Pines Retirement Center of Baton Rouge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure it was free of significant medication errors for 1 (#R2) of 2 (#R1 and #R2) residents reviewed for medications. The deficient practice had the potential to affect the 56 residents residing in the facility who received medications.Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation:7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #R2Review of Resident #R2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Neuropathic Arthropathy. Review of Resident #R2's current…

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 observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) residents observed for infection control practices. The facility failed to ensure:1. Staff used proper personal protective equipment when emptying Resident #R4's urinal; and2. Staff transported linens in a manner to prevent spread of infection.Review of the facility's policy, dated January 2025, titled, Infection Prevention and Control Program revealed the following, in part:Policy: This facility has established and maintains an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards…

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 observations, interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 2 (#1 and #3) of 3 (#1, #2 and #3) residents reviewed for care plans. The facility failed to ensure: 1. Resident #1's care plan was revised for the use of a geri chair; 2. Resident #3's care plan was implemented for neurological assessments after two unwitnessed falls; and 3. Resident #3's care plan was revised for a fall on 12/07/2024. Findings: 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Non-Alzheimer's Dementia, Muscle Weakness and Muscle Atrophy. Review of Resident #1's current care plan revealed no documented evidence to reflect the current use of Resident #1's geri chair. On 02/03/2025 observations were made throughout the day of Resident #1 sitting up in a geri chair in front of nurse's station. On 02/04/2025 at 2:30 p.m., an interview was conducted with S5LPN. She stated…

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 record reviews and interview, the facility failed to notify the physician when a resident had aggressive behaviors toward staff and other residents for 1(#52) of 6 (#18, #26, #42, #51, #52, and #111) residents reviewed for behaviors. Findings: A review of the facility's undated policy, Change in a Resident's Condition or Status revealed the following: 1. The nurse supervisor/Charge Nurse will notify the resident's attending physician or on call physician when there has been: a. An accident or incident involving the resident; d. A significant change in the resident's physical/emotional/mental condition. A review of Resident #52's Clinical Records revealed he was admitted to the facility on [DATE] and diagnosed with Adjustment Disorder, Unspecified. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of…

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 record reviews and interviews, the facility failed to ensure the resident's care plan was reviewed and revised for 2 (#5 and #52) of 19 sampled residents reviewed for care plans. The facility failed to ensure: 1. Resident #5's transfer status was documented on his care plan; and 2. Resident #52's care plan was reviewed and revised for behaviors. Findings: Review of the facility's undated policy titled Care Plans - Comprehensive revealed, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 8. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable…

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 record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#28) of 19 residents reviewed in the final sample. The facility failed to ensure Resident #28 received her required HIV medication. Findings: Review of Resident #28's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included HIV. Review of Resident #28's discharge instructions from a local rehabilitation center dated 06/19/2024 revealed an order for Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily. Review of Resident #28's MAR dated 06/10/2024-10/10/2024 revealed no documentation of Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily. On 10/10/2024 at 2:02 p.m., an interview was conducted with S8LPN. She stated Resident #28 had a diagnosis of HIV. She stated Resident #28's HIV medication was discontinued. She stated she discontinued the medication…

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 interviews and record review the facility failed to ensure direct care staff had appropriate competencies and skills to assure resident safety and maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility failed to ensure all direct care staff had competency training in crisis prevention interventions (CPI) for a resident (Resident #52) who displayed aggressive threatening behaviors. The deficient practice had the potential to effect all 59 residents that resided in the facility. Findings: A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Adjustment Disorder. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of Resident #52's Psychiatric NP Notes, dated 09/17/2024 revealed 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 interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 56 residents who consumed food from the kitchen. Findings: On 10/09/2024 at 1:10 p.m., an interview was conducted with S9DM. He stated he was hired one month ago. S9DM stated he had not received a dietary manager certification. On 10/09/2024 at 1:30 p.m., an interview was conducted with S10RD. She stated she was hired by the facility as a Consultant Dietitian and worked 20 hours per week. S10RD stated she was not a full-time employee at the facility. On 10/09/2024 at 11:22 a.m., an interview was conducted with S1ADM. He stated S9DM was hired one month ago. S1ADM confirmed S9DM did not have a dietary manager certification and should have.

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 56 residents who consumed food from the kitchen. Findings: On 10/07/2024 at 08:27 a.m., an observation was made of the kitchen food preparation area with S9DM, which revealed the following items: 2-12oz containers of parsley flakes opened and unlabeled. 1-18oz container of celery salt opened and unlabeled. 1-18oz container of ground cinnamon opened and unlabeled. 1-32oz bottle of lemon juice opened and unlabeled. 1 16oz box of brown sugar opened and unlabeled. On 10/07/2024 at 08:32 a.m., an observation was made of the dry storage area, which revealed the following items: 1-50lb bag of white granular sugar opened and unlabeled. 1-25lb bag of brown rice opened and unlabeled. On 10/07/2024 at 8:34 a.m., an interview was conducted with S9DM. He confirmed all opened container should have been labeled with open date and were not. On 10/07/2024 at 9:30 a.m., an interview was conducted with S1ADM.…

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 interviews and record reviews, the facility failed to promote and facilitate residents' self-determination through support of the residents' choice about aspects of his or her life in the facility which were significant to the resident for 3 (#42, #48, and #52) of 24 residents reviewed in the initial pool. The facility failed to ensure residents had rights as evidenced by: 1. Staff did not allow Resident #42 to visit Resident #48; 2. Staff did not allow Resident #48 out of his room; and 3. Staff did not wear gloves at Resident #52's request. Findings: Review of the facility's undated policy titled, Resident Rights revealed the following: 1. Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable…

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 record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge Status for 1 (#62) of 24 residents reviewed in the final sample. Findings: Review of Resident #62's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #62's Discharge MDS, with an ARD of 08/24/2024, indicated, in part, the following; Section A: discharge date : [DATE]. Discharge Status: 1. Home/Community. Review of Resident #62's Nurses Notes revealed, in part, a note written on 08/24/2024 at 11:38 p.m. by S8LPN indicating Resident #62 was transferred to a local hospital by ambulance. On 10/09/2024 at 10:55 a.m., an interview was conducted with S7RN. She confirmed she was responsible for entering MDS Assessments for the facility. She reviewed Resident #62's Discharge MDS and Nurses Notes dated 08/24/2024. She confirmed the resident was discharged to the hospital, not home/community and the MDS was coded inaccurately. On 10/09/2024 at 11:07…

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 interviews and record reviews, the facility failed to ensure residents remained free of accidents by failing to ensure residents were transferred with proper transfer assistance and devices for 1 (#5) of 19 sampled residents reviewed for accidents. Findings: Review of the facility's undated policy titled, Safe Resident Handling/Transfers revealed the following: Policy: It is the policy of this facility to ensure residents are handled and transferred safely to prevent or minimize risks for injury, and provide and promote a safe, secure, and comfortable experience for the resident, while keeping the employees safe, in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized, dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used.…

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 interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. All nursing staff were competent to implement a resident's assessed transfer needs for 1 (#5) of 19 sampled residents reviewed for transfer status. This deficient practice had the potential to affect 14 residents residing in the facility who required mechanical lift transfers. Findings: Review of the facility's undated policy titled, Safe Resident Handling/Transfers revealed the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury, and provide and promote a safe, secure and comfortable experience for the resident, while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation:…

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, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure S8LPN disinfected the glucometer between resident use for 1 (#1) of 3 (#1, #26, and #55) residents observed during blood glucose monitoring. Findings: Review of the facility's policy titled, Glucometer Disinfection, dated 05/2023, revealed in part, the following: Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use. 2. The glucometers will be disinfected with a wipe pre-saturated with a registered healthcare disinfectant. An observation was made on 10/07/2024 at 9:00 a.m. of S8LPN. S8LPN performed a blood glucose check on Resident #1. S8LPN then wiped the glucometer with an incontinence wipe, without disinfectant, and placed the glucometer in the top drawer of the medication cart. An interview was…

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 interviews and observations, the facility failed to ensure that residents had a clean and safe environment for 1 (#7) of 7 (#1,#3,#7, #8,#9,#10, and #11) residents reviewed for environment. The facility failed to ensure the following: 1. Resident #7's blanket and floor mattress were clean and free of debris. 2. Hall A and Hall C were clean and free of debris. Findings On 08/28/2024, review of the facility's undated policy titled Homelike Environment, revealed, in part: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment. 3. The facility will maintain a clean environment. 1. On 08/26/2024 at 11:50 a.m., an observation was made of Resident #7 in his room. Multiple areas of dried tube feeding were observed on a soiled, uncovered mattress on the floor beside Resident #7's bed. Further observation revealed a blanket soiled with three walnut-sized areas of a yellow, moist substance laying on the floor by the bed. On 08/26/2024 at 11:55 a.m., an…

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 interviews and record reviews, the facility failed implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 2 (#6 and #10) of 12 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) residents reviewed for comprehensive care plans. The facility failed to ensure the following: 1. MRI orders were implement per Physician's Orders for Resident #6, and 2. Oxygen orders were implemented per Physician's Orders for Resident #10. Findings: 1. Review of Resident #6's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Low Back Pain and Fibromyalgia. Review of Resident #6's Yearly MDS with an ARD of 07/16/2024 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #6's Physician Progress Note dated 04/02/2024 by S6MED revealed the following, in part: Tests and procedures to be scheduled: MRI Cervical Spine without contrast MRI Lumbar Spine without contrast MRI Shoulder…

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 observations, interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#R4) of 7 (#5, #6, #7, #R1, #R2, #R3, and #R4) residents reviewed for pharmaceutical services. Findings: Review of the facility's undated policy titled, Medications - Administering revealed the following, in part: Policy interpretation and Implementation: 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 19. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Review of Resident #R4's Clinical Record revealed he was admitted to…

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 observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each for 2 (#6 and #R4) of 7 (#5, #6, #7, #R1, #R2, #R3, and #R4) residents reviewed for pharmaceutical services. The facility failed to ensure Resident #6 and #R4's prescribed medications were available for administration. Findings: Review of the facility's undated policy titled, Pharmacy Services revealed the following, in part: Policy: It is the policy of this facility to ensure that pharmaceutical services are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Definitions: Pharmaceutical services refers to: The process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging,…

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 a record review, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) for 1(#8) of 2 (#7 and #8) residents who were on Enhanced Barrier Precautions (EBP). Findings: Review of the facility policy titled Enhanced Barrier Precautions, dated May 2023, revealed the following: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 47. Implementation of Enhanced Barrier Precautions a. Gowns and gloves will be available 48. High Contact resident care activities include: f. Changing briefs or assisting with toileting. Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Dysphagia, Oropharyngeal Phase, 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.

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pest and insects. The deficient practice had the potential to affect 67 residents who resided in the facility. Findings: An observation was made of Resident #6's room on 08/26/2024 at 11:33 a.m. There were two almond sized roaches crawling from under her wheelchair to under her bed. An interview was conducted with Resident #6 at that time. Resident #6 stated saw roaches in her room daily. An observation was made of Rm D 08/26/2024 at 1:30 p.m. There were four dead, peanut sized roaches inside the toilet paper roll in Rm D. An observation was made of Resident #3's bathroom on 08/27/2024 at 8:20 a.m. There were three live, brown, almond sized roaches crawling between the toilet and the baseboard. An interview was conducted with Resident #3 at that time. Resident #3 stated roaches were present in the bathroom every day. An observation was made of Rm C on 08/27/2024 at 8:56 a.m. There were two almond sized roaches and one small and round…

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 interviews and record review, the facility failed to ensure a resident's physician was notified after a change in physical and mental status occurred for 1 (#2) of 4 (#1, #2, #11, and #12) residents reviewed for notification of change. Findings: Review of the facility's policy titled, Change in a Resident's Condition or Status revealed the following, in part: Policy Statement: Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse will notify the resident's attending Physician or on-call physician when there has been: d. A significant change in a resident's physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical…

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 document the reason for transfer in the resident's Medical Record for 1 (#2) of 3 (#1, #2, and #10) residents reviewed with hospital transfers. Findings: Review of the facility's undated policy titled, Transfer or Discharge Documentation revealed the following, in part: Policy Statement: When a resident is transferred or discharged , the reason for the transfer or discharge will be documented in the medical record. Policy Interpretation and Implementation: 1. Information pertaining to the transfer or discharge of a resident will be documented in the resident's medical record. Review of Resident #2's Medical Record revealed an admission date of 05/28/2024 and a discharge date of 08/11/2024. Review of the facility's Emergency Transfer Log dated August 2024 revealed Resident #2 was transferred to the hospital on [DATE] for a medical transfer and did not return. Review of Resident #2's Nurses' Notes dated August 2024 revealed no documentation of the reason…

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 record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#7) of 2 (#7, and #8) residents reviewed for enteral feedings. The facility failed to ensure: 1. Enteral feeding solution bags were changed every 24 hours; and 2. Opened enteral feeding solution was labeled with the date and time. Findings: Review of the clinical record for Resident #7 revealed he was admitted to the facility on [DATE] with diagnoses which included Dysphagia and Gastrostomy Status. Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/2024 revealed, in part, a Brief Interview for Mental Status exam score of 4 which indicated Resident #7 was severely cognitively impaired. Further review of Section K revealed Resident #7 had a feeding tube. Review of the current Physician Orders for Resident #7, revealed, in part, the following: Jevit…

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 record review and interview, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1 (#8) of 12 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) sampled residents reviewed. Findings: A review of Resident #8's Clinical Record revealed he was admitted on [DATE] with diagnoses that included Diabetes Insipidus, Muscle Wasting and Atrophy, Congestive Heart Failure, Oropharyngeal Dysphagia, Hydrocephalus, Hypertensive heart disease with heart failure, and presence of gastrostomy tube. A review of the current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2024 revealed that Resident #8 had a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. A review of Resident #8's Medication Administration Record (MAR) dated August 2024 revealed medications and treatments were not administered and documented consistent with physician's orders. Further review revealed: 1. Levothyroxine 112 mcg:…

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 record review and interviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) of 2 (#1 and #2) residents reviewed for medical appointments. The facility failed to ensure Resident #1 attended their follow up outpatient wound clinic appointment as scheduled. Findings: Review of Facility's current policy titled, Skin Program, Pressure Ulcers & Other Wounds revealed in part: Care of Residents with Wounds (Pressure & Non-Pressure Related) c. Obtain treatment order from physician if needed or implement the facility's protocol if appropriate. Review of Resident #1's Clinical Record revealed he was admitted on [DATE]. His Diagnoses included the following: Type 2 Diabetes Mellitus with Foot Ulcer, Non Pressure Chronic Ulcer of Other Part of Left Foot with Fat Layer Exposed, Morbid Obesity Due to Excessive Calories, 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.

Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. Room A was clean and free of debris. This had the potential to affect any of the 60 residents residing in the facility who used Room A, and; 2. The ceiling tiles were clean and free of stains for 1 (Room B) of 20 rooms observed on Hall A. Findings: On 06/10/2024 at 9:00 a.m., an observation of Room A was made with S2DON. There were three walnut size hair balls, a toothbrush, open tube of toothpaste, and a hair comb in the first sink, and hair was noted on the floor. The second shower stall was observed with open shampoo bottles on the floor. The third shower stalls hot and cold control knobs were non-functional and dripping a steady stream of water .The shower head was laying on the floor in the fourth shower stall. S2DON confirmed there had been no resident showers that morning, and the shower was left in this condition by the weekend staff. She confirmed the shower should be cleaned and sanitized daily by…

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 observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect all residents who were served from the kitchen. Findings: On 06/10/2024 at 8:00 a.m., an initial tour of the kitchen was conducted with S3DW. The following observations were made and confirmed: -One bulk storage container contained an open bag of sugar. A paper cup was in the bag of sugar. The lid of the container was left open. -One bulk storage container contained opened bags of flour and rice. The lid of the container was left open. On 06/10/2024 at 8:34 a.m., an interview was conducted with S4DM. She was notified of the aforementioned findings made with S3DW. She confirmed the bulk storage containers should be securely closed and should not contain a paper cup. On 06/10/2024 at 9:30 a.m., an interview was conducted with S1ADM. He was notified of the aforementioned findings. He confirmed the bulk storage containers should be securely closed, and should not contain a paper cup.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (#5) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for abuse. The facility failed to ensure Resident #5 was free from physical abuse by Resident #4. Findings: Review of the facility's Abuse Prevention Program Policy with a revision date of 12/2016 revealed the following, in part: Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of the facility's Abuse and Neglect - Clinical Protocol with a revision date of 03/2018 revealed the following, in part: Definitions Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental…

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 record reviews and interviews, the facility failed to ensure new interventions were implemented following an allegation of physical abuse for 1 (#5) of 3 (#1, #4, and #5) sampled residents reviewed for abuse. Findings: Review of Resident #5's clinical record revealed an admission date of 02/19/2021. Resident #5 had diagnoses which included Cognitive Communication Deficit, Unspecified Mood Affective Disorder, and Other Recurrent Depressive Disorders. Review of Resident #5's MDS with an ARD of 02/07/2024 revealed a BIMS of 7, which indicated Resident #5 had severe cognitive impairment. Review of Resident #5's Incident Report dated/timed 01/09/2024 at 10:55 p.m. revealed the following, in part: It was reported to this nurse resident was choked by another resident. On assessment resident found to have red scratches to neck. First Aid by: S5LPN Type of Aid: Scratch to neck, Redness only no break in skin. Review of Resident #5's Care Plan revealed no documentation of the incident with Resident #4 on 01/09/2024. Further review of the care plan revealed no documentation of any…

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 record reviews and interviews, the facility failed to ensure new interventions were implemented following a resident's fall to prevent future falls for 1(#8) of 3 (#1, #7, and #8) sampled residents reviewed for falls. Findings: Review of the facility's Fall and Fall Risk Policy with a revision date of 09/2017 revealed the following, in part: Policy Statement The staff and physicians shall collaborate to address fall risk, falling, and fall-related complications. Procedure The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Treatment/Management Based on the preceding assessment (including the nature, causes, and category of falling) the staff and physician will identify and implement pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Monitoring The staff and physician will monitor and document the individual's response to the interventions intended to reduce falling or 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 and interview, the facility failed to post the required nurse staffing information on a daily basis. Findings: Observation 03/11/2024 at 5:20 a.m. revealed the posted staffing data near the nurse's station was dated 03/09/2024. Observation on 03/11/2024 at 10:21 a.m. revealed the posted staffing data near the nurse's station was dated 03/10/2024. Observation on 03/11/2024 at 1:20 p.m. revealed the posted staffing data near the nurse's station was dated 03/10/2024. On 03/12/2024 at 2:27 p.m., an interview was conducted with S9WC. She stated when she arrived to work on 03/12/2024 the staffing data for 03/10/2024 was posted. On 03/12/2024 at 2:29 p.m., an interview was conducted with S1ADM. He stated the staffing data should have been posted for the current day within two hours of the start of the day shift. He also stated if the surveyor observed the posted staffing data for 03/09/2024 upon entrance to the facility on [DATE], and the staffing data for Sunday 03/10/2024 displayed on 03/11/2024,…

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 interviews and record review, the facility failed to acquire and ensure medications were available for administration as ordered by the physician for 1 (#6) of 3 (#1, #6, and #7) sampled residents reviewed for discharges. Findings: Review of Resident #6's clinical record revealed an admission date of 01/23/2024. Further review revealed Resident #6 had diagnoses which included Acquired Absence of Right Leg Above the Knee and Unspecified Intracapsular Fracture of Unspecified Femur Sequela. Review of Resident #6's Telephone Orders dated 01/24/2024 revealed the following, in part: Lidocaine 5% patch apply to left knee daily. Remove after 12 hours. Review of Resident #6's Physician's Orders for January 2024 revealed no documentation of the order for Lidocaine 5% patch apply to left knee daily. Remove after 12 hours. Review of Resident #6's Medication Administration Record for January 2024 revealed no documentation of the order for Lidocaine 5% patch apply to left knee daily. Remove after 12 hours. On 03/12/2024 at 9:55 a.m., an interview was conducted with Resident #6. Resident…

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 interviews and record review, the facility failed to ensure a resident's fall was documented in the nurse's notes for 1 (#7) of 3 (#1, #6, and #7) sampled residents reviewed for discharges. Findings: Review of the facility's policy titled Falls and Fall Risk revealed the following, in part: Procedure: Recognition: 4. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Falls should be categorized as: a) those that occur while trying to rise from a sitting or lying to an upright position, b) those that occur while upright and attempting to ambulate, and c) other circumstances such as sliding out of a chair or rolling from a low bed to the floor. They should also be identified ass witnessed or unwitnessed event. Review of Resident #7's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Age-Related Physical Debility, Chronic…

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 observations and interviews, the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to ensure: 1. trash was not overflowing from the facility's dining room trash can; 2. supper meal trays were not left in the facility's dining room or in Room g overnight; 3. the kitchen floor and baseboards were free of any food or debris; 4. the kitchen entry door frame was free of any brown, flaky substances; 5. the baseboard and sheetrock were not separated from the frame of the kitchen door; 6. the black rubber baseboard measuring 4 inches in length was not missing from Room a's bedroom wall next to the in-room bathroom door; 7. the bedroom wall of Room b was free of a baseball-sized brownish yellow stain above the lower third of Resident #12's bed; 8. the privacy curtain ceiling track for Room e was properly secured to the ceiling above the foot of Resident #4's bed; 9. ceiling panels and ceiling grid covers in Room e were…

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 interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported to the facility administrator immediately, but not later than 2 hours after abuse occurred and/or an allegation was made for 1 (#9) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents reviewed for abuse. The facility failed to ensure the following: 1. S13CNA and S4CNA reported an allegation S12CNA verbally abused Resident #9; and 2. S3CNA reported an allegation S4CNA verbally abused Resident #9 Findings: Review of the facility's policy titled, Abuse Investigation and Reporting revealed the following, in part: Policy Statement All reports of resident abuse shall be promptly reported to local, state, and federal agencies (as defined by current regulations) Reporting: 2. Any alleged violation of abuse will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse . Review of Resident #9's Clinical Record revealed he was readmitted to 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 observations, interviews, and record review, the facility failed to provide both facility-sponsored group and individual activities for 3 (#1, #2, and #R1) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #R1, #R2, #R3 and #R4) sampled residents. The total facility census was 50. Findings: Review of the facility policy titled Activity Program revealed, in part, the following: Policy Statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation 3. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. 6. Activities are scheduled 7 (seven) days 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 interviews, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice had the potential to affect a census of 50 residents. Findings: On 12/12/2023 at 1:30 p.m., an interview was conducted with S8PCA. She stated about a month ago, she was assigned to assist with facility activities in addition to her duties as a PCA. She stated she did not receive training regarding the activities and confirmed she was not a qualified therapeutic recreation specialist or a licensed activities professional. On 12/12/2023 at 11:10 a.m., an interview was conducted with S1AA. He confirmed the facility did not have a qualified activities director and they should. He stated there had not been a qualified activities professional working in the facility since 11/17/2023. He stated he was acting as the Activities Director in the interim. He confirmed he was not a qualified therapeutic recreation specialist or a licensed activities professional. He stated he delegated the planning and hosting of facility sponsored activities to various…

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 record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (#7 and #13) of 3 (#7, #12, and #13) residents reviewed for tube feedings. The facility failed to ensure: 1. Enteral feeding solution bags were changed every 24 hours; 2. Enteral feeding solution and free water were infusing at ordered rate. Findings: Review of the facility's policy entitled Enteral Tube Feeding revealed in part, the following: Steps in the procedure: 5. Check the order to verify the type, amount, method, and rate of administration. Initiate Feeding: 3. On the formula label document initials, date and time the formula was hung/administered. 1. Resident #13 Review of the clinical record for Resident #13 revealed she was admitted to the facility on [DATE] with diagnoses which included Dysphagia Following Cerebral Infarction and Functional Quadriplegia. Review of the current…

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 an observation and interview, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 50 residents residing in the facility. Findings: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers revealed the following, in part: Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. On 12/11/2023 at 5:05 a.m., an observation…

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 observations, interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure a qualified activities professional was hired to direct the facility's Activity Program; and 2. Ensure facility policies and procedures were implemented for an effective Activities Program. This deficient practice had the potential to affect a census of 50 residents. Cross Reference F679, F680. Findings: 1. On 12/12/2023 at 1:30 p.m., an interview was conducted with S8PCA. She stated a month ago, S1AA asked her to assist in conducting facility activities in addition to her hired role as a PCA. She stated she had not received training regarding the activities, and she was unfamiliar with multiple activities on the calendar and how to facilitate…

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 observations, interviews, and record review, the facility failed to ensure low air loss mattresses were functioning correctly for 3 of 3 (#9, #11, and #R2) residents reviewed with air mattresses. Findings: Review of the Operation Manual for Proactive Medical Products Protekt Aire 2000 revealed the following, in part: Product Functions: Control Unit: The functions of the control unit are described below. Normal Pressure Indicator: A visible indicator (green) tells the pressure has reached a present or user-defined level. Low Pressure Indicator: A visible indicator (orange) warns the pressure is below a preset or user-defined level. Resident #9 Review of Resident #9's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses which included Paraplegia - Complete, Pressure Ulcer of Other Site - Stage 4, Pressure Ulcer of Right Hip - Stage 3, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Pressure Ulcer of Left Hip - Stage 4, Muscle Wasting and Atrophy, Other Lack…

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 observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of insects. This deficient practice had the potential to affect any of the 50 residents residing in the facility. Findings: Review of the facility's policy, titled, Pest Control revealed the following, in part: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. The facility maintains an on-going pest control program to ensure the building is kept free of insects . 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. On 12/11/2023 at 5:01 a.m., an observation was made of the facility's dining room. There was a table with a plate of potato chips and an open, clear glass of a yellow liquid. There was a table with two supper trays from 12/10/2023 with meal cards for Resident #2 and Resident #R4. On 12/11/2023 at 5:10 a.m., an interview was conducted with S10ACNA. She…

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 interviews and record reviews, the facility failed to protect the resident's right to be free from verbal abuse by S4CNA for 1 (#9) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse Prevention Program revealed the following, in part: Policy Statement: Our residents have the right to be free from abuse .This includes verbal abuse. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone, including facility staff . Review of Resident #9's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses which included Paraplegia - Complete, Schizophrenia, Other Neuromuscular Dysfunction of Bladder, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Muscle Wasting and Atrophy, Other Lack of Coordination, Cognitive Communication Deficit, and Neurogenic Bowel. Review of Resident…

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 record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct identified quality deficiencies. The facility failed to ensure staff were monitored for providing and documenting ADL care for 2 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. This failed practice had the potential to effect all 53 residents who currently resided in the facility. Findings: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program revealed the following, in part: Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Policy Interpretation and Implementation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes…

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 observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. The bathroom floor tiles and grout between the tiles were free of discoloration and a gray/black substance in Room a; and 2. The shower room, Room b was clean and free of debris. This had the potential to affect any of the 39 residents residing in the facility who used Room b. Findings: 1. Review of the Clinical Record for Resident #4 revealed she was admitted to the facility on [DATE]. On 10/23/2023 at 1:45 p.m., an interview was conducted with Resident #4 in Room a. She said she used her bathroom daily. She said when she admitted to the facility the bathroom floors used to be cleaner, looked whiter and now they looked dirty and awful. On 10/23/2023 at 8:13 a.m., an observation was made of Room a. The bathroom floor tiles were observed to be discolored with a black and gray substance on the tiles and in the grout. On 10/23/2023 at 1:13…

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 record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living without assistance received the necessary services to maintain good grooming and personal hygiene for 2 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. Findings: Review of the facility's policy titled, Bath, Shower/Tub revealed the following, in part: Documentation: 1. The date and time the shower/bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/bath. 5. If the resident refused the shower/bath . 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the shower/bath. Resident #4 Review of the Clinical Record for Resident #4 revealed she was admitted to the facility on [DATE] and had diagnoses which included Hypertensive Heart Disease without Heart Failure, Permanent Atrial Fibrillation, Other Sequelae of Cerebral Infarction, Hemiplegia…

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 record review and interviews, the facility failed to ensure residents received mail on Saturdays for 3 (#12, #18, and #26) of 5 (#9, #12, #18, #20, and #26) residents reviewed for mail during resident council. This deficient practice had the potential to affect 49 residents residing in the facility. Findings: Review of the facility's policy titled, Mail and Electronic Communication revealed the following, in part: Policy Interpretation and Implementation: 4. Mail packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). On 09/18/2023 at 1:43 p.m., during the Resident Council Meeting, Residents #12, #18, and #26 voiced concerns of not receiving mail on Saturdays. Residents #12, #18, and #26 stated mail delivered from the postal service on Saturdays was delivered to the residents on Mondays. On 09/18/2023 at 3:25 p.m., an interview was conducted with S3AD. She stated she was responsible for delivering mail to residents Monday through Friday. She stated mail delivered…

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 observations, interviews, and record reviews, the facility failed to ensure services were provided to meet quality professional standards for 7 (#7, #12, #21, #38, #39, #43, and #46) of 13 (#7, #12, #20, #21, #23, #26, #34, #38, #39, #43 #46, #154, and #155) residents reviewed for medication administration. Findings: Review of the facility's policy titled, Administering Medications revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 15) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 16) The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the facility's policy titled, Documentation of Medication Administration revealed the following, in part: Policy Interpretation and Implementation: 2.…

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 policy review, observations and interviews, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 49 residents residing in the facility. Findings: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers revealed the following, in part: Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Shift staffing information…

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 record reviews, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure: 1. Insulin pen needles were primed prior to administration of insulin for 3 (#26, #34, and #155) of 3 (#26, #34, and #155) residents observed for insulin administration; 2. Physician Orders were verified prior to medication administration for 1 (#23) of 7 (#7, #20, #23, #26, #34, #154, and #155) residents observed during medication pass; and 3. A system was in place for nursing staff to accurately document the amount of insulin administered to each resident for 4 (#13, #26, #39, and #46) of 5 (#13, #26, #31, #39, and #46) residents reviewed for insulin administration. This had the potential to affect the 14 residents who received insulin in the facility. Findings: 1. Review of Novolin R Flexpen's Manufacturer's Insert revealed the following, in part: Instructions for use: Preparing you Novolin R Flexpen: A. Pull…

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 policy review, observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart B) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure: 1.Inhalers, Insulin pens and Insulin vials were labeled with the date opened; 2.Insulin pens were labeled with the resident's name; and 3.Injectable Glucagon was not past the manufacturer's expiration date. Findings: Review of the facility's policy titled, Administering Medications revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 10) The expiration/ beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. An observation was conducted of Cart B on [DATE] at 9:50 a.m. The following was observed:…

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 record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practice for 4 (#13, #26, #39,#46) of 14 sampled residents reviewed for documentation of insulin doses. The facility failed to complete, and accurately document, the insulin dosage administered to residents per the medication administration record. Findings: Review of the facility's policy titled, Insulin Administration revealed the following, in part: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. Documentation: 2.) The dose and concentration of the insulin injection. Resident #13 Review of Resident #13's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathic Arthropathy. Review of Resident #13's Physician Orders revealed an active order as of 04/15/2022 for Accuchecks AC/HS with Novolin R per sliding scale, not to be…

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 record reviews, observations, and interviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 3 of 3 (#26, #34, and #155) residents reviewed for insulin administration. Findings: Review of the NovoLog Flexpen Manufacturer Insert revealed the following, in part: Preparing your NovoLog® FlexPen: A. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. Review of the Humalog Kwikpen Manufacturer's Insert revealed the following, in part: Preparing your Pen: Step 1: Pull the Pen Cap straight off. Wipe the Rubber Seal with an alcohol swab. Review of the Novolin R Flexpen Manufacturer's Insert revealed the following, in part: Instructions for use: Preparing your Novolin R Flexpen: A. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. Resident #26 Review…

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 interviews and record review, the facility failed to ensure a resident's right to be free from neglect for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents reviewed for abuse and neglect. S5CNA failed to provide incontinent care to Resident #2 after a bowel movement. Findings: Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnosis, which included Alzheimer 's Disease with Late Onset. Review of the most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/12/2023, revealed Resident #2 had a BIMS (Brief Interview of Mental Status) of 4, which indicated she had severe cognitive impairment. Review of Resident #2's current care plan revealed she was incontinent of bowel and bladder and currently unable to improve continence status. Interventions included checking and changing the resident every 2 hours and maintaining the residents' dignity by keeping her clean and dry. On 08/10/2023 at 10:20 a.m.,…

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.