Pearl Of St Charles, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed treat a resident with dignity by offering the resident slippers that were soiled with stool and by not cleaning the same slippers. This applies to 1 of 18 residents (R12) reviewed for dignity in the sample of 18. The findings include: R12's Face Sheet showed R12 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, abdominal aortic aneurysm without rupture, Partial intestinal obstruction, Ileostomy Status, malignant neoplasm of overlapping sites of the colon, and reduced mobility. R12's Minimum Data Set, dated [DATE] showed R12 was cognitively intact. On February 24, 2025 at 10:42 AM, V18 (Licensed Practical Nurse/LPN) entered R12's room to change R12's ileostomy. R12's gown, abdomen, fitted sheet, and back were wet with liquid stool. V18 wiped R12's abdominal area with an incontinence wipe and changed her ileostomy dressing. V18 left the room and said she would send…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the indwelling urinary catheters of residents were secured, and the urinary bag was not resting on the floor. This applies to 3 of 6 residents (R11, R41, and R57) reviewed for indwelling urinary catheters in the sample of 18. The findings include: 1. Face sheet shows, R57 is 66 years-old who has multiple medical diagnoses including chronic kidney disease, stage 3B, urethral stricture, male, unspecified site, obstructive and reflux uropathy, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, presence of urogenital implants. R57's Minimum Data Set (MDS) dated [DATE], shows, R57 is alert and oriented and requires assistance for toileting. R57's Care Plan with revision date of February 11, 2025, shows: R57 has chronic indwelling catheter related to BPH and urethral stricture. The goal is for R57 to be free from complications related to the use of catheter. The same care plan shows multiple interventions which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow physician's order for management of Peripherally Inserted Central Catheter (PICC) line. This applies to 1 of 2 residents (R57) reviewed for care of intravenous catheter in the sample of 18. The findings include: On February 25, 2025, at 9:37 AM, V15 (Registered Nurse) administered an IV (Intravenous) antibiotic (Ceftriaxone 2 grams) medication to R57 who had a PICC line on his right upper arm. The PICC line dressing, which was dated February 3, 2025, was loose and opened halfway. Physician Order Summary (POS) Report dated February 9, 2025, shows PICC line dressing change once a week and as needed one time a day every 7 days for infection prevention. R57's care plan with revision dated of February 11, 2025, shows R57 has PICC line on the right basilic for IV antibiotic infusion. The goal is for the PICC line to remain free from signs of infection. This same care plan shows multiple interventions which include to change dressing weekly, or sooner, if it is soiled, loose, or damp. Use sterile aseptic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have a physician order and care plan for oxygen administration in accordance with their policy. This applies to 1 of 1 resident (R325) reviewed for oxygen use in the sample of 18. The findings include: R325 was admitted to the facility on [DATE], with multiple diagnosis including chronic obstructive pulmonary disease, dependence on oxygen, chronic respiratory failure with hypoxia, centrilobular emphysema, influenza A, and cyst of the pancreas. On February 24, 2025, at 12:10 PM, R325 was observed with oxygen infusing via nasal cannula. R325's Health Status note dated February 24, 2025, at 11:12 PM showed continuous oxygen was administered at 3L (Liters) per NC (Nasal Cannula). On February 26, 2025, at 10:10 AM, R325 was observed with oxygen infusing via nasal cannula. V15 (RN/registered Nurse) stated the oxygen was infusing at 3L per NC and R325 can have 4L per NC if R325 gets anxious. R325's hospital H&P (History and Physical) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a resident's medical records within two working days upon request for two of three residents (R1, R7) reviewed for medical records request in the sample of eight. The findings include: 1. R1's Face Sheet dated February 20, 2025 shows she was admitted to the facility on [DATE] with diagnoses including spinal stenosis, low back pain, history of falling, urinary retention, and lack of coordination. R1 was discharged from the facility January 16, 2025. On February 20, 2025 at 9:34 AM, V7 (R1's Spouse) said he has been waiting to receive R1's medical records for over a month. V7 said they requested the records from V8 (Medical Records). V7 said that R1 just had another surgery on her back. V7 said R1 is entitled to those records. V7 said that he nor R1 has heard anything back from the facility regarding their medical records request. On February 20, 2025 at 11:18 AM, V8 (Medical Records) said if someone is requesting medical records, then she has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a fall assessment and monitor a resident after a fall for one of three residents (R1) reviewed for quality of care in the sample of eight. The findings include: R1's Face Sheet dated February 20, 2025 shows she was admitted to the facility on [DATE] with diagnoses including spinal stenosis, low back pain, history of falling, muscle wasting, urinary retention, abnormalities of gait and mobility, and lack of coordination. R1's Fall assessment dated [DATE] shows she is a high risk for falls. R1's Progress Note dated January 13, 2025 shows, R1 was reported to be lowered on the floor in her room. Per CNA (Certified Nursing Assistant) she was transferring R1 from her chair to her bed and R1's legs gave out and R1 was lowered to the floor. R1 denied any pain or discomfort. There was no fall report, fall assessment, or follow up assessment provided by the facility regarding R1's fall. On February 20, 2025 at 12:30 PM, V2 (Director of Nursing) said R1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from resident-to-resident verbal abuse. This applies to 3 of 6 residents (R1, R2, and R3) reviewed for abuse in the sample of 6. The findings include: On 11/1/24 at 10:36 AM, R1 said R2 and R3 told him to get out of the city, they don't want Mexicans here. On 11/1/24 at 11:45 AM, R3 was propelling backward in his wheelchair using his right leg. R3's left side appeared to be non-functional. R3 said he called R1 a p*y and R1 called him one arm. R1's current care plan provided by the facility shows R1 may have an increased susceptibility to abuse and is considered a vulnerable adult. R1 is to be treated with respect and dignity and will reside in the facility free of abuse. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact and has no behaviors including hallucinations, delusions, physical or verbal behavioral symptoms directed toward others, rejection of care, or wandering. R1's Progress Notes dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to administer antipsychotic drug, sleeping pill, nicotine patch and pain medication as ordered by the physician. The facility also failed to obtain physician order regarding administration of time-critical scheduled medications to ensure doses were evenly spaced to achieve accurate peak and maintain effectiveness. This applies to 12 of 19 residents (R3, R6, R10 through R19) reviewed for medications in the sample of 19. The findings include: The facility roster showed that R3, R6, R10 through R19 were all residing in the XXX unit of the facility. The roster also showed that census of the XXX unit was 27 residents. The staffing schedule of August 1, 2024, for the night shift nurses showed that V5 (Agency Registered Nurse) was assigned to the XXX unit for the night shift. The schedule time for night shift nurses was from 7:00 P.M. through 7:00 A.M. (12-hour shift). The staffing schedule showed that V5 came late at 11:30 P.M. on August 1,2024 P.M. 1. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was cared for in a dignified manner for 1 of 3 residents (R6) reviewed for dignity in the sample of 16. The findings include: R6's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include epilepsy, malignant neoplasm of brain, hemiplegia and hemiparesis following cerebral infarction, malignant neoplasm of right female breast, and malignant neoplasm of left female breast. R6's facility assessment dated [DATE] showed she has no cognitive impairment and is dependent on staff for showers. R6's care plan initiated 2/2/24 showed, The resident has an ADL self-care performance deficit needs and participation may vary related to weakness and multiple medical comorbidities . On 4/23/24 at 12:18 PM, R6 said a few weeks ago she had some issues during a shower. R6 said she was in the shower and the CNA (Certified Nursing Assistant) who was assisting her had ear buds in her ears. R6 said the CNA was having a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to notify a resident's (R1) Power of Attorney (POA) for a change in medical condition for 1 of 3 residents reviewed for change in condition in the sample of 16. The findings include: R1's electronic face sheet printed on 4/25/24 showed R1 had diagnoses including but not limited to acute on chronic congestive heart failure, chronic respiratory failure with hypoxia, end stage renal disease, and pleural effusion. R1's progress notes dated 4/11/24 showed, Around 1AM, CNA (Certified Nursing Assistant) made writer aware that resident complained of shortness of breath, even with oxygen on at 2L/min. Oxygen was 77%, blood pressure 122/69, pulse 70, clear lung sounds. Called physician and received orders to increase oxygen to 5L/min to keep oxygen saturations above 90%. Resident's oxygen improved to 86%. Bumex 2mg to be given. Tablet given at 2:16AM. STAT chest x-ray and STAT BNP/CMP (b-type natriuretic peptide/comprehensive metabolic panel) to be completed. Orders placed. R1's nursing progress notes from 4/9/24-4/11/24 were reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure activities of daily of living were provided for a resident dependent on staff for cares for 1 of 3 residents (R6) reviewed for activities of daily living in the sample of 16. The findings include: R6's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include epilepsy, malignant neoplasm of brain, hemiplegia and hemiparesis following cerebral infarction, malignant neoplasm of right female breast, and malignant neoplasm of left female breast. R6's facility assessment dated [DATE] showed she has no cognitive impairment and is dependent on staff for showers. R6's care plan initiated 2/2/24 showed, The resident has an ADL self-care performance deficit needs and participation may vary related to weakness and multiple medical comorbidities . On 4/23/24 at 12:18 PM, R6 said she has issue with staff on the weekends. R6 said this previous weekend she was not assisted to get dressed, get out of bed, or brush her teeth on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to use a gait belt while transferring a resident, failed to re-evaluate interventions put in place for a resident identified as an elopement risk. These failures apply to 1 of 3 (R3) residents reviewed for safety/supervision in the sample of 16. The findings include: 1) R3's electronic face sheet printed on 4/25/24 showed R3 has diagnoses including but not limited to senile degeneration of the brain, dementia with behaviors, overactive bladder, and primary generalized osteoarthritis. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment and has no wandering behaviors. R3's care plan dated 11/20/23 showed, The resident is an elopement risk/wandered related to dementia, confusion, impaired safety awareness, agitation, wandering, looking to keep busy, resident able to propel wheelchair around facility, residents is noted to attempt pushing exit doors. Resident is noted to wander into other resident rooms. R3's elopement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to wear hairnets in the kitchen, failed to store thickener in a sanitary manner, and failed to maintain a lunch tray for a dialysis resident in a safe manner. This has the potential to affect all residents residing in the facility. The findings include: 1. On 3/12/24 at 10:11 AM the initial kitchen tour was initiated with V19 (Dietary Manager). V19 had a black hat on his head and his long, dark hair was pulled back in a low ponytail, resting on his shoulders. V19 had several shorter, loose strands of hair around his neck and ponytail. V19 did not have his hair contained in a hair net while he toured the dry storage, food preparation area, freezers, and refrigerators with the surveyor. During the time, the noon meal was being prepared in the kitchen. At 10:54 AM the surveyor returned to the kitchen to observe the pureed food preparation with V22 (Cook). V22 had a hair net on, but a large bunch of shoulder length hair was outside her hairnet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician's orders for advanced directive information regarding the resident's choice for life-sustaining medical treatment was obtained and the information was readily available in case of an emergency for 1 of 1 resident (R22) reviewed for advanced directives in the sample of 26. The findings include: R22's admission Record, printed by the facility on [DATE], showed he was admitted to the facility on [DATE]. On [DATE] at 9:16 AM, a review of R22's electronic medical record showed no order for R22's advanced directive information. R22's banner page (where this information can usually be found in a resident's electronic medical record), did not have any information regarding advanced directives for R22. The miscellaneous tab in R22's electronic medical record did not have any POLST (Practitioner Order of Life-Sustaining Treatment) document. On [DATE] at 3:37 PM, V3 (Licensed Practical Nurse/Restorative Nurse) said if a resident was in cardiac…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide feeding assistance to a resident and failed to provide two showers per week as requested by a resident. This applies to two of three residents (R237 and R65) reviewed for activities of daily living in the sample of 26. The findings include: 1. The facility face sheet for R237 shows an admission date of 3/5/24 and diagnoses to include vascular dementia, severe protein-calorie malnutrition, and dysphagia. The functional abilities and goals assessment completed on admission shows R237 requires partial to moderate assistance with eating. On 3/12/24 at 9:30 AM, R237 was observed sitting in her bed with her breakfast tray in front of her not attempting to eat anything. On 3/13/24 at 10:44 AM, R237 was in bed with her breakfast tray in front of her. Approximately 15% of the meal was gone. R237 said if she could get the food to her mouth, she would eat more because she was still hungry. That same day, R237 was observed in the lounge at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure quality care was provided to a resident before leaving for dialysis (R2) and failed to obtain daily weights for residents with CHF (Congestive Heart Failure) for 2 of 2 residents (R54, R22) reviewed for quality of care in the sample of 26 and 1 resident (R2) outside of the sample. The findings include: 1. On 3/13/24 at 9:04 AM, V4 (Agency Registered Nurse/RN) was standing in the middle of R2's hallway, at the medication cart, typing on his personal cell phone. When V4 looked up and realized he was being watched by the surveyor, he stopped typing and put his personal cell phone back in his scrubs pocket. At 9:07 AM, the surveyor approached V4 to observe medication administration. V4 stated, I'm about to go check [R2's] blood pressure (BP) because she has to go for dialysis at 10 AM. I'll take her BP and see if she needs her Midodrine. I don't think she takes any other medications before dialysis besides her pain medication. She told…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to supervise a resident with swallowing difficulties during her meals and failed to safely transfer a resident. This applies to two of five residents (R237 and R1) reviewed for safety/supervision in the sample of 26. The findings include: 1. The facility face sheet for R237 shows an admission date of 3/5/24 and diagnoses to include vascular dementia, severe protein-calorie malnutrition, and dysphagia. The functional abilities and goals assessment completed on admission shows R237 requires partial to moderate assistance with eating. On 3/12/24 at 9:30 AM, R237 was observed sitting in her bed with her breakfast tray in front of her not attempting to eat anything. On 3/13/24 at 10:44 AM, R237 was in bed with her breakfast tray in front of her. Approximately 15% of the meal was gone. R237 said if she could get the food to her mouth she would eat more because she was still hungry. On 3/14/24 at 9:00 AM, R237 was observed in bed attempting to eat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure an indwelling urinary drainage bag remained below the bladder and staff wore proper Personal Protective Equipment (PPE) during catheter care (R60). The facility also failed to ensure catheter care orders were in place, catheter tubing was secure, and a urologist follow up appointment was scheduled (R238) for 2 of 3 residents reviewed for catheters in the sample of 26. The findings include: 1. R60's face sheet printed on 3/13/24 showed diagnoses including but not limited to quadriplegia, pneumonia, anxiety, and neuromuscular bladder. R60's facility assessment dated [DATE] showed staff assistance needed for toilet hygiene, bathing, dressing, and transfers. The same assessment showed R60 uses an indwelling catheter for urinary incontinence and is always incontinent of bowel. On 3/12/24 at 11:20 AM, R60 was lying in bed covered with a light blanket. An empty blue dignity bag cover was noted hanging from the left side of the bed. V16 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's feeding tube pump was clean for 1 of 2 residents (R57) reviewed for tube feeding in the sample of 26. The findings include: R57's face sheet printed on 3/14/24 showed diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction, dysphagia (difficulty swallowing), and aphasia (communication disorder). R57's facility assessment dated [DATE] showed severe cognitive impairment and requires total staff assistance with bed mobility, transfers, dressing, eating, toileting, and hygiene. The same assessment showed additional diagnoses including human immunodeficiency virus disease (blood disease). The assessment showed R57 uses a PEG tube for nutrition (percutaneous endoscopic gastronomy tube inserted directly into the stomach). R57's March physician orders showed an order start dated 3/2/24 for: Enteral Feed Order one time a day .via feeding tube at 65 milliliters per hour .up at 5 PM, to run…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident received oxygen therapy as prescribed by her physician for 1 resident (R2) reviewed for oxygen outside of the sample. The findings include: On 3/13/24 at 9:07 AM, the surveyor approached V4 (Agency Registered Nurse/RN) to observe medication administration. V4 stated, I'm about to go check [R2's] blood pressure (BP) because she has to go for dialysis at 10 AM. I'll take her BP and see if she needs her Midodrine. I don't think she takes any other medications before dialysis besides her pain medication. She told me she wants pain medication. V4 obtained an automated, wrist BP cuff and a pulse oximeter from the medication cart and entered R2's room. R2 was sitting up in her wheelchair, fully dressed. V4 told R2 he needed to check her BP and placed the wrist cuff on her left wrist. R2 had a nasal cannula in her nose, and it was attached to an empty, portable oxygen tank that was attached to her wheelchair. The needle on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to have a provider evaluate a resident for the use of as needed antipsychotic medication after 14 days and failed to have a stop date for an as needed antipsychotic medication. This applies to 1 of 5 residents (R62) reviewed for psychotropic medications in the sample of 26. The findings include: R62's admission Record (Face Sheet) showed an original admission date of 12/4/23. R62's Order Summary Report (Physician Order Sheet, provided 3/14/24) showed an active order for Haloperidol Lactate Oral Concentrate 2 milligrams per milliliter and to give 0.5 milliliters by mouth every 6 hours as needed for restlessness/agitation. The order shows it was started on 2/26/24 (17 days prior). The End Date column for this order was blank. R1's Order Summary Report showed R62 had not been on this medication since her admission date. R62's Progress Notes showed no provider evaluation for R62's as needed haloperidol on or about 3/11/24. R62's provider progress note on 3/4/24 at 12:18 PM (most recent documented progress note before 3/14/24)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to perform quarterly restorative assessments for a resident receiving restorative services then discontinued the resident's preferred restorative interventions without the resident's input or assessment. This applies to 1 of 2 residents (R13) reviewed for rehabilitation in the sample of 26. The findings include: R13's admission Record (Face Sheet) showed an Original admission date of 4/15/22 with diagnoses to include reduced mobility, abnormal posture, heart failure, and depression. R13's 12/12/23 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS showed R13 required partial/moderate assistance for rolling in bed and substantial/maximal assistance for transferring from bed to chair. The MDS showed R13 used a wheelchair for mobility. On 3/12/24 at 3:15 PM, R13 stated, I haven't done restorative for 3 weeks. Administration told us they weren't doing it because they were revamping the restorative program. R13 stated she enjoyed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to have the correct isolation signage for a resident with COVID-19 resulting in staff entering 1 resident's (R35) room with the incorrect personal protective equipment (PPE), and failed to wear the correct PPE while providing care for 2 residents (R65, R18) on Enhanced Barrier Precautions. This applies to 3 of 5 residents (R35, R65, R18) reviewed for infection control in the sample of 26. The findings include: 1. R35's admission Record (Face Sheet) showed an original admission date of 6/27/19. R35's Order Summary Report (provided 3/13/24) showed an order for Contact and Droplet Isolation precautions for COVID-19 to begin on 3/5/24 for 10 days. R35's 3/5/24 Progress Note from 10:45 PM showed, Routine rapid covid test done, results positive, patient now isolated. R35's 3/11/24 Health Status Note from 6:14 PM showed, Resident on contact isolation no complaint of pain . On 3/12/24 at 10:01 AM, R35's door had a contact isolation sign on the door.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient staffing to provide timely care and treatment to facility residents. This applies to all 88 residents residing in the facility. The findings include: Facility Resident List Report, dated 2/13/24, shows the facility census was 88 residents. 1. MDS (Minimum Data Set), dated 1/20/24, shows R8's cognition was intact. On 2/21/24 at 11:46 AM, R8 stated on the morning of 1/1/24 at approximately 7:00 AM, he became nervous because he was having difficulty breathing. R8 stated an hour prior he was forced to ask an aid to retrieve his nurse from the other side of the building because he needed pain medication for severe pain in his chest and the nurses were working short and were covering residents on both sides of the building. R8 stated when he became short of breath, he placed his call light on and waited 45 minutes with no answer from staff. R8 stated when he finally called 911 for assistance, he told the 911 operator he had waited 45…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident was able to determine her POA (Power of Attorney) agent and make decisions regarding her care. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 16. The findings include: 1. Face sheet, dated [DATE], shows R1 was admitted to the facility on [DATE] and R1's diagnoses included unspecified dementia, bipolar disorder, anxiety disorder, depression, unspecified psychosis, and insomnia. The face sheet shows V40 (Caregiver, The Company - Outside vendor providing healthcare navigation for clients) as R1's Guardian, Responsible Party, and Emergency Contact #2. The face sheet also shows V10 (Director of Operations, The Company) as R1's POAHC (Health Care Power of Attorney for Health Care), POA-Care, and Emergency Contact #1. On [DATE] at 11:52 AM, V1 (Administrator) reviewed R1's face sheet and stated the face sheet was incorrect because R1 had no legal guardian established. MDS (Minimum Data Set)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide timely care and treatment to residents in respiratory distress. This applies to 2 of 3 residents (R2 and R8) reviewed for improper nursing in a sample of 16. The findings include: 1. MDS (Minimum Data Set), dated 1/20/24, shows R8's cognition was intact. On 2/21/24 at 11:46 AM, R8 stated on the morning of 1/1/24 at approximately 7:00 AM, he became nervous because he was having difficulty breathing. R8 stated an hour prior he was forced to ask an aid to retrieve his nurse from the other side of the building because he needed pain medication for severe pain in his chest and the nurses were working short and were covering residents on both sides of the building. R8 stated when he became short of breath, he placed his call light on and waited 45 minutes with no answer from staff. R8 stated when he finally called 911 for assistance, he told the 911 operator he had waited 45 minutes with no response from facility staff. Review of R8's electronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility Social Services failed to clarify POA (Power of Attorney) and guardianship status of a resident residing at the facility. This applies to 1 of 3 residents (R1) reviewed for social services in a sample of 16. The findings include: 1. Face sheet, dated [DATE], shows R1 was admitted to the facility on [DATE] and R1's diagnoses included unspecified dementia, bipolar disorder, anxiety disorder, depression, unspecified psychosis, and insomnia. The face sheet shows V40 (Caregiver, The Company - Outside vendor providing healthcare navigation for clients) as R1's Guardian, Responsible Party, and Emergency Contact #2. The face sheet also shows V10 (Director of Operations, The Company) as R1's POAHC (Power of Attorney for Health Care), POA-Care and Emergency Contact #1. On [DATE] at 11:52 AM, V1 (Administrator) reviewed R1's face sheet and stated the face sheet was incorrect because R1 had no legal guardian established. MDS (Minimum Data Set) assessments,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to handle, store, wash, and sanitize dishes and utensils in a sanitary manner. This has the potential to affect all residents in the facility. The findings include: The facility's Centers for Medicare and Medicaid Services Resident Census and Condition of Residents (CMS 672 form) dated 1/23/2023, shows there are 93 residents residing in the facility. 1. On 1/23/2023 at 9:58 AM, V9 (Dietary Aide) and V10 (Dietary Aide) were washing dishes wearing gloves. V9 was removing food debris from soiled dishes while V10 was pre rinsing the soiled dishes and then putting them into a dish rack before loading it into the dish machine. V10 then removed clean and sanitized dishes from dish racks in the drying area without changing his gloves. At 10:05 AM, V8 (Food Service Manager) said that the proper process of handling dishes is to grab the dishes, put them into the dish rack, pre spray them and then put them through the dish machine. Before removing the clean dishes from the racks, employees are to change gloves or wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to adjust an antibiotic start and end date on a Medication Administration Record (MAR) when the medication became available, failed to inform a Nurse Practitioner when several doses of an antibiotic were missed, and failed to ensure medications were not left at residents' bedside for 4 of 19 residents (R3, R29, R58, and R72) reviewed for pharmacy services in the sample of 19. The findings include: 1. On 01/23/23 at 10:31 AM, R29 said she did not get all of her antibiotic. R29's Progress Note dated 10/27/22 entered by V15 (Nurse Practitioner) showed R29 was complaining of, pain and pressure with urination. The same note showed R29 was started on an antibiotic for a urinary tract infection. R29's order history report showed the antibiotic was to be given 3 times a day for 7 days. On 1/25/23 at 11:45 AM, V23 (Pharmacy Customer Service Lead) said the antibiotic was approved to be dispensed on 10/28/22 and delivered to the facility on [DATE].…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a room set up which allows unobstructed access to the bathroom and entrance/exit door for 1 of 19 residents (R4) reviewed for accommodation of needs in the sample of 19. The findings include: On 1/23/23 at 1:05 PM, R4 was sitting in the dining room. R4 said her roommate has extra storage furniture in their room and uses a mechanical lift which blocks the bathroom door, and she has had accidents because she could not get to the bathroom. On 1/24/23 at 9:01 AM, V18 (Registered Nurse/RN) was passing medications to R16 (R4's roommate) in their room. R16 was sitting in her wheelchair next to her bed with her bedside table behind and to her left side next to the sink. As V18 was giving R16's medications, R4 tried to exit the room with her walker and there was no room to get by in order to access the door (or bathroom had it been needed). V18 asked this surveyor to move R16's table so R4 could leave the room. V18 ended up moving R16's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide R89 with bed hold policy and return when discharged to the hospital for one of two residents (R89) reviewed for discharge in the sample of nineteen. The findings include: On 01/25/2023 V1 (Administrator) was unable to provide a copy or documentation of R89 being provided with the facility's bed hold policy and return. On 01/25/2023 at 12:45PM, V21 (Admissions) said, I provide the resident with a copy of the bed hold policy on admission. I do not provide a copy at the time of transfer. R89's Progress Notes dated 12/09/2022 shows, Laboratory Note, Note Text: hospitalized as of 12/8/22. No nursing documentation related to R89's discharge were found in R89's Progress Notes. The facility's Bed-Hold Policy revised 4/21/2021 shows, bed-hold policy should be provided, at the time of transfer and if applicable, given with in advance to the transfer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents requiring extensive assistance were provided personal cares for 2 of 19 residents (R23 and R240) reviewed for Activities of Daily Living (ADLs) in the sample of 19. The findings include: 1. On 1/23/23 at 10:54 AM, R23 was lying in bed in her room. V19 (Certified Nursing Assistant/CNA) began changing R23's brief. R23's brief was saturated with urine which soaked through a draw sheet, a fitted sheet, and left the mattress wet, as well. V19 said she began her shift at 7:00 AM today and has not yet changed R23 since she arrived. V19 said residents are changed every two hours. R23 said she was last changed by the night shift before they left around 7:00 AM that morning. R23's Minimum Data Set (MDS) dated [DATE] shows she is cognitively intact and requires extensive assistance with bed mobility, toilet use, and personal hygiene. R23's current Care Plan provided by the facility shows R23 has an ADL self-care performance deficit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure pressure reducing interventions were being implemented and failed to ensure a physician prescribed pressure injury dressing was re- applied for 1 of 4 residents (R240) reviewed for pressure injuries in the sample of 19. The findings include: On 1/23/23 at 10:00 AM R240 was lying in bed. He had no pillows underneath his feet, and they were not being off loaded. His right heel and left ankle were flat against the mattress. There were green pressure reduction boots sitting across the room in his wheelchair. On 1/23/23 at 12:49 PM, R240's heels were still flat against the mattress with no pillows underneath them. R240 did not have an air mattress on his bed. On 1/24/23 at 8:20 AM, R240 was in bed. R240's legs were curled up and his left ankle and right heel were lying flat on the mattress. There was no dressing covering R240's pressure injury to the outer aspect of his left ankle. The open pressure injury was exposed, and he was rubbing it back and forth against the bottom sheet. On 1/24/23 at 8:46 AM, V7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter collection bag was kept off the floor for 1 of 2 residents (R47) reviewed for indwelling urinary catheters in the sample of 19. The findings include: R47's Infection Disease Consult Note dated 1/16/23 showed R47 had a history of a urinary tract infection that required intravenous antibiotics. On 1/23/23 at 10:47 AM, R47 was in bed. R47's indwelling urinary catheter collection bag was not hanging from anything, and the bottom half of the bag was resting directly on the floor. The collection bag was in the same position at the following times: 11:28 AM, 12:50 PM, and 1:30 PM. On 1/24/23 at 1:05 PM, V17 (Certified Nursing Assistant) said the urinary drainage bag should be kept off the floor to help prevent a urinary tract infection. The facility's Standards and Guidelines: SG Indwelling Catheters policy with a revised date of 3/27/21 showed, Catheter care should be provided in a manner that promotes infection control .

Based on interview and record review the facility failed to ensure a resident was free from a significant medication error for 1 of 4 residents (R29) reviewed for medications in the sample of 19. The findings include: On 01/23/23 at 10:31 AM, R29 said she did not get all of her antibiotic. R29's Progress Note dated 10/27/22 showed R29 was started on a 7-day course of antibiotics for a urinary tract infection. R29's order history report showed an order for an antibiotic that was to be given 3 times a day for 7 days. R29's October and November 2022 Medication Administration Record (MAR) showed the antibiotic was to start on 10/27/22 and end on 11/3/22. The MAR indicated the medication was not available or not given for the following doses: 10/27/22 at 10:00 PM, 10/28/22 at 6:00 AM, 10/28/22 at 2:00 PM, 10/28/22 at 10:00 PM, 10/29/22 at 6:00 AM, and 10/30/22 at 2:00 PM. The MAR indicated R29 missed 6 out of 21 doses of the antibiotic. On 1/24/23 at 9:09 AM, V14 (Licensed Practical Nurse/LPN) said medications should be given as ordered. On 01/23/23 at 01:45 PM, V2 (Director of Nursing)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide radiological services in a timely manner. This applies to 1 of 4 residents (R73) reviewed for radiological services in the sample of 19. The findings include: R73's admission Record sheet shows the following diagnoses: right humerus fracture, hemiplegia and hemiparesis, type 2 diabetes mellitus, respiratory failure, dysphagia, cerebral infarction, paroxysmal atrial fibrillation, Barrett's esophagus, dysphagia, aphasia, and chronic kidney disease stage 2. R73's Health Status Note dated 1/4/2023 at 9:55 PM, showed R73 was found seated on wheelchair leg stands in her room. R73 was assessed and assisted to bed. R73's Post Fall Day 2 Health Status Note dated 1/6/2023 at 11:48 PM, states that R73 vocalized cries of pain and discomfort during touch to right upper extremity and noted bruising and discoloration.have STAT x-ray performed to right upper extremity to r/o fracture. R73's Health Status Note dated 1/6/2023 at 8:19 PM, showed the x-ray company was unable to conduct the x-ray because she was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.