Acadia St. Landry Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure the residents received mail on Saturdays. The deficient practice had the potential to affect 121 residents residing in the facility. Findings: A review of Resident #55's Quarterly MDS (Minimum Data Set) dated 11/27/2024 revealed she had a BIMS (Brief Interview for Mental Status) of 12, indicating she had moderately impaired cognition. A review of Resident #63's Quarterly MDS dated [DATE] revealed she had a BIMS of 13, indicating her cognition was intact. A review of Resident #99's Quarterly MDS dated [DATE] revealed she had a BIMS of 15, indicating her cognition was intact. On 02/10/2025 at 02:46 PM, during the resident council meeting, Resident #55, Resident #63, and Resident #99 stated they did not receive or were unsure if they received mail on Saturdays. On 02/11/2025 at 12:50 PM, an interview was conducted with S10T/SSA (Transportation/Social Services Assistant). S10T/SSA confirmed she is responsible for delivering mail to residents…

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

Based on observations and interviews, the facility failed to ensure drugs were stored in accordance with currently accepted professional principles by: 1. having loose pills in 2 (Cart A and Cart B) of 2 medication carts checked for safe and secure storage; 2. failing to ensure expired medications were not available for administration to residents in 2 (Cart A and Cart B) of 2 medication carts checked for safe and secure storage; and 3. failing to ensure medications were stored at the proper temperatures to preserve their integrity. This deficient practice had the potential to affect 121 residents residing in the facility. Findings: On 02/12/2025, a review of the facility's undated policy entitled, Storage of Medications, revealed, in part, drugs are stored at the proper temperature. Drugs are stored in the packaging, containers or other dispensing systems in which they are received. Nursing staff is responsible for maintaining medication storage areas in a safe manner. Outdated drugs are returned to the pharmacy or destroyed. Medications requiring refrigeration are stored in 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 observations and interviews, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and store and serve meals in accordance with professional standards for food service safety. The deficient practice had the potential to effect the 118 residents who consumed meals prepared from the facility's kitchen. On 02/10/2025 at 8:35 AM, an initial tour of the kitchen was conducted with S17DM (Dietary Manager) and revealed the following: 1. Food storage: A. Refrigerated items: 1. One bottle of lemon juice with an expiration date of 12/14/2024 2. One bottle of barbecue sauce with an expiration date of 09/11/2024 3. One bottle of whipped topping with an expiration date of 06/27/2024 4. One container of sour cream with an expiration date of 01/27/2025 5. One container of sour cream with an expiration date of 01/27/2025 6. One bag of cabbage with an expiration date of 01/19/2025 7. A freezer burned box of pies 8. Opened and undated beef B. Dry storage: 1. Ten individually packed soft baked cookies with an expiration date of 09/25/2024…

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 observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight of the kitchen's cleanliness, sanitation, and practices for safe food service. The deficient practice had the potential to effect the 118 residents who consumed meals prepared from the facility's kitchen. Findings: Cross Reference F812 On 02/10/2025 at 8:35 AM, an tour of the facility's kitchen revealed surfaces with an accumulation dust, dirt, food residue and other debris and expired food items. In addition, a meal was served at temperatures that were not within an appropriate range during distribution of hall trays. Review of the facility's State of Louisiana Department of Health, Office of Public Health, Retail Food Notice of Violations dated 05/13/2024 at 12:30 PM, read in part: Non-Critical Items: Description of Violations: Non-food contact surfaces of equipment have an accumulation of dust, dirt, food residue and other debris. Food carts are…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to ensure contact precautions were followed for 1 (#74) of 4 (#21, #27, #74 and #273) residents on contact precautions. Findings: On 02/13/2025, a review of the facility's policy titled Application of Transmission-Based Precautions with a revised date of 11/05/2024, read in part .Contact Precautions: Intended to prevent transmission of infectious agents that are spread by direct or indirect contact with the resident or the resident's environment. Staff caring for residents on Contact Precautions should wear gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Resident # 74 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, observation, and interviews, the facility failed to ensure a resident's change in condition was immediately reported for 2 (#43, #82) of 2 (#43, #82) residents as evidenced by: 1. Staff failing to report bilateral lower extremity edema for Resident #43 and; 2. S10T (Transportation) failing to notify the physician of failed attempts to complete a consult for Resident #82's left shoulder pain. Findings: Review of the facility's policy titled Change in Resident's Condition or Status, with a last reviewed date of 05/2017, read in part . Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician, or physician on call when there has been a(n): d. significant change in the resident's physical, emotional, mental condition. 2. A significant change of condition is a major decline or improvement in 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 review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 2 (#22, #74) of 3 (#22, #74 and #89) residents investigated for PASARR in a final sample of 39 residents. Findings: Resident #22 Review of Resident #22's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Insomnia and Anxiety Disorder. Review of Resident #22's EHR revealed a Level I PASARR screening was completed on 02/07/2023 by the hospital case manager that the resident was admitted from. Further review of Resident #22's EHR revealed the resident was later diagnosed with Unspecified Psychosis on 12/08/2023. Review of Resident #22's February 2025 physician's orders revealed an order dated 02/15/2024 for an antipsychotic…

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 plan of care was implemented for 1 (#107) out of 1 (#107) resident out of 39 sampled residents. The facility failed to ensure Resident #107's weekly weights were completed as ordered. Findings: A review of Resident #107's admission Record, revealed she was admitted to the facility on [DATE] with diagnoses that included in part, gastrostomy status and acute kidney failure. A review of Resident #107's most recent quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 8, which indicated the resident's cognition was moderately impaired. A review of Resident #107's Order Summary Report revealed a physician's order, dated 09/20/2024 that read, weekly weight Q (every) Friday every evening shift every Friday. A review of Resident #107's weights in the EHR (Electronic Health Record) failed to reveal weekly weights on 10/04/2024, 10/11/2024, 10/18/2024, 11/01/2024,…

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 interview and record review, the facility failed to provide form CMS (Centers for Medicare and Medicaid Services) 10123- Notice of Medicare Non Coverage (NOMNC) as required for 1 Resident (#97) out of 3 (#13, #97 and #107) residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Notification. The facility had a census of 121 residents. A review of Resident #97's SNF Beneficiary Notification Review form revealed that the facility initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted. Resident #97 was discharged from Medicare Part A services on 1/31/2025. Further review of Resident #97's EHR failed to reveal that a Notice of Medicare Non Coverage (NOMNC) form was provided to the resident. On 02/12/2025 at 3:19 PM, an interview was conducted with S19MDS/LPN (Minimum Data Set/Licensed Practical Nurse). S19MDS/LPN stated Resident #97's discharge was facility initiated, and the resident also had skilled benefit days remaining at the time of the discharge. S19MDS/LPN confirmed she did not provide Resident #97 a NOMNC form,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to provide a communication aid for 1 (#88) out of 3 (#65, #88, and #115) residents reviewed for communication. Findings: A review of Resident #88's admission record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, heart failure, hypertension, and atrial fibrillation. A review of Resident #88's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, which indicated the resident was cognitively intact. A review of Resident #88's care plan initiated on 06/03/2024, revealed the resident had the potential for communication difficulties or declines due to speaks Spanish. Interventions included that read in part, use communication board or chart when needed/ordered for resident with difficulty in communication (initiated on 06/03/2024). On 02/10/2025 at 10:03 AM, an observation 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 record reviews and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility through use of dialysis communication forms for 1 (#8) out of 2 (#8 and #223) residents sampled for dialysis services. Findings: On 02/12/2025, a review of the facility's agreement with the Contracted Dialysis Agency with an effective date of 01/01/2011 read in part, Collaboration of Care - Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD (End-Stage Renal Disease) Dialysis Unit. A review of Resident #8's admission record revealed an admission date of 11/27/2023 with diagnoses that included, but were not limited to, dependence on renal dialysis and chronic kidney disease. A review of Resident #8's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating his cognition was moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that residents who were capable of using call bells were able to reach the call bell for 1 (#60) of 39 sampled residents. Findings: Resident #60 was admitted to the facility on [DATE] with diagnoses which included, but were not limited, to major depressive disorder and repeated falls. A review of Resident #60's quarterly MDS (Minimum Data Set) dated 10/30/2024, revealed in Section GG that she had no upper extremity impairments. On 02/10/2025 at 9:46 AM, an observation was made of Resident #60 in her room. The resident was lying in her bed and her call bell was on the night stand at the foot of her bed. The call bell was outside of the resident's reach. When asked, Resident #60 stated that she did not know where her call bell was. During an observation and interview with S18LPN (Licensed Practical Nurse) on 02/10/2025 at 9:50 AM, she confirmed the resident's call bell was out of Resident #60's reach. S18LPN stated Resident #60 was capable of using…

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

Based on interviews and record review, the facility failed to notify the resident's Responsible Party (RP) of a change in skin condition for 1 (Resident #3) of 6 (Resident #1,#2, #3, #R1, #R2, and #R3) sampled residents. Findings: A review of the facility's policy Diabetic Skin and Foot Care, with a last review date of 12/05/2024, revealed in part . 2. Notify MD (Medical Doctor) and responsible party on any changes in skin integrity. Review of nurse's progress note dated 11/19/2024 at 12:34 p.m. written by S2LPN/TN (Licensed Practical Nurse/Treatment Nurse) read in part . Resident has current skin issues. Skin note: left & right 2nd & 5th toes are black not sure why will have NP (Nurse Practitioner) look at them. Further review of Resident #3's nurse's progress notes failed to show evidence the RP was notified of the skin changes to the residents left and right toes. Review of the facility's grievances dated 11/25/2024, revealed in part: Resident #3's RP stated he was upset for not being called in a timely manner about a wound on Resident #3's toe, and discoloration to the…

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

Based on observations, interview, and menu review, the facility's kitchen staff failed to follow the menu to ensure residents were served the appropriate portion/serving size of food during meals in order to meet the nutritional needs of the residents as evidenced by kitchen staff failing to use the correct serving utensils for pureed, mechanically soft, and non-mechanically altered foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 111 residents who consumed meals from the facility's kitchen. Findings: On 05/29/2024, a review of the facility's policy, Policy on Dietary Serving Sizes, revealed: Policy Purpose: To serve the appropriate portion/size of foods for meals. Procedure: 1. Use dietary menus provided by food supply company to provide the portion spread as recommended for each diet/texture using portion control information which is provided in dietary. Review of the lunch menu for 05/28/2024 revealed the following recommended serving portions: Carrot Souffle- ½…

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 physician orders/plan of care were implemented as ordered for monitoring a bed alarm for proper functioning Q (every) shift for 1 (#2) of 4 (#1-#4)sampled residents. Findings: Review of Facility Policy titled, Policy for Fall Alarm, received and reviewed on 05/29/2024 read in part: 3. Alarms will be monitored every shift for proper functioning. Review of Resident #2's health record revealed an admission date of 10/18/2021 with diagnoses which included, but were not limited to, Alzheimer's disease, Depression, Schizoaffective Disorder, and Insomnia. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 0 indicating the resident's cognition was severely impaired. Review of Resident #2's physician's orders revealed an order dated 01/16/2023 that read: Bed alarm while in bed monitor for proper functioning Q shift. Review of Resident #2'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 record review and interview, the facility failed to electronically transmit a completed Minimum Data Set (MDS) to the CMS (Center for Medicare and Medicaid Services) system within 14 days after completion for 10 (#11, #21, #32, #37, #45, #54, #110, #113, #114 and #115) out of 11 (#11, #21, #32, #37, #45, #54, #110, #113, #114, #115 and #276) resident's investigated for resident assessment submission activities as evidenced by: Failing to submit a Quarterly MDS assessment for Resident #45 and submit Discharge MDS assessments for Residents #11, #21, #32, #37, #45, #54, #110, #113, #114, and #115. Findings: Resident #54: Resident #54 was admitted to the facility on [DATE] with diagnoses including: Major Depressive Disorder and Schizophrenia. A review of Resident #54's Discharge MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/15/2023, revealed a status of opened, indicating the resident's assessment had not been completed. On 01/10/2024 at 2:39 p.m., an interview and review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to implement the residents' plan of care by not following physician orders and the care plan for 3 (#15, #53, #72) out of a finalized sample of 55 residents as evidenced by: 1.Failing to monitor and document for adverse reactions to an anticoagulant for Resident #15 and Resident #53. 2.Failing to apply hand splint as ordered for Resident #72. This deficient practice had the potential to affect a total census of 118 residents. Findings: Resident #53 Review of the facility's policy titled Anticoagulation-Clinical Protocol revealed; #5 The staff and physician will monitor for possible complications in individuals who are being anticoagulated. Review of Resident #53's records revealed an admission date of 07/21/2023 with diagnoses that included Cerebral Infarction and Atherosclerotic Heart Disease of the Native Coronary Artery. Review of Resident #53's EMAR (Electronic Medication Administration Record) revealed Resident #53 was receiving 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.

Based on observations, record review, and interview, the facility failed to ensure recipes for pureed meals were available for staff. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for 3 (#28, #35, and #81) out of 3 (#28, #35, and #81) residents who received pureed meals. Findings: Review of the manufacturer's instructions for the pureed rice in the facility's kitchen read in part: 6 servings = 3 cups water and 1/2 cup of rice 12 servings = 6 cups water and 1 cup of rice 24 servings =12 cups of water and 2 cups of rice Review of the manufacturer's instructions for the pureed meatloaf in the facility's kitchen read in part: Prepare on Stove top or conventional oven. On 01/08/2024 at 9:50 a.m., S16C (Cook) was observed preparing pureed rice. S16C boiled 8 cups (64 fluid ounces) of water then added two 8 ounce scoops (equal to 2 cups) of pureed rice. S16C should have used 3 cups of water and ½ cup of puree rice. On 01/09/2024 at 3:30 p.m., an observation was conducted in the kitchen 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 observations, record review and interviews, the facility failed to serve food in a sanitary manner as evidenced by: 1. staff failing to wear gloves while handling raw meat; and 2. staff failing to discard contaminated meat. This deficient practice had the potential to affect 109 residents who consumed meals from the kitchen. The facility's census was 118. Findings: Review of a facility document titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, read in part: 6. Employees must wash their hands: e. After handling raw meat and when switching between working with raw food and working with ready to eat food. 8. Contact between food and bare (ungloved) hands is prohibited. Review of a facility document titled Food Safety Requirements read in part: 2. Any suspicious or obviously contaminated food will be checked and discarded immediately. On 01/08/2024 at 8:35 a.m., an observation was made of the kitchen. Upon further observation it was revealed that S16C (Cook) was handling sausage without wearing gloves. S16C was observed rinsing her hands. She did…

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 maintain a system of accounting of each resident's personal funds entrusted to the facility on the resident's behalf by failing to provide quarterly statements for 1 (# 54) of 3 (#48, #54, and #109) residents investigated for personal funds. Findings: A review of the facility's policy titled Accounting and Records of Resident Funds, read in part. Policy Statement. Our facility maintains accounting records of resident funds on deposit with the facility. Policy Interpretation and Implementation .5. Individual accounting records are made available to the resident through quarterly statements and upon request . Resident #54 was admitted to the facility on [DATE] with diagnoses including: Major Depressive Disorder and Schizophrenia. A review of the resident's admission MDS (Minimum Data Set) dated 12/28/2023 revealed that she had a BIMS (Brief Interview for Mental Status) of 14, indicating that her cognition was intact. On 01/08/24 at 09:49 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.

Based on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records for 2 out of 6 residents observed during medication pass. The facility had a total census of 118 residents. Findings: Review of the facility's document titled, Security of Medication Cart, read in part: When EMAR (Electronic Medication Administration Record) is not being used, computer screen must be turned into privacy screen or laptop must be closed. On 01/08/2024 at 12:15 p.m., an observation of medication pass was conducted on Hall 1 with S15LPN (Licensed Practical Nurse). S15LPN was observed entering Resident #35's room to administer her medication. Further observation revealed that Resident #35's private medical information was visible on the laptop mounted on top of the medication cart. On 01/08/2024 at 12:17 p.m., an interview was conducted with S15LPN, who confirmed that she should have initiated the privacy screen before she left the medication cart to administer Resident #35's medication. On 01/09/2024 at 8:37 a.m., an observation of medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide residents with a safe, clean and homelike environment for 2 (#13 and # 34) out of 2 (#13 and #34) residents investigated for environment out of a total sample of 55 residents. Findings: Review of Policy titled Routine Resident Checks read in part, 1. To ensure the safety and well-being of our residents, designated staff shall make a routine resident and room check on each unit at least once per week. Review of the Supervisor Rounds log with each resident's room dated 01/03/2024 at 4:00 a.m. revealed a checklist that included in part checks for toilets and refrigerators. Resident #13 and Resident #34 were included in this log and marked that these items had been checked with no issues identified. Review of Resident #13's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus without complication, Unspecified Macular degeneration, Hyperlipidemia, Hypertension and Glaucoma. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to have an RN (Registered Nurse) conduct/coordinate each assessment with other health care professionals; certify that assessments are complete; sign and certify the accuracy of the assessment for 3 (#45, #54 and #276) residents of 55 total sampled residents. Findings: Review of the facility's policy titled, MDS (Minimum Data Set) Completion and Submission Timeframes, read in part .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 1. The assessment coordinator or designee is responsible for ensuring that resident assessment are submitted to CMS's (Centers for Medicare & Medicaid Services) assessment submission and processing (ASAP) system in accordance with current federal and state guidelines. Resident #45 Review of Resident #45's MDS with an ARD (Assessment Reference Date) of 11/08/2023 revealed a status of opened, indicating the Resident's assessment was not completed. Further…

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 reviews, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards for 1 (#29) of 2 (#29 and #56) residents investigated for respiratory care out of a total of 55 sampled residents, by failing to ensure that the resident's oxygen tubing was stored in a sanitary manner when not in use. Findings: A review of the facility's policy titled Departmental (Respiratory therapy)-Prevention of Infection read in part, Purpose. The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .Steps in the Procedure Infection Control Considerations Related to Oxygen Administration .8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use . Resident #29 was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease and Atherosclerotic Heart Disease. A review of the physician's orders…

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 ensure its medication error rate was not 5 percent or greater, as evidenced by a calculated medication error rate of 33.33 percent. Findings: Review of a facility document titled, Administering Medications, read in part: Medications are administered in a safe and timely manner and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Resident #19 Resident #19 was admitted to the facility on [DATE] with diagnoses in part: Stage 3 Chronic kidney disease, Polyneuropathy, Psychoactive substance abuse, Peripheral vascular disease, Dry eye syndrome, and Chronic pain syndrome. Review of Resident #19's January 2024 physician's orders revealed: Hydrocodone 7.5 mg (Milligrams) -acetaminophen 325 mg table, take 1 every 8 hours every…

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 medications were stored properly and not left unattended on top of the medication cart while administering medications. Findings: Review of the facility's policy titled, Administering Medications revealed, in part: No medications are kept on top of the cart. The cart must be inaccessible to residents or others passing by. On 01/09/2024 at 8:05 a.m., an observation of medication pass on Hall 1 was conducted with S14LPN (Licensed Practical Nurse), who was preparing to administer Resident #176's medication. After preparing the resident's medications, S14LPN entered Resident #176's room and left three medications on top of the medication cart unattended. Further review revealed that the medications were Pantoprazole 40 mg (Milligrams), Potassium chloride 10 meq (Milequivalant), and Amiodarone 200 mg. On 01/09/2024 at 8:07 a.m., an interview was conducted with S14LPN who confirmed that she left Pantoprazole, Potassium, and Amiodarone on top of the medication cart unattended and should not have. 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 the facility-wide assessment included any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility. This deficient practice affected 1 resident (#105) with a potential to affect a census of 118 residents currently residing in the facility. Findings: Review of the facility's policy, Facility Assessment, revealed in part, the following: Policy Statement: A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our resident during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Policy Interpretation and Implementation: . d. Religious, ethnic or cultural factors that affect the delivery of care and services, such as: . (4) Language translation requirements. Review of the Facility assessment dated [DATE] - 12/01/2023 included a profile…

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 facility failed to make efforts to demonstrate diligence and a genuine attempt to develop and implement appropriate plans of action to ensure residents were free from verbal and physical abuse in a timely manner after S6CNA (Certified Nursing Assistant) abused 1 (#3) out of 3 (#1, #2, #3) sampled residents. Findings: Cross Reference F600 Review of Resident #3's progress notes dated 10/13/2023 at 10:54 a.m. revealed a late entry on 10/11/2023 per S4ALPN (Agency Licensed Practical Nurse): S7CNA summoned me concerning resident. S7CNA reported S6CNA physically pushed Resident #3. S5CNA intervened and removed Resident #3 from the environment. Also, they both (S7CNA and S5CNA) stated S6CNA verbally stated (to the resident), I will put your head through the wall. As I was standing at my cart, I witnessed S6CNA telling her fellow aides, (Resident #3) tried to stand up on me, I pushed that bch out my way and I bet that bch will not try me again. I told (Resident #3) that I am not in the mood today because my mind not stable. S6CNA stated she 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 record review and interview, the facility failed to ensure 1 (#3) of 3 (#1, #2, #3) residents were free from abuse as evidenced by the facility failing to protect Resident #3 from physical and verbal abuse by S6CNA (Certified Nursing Assistant). The deficient practice had the potential to affect a census of 117. Findings: Review of Resident #3's electronic health records revealed she was admitted on [DATE] with diagnoses that included, CVA (Cerebrovascular Accident), Convulsions, Dementia, Bipolar Disorder, Anxiety Disorder, Type 2 Diabetes Mellitus and Hypertension. Review of Resident #3's MDS (Minimum Data Set) revealed a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. The MDS also revealed Resident #3's Functional Status as requiring supervision with bed mobility and limited assistance with transfer and locomotion. Review of Resident #3's progress notes dated 10/13/2023 at 10:54 a.m. revealed a Late Entry 10/11/2023 per S4ALPN (Agency Licensed Practical…

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's nursing staff failed to implement the residents' plan of care for obtaining intake and output (I&Os) daily every shift for 3 (#1, #4, #5) of 3 residents care planned for dehydration in a sample of 5 (#1-#5) residents. Findings: Resident #1 Resident #1 was admitted on [DATE] with diagnoses that included Major Depressive Disorder, Unspecified Mood Disorder, Dementia, Congestive Heart Failure, Multiple Myeloma, Psychotic Disorder with Delusions, and Acute Pulmonary Edema. Review of Resident #1's physician orders dated 05/16/2023 revealed, in part, an order for Torsemide (Diuretic) 20 mg (milligrams) tablet oral once daily every day. Review of Resident #1's Care Plan revealed, in part, a problem for Potential for dehydration related to diuretic use due to edema. One of the interventions for this problem included I & O (Intake and Output) recorded every shift. Review of Resident #1's electronic health record and paper chart did not reveal any records of I & O from…

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's nursing staff failed to revise the resident's care plan upon return from the hospital and after a medication change for 1 (#5) of 5 (#1-#5) sampled residents. Findings: Review of Resident #5's record revealed he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, Dementia, and Benign Prostatic Hyperplasia. Review of the resident's progress notes revealed he was transferred to the hospital on [DATE] where he was diagnosed with dehydration. The resident was discharged from the hospital on [DATE]. Review of the resident's physician orders revealed in part: Order dated 07/05/2023 Hydrochlorothiazide (HCTZ) 12.5 mg (milligram) capsule give 1 capsule oral once daily every day. Discontinued 08/21/2023; Order dated 07/05/2023 Furosemide (Lasix) 20 mg tablet give 1 tablet oral once daily every other day. Monitor for signs and symptoms of dehydration. Discontinued 07/27/2023. Review of MAR (Medication Administration Record) July 2023 -…

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.