Camelot Of Broussard

Based on observations, interviews and record review, the facility failed to ensure resident were cared for in a manner and in an environment that maintained or enhanced his or her dignity by placing a sign outside the residents door visible to the public indicating she required feeding assistance for 1 (Resident #14) out of 39 sampled residents, This failure could have caused decreased feeling of self-worth, feelings of embarrassment and a diminished quality of life. Findings: Review of the facility's policy, Quality of Life- Dignity, with a reviewed date of 12/27/2024 revealed: read in part, Policy statement, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality 9. Staff shall maintain an environment in which confidential clinical information is protected, for example .b. signs indicating the resident's clinical status or care needs shall not be openly posted . Review of Resident #14's medical records revealed an admit date of 02/05/2010 with diagnoses that included: Hemiplegia and hemiparesis following cerebral…

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 provide care and services that met professional standards of quality by failing to ensure rounding was conducted every two hours for 1 (#99) resident out of a final sample of 39 residents. Findings: Review of Resident #99's medical record revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, anxiety, and vascular dementia. Review of Resident #99's plan of care initiated on 11/15/2023 revealed the resident was moderate risk for falls related to psychoactive drug use. Further review of the resident's plan of care revealed the resident had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia. On 03/09/2025 at 12:48 PM, an interview was conducted with Resident #99's RP (Responsible Party) who stated the staff were not rounding on the resident as they should. She further stated that the resident had a fall on 01/30/2025 and was not rounded on for six hours. 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 record review and interview, the facility failed to ensure that services were provided to meet professional standards of quality as evidenced by S2LPN (Licensed Practical Nurse) borrowing medication from one resident to give to 1 (Resident #1) out 3 (Resident #1-3) sampled resident investigated during a complaint survey. This deficient practice had the potential to affect the 127 residents in the nursing home. Findings: Review of Resident #1's clinical record revealed he was admitted on [DATE]. His diagnoses included in part, Generalized Osteoarthritis, Morbid Obesity, Muscle Weakness, Essential Hypertension and Benign Prostatic Hyperplasia with lower urinary tract symptoms. He expired on [DATE]. Review of the Resident #1's [DATE] MAR (Medication Administration Record) revealed an order dated [DATE] for Zofran (nausea medication) 4mg (milligram) by mouth three times a day for nausea until [DATE]. The start date was [DATE]. Review of a list of medications available in the facility's medication pyxis…

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 assure the accurate administering of a medication for 1 (Resident #1) out of 3 (Resident #1-3) sampled residents investigated during a complaint survey. This deficient practice has the potential to affect the 127 resident in the nursing home. Findings: Review of Resident #1's clinical record revealed he was admitted on [DATE]. His diagnoses included in part, Generalized Osteoarthritis, Morbid Obesity, Muscle Weakness, Essential Hypertension and Benign Prostatic Hyperplasia with lower urinary tract symptoms. He expired on [DATE]. Review of the facility's Documentation of Medication Administration policy with a revision date of [DATE] read the following in part .The facility shall maintain a medication administration record to document all medication administered. A Nurse .shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented after (never…

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 medical records in accordance with accepted professional standards and practices for 1 (#1) out of 3 (#2 and #3) sampled residents. S2LPN failed to accurately document on the EMAR (Electronic Medication Administration Record) and/or nurse's notes the administration of a medication. This deficient practice had the potential to affect the 127 residents in the nursing home. Findings: On 12/10/2024, a review of the facility's policy titled Documentation of Medication Administration with a last revision date of April 2007, read in part, Policy Interpretation and Implementation: A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's EMAR (electronic medication administration record). The policy also indicated that the following information is to be documented in the resident's medical record: Name and strength of the drug, dosage, method of administration,…

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, observations, interviews, and facility policy and procedure review, the facility failed to protect the residents' right to be free from abuse. The facility failed to protect: 1. Resident #2 from verbal abuse and mental abuse by S6CNA (Certified Nursing Assistant), and 2. Resident #1 from physical abuse by Resident #3. Findings: On 11/06/2024, a review of the facility's policy titled, Abuse and Neglect - Clinical Protocol with a last reviewed date of 12/27/2023, read in part, . Policy Statement: The facility will ensure that each resident had the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy interpretation and Implementation: . Staff to Resident Abuse of any Types: . The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident . Staff are expected to be in control of their behavior and behave…

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, observations, interviews, and review of facility policy and procedure the facility failed to ensure a resident was provided privacy during personal care for 1 (#2) out of 3 (#1, #2, and #3) sampled residents reviewed for resident rights. Findings: On 11/06/2024, a review of the facility's policy titled, Quality of Life - Dignity with a last reviewed date of 12/27/2023, read in part, . Policy Statement: Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation . 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care . Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Disease of Basal Ganglia, Muscle Weakness, Parkinson's Disease, and Tremor. Review of Resident #2's most recent Quarterly Minimum Data Set (MDS) dated [DATE], 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, interviews, and review of facility's manual the facility failed to report to the administrator of the facility an event involving verbal abuse for 1 (#2) out of 3 (#1, #2, and #3) sampled resident reviewed for reporting alleged violations. Findings: On 11/06/2024, a review of the facility's manual titled, Abuse Neglect Reporting with a last revision date of 09/01/2016, read in part, Verbal Abuse - the use of oral, written or gesture language that willfully include disparaging and derogatory terms to residents . regardless of their age, ability to comprehend . Mental Abuse - this includes but is not limited to humiliation, harassment, and threats of punishment or deprivation . additional definitions: mistreatment: means to inappropriately treat or exploit a resident.In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, and an occurrence will be reported to the administrator of 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 interviews and record review, the facility failed to ensure a resident's change in condition was immediatley reported for 2 (#1, #2) residents out of 3 (#1, #2, #3) sampled residents as evidenced by: 1. S8VD/CNA (Van Driver/Certified Nursing Assistant) failing to report complaints of pain for Resident #1 and; 2. S6RN (Registered Nurse) failing to notify Resident #2's responsible party (RP) and physician of a significant change in Resident #2's physical condition. Findings: Review of the facility's policy titled Change in Resident's Condition or Status, with a last reviewed date of 12/27/2023, read in part .Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician, Nurse Practitioner, or physician on call when there has been a(n): d. significant change in the resident's physical,…

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 develop and/or implement a comprehensive person-centered plan of care and/or physician's orders for 2 (#1 and #3) out of 3 (#1, #2, and #3) sampled resident as evidence by failing to: 1. implement a physician's order to monitor for changes post incident for Resident #1; and 2. develop appropriate interventions to prevent future falls from occurring for Resident #3. Findings: On 10/08/2024, a review of the facility's policy titled, Assessing Falls and Their Causes with a last reviewed date of 12/27/2023, read in part, Documentation: When a resident fall, the following information should be recorded in the resident's (electronic medical record): . 6. Appropriate interventions taken to prevent future falls . Resident #1 Review of Resident #1's record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer 's Disease, Pain, and Dorsalgia. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS)…

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 effectively monitor a resident's intake and output, consistent with the resident's assessed needs and goals, to maintain acceptable parameters of hydration status for 1 resident (#2) out of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #2's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] and had diagnoses including, but not limited to, Overactive Bladder, Cognitive Communication Deficit, and Acute Cystitis without Hematuria. Review of Section H of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was frequently incontinent of bladder. Review of Resident #2's progress notes revealed a visit note written by S11NP (Nurse Practitioner) on 09/16/2024 that read in part: .labs obtained today, labs are reviewed and does show acute elevation of creatinine at 5 (Reference range 0.7 to 1.4 ) .Plan: .Acute kidney injury: Will transfer to ER for evaluation . 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.

Based on observation and interview the provider failed to post in a prominent place, readily accessible to residents and visitors, the daily nurse staffing data which reflect the current daily totals of the number of hours worked by the nursing staff. The deficient practice had the potential to affect a census of 129. Findings: On 02/27/2024 at 9:15 a.m., an interview was conducted with S16HR (Human Resources). S16HR revealed she is responsible for posting the daily nursing hours. At that time, an observation was made with S16HR that revealed the posting on the wall with the facility's nursing staffing hours. Further review of this document with S16HR confirmed that the data on the form was for 2/24/2024 was not current.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Review of Resident #34's electronic health record revealed he was admitted to the facility on [DATE]. On 02/26/2024 at 11:00 a.m., an observation was made of Resident #34's room. A urinal with 400 ml (milliliter) of dark amber urine was observed standing upright on bedside table. A dark brown ring was observed around the top of the urinal with yellow and brown debris observed in and around the bottom portion of the urinal. On 02/26/2024 at 11:10 a.m., an interview and room observation was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed the urinal was on the bedside table, with a dark brown ring around top of urinal, with yellow and brown debris in and around the bottom portion of the urinal. S3ADON stated the urinal should have been discarded and replaced with a new urinal. On 02/26/2024 at 11:34 a.m., an observation was conducted of Resident #103's room. The wall next to the resident's window and bed had chipped paint and 3 holes exposing the sheetrock. On 02/27/2024 at 8:52 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 observations, interviews, record and policy and procedure reviews, the facility failed to ensure residents were free from unnecessary physical restraint for 2 (Resident #61 and #86) of 2 (Resident #61 and #86) sampled resident reviewed for restraints. Findings: Review of the facility's policy, Use of Restraints, revealed in part, the following: Policy Statement: Restraints shall only be used to treat the resident's medical symptom(s) and never fore discipline or staff convenience, or for the prevention of falls . Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement of restricts normal access to one's body . 3. Examples of devices that are//may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs,…

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 residents identified with Mental Disorder and/or Intellectual Disability had an accurately completed PASARR (Pre-admission Screening and Resident Review) Level I and/or Level II for 2 (#16, #45) of 4 (#8, #16,#45,#83) residents reviewed for PASARR screening. Findings: Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring revealed, in part: .1. As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of impaired cognition, altered behavior .or mental disorder. a. All residents will receive a Level I PASARR (Preadmission Screening and Resident Review) screen prior to admission. b. If the level I screen indicated that the individual may meet the criteria for a mental disorder, intellectual disability or related condition he or she will be referred to the state PASARR representative for the Level II (evaluation and determination) screening process .5.…

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 develop and implement a person-centered care plan for 3 (#6, #33, # 45) residents out of 3 (#6, #33, #45) sampled residents reviewed by: 1. Failing to follow physician's orders for using SASH (Saline, Administer, Saline, Heparin) after disconnecting a medication infusion from Resident #6's intravenous catheter; 2. Failing to implement an intervention of nebulizer treatment for Resident #33 with a diagnosis of Shortness of Breath; and 3. Failing to develop a care plan for impaired vision for Resident #45. Findings: Resident #6 was admitted to the facility on [DATE] with diagnoses including Acute Cystitis without Hematuria. Review of the resident's physician orders dated 02/22/2024 revealed the following order: - Flush Peripheral Intravenous (IV) per SASH (Saline, Administer, Saline, and Heparin) protocol, administer medication, follow up and disconnect when medication infusion is complete then provide post administration flush per SASH…

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 properly store respiratory equipment for 5 residents (#25, #33, #83, #101, and #104) out of 5 residents (#25, #33, #83, #101, and #104) investigated for respiratory care. Findings: Review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention of Infection read in part, Steps in the Procedure, Infection Control Considerations Related to Oxygen Administration: 8. Keep the oxygen cannulae and tubing used PRN in a plastic bag when not in use. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store circuit in plastic bag, marked with date and resident's name, between uses. Findings: Resident #25 Review of Resident #25's electronic health record revealed that she was admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Shortness of Breath and Acute on Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Review of Resident #25's Annual…

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 review, the facility failed to ensure the medication error rate was less than 5% for 2 (#10 and #29) of 5 residents observed during medication administration. A total of 28 opportunities were observed with 5 medication errors, which resulted in a medication error rate of 17.86%. The facility failed to ensure: 1. Resident #10's Ferrous Sulfate and Azelastine HCL (Hydrogen Chloride) Nasal Solution .1% was administered per physician orders. 2. Resident #29's Potassium, Protonix, and Guaifenesin were not administered per manufacturer's recommendations. Findings: Review of the facility's policy titled, Administering Medications revealed the following, in part: . 3. Medications are administered in accordance with prescriber orders . Resident #10 Review of Resident #10's current physician's orders revealed the following, in part: Ferrous Sulfate 325 mg (milligrams) PO (by mouth), every day. Azelastine HCL Nasal Solution .1%. 1 spray in both nostril two times a day. Resident #29 Review of Resident #29's current physician's orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain personal hygiene. The facility failed to provide nail care to dependent residents for 1 (Resident #49) out of 1 (Resident #49) resident sampled for ADLs. Findings: Review of the facility's policy, Care of Fingernails/Toenails, revealed in part, the following: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail can aid in the prevention of skin problems around the nail bed . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Resident #49 Review of Resident #49's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Weakness, Other…

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 records reviewed, the facility failed to identify and provide resident centered care and services according to the resident's preferences to self-administer medications in order to attain the highest practicable well-being. This deficient practice was evidenced when facility staff failed to assess and initiate a care plan for Resident #119 to self-administer medications out of a finalized sample of 39 residents. Findings: Review of Resident #119's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with a BIMS (Brief Interview for Mental Status) score of 12 indicating the resident was cognitively intact. Review of Resident #119's February 2024 eMAR (electronic Medication Administration Record) revealed the medication Diclofenac Sodium External Gel 1% to be applied to affected area topically (a body surface including the skin) every 12 hours as needed for pain. Review of Resident #119's electronic health…

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 interview, the facility failed to ensure that a resident's enteral feeding was properly labeled for 2 (#34, #474) residents out of 2 (#34, #474) sampled residents reviewed for tube feeding. Findings: Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump under the heading of Initiate Feeding read, in part .5. On the formula label document initials, date and time the formula was hung/administered . Review of Resident #34's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses including Muscle wasting and atrophy, Mild protein-calorie malnutrition, Gastro-Esophageal Reflux Disease, Dysphagia and Encounter for attention to Gastrostomy. Review of Resident #34's February 2024 physician's orders revealed an order dated 11/01/2023 that read in part .Change feeding administration set daily, label the formula container, syringe and administration set with resident's name, date, time and nurse's initial. On 02/26/2024 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 and interviews, the facility failed to accurately obtain pharmaceutical services, including supplying routine medications with the appropriate strength as ordered by the physician, for 1 (#10) of 5 residents observed during medication administration pass. Findings: Review of Resident #10's February 2024 eMAR (electronic Medication Administration Record) revealed the medication Cranberry oral capsule to be administered as followed: Give 200 mg (milligrams) by mouth two times a day. Further review of the resident's February 2024 eMAR revealed S18LPN (Licensed Practical Nurse) administered 200 mg Cranberry oral capsule on 02/28/2024 for the morning dose. On 02/28/2024 at 11:27 a.m., an interview was conducted with S18LPN. S18LPN confirmed he administered Resident #10's ordered morning medications, which included 200 mg Cranberry oral capsule. Review of Cart A was conducted with S18LPN who confirmed there was no 200 mg Cranberry oral capsules available in the medication cart. Cart A revealed…

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 re-evaluated for the continued use of PRN (as needed) antipsychotic medications after 14 days for 2 (#44, #51) residents out of a final sample of 39 residents. Findings: Review of the facility's policy titled Antipsychotic Medication Use read in part .The Attending Physician and/or Nurse Practitioner will identify, evaluate, with input from other disciplines and consults as needed, symptoms, that may warrant the use of antipsychotic medication.The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for appropriateness of that medication. Review of Resident #44's clinical record revealed he was admitted to the facility on [DATE] with…

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 and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of medication cart drawers for 1 (Cart A) of 3 medication carts reviewed. Findings: Review of the facility's policy titled Storage of Medications revealed, in part, the following: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. Nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 02/27/2024 at 3:00 p.m., Cart A was observed with S17LPN (Licensed Practical Nurse). Thirteen and one half pills were observed underneath resident medication blister packs. These pills included the following: one large oblong tablet, seven white round tablets, two square peach tablets, one round pink tablet, one half white oblong tablet, one yellow oval tablet, and one white oval tablet. S17LPN confirmed that loose pills should not have been in the medication cart.

Based on observation and interview, the facility failed to ensure food was prepared in a form to meet individual needs for residents who received pureed diets. Findings: On 02/28/2024 at 9:20 a.m., an observation was made of S5DM (Dietary Manager) puree vegetable medley for the 4 residents who received pureed diets. The vegetable medley contained green beans, corn, and carrots. S5DM poured the vegetable medley into the food processor and began to puree the vegetables. S5DM proceeded to add 3 more scoops of vegetable medley to the food processor. He then added thickener to a 1 and ¼ cup measuring cup. S5DM stated that he was not adding all of the thickener to the pureed vegetables and proceeded to add a portion of the thickener to the pureed vegetables. S5DM stated that he usually eyeballed the amount of thickener added to dishes and he was not sure of how much thickener he added. S5DM proceeded to puree the vegetable medley. Upon completion, an observation was made of the pureed vegetable medley. The medley had small clumps and was not smooth. Small seeds from the green beans 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.

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced when S17LPN (Licensed Practical Nurse) failed to perform hand hygiene according to accepted standards of practice before, during, and after medication administration for 3 (# 10, # 29 and # 523) of 5 residents observed during medication pass. Findings: Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revealed in part .This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene .3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies .7. Use an alcohol-based hand rub .for the following situations: .b. Before and after direct contact with residents; c.…

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 the nurse notified the RP (Responsible Party) that resident #2 had a fall for 1 (#2) out of 3 (#1, #2, and #3) sampled residents. Findings: Resident #2. Review of the facility's policy and procedure for Assessing Falls and Their Causes revealed, .Defining Details of Falls: 2. For each individual, distinguish falls in the following categories: a. Rolling, sliding, or dropping from an object (e.g., from bed or chair to floor) .Documentation: When a resident fall, the following information should be recorded in the resident's (electronic medical record): 4. Notification of the physician and family . Review of the resident's electronic medical record revealed the resident was admitted to the facility on [DATE] and was diagnosed with Degenerative Disease of Basal Ganglia, Cognitive Communication Deficit, and Parkinson's Disease. Review of the resident's nursing progress note dated 10/22/2023 at 3:55 p.m. revealed, This nurse made aware of resident 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 record review, observation and interview, the facility failed to ensure residents were treated with dignity for 1 (#3) of 5 (#1- #5) sampled residents. This deficient practice was evidenced by S5CNA (Certified Nursing Assistant) slamming the room door of Resident #3, after he requested she assist him in getting out of bed. Findings: Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] read in part Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident was cognitively intact. Review of Resident #3's Care Plan dated 07/20/2022 read in part .at risk for falls with an intervention for one staff member to assist for all ambulation. Review of Physician Orders dated 07/01/2022 - activity as tolerated. On 08/15/2023 at 9:54 a.m., an interview was conducted with the resident, who stated that he has been in the bed for days and that S5CNA kept making excuses as to why she couldn't help him with getting out of bed. At this time, S5CNA entered the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the provider failed to ensure staff provided assistance with transfers, and ambulation for 1 (#3) of 5 (#1- #5) sampled residents. Finding: Review of Resident #3's electronic health record (EHR) revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Unspecified Abnormalities of Gait and Mobility. Review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated he was cognitively intact. Resident #3's functional status was assessed as 3 meaning he required extensive two person assistance with transfers. Review of Resident #3's Care Plan, dated 7/20/2022, read in part, Risk for falls due to Hemiparesis and limited mobility (uses a wheelchair for long distances) with interventions in part to remind resident to ask staff for assistance with ambulation and requires one staff member assistance for all ambulation. Review of 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 record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care, assure residents' safety, and maintain the residents' highest practicable physical well-being. The facility failed to ensure S6CNA (Certified Nursing Assistant) completed rounds every two hours for 1 (#1) of 5 (#1-#5) residents sampled. Findings: Review of Resident #1's record revealed an admit date of 02/06/2023 and diagnoses including Displaced Comminuted fracture of shaft of humerus, left arm , Type 2 Diabetes mellitus, Muscle weakness, abnormalities of gait and mobility, and Cognitive communication deficit. Review of Resident #1's Minimum Data Set Assessment with an Assessment Reference Date of 04/28/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. Review of the facility's incident logs revealed Resident #1 had an unwitnessed fall in her room on 04/27/2023 approximately 4:00 a.m. The report was written by S7 LPN (Licensed Practical Nurse), which read in part .resident noted…

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.