Evangeline Oaks Guest House

Based on record review, observations, and interviews the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#1) of 3 sampled residents as evidenced by failing to ensure Resident #1 wore heel lift boots while in bed. Findings: Review of Resident #1's EHR (Electronic Health Record) revealed an admission date of 12/22/2005 and had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and type 2 diabetes. Review of Resident #1's care plan revealed the following goals and interventions in part: Potential for skin breakdown r/t (related to) decreased mobility and incontinence, dx (diagnosis) hemiplegia - Interventions: heel lift boots while in bed. Review of Resident #1's physician's orders revealed the following order dated 03/24/2025 that read: Heel lift boots while in bed every day shift. On 02/23/2026 at 2:50 p.m., an observation was made of Resident #1 in bed. The resident was not wearing heel lift boots at this time. On 02/24/2026 at 9:11 a.m., a second 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.

Based on observations, interview and record review, the facility failed to ensure licensed agency nurses had specific competencies and skills sets necessary to appropriately administer wound care to 1 resident (#2) out of 2 resident's reviewed for wound care in a sample of 3 residents. Findings:Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 06/14/2017 and diagnoses including, but not limited to: Pressure ulcer of sacral region stage 4, type 2 diabetes, and UTI (Urinary Tract Infection).Review of Resident #2's physician's orders revealed the following order dated 01/20/2026, that read: Sacrum - cleanse with wound cleanser, apply gentian violet to wound then apply collagen and silver alginate to wound bed, cover with dry dressing and prn (as needed). On 02/24/2026 at 8:41 a.m., an observation was made of S4TNAgency perform Resident #2's wound care. S5CNA was also present during the wound care observation. There was a sign posted on the outside of the resident's door that read: Enhanced Barrier Precautions. Providers and staff must also: Wear…

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 that a resident's physician and responsible party were immediately notified when the resident was injured for 1 (Resident #2) of 10 (#1-#9 and #R1) sampled residents. Findings:Review of the facility's policy with a review date of 01/01/2024 titled, Accidents and Incidents - Investigating and Reporting read in part, Policy Interpretation and Implementation, 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom.Review of Resident #2's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included…

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, interviews and record reviews, the facility failed to file a grievance for 1 (Resident #2) out of 10 (#1-#9 and #R1) sampled residents.Findings:Review of the facility's policy and procedure titled, Grievances/Complaints, Filing, with a revised date of April 2017 revealed, in part: Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care not furnished.Grievances and/or complaints may be submitted orally or in writing.Upon receipt of a grievance and/or complaint, the Grievance officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.Review of Resident #2's electronic medical record revealed the resident 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 policy review, interviews and record reviews, the facility failed to ensure staff provide care and services that meet professional standards of quality as evidenced by failing to perform chest compressions immediately to a resident requiring cardiopulmonary resuscitation (CPR) for 1 (#5) resident out of 10 (#1-#9 and #R1) sampled residents.Findings:Review of Resident #5's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction (Stroke), weakness, jaw pain, hyperlipidemia, type 2 diabetes mellitus without complications and hypertension. Review of Resident #5's June 2025 physician's orders revealed an order date of 09/25/2024 for full code status.Review of the facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, with a revised date of April 2016, revealed in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), for…

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, interviews and record reviews, the facility failed to ensure staff maintained current CPR certification for 1 (S3LPN-Licensed Practical Nurse) of 3 (S3LPN, S5LPN and S6CNA-Certified Nursing Assistant) personnel records reviewed.Findings: Review of the facility's policy and procedure titled, Emergency Procedure-Cardiopulmonary Resuscitation, with a revised date of [DATE], revealed in part: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), for victims of sudden cardiac arrest.Preparation for CPR 1. Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts. 2. The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of facility BLS training material. On [DATE] at 4:26 p.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.

Based on record review and interview, the provider failed to implement the plan of care by not following physician orders to obtain laboratory testing as ordered for 1 (#2) out of 3 (#1, #2, #3) sampled residents.Review of Resident #2's medical record revealed his most recent readmission to the facility was on 02/04/2025 with diagnoses which included: essential hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia, and hyperlipidemia. Review of Resident #2's order summary report revealed laboratory orders dated 02/25/2025 for the following: Lipid panel q (every) 6 months (June/December); and PSA (Prostate Specific Antigen) and urine for microalbumin yearly (June). Further review of Resident #2's medical record failed to reveal evidence a Lipid panel, PSA and urine for microalbumin were obtained during the month of June.On 07/29/2025 at 10:30 a.m., an interview and record review of physician orders and laboratory testing results was conducted with S1DON (Director of Nursing). She confirmed Resident #2 had orders to obtain a Lipid panel every 6 months (June/December),…

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, record review, and interview, the facility failed to ensure residents that were unable to carry out activities of daily living received personal hygiene (incontinent care) per their care plan for 1 (#1) out of 3 (#1-#3) sampled residents. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypertension, and copd (chronic obstructive pulmonary disease). Review of the resident's annual MDS (Minimum Data Set) dated 06/11/2025 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 for being cognitively intact. Further review of the annual MDS revealed the resident had limited ROM (Range of Motion) on one side; used a wheelchair for mobility device; was dependent for toileting and personal hygiene. The resident was dependent for mobility. The resident was assessed to be incontinent for…

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, record review, and interview, the facility failed to ensure the resident was receiving continuous oxygen as ordered for 1 (#1) out of 3 (#1-#3) sampled residents.Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, hypertension, and copd (chronic obstructive pulmonary disease).Review of the resident's annual MDS (Minimum Data Set) dated 06/11/2025 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 for being cognitively intact. Review of the resident's care plan revealed that it addressed the resident was at risk for edema and sob (shortness of breath) related to copd. Interventions included administer respiratory therapy treatments, assess for signs and symptoms of respiratory distress, and oxygen as ordered.Review of the resident's current physician's orders revealed an order for…

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 interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 87. Findings: On 05/06/2025 at 8:35 A.M., an observation of the daily posted staffing information revealed a date of 05/05/2025 with a census of 90 residents. On 05/08/2025 at 8:15 A.M., a second observation of the daily posted staffing information revealed a date of 05/05/2025 with a census of 90 residents. On 05/08/2025 at 10:50 A.M., an interview was conducted with S11AC (Administration Clerical). She confirmed that the staffing information posted daily included information from the day before. The staffing information with a date of 05/05/2025 including staffing information and census from 05/04/2025. She stated the information had always been posted with the previous day's information, and not the current date.

Based on observations, record review, and interview, the facility failed to ensure recipes for pureed, chopped, and bite-sized meals were used during meal preparation. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for 15 (#4, 10, 14, 27, 30, 33, 42, 48, 60, 67, 70, 73, 74, 87, 90) residents who received pureed meals, 12 (Residents #1, 19, 34, 37, 49, 51, 54, 56, 64, 72, 76, 77 ) who received finely chopped and 10 (Residents #2, 8, 11, 21, 23, 24, 43, 52, 78, 80 ) who received bite sized. Findings: Review of the facility's Lunch menu for 05/05/2025 revealed, in part: black eyed peas & sausage, steamed rice, and greens. On 05/05/2025 at 10:12 A.M., an observation was made of S9Cook preparing puree greens with an electric food processor. S9Cook was observed pouring an unmeasured amount of thickener into the mixture of greens, mixed the thickener with the greens, then poured an additional unmeasured amount of thickener in to the mixture of greens, mixed the greens and thickener, then poured…

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 have a system in place to ensure 1 resident's (#34) funds was safeguarded against any misappropriation. The deficient practice had the potential to affect a census of 87. Findings: A review of Resident #34's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Left Non-Dominant Side and Essential Primary Hypertension. A review of Resident #34's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/19/2025 revealed a BIMS (Brief Interview for Mental Status) of 11, indicating moderate cognitive impairment. On 05/05/2025 at 9:57 A.M., an interview was conducted with Resident #34. He stated that he was missing $40 about a month ago that was given to him by a friend. He stated that he had given the money to a CNA (Certified Nursing Assistant). On 05/06/2025 at 1:29 P.M., an interview…

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 interviews, the facility failed to provide a safe, clean, and homelike environment as evidenced by failing to ensure shower drains in Room A were free from excessive hair. Findings: Review of the facility's policy titled Homelike Environment, with a last reviewed date of 01/05/2025, read in part: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary, and orderly environment. On 05/06/2025 at 12:40 P.M., an observation was made of Room A. The shower drains were observed in each shower. There was hair clogged in the shower drains and sitting on top of the drains. On 05/06/2025 at 12:47 P.M., an observation and interview was conducted with S2DON (Director of Nursing). S2DON observed the hair in the shower drains, and stated that the CNAs (Certified Nursing Assistants) were responsible for cleaning the shower room, whirlpool, and showers in between resident showers. On 05/06/2025 at 2:43 P.M., S2DON confirmed that…

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 resident's Minimum Data Set (MDS) assessment accurately reflected the status of 1 (Resident #45) out of 56 sampled residents by failing to ensure that Resident #45 was coded correctly for the use of a wander bracelet. Findings: Review of Resident #45's electronic medical record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Bipolar Disorder, Unspecified, Wandering in Diseases Classified Elsewhere and Anxiety Disorder, Unspecified. Review of Resident #45's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 08, indicating moderate cognitive impairment. Further Review of Resident #45's most recent quarterly MDS dated [DATE] Section P - Restraints and Alarms, P0200 Alarms, E. Wander/elopement Alarm, revealed it was coded as 0, Not used. Review of Resident #45's Order Audit Report revealed 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 record reviews and interviews, the facility failed to develop and/or implement a comprehensive person-centered plan of care and/or follow physician's orders for 2 (#34 and #42) residents as evidence by failing to: 1. Follow physician's orders for applying a carrot splint to the left hand for Resident #34 2. Update Resident #42's care plan to address a urinary tract infection. Findings: Resident #34 A review of Resident #34's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Left Non-Dominant Side and Essential Primary Hypertension. A review of Resident #34's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/19/2025 revealed a BIMS (Brief Interview for Mental Status) of 11, indicating moderate cognitive impairment. A review of Resident #34's May 2025 Order Summary Report revealed a physician's order, dated 11/04/2024 that read, in part,…

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 comprehensive care plan was revised for 2 (#21 and #47) out of 30 sampled residents. The facility failed to ensure that comprehensive care plan were updated: 1. to include accurate advance directive code status for Resident #21, and 2. to include the removal of floor mats for Resident #47. Findings: Resident #21 A review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction and Congestive Heart Disease. A review of Resident #21's physician's orders revealed he was admitted to Hospice services and a change in advance directive to reflect DNR (Do Not Resuscitate) code status on 01/27/2025. A review of Resident #21's clinical record documentation, Louisiana Physician Order for Scope of Treatment (LaPOST), revealed a DNR code status was initiated on 01/27/2025. A review of Resident #21's comprehensive care plan revealed it 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 observation, interview and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition for 1 (#42) of 4 (#21, #42, #48, and #87) residents investigated for ADLs. Findings: On 05/08/2025, a review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, with a last revised date of 01/05/2025, read in part, Policy Statement .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition .4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is declining care. Approaching the resident in a different way, at a different time, or having another staff member speak with the resident may be appropriate. A review of Resident #42's electronic record revealed the resident was admitted…

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 assure that residents received foods in the appropriate form to support the resident's plan of care, in accordance with their goals and preferences for 1 (#90) resident out of a final sample of 56 residents. Findings: Review of the facility's policy titled Therapeutic Diets with a last revised date of 01/01/2024, read in part: Policy Statement- Therapeutic Diets are prescribed by the Attending Physician to support the resident's treatment plan of care and in accordance with his or her goals and preferences. Review of Resident #90's medical record revealed she was admitted to the facility on [DATE] with diagnoses including: dysphagia pharyngeosophageal phase, gastro-esophageal reflux disease, and esophagitis. Review of section C - Cognitive Patterns, of Resident #90's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13, indicating she was cognitively intact.…

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 obtain the recertification of terminal illness for 1 (#21) out of 1 (#21) sampled residents reviewed for hospice. Findings: A review of the facility's undated policy titled, Hospice Program, with a last review date of 01/05/2025, revealed, in part, Our facility has designated . to coordinate care provided to the resident by our facility staff and hospice staff. He or she is responsible for the following: . d. obtaining the following information from the hospice: 1. The most recent hospice plan of care 3. Physician certification and recertification of the terminal illness specific to each resident . A review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but not limited to, Cerebral Infarction and Congestive Heart Disease. A review of Resident #21's Significant Change Minimum Data Set, dated [DATE] revealed, in part, Section O: Special Treatments, revealed the resident was admitted…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure appropriate hand hygiene was performed during wound care for 1 (#65) resident out of a final sample of 56 residents. Findings: Review of the facility's policy titled Handwashing/Hand Hygiene, with a last reviewed date of 01/05/2025, read in part: Use an alcohol based hand rub containing at least 62% alcohol; or alternatively soap and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc .k. after handling used dressings .8. Hand hygiene is the final step after removing and disposing of PPE (Personal Protective Equipment). 9. The use of gloves does not replace hand washing/hand hygiene. Review of Resident #65's medical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to: 1. Ensure the resident's respiratory equipment was stored properly for 1 (Resident #2) and 2. Indicate when to use BIPAP(Bilevel Positive Airway Pressure) for 1 (Resident #2) out of a 3 residents (Resident #1, #2, and #3) sampled for respiratory care. Findings: A review of the facility's policy titled Respiratory: Pulmonary Conditions, with a last review date of 01/20/2025 read in part: Storage- 1. All nasal cannulas are to be stored in sealed and dated storage bags when not in use. Review of Resident #2's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Chronic Obstructed Pulmonary Disease, Heart Failure, Unspecified Dementia, Morbid Obesity, and Obstructive Sleep Apnea. Review of Resident #2's Significant Change MDS (Minimum Data Set) assessment date of 01/28/2025 revealed the Resident had a BIMS (Brief Interview of Medical Status) of 8, indicating that 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 observation, interview, and record review, the facility failed to ensure medical records were accurately documented and maintained in accordance with professional standards of practice for one (# 1 ) resident out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy titled Guidelines for Charting and Documentation , with a last reviewed date of January 2025, read in part .the purpose of charting and documentation is to provide: 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident .General Rules for Charting and Documentation .2. Be concise, accurate, and complete .6. Document assessments, interventions, treatments, outcomes, etc. Review of Resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, shortness of breath, and obstructive sleep apnea. Review of Resident #1's physician's orders revealed an order dated 10/01/2024…

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 observations and interview, the facility failed to ensure staffing information posted daily was accurate and current. The facility's census was 96. Findings: On 03/03/2025 at 10:00 AM, an observation was made of the nurse staffing data posted on a whiteboard upon entry into the facility. The nurse staffing data revealed dates of 02/11/2025 and 02/12/2025. On 03/03/2025 at 10:45 AM, an observation and interview was conducted with S1DON (Director of Nursing). S1DON confirmed that the nurse staffing data was posted on a whiteboard upon entry into the facility. She also confirmed the dates were 02/11/2025 and 02/12/2025. S1DON confirmed the nurse staffing data should have been updated daily and was not.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming by failing to trim a resident's fingernails for 1 (#2) out 7 (#1-#7) sampled residents. Findings: Review of the facility policy and procedure entitled Fingernails/Toenails, Care of last reviewed August 2024 revealed that the purpose of this procedure are to clean the nail bed, to keep nails trimmed . The general guidelines included 1. Nail care included cleaning as needed and regular trimming . Review of Resident #2's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Huntington disease, mood affective disorder, depression, and anxiety disorder. Review of the resident's quarterly MDS (minimum data set) dated 02/12/2025 revealed the resident's BIMS (brief interview mental status) score was 6, meaning the resident was severely impaired for…

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 that a resident's physician and responsible party were immediately notified when the resident was injured for 1 (Resident #5) of 5 (#1, #2, #3, #4, #5) residents reviewed. Findings: On 02/12/2025, a review of the facility's policy with a review date of 01/01/2024 titled, Accidents and Incidents - Investigating and Reporting read in part, Policy Interpretation and Implementation, 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included in the Report of Incident/Accident form: g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom. Review of Resident #5's electronic medical record revealed she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to write a telephone order and obtain a wound culture in a timely manner as ordered by a physician for 1 (#2) out of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of Resident #2 record revealed she was admitted to the facility on [DATE] with diagnosis not limited to, stage 4 pressure ulcer of sacral region, stage 4 pressure ulcer of left elbow, pain, pressure ulcer of her left elbow, sepsis, cachexia, hemiplegia and hemiparesis of left side, and server protein calorie malnutrition. Record review of Resident #2's nurse notes written and dated by S2Treatment Nurse, 10/02/2024 read in part, Upon performing wound care, this nurse noted malodorous odor with moderate amount of serosanguinous drainage from left hip stage III (3) pressure ulcer. Moderate amount of bright green exudate from right upper back stage IV (4) pressure ulcer .This nurse called .wound care clinic .new order per doctor to collect wound culture to left hip and collect wound…

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 by failing to ensure there was documentation of an incident that occurred for 1 (Resident #5) of 2 (Resident #3 and #5) residents reviewed for incidents. Findings: On 02/12/2025, a review of the facility's policy with a revised date of 04/2012 titled Guidelines for Charting and Documentation read in part. Purpose, 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care. General Rules for Charting and Documentation, 1. Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. Nursing Summaries and/or Assessments, 16. Unusual Occurrence/Significant Events. Resident #5 Review of Resident #5's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included…

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 provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that Resident #1's back door frame and north wall were in good repair for 1 (Resident #1) out of 3(#1, #2, and #3) residents sampled. Findings: On 06/24/2024 a review of the facility's policy titled, Homelike Environment with a review date of 01/01/2024 read in part, Residents are provided with a safe, clean, comfortable and homelike environment . Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified Dementia and Essential Hypertension. Review of Resident #1 MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/27/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 10, indicating his cognition was moderately intact. On 06/24/2024 at 11:11 a.m., an observation and interview was conducted with Resident #1. He stated that the facility should fix the rotten wood on the back…

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. This had the potential to affect 95 residents residing in the facility. Findings: Review of the facility's policy titled, Mail and Electronic Communication revealed the following: Policy Interpretation and Implementation: 4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box. 5. The resident's out-going mail will be picked up by postal carriers and/or delivered to the postal service within twenty-four (24) hours of deposit of such mail with the facility, except when there is no regularly scheduled postal delivery and pick-up service. (no pickup/delivery on Saturdays, Sundays and holidays). Review of a document dated 05/21/2024 read in part .this is to attest that the facility does not receive mail from the post office on Saturdays or Sundays, and signed per S1ADM (Administrator). On 05/21/2024 at 9:35 a.m., during the resident council meeting, Resident #301 voiced concerns of not…

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

Based on review of policy and procedure, observations, and interviews, the facility failed to store food in accordance with professional standards by failing to follow appropriate food handling practices as evidenced by: 1. Expired foods observed in the kitchen's walk in cooler and dry storage area; 2. Opened food items not labeled with the date and time; and 3. Absent temperature logs for the kitchen's reach in cooler, walk in cooler, and walk in freezer for the week of 03/24/2024-03/30/2024. This deficient practice had the potential to affect the 93 residents who consumed food from the kitchen. Findings: On 05/20/2024, a review of the facility's policy titled, Refrigerators and Freezers, with a review date of 01/01/2024, revealed in part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expirations guidelines. 7. Expiration dates on unopened food will be observed and use by dates are indicated once food is opened .8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers…

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, and interviews, the facility failed to treat each resident with respect and dignity in a manner that promoted maintenance or enhancement of his or her quality of life by failing to address the resident by her name for 1 (#11) of 2 (#11, #74 ) sampled residents reviewed for dignity. Findings: Review of the facilities document Quality of Life - Dignity read in part .1. Residents are treated with dignity and respect at all times .7. Staff speak respectfully to resident at all times, including addressing by his or her name of choice and not labeling. Resident #11 Review of the medical record for Resident #11 revealed the resident was admitted on [DATE] with diagnoses including Bipolar disorder, Chronic kidney disease, stage 4, and Type 2 diabetes mellitus. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 06, indicating severe cognitive impairment. Review of 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.

Based on review of the resident council minute meetings and interviews, the facility failed to organize resident group meetings in the facility monthly. This deficient practice had the potential to affect 95 residents residing in the facility. Findings: Review of the facility Resident Council Meeting Binder revealed on January 2024 and February 2024 Resident Council Meetings were held. Further review of the binder failed to provide further meetings for March 2024 or April 2024. On 05/21/2024 at 9:30 a.m. an interview was conducted with the Resident #56, who was the Resident Council President, and three other residents (Resident #6, #10, #301) who attended the meeting for resident council review. They verbalized that the facility had not been conducting resident council meetings monthly. On 05/21/2024 at 10:15 a.m., an interview was conducted with S10AD (Activity Director) who stated she had been conducting monthly meetings. S10AD was not able to provide documentation that resident council meetings were being conducted monthly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment for 1 (#13) out of 3 (#13, #37, #62) residents investigated for environment, out of a total sample of 34 residents. Findings: On 05/22/2024 a review of the facility's policy titled, Homelike Environment with a review date of 01/01/2024 read in part, Residents are provided with a safe, clean, comfortable and homelike environment . Resident #13 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Chronic Pain and Acquired Absence of Right Leg Above Knee. Review of Resident #13's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/13/2024 revealed he had a BIMS (Brief Interview for Mental Status) of 15, indicating his cognition was intact. On 05/20/2024 at 10:15 a.m., an observation and interview was conducted with Resident #13. The ceiling across from the resident's bed was cracked, peeling, and hanging. The resident stated the ceiling had been like that since his…

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 resident's Minimum Data Set (MDS) assessment accurately reflected the status of 2 (#63) and (#89) out of 34 sampled residents by failing to ensure that: 1. Resident #63 was coded correctly for medications received; and 2. Resident #89 was coded correctly for use of a restraint. Findings: Resident #63 Review of Resident #63's quarterly MDS assessment with an ARD (Assessment Reference Date) of 04/17/2024 revealed the resident was admitted to facility on 01/06/2023 and was coded as having received an injectable medication for one day. Review of the resident's April 2024 eMAR (electronic Medication Administration Record) revealed there was no injectable medication administered for the entire month of April 2024. On 05/22/2024 at 3:19 p.m., an interview and review of Resident #63's quarterly MDS assessment dated [DATE] was conducted with S15MDSC (Minimum Data Set Coordinator). She was unable to recall which injectable medication the resident had…

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 a person-centered care plan by failing to: 1. Ensure staff repositioned Resident #198 every 2 hours and provided a notebook and pen so she could make her needs known; and 2. Monitor padding on Resident #82's bedframe. Findings: Resident #198 Review of facility document titled Repositioning dated 01/01/2024 read in part: General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Resident #198 was admitted to the facility on [DATE] with a diagnoses including Acute kidney failure, Adult failure to thrive, Pneumonia, Cerebrovascular accident, and Major depressive disorder. Review of the resident's care plan with a start date of 05/16/2024 revealed that she was at risk for skin impairment related to Gastro tube. Intervention - turned…

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 that a resident and/or a resident's RP (Responsible Party) was invited to the resident's care planning meeting for 1 (#70) out of a total sample of 34 residents. This deficient practice had the potential to affect a census of 95. Findings: On 05/22/2024, a review of the facility's policy titled Care Planning-Interdisciplinary Team with a review date of 01/01/2024, read in part: Policy Statement. The Interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation .3. The resident and Resident Representative are encouraged to participate in the development of and revisions to the resident's care plan. 8. If it is determined that participation of the resident or representative is not practicable for the development of the care plan, an explanation is documented in the medical record. Resident # 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited 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 record review, observations and interviews, the facility failed to ensure activities were provided based on the care plan for 1 (#198) of 1 residents investigated for activities out of a final sample of 34 residents. Findings: Review of Resident #198's record revealed she was admitted to the facility on [DATE] with diagnoses including: Major Depressive Disorder, Pneumonia, Cerebrovascular accident, and Adult failure to thrive. Review of Resident #198's plan of care revealed in part activities of choice - will encourage resident to participate in at least one activity per week. Intervention - find out resident's activity preferences; assist to activities as needed. On 05/22/2024 at 9:49 a.m., review of the activity director's binder for room visits did not reveal that Resident #198 had been seen or engaged in activates since her return from the hospital on [DATE]. On 05/20/2024 at 9:00 a.m., an observation was conducted in Resident #198's room. Resident #198 was observed awake and alert. No television or…

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 facility failed to provide appropriate treatment and care for 1(#70) of 3 (#30, #41, and #70) residents investigated for Urinary Catheter or UTI (Urinary Tract Infection) out of 34 sampled residents. Findings: On 05/22/2024, a review of the facility's policy titled Catheter Care, Urinary with a review date of 01/01/2024 read in part, Purpose. The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Preparation 1. Review the resident's care plan to assess for any special needs of the resident. Resident # 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Hydronephrosis with Renal and Ureteral Calculous Obstruction, Obstructive and Reflux Uropathy, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Chronic Kidney Disease, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms. A review of Resident #70's quarterly 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.

Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent, by failing to administer medications at the right time for 2 (#51, #90) of 5 (#11, #51, #74, #83, #90, ) residents observed during morning medication pass. There were 32 opportunities with 2 errors observed during medication pass with a calculated error rate of 6.25%. This deficient practice had the potential to affect a census of 95 residents. Findings: On 05/20/2024, a review of the facility's policy titled Medication Administration Schedule with a revision date of 01/01/2024, read in part: Policy Interpretation and Implementation: 3. Scheduled medications are administered within two (2) hours before or after their prescribed time. A review of the facility's medication pass schedule revealed Med Pass Times: .BID (twice a day): 8 a.m., and 8 p.m. On 05/20/2024 beginning at 9:50 a.m., an observation was made of S7LPN (Licensed Practical Nurse) during morning medication pass on Hall A. As she was preparing the resident's medications, 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 data review and interviews, the facility failed to ensure accurate payroll data information was submitted for direct care staffing as required. The facility's census was 95. Findings: Review of the facility's Payroll Base Journal (PBJ) Staffing Data Report 1705D Fiscal Year Quarter 1 2024 (October 1, 2023 - December 31, 2023) revealed the facility failed to submit staffing data that verified 8 consecutive hours of Registered Nurse (RN) coverage during the weekend days on 10/14/2023, 10/15/2023, 10/28/2023, 10/29/2023, 11/11/2023, 11/12/2023, 11/25/2023, 11/26/2023, 12/09/2023,12/10/2023, and 12/23/2023 during the quarter. On 05/20/24 at 10:10 a.m., an interview was conducted with S18CAdm (Consultant Administrator), S1ADM (Administrator) and S19OM (Office Manager) stated that PBJ staffing data reporting had been completed and submitted by the office manager with verification it was received by Centers for Medicare and Medicaid Services (CMS). On 05/20/2024 at 2:00 p.m., S19OM (Office Manager) stated that she tried to communicate with CMS to correct the missing Registered…

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 maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by staff failing to remove PPE (Personal Protective Equipment) prior to exiting Resident #12's room who was on contact isolation precautions. Findings: Review of the facility policy and procedure Isolation-Categories of Transmission-Based Precautions read in part: Contact Precautions .1. contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces .7. staff and visitors wear gloves (clean, non sterile) when entering the room. A. while caring for a resident, staff will change gloves after having contact with infective material. b. gloves are removed and hand hygiene performed before leaving he room .8. Staff and visitors wear 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide a call system to allow residents to call staff for assistance for 3 (#37, #62, #83) of 3 residents investigated for call devices, by failing to: 1. Place the call bell within reach of Residents #37 and 62; and 2. Provide a usable call bell for Resident #83. Findings: On 05/22/2024, a review of the facility's policy titled, Call System, Resident with review date of 01/01/2024 read in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized station Policy Interpretation and Implementation .1. Each resident is provided with a means to call staff directly for assistance from his/her bed .4. If a resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided . Resident #37 Resident #37 was admitted on [DATE] with diagnoses that included,…

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, observations and interviews, the facility failed to maintain a clean, comfortable, and homelike environment. The facility failed to ensure: 1. Room A had a tan blanket, pillow, blue gloves, an adult brief, green clothing hanger, and two turn cushions on the floor. 2. Room B and C had a white substance at the base of the faucets, and room C faucet was leaking. 3. Room D had a blue surgical mask and paper on the floor. 4. Room E had paper towel, a brown cigarette bud, brown colored stains on the fall mats, a purple pillow on the floor, and a large brown stain in the corner of the room on the floor. 5. Room F had three dresser drawers with a green and white substance on the exterior of the drawers. 6. Room G had a towel on the floor inside the shower. Findings: Review of the facility document which states Maintenance Problem dated 02/24/2024 - 04/16/2024 did not reveal that Rooms B and C faucets were in disrepair. Rooms A Observations of Room A on 04/15/2024 at 10:20 a.m., revealed a pillow, tan blanket, blue gloves, two positioning pillow, an adult brief, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep urinary catheter bag contained and private for 1 (Resident #4) of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of facility's Quality of Life - Dignity policy with the revision date of October 4, 2022 revealed in part: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 11. Demeaning practices and standards of care the compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags contained and private. Resident #4…

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, observations, and interviews, the facility failed to ensure a medication cart was locked and the medication cart keys were not left on top of cart when left unattended and/or out of view during medication administration. Findings: Review of facility's Storage of Medications policy revealed, in part: 5. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Observation on 04/16/2024 at 2:14 p.m., revealed S8LPN (Licensed Practical Nurse) left her medication cart unlocked, and unattended while she sat at the nurses station talking on the telephone and with other staff. Further observation on 04/16/2024 at 2:15 p.m., revealed S8LPN left the medication cart keys on top of the unlocked and unattended medication cart. On 04/16/2024 at 2:15 p.m., an observation and immediate interview was conducted with S3LPN/CNASUP (Licensed Practical Nurse/Certified Nursing Assistant Supervisor) who observed the unlocked…

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 properly process potentially contaminated resident clothing and linens in order produce sanitary laundry and prevent the development and transmission of communicable diseases by failing to ensure detergent was being dispensed during wash cycles. There were 98 residents in the facility. Findings: On 04/15/2024, a review of facility document titled Departmental (Environmental Services) - Laundry and Linen read in part General Guidelines: Washing Linen and other Soiled Items: 1. Use any detergent designated for laundry processing and follow manufacturer's instructions. There was no date listed on the policy. On 04/15/2024, a review of facility document titled Laundry and Bedding, Soiled read in part: Onsite Laundry Processing: 1. Use any detergent designated for laundry processing .4. Laundry equipment (e.g., washing machines, dryers) is used and maintained according to the manufacturer's Instructions for Use (IFU) to prevent microbial contamination of the system. There was no date listed on the policy. 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 each resident receives adequate supervision and assistance to prevent accidents during a transfer for 1 (#3) out of 3 (#1, #2, #3) sampled residents. Findings: Resident #3. The resident was admitted to the facility on [DATE]. The resident's diagnoses included Hypertension, Hyperlipidemia, Atrial Fibrillation, Atherosclerotic Heart Disease, and Dementia. Review of the resident's yearly MDS (Minimum Data Set) dated 10/18/2023 revealed the resident's BIMS (Brief Interview for Mental Status) score was 3, which meant the resident was severely impaired for cognition. Further review of the resident's MDS revealed the resident was coded extensive assistance with 2 plus person physical assist for transfers. Review of the resident's care plan with start date 10/25/2023 revealed the resident was care planned for 2 person physical assist for transfers. Review of the resident's nurse's note dated 12/13/2023 at 6:21 p.m. revealed, CNA (Certified Nursing…

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