Inspection Reports for
Legacy Nursing and Rehabilitation of Plaquemine
59215 RIVER WEST DRIVE, PLAQUEMINE, LA, 70764
Back to Facility Profile14 Reports
Inspection Report — Jan 29, 2026
Complaint Investigation CMS
Date: Jan 29, 2026
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide assistance with activities of daily living, specifically personal hygiene, to a resident dependent on staff.
Complaint Details
The complaint investigation found that Resident #102 was not assisted with personal hygiene as required. The deficiency was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure that Resident #102, who was totally dependent on staff for activities of daily living, received assistance with personal hygiene. Observations and interviews revealed the resident had oily hair with small, dried, white flakes, and there was no documentation confirming care was provided.
Deficiencies (1)
F 0677: The facility failed to provide care and assistance for activities of daily living to a resident who was unable. Resident #102 did not receive assistance with personal hygiene, as evidenced by oily hair with small, dried, white flakes and lack of documentation of care.
Report Facts
Residents sampled for activities of daily living: 5
Residents affected: 1
Inspection Report — May 29, 2025
Complaint Investigation CMS
Date: May 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding privacy and infection control practices during incontinence care at the facility.
Complaint Details
The complaint investigation found substantiated issues related to privacy violations and infection control lapses during incontinence care for Resident #1.
Findings
The facility failed to provide privacy for a resident during incontinence care and failed to ensure proper hand hygiene by a Certified Nursing Assistant during incontinence care for the same resident.
Deficiencies (2)
F 0583: The facility failed to provide privacy for Resident #1 during incontinence care by not pulling the privacy curtain, exposing the resident to her roommate.
F 0880: The facility failed to ensure a CNA completed hand hygiene during incontinence care for Resident #1 and improperly used soiled gloves to obtain wipes from a multi-use package.
Report Facts
Residents observed during incontinence care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (S3CNA) | Named in findings for failure to provide privacy and hand hygiene during incontinence care | |
| Director of Nursing (S2) | Interviewed regarding privacy and hand hygiene deficiencies | |
| Administrator (S1) | Interviewed regarding privacy and hand hygiene deficiencies |
Inspection Report — Jan 29, 2025
Annual Inspection CMS
Date: Jan 29, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident privacy during care, sanitation of feeding equipment, accuracy of resident assessments, implementation of care plans to prevent falls, catheter care, respiratory equipment maintenance, food safety practices, and call bell accessibility.
Deficiencies (8)
F 0583: The facility failed to maintain Resident #17's privacy during care as the privacy curtain and blinds were not properly used, exposing the resident's nude body to the outside.
F 0584: The facility failed to maintain sanitary conditions for Resident #32 and Resident #37's enteral feeding equipment and surrounding floor, which had dried feeding formula residue.
F 0641: The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for Resident #42 and Resident #51.
F 0656: The facility failed to implement care plan interventions for Resident #84 to reduce fall risk, as the resident was observed without a required self-release lap tray while in a wheelchair.
F 0690: The facility failed to maintain Resident #64's urinary catheter bag below bladder level during care, increasing risk of urinary tract infections.
F 0695: The facility failed to properly store Resident #23's respiratory equipment as the nebulizer mask and tubing were uncontained and lying on surfaces.
F 0812: The facility failed to ensure food safety in the kitchen, including staff not wearing hairnets properly, unlabeled and undated food items, uncovered prepared foods, storage of personal food in resident food areas, and presence of expired food.
F 0919: The facility failed to ensure call bells were within reach for Residents #2 and #95, limiting their ability to summon staff assistance.
Report Facts
Residents sampled: 22
Residents investigated for environment: 6
Residents investigated for falls: 3
Residents investigated for urinary catheter and/or UTI: 4
Residents investigated for respiratory care: 3
Residents investigated for call bell accessibility: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed cleanliness issues and call bell accessibility problems |
| S2 Director of Nursing | Director of Nursing | Confirmed privacy issues, respiratory equipment concerns, catheter care, and call bell accessibility |
| S3 Assistant Director of Nursing | Assistant Director of Nursing/Infection Preventionist | Confirmed catheter care and infection history for Resident #64 |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed catheter care issues for Resident #64 |
| S5 Certified Nursing Assistant | Certified Nursing Assistant | Observed catheter care for Resident #64 |
| S6 CNA Supervisor | CNA Supervisor | Confirmed privacy curtain and blinds should have been used |
| S7 Dietary Manager | Dietary Manager | Confirmed food safety violations in kitchen |
| S8 Dietary Helper | Dietary Helper | Observed not wearing hairnet properly and storing personal food in kitchen refrigerator |
| S9 Dietary Helper | Dietary Helper | Observed not wearing hairnet properly |
| S10 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed fall care plan and call bell accessibility issues |
| S11 Director of Rehabilitation | Director of Rehabilitation/Physical Therapy Assistant | Responsible for MDS completion and confirmed assessment inaccuracies |
| S12 MDS Nurse | MDS Nurse | Confirmed MDS assessment inaccuracies |
| S13 Assistant Director of Nursing | Assistant Director of Nursing | Confirmed privacy and fall care plan issues |
| S16 MDS Nurse | MDS Nurse | Confirmed MDS assessment inaccuracies |
Inspection Report — Dec 11, 2024
CMS
Date: Dec 11, 2024
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, including proper resident transfer communication and staffing requirements for licensed nurses as charge nurses on each shift.
Findings
The facility failed to communicate appropriate resident information during a transfer to an emergency department and failed to designate a licensed nurse as charge nurse for each shift according to nurse staff regulations.
Deficiencies (2)
F 0622: The facility failed to communicate required resident information to the receiving facility during a transfer of Resident #1 on 11/16/2024.
F 0725: The facility failed to ensure a licensed nurse was designated as charge nurse for each shift from 12/02/2024 through 12/11/2024.
Report Facts
Date of transfer: Nov 16, 2024
Date range of nurse schedules reviewed: Dec 2, 2024
Date range of nurse schedules reviewed: Dec 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 License Practical Nurse | Licensed Practical Nurse | Named in failure to call report during Resident #1 transfer |
| S2 Director of Nursing | Director of Nursing | Named in failure to designate charge nurse and failure to ensure report call |
| S1 Administrator | Administrator | Named in failure to provide documented evidence of report call and charge nurse designation |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Named in interview regarding lack of designated charge nurse |
| S9 Licensed Practical Nurse | Licensed Practical Nurse | Named in interview regarding lack of designated charge nurse |
| S6 Licensed Practical Nurse | Licensed Practical Nurse | Named in interview regarding lack of designated charge nurse |
Inspection Report — Sep 23, 2024
Routine CMS
Date: Sep 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding timely COVID-19 testing of residents showing symptoms.
Findings
The facility failed to test one resident with signs and symptoms of COVID-19 in a timely manner, resulting in a delay of more than a day before testing was performed.
Deficiencies (1)
F 0880: Provide and implement an infection prevention and control program. The facility failed to test Resident #2 for COVID-19 in a timely manner despite signs and symptoms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | S2 LPN indicated that when Resident #1 had a fever, Tylenol was given and a nurse's note was written to test the resident the next day. |
Inspection Report — Apr 4, 2024
Complaint Investigation CMS
Date: Apr 4, 2024
Visit Reason
The inspection was conducted due to complaints related to resident-to-resident abuse, failure to timely report suspected abuse, failure to develop a crisis intervention plan, and inadequate pain management for residents.
Complaint Details
The complaint investigation substantiated that Resident #4 physically abused Resident #5 causing actual harm. The facility also failed to report the abuse timely, failed to develop a crisis intervention plan for Resident #4, and failed to manage pain appropriately for Resident #1.
Findings
The facility failed to prevent resident-to-resident physical abuse resulting in actual harm, failed to timely report the abuse to the State Survey Agency, failed to develop a required crisis intervention plan for a resident, and failed to provide appropriate pain management for a nonverbal resident.
Deficiencies (4)
F 0600: The facility failed to protect residents from physical abuse when Resident #4 attacked Resident #5 with a belt causing scratches requiring daily wound care. Supervision was not increased despite known agitation behaviors.
F 0609: The facility failed to timely report an allegation of resident-to-resident abuse to the State Survey Agency within 5 working days for Residents #4 and #5.
F 0644: The facility failed to develop a crisis intervention plan for Resident #4 as required by the pre-admission screening and resident review program.
F 0697: The facility failed to provide appropriate pain management for Resident #1, who had documented pain levels of 7 and 8 but did not receive pain medication as ordered.
Report Facts
Residents affected: 2
Pain levels: 8
BIMS scores: 14
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Named in assessment of Resident #5's injuries and prior recommendation to separate residents |
| S1 Administrator | Administrator | Named in investigation and interview regarding awareness and reporting of incidents |
| S2 Director of Nursing | Director of Nursing | Named in interviews regarding supervision and pain management failures |
| Resident #4's Psychiatric Counselor | Named in interview regarding crisis intervention plan and resident behavior | |
| S10 Certified Nursing Assistant | Certified Nursing Assistant | Named in interview describing Resident #4's behavior |
| S11 Certified Nursing Assistant | Certified Nursing Assistant | Named in interview describing Resident #4's behavior |
| S12 CNA Supervisor | CNA Supervisor | Named in interview describing Resident #4's agitation and supervision |
| S7 Certified Nursing Assistant | Certified Nursing Assistant | Named in observation of Resident #1's pain signs |
| S8 Licensed Practical Nurse | Licensed Practical Nurse | Named in interview about pain assessment for nonverbal residents |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Named in interview about pain medication administration |
| Resident #1's Nurse Practitioner | Nurse Practitioner | Named in interview regarding pain management orders |
Inspection Report — Feb 9, 2024
Annual Inspection CMS
Date: Feb 9, 2024
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, failure to post survey results for resident access, failure to maintain the environment, failure to honor residents' code status in emergencies, failure to ensure safe smoking practices, failure to perform catheter care per policy, and failure to follow therapeutic diet recommendations.
Deficiencies (7)
F 0554: The facility failed to assess Resident #21 for self-administration of medications and did not have orders allowing medications to be kept at the bedside.
F 0577: The facility failed to ensure the results of the last annual survey were posted and accessible to residents and family members.
F 0584: The facility failed to repair a resident's wall that had paint and top layer missing, despite multiple maintenance requests.
F 0678: The facility failed to ensure Resident #406's code status was honored due to an unsigned DNR order, resulting in inappropriate initiation of CPR.
F 0689: The facility failed to ensure Resident #90, an unsafe smoker, used a smoking apron and was supervised while smoking, resulting in an Immediate Jeopardy situation.
F 0690: The facility failed to perform catheter care per policy for Resident #20 by not cleaning the catheter tubing at the insertion site.
F 0692: The facility failed to follow a speech therapist's recommendation for Resident #97 to receive a pureed consistency diet, resulting in missed meal trays.
Report Facts
Residents reviewed for environment: 27
Residents reviewed for death: 3
Residents reviewed for smoking: 3
Residents reviewed for catheter care: 3
Residents reviewed for nutrition: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S10 Licensed Practical Nurse | Licensed Practical Nurse | Named in medication self-administration finding related to Resident #21 |
| S9 MDS/Care Plan Coordinator | MDS/Care Plan Coordinator | Named in medication self-administration finding related to Resident #21 and smoking supervision for Resident #90 |
| S2 Director of Nursing | Director of Nursing | Named in medication self-administration and smoking supervision findings |
| S1 Administrator | Administrator | Named in survey results posting, medication self-administration, smoking supervision, and code status findings |
| S17 Dietary Manager | Dietary Manager | Named in maintenance and environment deficiency related to Resident #48 |
| S23 Maintenance Supervisor | Maintenance Supervisor | Named in maintenance and environment deficiency related to Resident #48 |
| S24 Maintenance | Maintenance | Named in maintenance and environment deficiency related to Resident #48 |
| S30 Licensed Practical Nurse | Licensed Practical Nurse | Named in code status and CPR initiation finding related to Resident #406 |
| S8 Certified Nursing Assistant | Certified Nursing Assistant | Named in smoking supervision finding related to Resident #90 |
| S13 Licensed Practical Nurse | Licensed Practical Nurse | Named in smoking supervision finding related to Resident #90 |
| S6 Recreational Therapist | Recreational Therapist | Named in smoking supervision finding related to Resident #90 |
| S28 Certified Nursing Assistant | Certified Nursing Assistant | Named in catheter care deficiency related to Resident #20 |
| S22 Certified Nursing Assistant | Certified Nursing Assistant | Named in nutrition deficiency related to Resident #97 |
| S25 Speech Language Pathologist | Speech Language Pathologist | Named in nutrition deficiency related to Resident #97 |
| S26 Director of Therapy | Director of Therapy | Named in nutrition deficiency related to Resident #97 |
Inspection Report — Feb 9, 2024
Immediate Jeopardy CMS
Date: Feb 9, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, behavioral health, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to assess and supervise medication self-administration, failure to maintain a safe and clean environment free from pests, failure to protect residents from abuse and to report and investigate abuse allegations, failure to provide adequate behavioral health services, failure to follow care plans for unsafe smokers, failure to provide proper catheter care, failure to provide therapeutic diets, failure to post nurse staffing information, failure to administer vaccines, and failure to ensure residents' code status was respected in emergencies. Immediate Jeopardy was identified related to unsafe smoking practices, pest infestation, and failure to honor code status.
Deficiencies (21)
F 0554: The facility failed to assess Resident #21 for self-administration of medications and failed to educate or have orders for self-administration despite medications being kept at bedside unsecured.
F 0577: The facility failed to ensure the results of the last annual survey were posted and accessible to residents and families.
F 0584: The facility failed to repair a resident's wall that had paint and top layer missing for several weeks despite multiple maintenance requests.
F 0600: The facility failed to protect residents from resident-to-resident physical abuse for multiple residents and confirmed abuse incidents without adequate prevention.
F 0609: The facility failed to timely report allegations of abuse and the results of investigations to proper authorities for multiple residents.
F 0610: The facility failed to conduct a thorough investigation following an allegation of abuse for Resident #104.
F 0644: The facility failed to ensure Resident #63 was referred for a required Level II PASARR evaluation for mental health diagnoses.
F 0646: The facility failed to notify the appropriate authority and complete a Level II PASARR evaluation for Resident #42 after a significant change in condition.
F 0656: The facility failed to implement the care plan for Resident #90 identified as an unsafe smoker by not providing a smoking apron or supervision while smoking.
F 0677: The facility failed to provide nail care to dependent residents #7 and #89, resulting in long, jagged nails with debris.
F 0678: The facility failed to ensure Resident #406's code status was respected during an emergency due to an unsigned DNR order, resulting in CPR being initiated contrary to resident wishes.
F 0689: The facility failed to ensure Resident #90 used required safety smoking devices and supervision, failed to maintain an environment free from roaches on Hall D, and failed to ensure Resident #406's code status was respected in an emergency.
F 0690: The facility failed to perform catheter care per policy for Resident #20 by not cleaning the catheter tubing at the insertion site.
F 0692: The facility failed to follow speech therapist's recommendation for Resident #97 to receive a pureed consistency diet.
F 0732: The facility failed to post required nurse staffing information in a visible location.
F 0740: The facility failed to provide necessary behavioral health care services for Residents #42 and #61, including failure to provide psychiatric evaluations and treatment.
F 0812: The facility failed to ensure food served was free from contamination and failed to keep sanitizer bottles off food preparation surfaces.
F 0835: The facility failed to administer vaccines and failed to maintain a pest-free environment, resulting in Immediate Jeopardy for unsafe smoking, pest infestation, and failure to honor code status.
F 0883: The facility failed to administer Influenza and Pneumococcal vaccines to Resident #42 despite signed consent.
F 0887: The facility failed to administer COVID-19 vaccine to Resident #42 despite signed consent.
F 0925: The facility failed to maintain an environment free from roaches on Hall D, with multiple live roaches observed in resident rooms and facility areas.
Report Facts
Residents affected by abuse: 6
Residents refusing medications: 28
Residents refusing medications: 25
Residents refusing medications: 25
Residents refusing medications: 28
Roach infestation dates: 5
Gaps in exit doors: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1Administrator | Administrator | Confirmed multiple deficiencies including pest issues, abuse investigations, and code status discrepancies |
| S2Director of Nursing | Director of Nursing | Confirmed failures in supervision of unsafe smokers, abuse reporting, catheter care, and psychiatric evaluations |
| S30Licensed Practical Nurse | Licensed Practical Nurse | Presented unsigned LaPOST to EMS resulting in CPR initiation |
| S17Dietary Manager | Dietary Manager | Confirmed unsanitary food handling and sanitizer placement |
| S9Minimum Data Set/Care Plan Coordinator | MDS/Care Plan Coordinator | Confirmed care plan requirements for unsafe smoker and psychiatric needs |
| S3Assistant Director of Nursing | Assistant Director of Nursing | Confirmed psychiatric rounds and care plan issues |
| S31Certified Nursing Assistant | Certified Nursing Assistant | Reported resident agitation related to urinal in dining room |
| S6Recreational Therapist | Recreational Therapist | Confirmed unsafe smoker requirements |
| S22Certified Nursing Assistant | Certified Nursing Assistant | Observed failure to provide meal trays per diet orders |
| S25Speech Language Pathologist | Speech Language Pathologist | Recommended pureed diet for Resident #97 |
Inspection Report — Dec 28, 2023
Complaint Investigation CMS
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to investigate complaints related to neglect, inaccurate resident assessments, incomplete care plans, inadequate catheter care, and pharmaceutical service deficiencies at Legacy Nursing and Rehabilitation of Plaquemine.
Complaint Details
The complaint investigation substantiated failures in neglect reporting, resident assessment accuracy, care planning, catheter care, and pharmaceutical services including medication availability and controlled substance accounting.
Findings
The facility failed to report an allegation of neglect by a certified nursing assistant, did not accurately assess or care plan for a resident's catheter, failed to provide appropriate catheter care, and did not ensure availability and accurate accounting of controlled medications for three sampled residents.
Deficiencies (5)
F 0607: The facility failed to ensure the certified nursing assistant reported an allegation of neglect for Resident #1.
F 0641: The facility failed to ensure Resident #3's catheter was properly assessed, as the MDS did not reflect catheter use.
F 0656: The facility failed to develop and implement a care plan with measurable interventions for Resident #3's catheter use.
F 0690: The facility failed to provide appropriate catheter care and prevent urinary tract infections for Resident #3.
F 0755: The facility failed to ensure routine drugs were available for Resident #1 and Resident #2 and failed to accurately account for controlled drugs for Residents #1, #2, and #3.
Report Facts
Residents reviewed for neglect: 3
Residents with catheter: 1
Residents reviewed for medication availability and controlled substance reconciliation: 3
Foley catheter size: 16
Foley catheter volume: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Discussed failures in medication refill communications and controlled substance accounting. |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Reported working with Resident #3 and lack of catheter care interventions. |
| S5 Certified Nursing Assistant | Certified Nursing Assistant | Confirmed only emptying catheter bag with no other catheter care interventions. |
| S11 Licensed Practical Nurse | Licensed Practical Nurse | Acknowledged occasional distraction leading to incomplete controlled substance sign-out. |
Inspection Report — Dec 6, 2023
CMS
Date: Dec 6, 2023
Visit Reason
The inspection was conducted to assess compliance with restorative services provision for residents, specifically to evaluate whether restorative nursing services were provided as ordered.
Findings
The facility failed to ensure restorative services were provided for one resident (Resident #1) as required. Interviews and record reviews confirmed that restorative services were not started despite a referral dated 10/18/2023.
Deficiencies (1)
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion and mobility for Resident #1. Restorative services were not initiated as ordered following a referral on 10/18/2023.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Rehabilitative Services | Director of Rehabilitative Services | Stated referral was given to administration for restorative care on 10/18/2023. |
| S1 Director of Nursing | Director of Nursing | Stated restorative services were not started for Resident #1 and should have been started on 10/18/2023. |
Inspection Report — Oct 31, 2023
CMS
Date: Oct 31, 2023
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control protocols, specifically focusing on wound care practices.
Findings
The facility failed to ensure that the wound care nurse performed hand hygiene when changing gloves during wound care for a resident. Observations and interviews confirmed the nurse did not perform hand hygiene between glove changes as required by facility policy.
Deficiencies (1)
F 0880: Provide and implement an infection prevention and control program. The wound care nurse failed to perform hand hygiene when changing gloves during wound care for Resident #2.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Licensed Practical Nurse | Wound Care Nurse | Named in infection prevention deficiency related to hand hygiene during wound care. |
| S2 Director of Nursing | Director of Nursing | Provided interview confirming hand hygiene expectations for wound care nurse. |
Inspection Report — Oct 31, 2023
Annual Inspection CMS
Date: Oct 31, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in maintaining accurate and complete documentation of residents' activities of daily living (ADL) related to bathing for three sampled residents. Additionally, infection control practices were inadequate as a wound care nurse failed to perform hand hygiene between glove changes. Environmental issues included dried sticky unknown substances on floors in resident rooms and unsealed air conditioners allowing outside access.
Deficiencies (3)
F 0842: The facility failed to maintain accurate and complete ADL documentation for bathing for three sampled residents, with missing records for specific dates in October 2023.
F 0880: The wound care nurse failed to perform hand hygiene when changing gloves during wound care for one resident, contrary to facility policy.
F 0921: The facility failed to ensure resident rooms were clean, with dried sticky unknown substances on floors for two residents and unsealed air conditioners allowing outside access.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Dates with missing ADL documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Licensed Practical Nurse (LPN)/Wound Care Nurse | Named in wound care hand hygiene deficiency | |
| S2 Director of Nursing (DON) | Interviewed regarding ADL documentation and wound care deficiencies | |
| S5 CNA Supervisor | Interviewed regarding incomplete ADL documentation | |
| S1 Administrator | Observed environmental deficiencies with surveyor |
Inspection Report — Oct 11, 2023
Complaint Investigation CMS
Date: Oct 11, 2023
Visit Reason
The inspection was conducted due to an allegation of misappropriation of resident funds involving Resident #1.
Complaint Details
The complaint involved an allegation that the Business Office Manager was stealing money from Resident #1. The facility did not submit a Statewide Incident Management System (SIMs) report for this allegation and failed to provide documented evidence of reporting investigation findings.
Findings
The facility failed to timely report the suspected misappropriation of Resident #1's funds and did not provide documented evidence of submitting required reports or investigation results to proper authorities.
Deficiencies (1)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed that a SIMs report should have been filed regarding the allegation of theft of Resident #1's money. |
| S2 Regional Director of Operations | Regional Director of Operations | Notified the Administrator of the findings approximately 3 months prior and was informed by the Business Office Manager's husband about the alleged theft. |
| S3 Business Office Manager | Business Office Manager | Alleged to have stolen money from Resident #1. |
Inspection Report — Apr 20, 2023
Annual Inspection CMS
Date: Apr 20, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care and facility operations.
Findings
The facility was found to have minimal harm deficiencies related to failure to cover a resident's urinary catheter bag and failure to provide adequate nail care to a resident dependent on staff assistance. These issues affected a few residents and were confirmed through observations and interviews.
Deficiencies (2)
F 0550: The facility failed to cover the urinary catheter bag for Resident #1 during multiple observations. Staff and the resident confirmed the catheter bag should have been covered.
F 0677: The facility failed to provide nail care to Resident #2, whose toenails extended past the tips of toes with substances under several nails. Staff confirmed nail care should have been provided.
Report Facts
Residents with urinary catheters: 17
Residents reviewed for ADLs: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Director of Nursing | Director of Nursing | Confirmed urinary catheter bag should be covered and nail care should have been provided |
| S2 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed urinary catheter bag should be covered and described nail care issues |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Stated no podiatrist had been in the building since COVID-19 |
| S4 Master Social Worker | Master Social Worker | Was unsure if a podiatrist came into the building to provide resident care |
| S6 Certified Nurses Aid | Certified Nurses Aid | Observed and stated urinary catheter bag should be covered |
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