25
Expired food items: 6
Missing temperature log week: 1
PBJ staffing missing RN coverage days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Licensed Practical Nurse | Named in medication error finding and call bell accessibility |
| S8CNA | Certified Nursing Assistant | Named in dignity violation and call bell accessibility |
| S2DON | Director of Nursing | Interviewed regarding dignity, mail delivery, infection control, and call bell issues |
| S15MDSC | Minimum Data Set Coordinator | Interviewed regarding inaccurate MDS assessments and care plan meetings |
| S16DS | Dietary Supervisor | Interviewed regarding food safety violations |
| S19OM | Office Manager | Interviewed regarding PBJ staffing data submission |
| S11HSK | Housekeeper | Observed failing to remove PPE properly in isolation room |
Inspection Report — May 22, 2024
Routine CMS
Date: May 22, 2024
Visit Reason
Routine inspection of Evangeline Oaks Guest House to assess compliance with regulatory requirements related to resident dignity, communication, environment, care planning, activities, catheter care, medication administration, and staffing data submission.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to provide mail on Saturdays, failure to maintain a homelike environment, failure to implement person-centered care plans, failure to provide activities as per care plans, failure to provide appropriate catheter care, medication administration errors exceeding 5%, and failure to submit accurate direct care staffing data to CMS.
Deficiencies (8)
F 0550: The facility failed to treat a resident with dignity by addressing her as 'girl' instead of by her name, affecting 1 of 2 residents reviewed for dignity.
F 0576: The facility failed to ensure residents received mail on Saturdays, potentially affecting 95 residents due to no mail delivery or pickup on weekends.
F 0584: The facility failed to provide a homelike environment for 1 of 3 residents investigated, evidenced by a cracked, peeling, and hanging ceiling in a resident's room.
F 0656: The facility failed to implement a person-centered care plan by not repositioning Resident #198 every 2 hours or providing a communication notebook and pen, and failed to monitor padding on Resident #82's bedframe.
F 0679: The facility failed to provide activities based on the care plan for Resident #198, who had not participated in activities since returning from the hospital.
F 0690: The facility failed to provide appropriate catheter care for Resident #70 by not taping the catheter tubing to the thigh as ordered.
F 0759: The facility failed to ensure medication error rates were below 5%, with 2 medication administration errors out of 32 opportunities (6.25% error rate) during morning medication pass.
F 0851: The facility failed to submit accurate payroll data for direct care staffing to CMS, missing verification of 8 consecutive hours of RN coverage on multiple weekend days in Q1 2024.
Report Facts
Residents affected: 95
Medication administration opportunities: 32
Medication errors: 2
Medication error rate: 6.25
Missing RN coverage days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S7LPN | Licensed Practical Nurse | Named in medication error finding and medication administration observations |
| S8CNA | Certified Nursing Assistant | Named in dignity deficiency related to disrespectful address of resident |
| S2DON | Director of Nursing | Interviewed regarding dignity and mail delivery deficiencies |
| S12SS | Social Services | Interviewed regarding communication notebook and activity participation deficiencies |
| S14LPN | Licensed Practical Nurse | Confirmed catheter care deficiency |
| S15MDS | MDS Coordinator | Interviewed regarding care plan implementation and catheter care |
| S19MNTSup | Maintenance Supervisor | Interviewed regarding homelike environment deficiency |
| S18MNT | Maintenance | Interviewed regarding homelike environment deficiency |
| S19OM | Office Manager | Interviewed regarding payroll data submission deficiency |
| S1ADM | Administrator | Interviewed regarding payroll data submission and mail delivery |
| S18CAdm | Consultant Administrator | Interviewed regarding payroll data submission deficiency |
Inspection Report — Apr 16, 2024
Routine CMS
Date: Apr 16, 2024
Visit Reason
Routine inspection to assess compliance with resident rights, environment safety, medication storage, and infection control policies.
Findings
The facility was found deficient in maintaining resident dignity regarding catheter privacy, cleanliness and maintenance of resident rooms, medication cart security, and proper laundry detergent use during wash cycles.
Deficiencies (4)
F 0557: The facility failed to ensure Resident #4's urinary catheter bag was contained and private during dining room observation.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment with multiple rooms having items and substances on floors and leaking faucets.
F 0761: The facility failed to ensure a medication cart was locked and keys were not left on top when unattended during medication administration.
F 0880: The facility failed to properly process contaminated resident clothing and linens by not ensuring detergent was dispensed during wash cycles.
Report Facts
Residents in facility: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S8 LPN | Licensed Practical Nurse | Left medication cart unlocked and unattended with keys on top |
| S3 LPN/CNASUP | Licensed Practical Nurse/Certified Nursing Assistant Supervisor | Acknowledged catheter bag privacy issue and medication cart security deficiency |
| S2 DON | Director of Nursing | Confirmed medication cart should be locked and keys not left on unattended cart |
| S4 HSKSUP | Housekeeping Supervisor | Confirmed cleanliness issues and maintenance needs in resident rooms |
| S9 LS | Laundry Staff | Reported detergent dispenser hose was disconnected and used washer without detergent |
Inspection Report — Jan 4, 2024
Complaint Investigation CMS
Date: Jan 4, 2024
Visit Reason
The inspection was conducted due to a complaint regarding inadequate supervision and assistance during resident transfers, specifically concerning Resident #3 who sustained an injury during transfer.
Complaint Details
The complaint investigation found that Resident #3 was not provided the required two-person assist during transfers, leading to injury. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to ensure adequate supervision and assistance during the transfer of Resident #3, resulting in the resident sustaining a hematoma after hitting her left hand on a bedside table. The resident was assessed and care planned for two-person assist transfers but was transferred with only one-person assist at the time of the incident.
Deficiencies (1)
F 0689: The facility failed to ensure each resident receives adequate supervision and assistance to prevent accidents during transfers. Resident #3 was transferred with one-person assist instead of the required two-person assist, resulting in injury.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nurses | Reviewed incident report and confirmed transfer deficiency |
| S3LPN | Licensed Practical Nurse | Interviewed regarding resident transfer assistance |
| S4CNA Supervisor | CNA Supervisor | Interviewed regarding resident transfer assistance |
Inspection Report — Jun 21, 2023
Routine CMS
Date: Jun 21, 2023
Visit Reason
Routine inspection of Evangeline Oaks Guest House to assess compliance with healthcare regulations including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of resident injuries, incomplete investigations of abuse allegations, inaccurate resident assessments, incomplete PASARR screenings, failure to follow care plans, improper medication administration and storage, unsanitary conditions of equipment, inadequate infection control practices, and failure to maintain clean wheelchairs.
Deficiencies (13)
F 0580: The facility failed to notify the responsible party of an injury of unknown origin for Resident #38.
F 0609: The facility failed to timely report an injury of unknown origin and an abuse allegation involving Resident #38 to the state survey agency.
F 0610: The facility failed to provide evidence of a thorough investigation of the allegation that someone hit Resident #38.
F 0641: The facility failed to ensure Resident #3's MDS assessment accurately reflected upper extremity impairment.
F 0645: The facility failed to complete a Level II PASARR screening for Resident #41 diagnosed with Schizophrenia with auditory hallucinations.
F 0656: The facility failed to provide care as outlined in plans for 6 residents, including failure to monitor blood glucose, bleeding, provide range of motion, and orientation aids.
F 0695: The facility failed to properly store respiratory equipment for Resident #67; nasal cannula was found on the floor and not in a labeled bag.
F 0698: The facility failed to ensure dialysis communication sheets were completed and placed in Resident #60's chart after dialysis visits.
F 0761: The facility failed to properly store drugs; loose pills were found in medication carts.
F 0812: The facility failed to maintain sanitary conditions of three ice machines used for resident meals and beverages.
F 0880: The facility failed to maintain an effective infection prevention and control program including lack of water system assessment, failure to apply PPE when cleaning isolation room, and failure to sanitize hands between glove changes during wound care.
F 0882: The facility failed to ensure the designated Infection Preventionist completed specialized infection prevention and control training.
F 0921: The facility failed to ensure residents' wheelchairs were clean and sanitary as required by policy.
Report Facts
Residents sampled: 45
Medication carts inspected: 2
Ice machines inspected: 3
Residents affected by wheelchair cleanliness: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Licensed Practical Nurse | Named in findings related to failure to notify responsible party and respiratory equipment storage |
| S2DON | Director of Nursing | Named in multiple findings including failure to notify, infection control, medication storage, and dialysis communication |
| S1ADM | Administrator | Named in findings related to injury reporting, infection control, dialysis communication, and ice machine maintenance |
| S23MDS | Licensed Practical Nurse/MDS Coordinator | Named in finding related to inaccurate MDS assessment |
| S14SSA | Social Services Assistant | Named in finding related to incomplete PASARR screening |
| S13AD | Activity Director | Named in finding related to failure to inform resident of activities |
| S16MDS Coordinator | MDS Coordinator | Named in finding related to care plan and range of motion |
| S18 Restorative Nurse | Restorative Nurse | Named in finding related to range of motion care |
| S19 Rehab Coordinator | Rehab Coordinator | Named in finding related to range of motion care |
| S4LPN | Licensed Practical Nurse | Named in finding related to dialysis communication sheets |
| S5LPN | Licensed Practical Nurse | Named in medication cart inspection |
| S11MAINT | Maintenance Supervisor | Named in findings related to ice machine cleaning and wheelchair cleanliness |
| S3TN | Treatment Nurse | Named in infection control and wound care findings |
| S9LPN | Licensed Practical Nurse | Named as Infection Preventionist without required training |
| S10HSKP | Housekeeping Staff | Named in infection control finding for failure to wear PPE while cleaning isolation room |
| S17Assistant CNA Coordinator | Assistant CNA Coordinator | Named in wheelchair cleanliness finding |
Inspection Report — Jun 21, 2023
Complaint Investigation CMS
Date: Jun 21, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to notify responsible parties of resident injuries, failure to report injuries of unknown origin, failure to investigate alleged abuse, inaccurate resident assessments, failure to provide care as outlined in care plans, and failure to ensure nurse aide competency.
Complaint Details
The complaint investigation involved Resident #38, who had injuries of unknown origin and allegations of abuse. The facility failed to notify the responsible party timely, failed to report the injury to the state, and failed to conduct a thorough investigation. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to notify the responsible party of a resident's injury, failed to report an injury of unknown origin to the state within required timeframes, failed to conduct a thorough investigation of alleged abuse, inaccurately coded a resident's assessment, failed to provide care as outlined in care plans for multiple residents, and failed to ensure nurse aides reported injuries found during care.
Deficiencies (6)
F 0580: The facility failed to notify the responsible party of an injury of unknown origin for Resident #38.
F 0609: The facility failed to report an injury of unknown origin (hematoma) to the state within 2 hours as required for Resident #38.
F 0610: The facility failed to have evidence of a thorough investigation of the allegation that someone hit Resident #38.
F 0641: The facility failed to ensure Resident #3's MDS assessment accurately reflected his upper extremity impairment.
F 0656: The facility failed to provide care as outlined in the plan for 6 residents, including failure to monitor blood glucose prior to insulin, monitor bleeding for anticoagulant use, provide range of motion, and ensure access to a clock or watch.
F 0726: The facility failed to ensure nurse aides demonstrated competency by failing to report a resident's injury to the nurse for Resident #38.
Report Facts
Residents sampled: 45
Residents affected: 1
Residents affected: 6
Residents affected: 1
Viewing
Loading inspection reports...
