Axiom Healthcare of Rosiclare

Inspectors wroteBased on interview and record review, the facility failed to ensure that direct resident care staffing was adequate to meet the needs of residents in the facility. The failure has the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on interview, and record review the facility failed to ensure they used the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 29 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to staff a Director of Nursing (DON). The facility also failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 33 residents residing in the facility. The Findings Include:On 12/2/25 at 10:00 AM, V1 (Administrator) stated that they do not have a Director of Nursing at this time. V1 stated that the position is posted, and they are actively seeking qualified candidates. At this same time, V1 stated that they do not have a Registered Nurse (RN) on the schedule 7 days a week, 8 consecutive hours a day. Nursing schedules were reviewed from May 2025 through December 2025. There was no documentation of RN coverage on the following dates: May 2025: 3rd and 10thJune 2025: 3, 5, 7, 9, 13, 17,18, 28, 30 and 31stJuly 2025: 5thSeptember 2025: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow the recipe for the scheduled menu item. This has the ability affect all 33 residents that reside in the facility. The Findings Include: On 12/3/25 the planned lunch menu was for a barbeque riblette, pasta salad and fruit cup. During the lunch observation on 12/3/25 it was observed that the residents receiving a regular diet received a barbeque riblette that did not have sauce on it and residents receiving mechanical soft diets received ground meat with a squirt/drizzle of ketchup on top. The recipe for the barbeque pork riblette is as follows: Ingredients: pork pattie, rib shaped boneless, 3 oz (ounces) frozen and sauce, barbeque. Instructions for cooking: 1. Place frozen riblettes on a sheet pan sprayed with nonstick cooking spray. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to prepare the mechanical soft diet per resident needs for 5 of 5 (R2, R15, R17, R22 and R25) residents reviewed for a mechanical soft diet, in a sample of 23. The Findings Include:On 12/3/25 at 12:15 PM, during a lunch observation it was noted that the barbeque riblets did not have barbeque sauce. During this time, it was observed that the mechanical soft meal trays had dry ground barbeque riblets with a small drizzle of ketchup on top.1. R2's admission profile sheet documents an admission date of 12/1/2020 and includes the following diagnosis: cerebral infarction, unspecified dementia, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a full time Director of Nursing and to have a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 34 residents living in the facility. Findings Include: The Long Term Care Facility Application For Medicare and Medicaid document dated 11/19/2024, documents 34 residents residing in the facility. The facility's nursing schedules document there was no RN on shift for coverage on the following dates: 9/3/2024, 9/7/2024, 9/21/2024, 9/25/2024, 9/26/2024, 9/30/2024, 10/5/2024, 10/9/2024, 10/10/2024, 10/14/2024, 10/15/2024, 10/19/2024, 10/21/2024, 10/22/2024, 10/23/2024, 10/28/2024, 10/29/2024, 11/6/2024, 11/13/2024,11/14/2024, 11/18/2024, 11/19/2024 and 11/21/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R27) of 1 resident reviewed for PASRR Screening in the sample of 18. Findings Include: 1. R27's admission Record documented an initial admission date to the facility of 1/23/23. The current admission Date is listed as 05/10/2024 and included a diagnosis of psychotic disorder with delusions due to known physiological condition with onset date of 05/10/2024. R27's Notice of PASRR Level I Screen Outcome dated 5/7/24 documented a PASRR Level I Determination of No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability/RC (Related Condition). In the section titled Diagnoses under Mental Health Diagnoses this document noted No mental health diagnosis is known or suspected. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 2 (R5, R24) of 5 residents reviewed for Gradual Dose Reductions (GDR) in a sample of 18. Findings Included: 1. R5's admission Record documented an admission date of 7/21/2012 and included diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance, depression unspecified and anxiety. R5's current Medication Administration Record (MAR) for November 2024 documented R5 is prescribed the following psychotropic medications: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assist dependent residents with repositioning and incontinence care for 2 of 3 residents (R5 and R 15) reviewed for Activities of Daily Living (ADL's) in a sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to rid the facility of flies and roaches. This failure has the potential to affect all 40 residents currently residing at the facility. Findings Include: The facility Nurses Midnight Census report provided to this surveyor on 7/8/24 document 40 residents currently reside at the facility. On 7/8/24 at 10:32 AM, there was a live roach crawling under the three-compartment sink and in the dry food storage area. There were multiple flies seen in the food preparation area. V8 (Dietary Manager) stated the roaches are better now. V8 stated the exterminator came in and is due back anytime now. On 7/8/24 and 7/9/24 between 10:00 AM and 4:00 PM, each time this surveyor walked through the dining room there were multiple flies observed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety and maintain floors, walls, and equipment in a safe and sanitary condition. This failure has the potential to affect all 40 residents residing in the facility. Findings Include: The facility Nurses Midnight Census provided to this surveyor on 6/3/24 documents 40 residents currently reside at the facility. On 6/3/24 at 11:16 AM, this surveyor opened the refrigerator door in the kitchen and observed fruit in individual bowls sitting on the shelf, uncovered and undated. On 6/3/24 at 11:20 AM, this surveyor showed V8 (Dietary Manager) the uncovered, undated fruit in the refrigerator and V8 told V6 (Cook) that all food should be covered and dated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent the development of new pressure ulcers for a resident at high risk and failed to timely identify a new pressure ulcer for 1 of 3 (R13) residents reviewed for pressure ulcers in the sample of 17. This failure resulted in R13 developing an unstageable pressure ulcer to her right heel. Findings Include: R13's New admission Record undated, documented R13's initial admission date to the facility as 11/05/2014. R13's POS (Physician Order Sheet) dated 6/1/2024, documents diagnosis to include Dementia, Hypertension, Diabetes Mellitus, Hyperlipidemia, Degenerative Joint Disease, Cyclic Neutropenia, and Depression. R13's POS includes orders for Skin Prep to Left Heel twice a day with order date of 4/25/2024, and float heels while in bed as tolerated with order date of 3/13/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program. This has the potential to affect all 40 residents residing at the facility. Findings Include: The facility Nurses Midnight Census provided to this surveyor on 6/3/24 documents 40 residents currently reside at the facility. On 6/3/24 at 11:20 AM, a roach crawled out from underneath the freezer and crawled towards this surveyor's feet. V8 (Dietary Manager) stated they have been without pest control services. V8 stated she was aware of the roaches and there had been an uptick in them since they hadn't had pest control services. On 6/3/24 at 11:46 AM, V4 (Maintenance Director) gave this surveyor a pest control summary dated 12/27/23. V4 stated that was the last report he had from a pest control company. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents rights were protected when they failed to ensure their privacy by not providing a curtain or door to cover the commode stall area in the women's common area bathroom. This failure has the potential to affect 33 female residents currently residing at the facility. Findings Include: The facility Nurses Midnight Census report provided to this surveyor by the facility on 6/3/24 documents 33 female residents currently reside at the facility. The facility resident rooms were observed to have no private/semi-private bathrooms. There was only one women's shower/bathroom located at the end of the women's hall for the women to use. On 6/3/24 at 11:31 AM, the women's shower room/bathroom was observed by this surveyor and had three stalls with commodes in them. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were able to choose what time they got up in the morning for 1 of 5 (R12) residents reviewed for resident's rights in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of staff to resident abuse to the State Survey Agency for 1 of 3 (R3) residents reviewed for abuse in the sample of 17. Findings Include: On 6/3/24 at 3:17 PM, V1 (Administrator) stated this surveyor had been provided with all of the facility abuse/neglect investigations. When asked if she had any reports of a resident being forced down the hall and yelling, V1 stated, No. At this time this surveyor reported an allegation of abuse to V1 of an unknown resident being pushed down the hall, dragging their feet, while an unknown staff member yelled at the resident. On 06/04/2024 the facility provided this surveyor with a document titled; Incident Investigation Form dated 5/24/24. This form included the following. Newly admitted resident (R4), had her husband (V21) in visiting. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident abuse for 1 of 3 (R3) residents reviewed for abuse in the sample of 17. Findings Include: On 6/3/24 at 3:17 PM, V1 (Administrator) stated this surveyor had been provided with all of the facility abuse/neglect investigations. When asked if she had any reports of a resident being forced down the hall and yelling, V1 stated, No. At this time this surveyor reported an allegation of abuse to V1 of an unknown resident being pushed down the hall, dragging their feet, while an unknown staff member yelled at the resident. On 06/04/2024 the facility provided this surveyor with a document titled; Incident Investigation Form dated 5/24/24. This form includes the following. Newly admitted resident (R4), had her husband (V21) in visiting. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely incontinence care per current standards of practice for 2 of 3 (R12 and R16) residents reviewed for incontinence care in the sample of 17. Findings Include: 1. R12's undated New admission Information sheet documents R12 was admitted to the facility on [DATE]. R12's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R12's diagnoses include intractable seizures, debility, depression, and anxiety. R12's current Care Plan documents a Focus Category dated 8/2019 of Continence. This Focus area includes the following interventions dated 8/2024, Allow brief when up. Assist to change PRN (as needed) .Consider scheduled toileting if pattern is evident. Set schedule per pattern. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure interventions to prevent falls were implemented and followed for 1 of 3 (R3) residents reviewed for falls in the sample of 17. Findings Include: R3's undated New admission Information sheet documents R3 was admitted to the facility on [DATE]. R3's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R3's diagnoses include left hip nailing, dementia, osteoarthritis, depression, and anemia. R3's MDS (Minimum Data Set) dated 5/22/24 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R3 has a severe cognitive deficit. This same MDS documents under Section J, R3 has a history of falls with injuries. R3's current Care Plan documents a Focus Category of Safety dated 5/2024. This focus area includes the following interventions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide incontinence care per current standards of practice for 1 of 3 (R12) residents reviewed for incontinence care in the sample of 17. Findings Include: 1. R12's undated New admission Information sheet documents R12 was admitted to the facility on [DATE]. R12's Physician's Order Sheet dated 6/1/24 to 6/30/24 documents R12's diagnoses include intractable seizures, debility, depression, and anxiety. R12's current Care Plan documents a Focus Category dated 8/2019 of Continence. This Focus area includes the following interventions dated 8/2024, Allow brief when up. Assist to change PRN (as needed) .Consider scheduled toileting if pattern is evident. Set schedule per pattern. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with eating for 1 (R30) of 4 residents reviewed for nutrition out of a sample of 38. This failure resulted in R30 having a significant weight loss of 14.8% in 6 months. The Findings Include: R30's Minimum Data Set (MDS) documents a most recent admission date of 11/25/22. The November 2023 Physician Orders includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Hypertension, malignant neoplasm of eye, and dementia. Current Diet order is listed as regular diet. R30's care plan with a goal date of 2/24 lists a goal that resident weight will be a proper Body Mass Index (BMI). Interventions with a start date of 3/15/23 is listed for the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate staff to meet resident needs. This has the potential to affect all 36 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Director of Nursing on a full-time basis. This has the potential to affect all 36 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain food preferences and offer substitute options to residents at mealtime. This has the potential to affect all 36 residents residing in the facility. The Findings Include: 1. R1's new admission information sheet documents an admission date of 6/17/22. R1 was alert to person and place during the interview on 12/1/23 at 12:30 PM when she stated that she is never asked about meal preferences or options other than the main selection. R1 stated that she is blind, so she would not be able to read the board if they did fill it out. R1 stated that she just gets what they serve her at meals, and that is what she eats. R4's food preference questionnaire is dated 6/17/23. 2. R4's new admission information sheet documents an admission date of 1/11/19. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain an effective pest control program. This has the potential to affect all 36 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess residents to ensure the necessary level of assistance was provided with eating for 4 of 4 (R2, R5, R28, and R30) residents reviewed for meal assistance in a sample of 38. The Findings Include: 1. R30's Minimum Data Set (MDS) documents a most recent admission date of 11/25/22. The November 2023 Physician Orders includes the following diagnoses: Chronic Obstructive Pulmonary Disease, Hypertension, malignant neoplasm of eye, and dementia. Current Diet order is listed as regular diet. On 12/1/23 at 10:30 AM, V1 (Administrator) stated that R30 does not have current supplements ordered due to poor intake of those supplements. V1 stated that several different types had been trialed. R30's report of monthly weight and vitals for the 2023 year lists the following weights: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to allow an independent smoker the right to choose when to smoke for 1 (R32) of 4 residents reviewed for smoking in a sample of 38.

Inspectors wroteBased on interview and record review, the facility failed to provide resident/resident representative with required notice of transfer/discharge for 2 of 2 residents (R2, R33) reviewed for hospitalizations in the sample of 38.

Inspectors wroteBased on interview and record review, the facility failed notify resident/resident representative in writing of the bed hold policy for 2 of 2 residents (R2, R33) reviewed for hospitalizations in the sample of 38.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure results of a urine culture and sensitivity were received timely and physician notification of those results were communicated to ensure necessary treatment for a urinary tract infection for 1 (R29) of 3 residents reviewed for urinary tract infections out of a sample of 38.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide incontinence care in a timely manner for 1 of 1 resident (R9) reviewed for bowel and bladder in the sample of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide physician ordered therapeutic diets for 2 (R21 and R29) of 4 residents reviewed for nutrition in a sample of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who require antibiotics are prescribed the appropriate antibiotics to treat infections for 1 (R29) of 3 residents reviewed for urinary tract infections in a sample of 38.

Inspectors wroteBased on interview and record review the facility failed to follow the Immunization of Residents policy and failed to provide the Pneumococcal Immunization for 1 (R29) of 5 residents reviewed for immunizations in a sample of 38.