Gonzales Healthcare Center

Based on record reviews and interviews, the facility failed to keep a resident free from staff to resident verbal abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy Revised 01/01/2024 revealed, in part: Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Policy: The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Definitions: Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of…

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

Based on record reviews and interview, the facility failed to ensure the activities program was directed by a qualified professional for 1 (S4Former Activities Director) of 1 (S4Former Activities Director) staff personnel files reviewed for activities director qualifications. Findings: Review of the facility's job description for the Activities Director revealed, in part, the following education and experience requirements: Education: must possess, as a minimum, two years of college. Degree preferred but not necessary. Experience: Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for certification as a recreation specialist or as an activities professional; or Must have a minimum two year experience in a social or recreation program within the last five years, one of which was full time in a patient activities program in a health care setting; or Must be a qualified occupational therapist or occupational therapy assistant; or Must have completed a training course approved by this state. Review of S4FAD'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 interviews and record review the facility failed to ensure the investigation of an allegation of neglect was reported to the State Survey agency within the required time frame for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated. Findings: Resident #1 Review of the Health Standards Incident Report (HSIR) dated 09/03/2024 at 9:18 a.m. revealed, in part, a an allegation of neglect involving Resident #1 was reported to the State Survey Agency on 09/03/2024 at 9:18 a.m. Further review revealed a final investigation report was due on 09/10/2024 at close of business. Review of S2Interim Administrator's email dated 09/10/2024 at 4:12 p.m. revealed, in part, S2Interim Administrator emailed a State Survey Agency Program Manager to request an extension for the due date to report the results of the above mentioned investigation. Review of an email dated 09/10/2024 at 4:31 p.m. revealed, in part, an extension was granted for 09/12/2024 by close of business. Review the HSIR dated 09/10/2024 revealed, in part, S1Administrator…

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 reviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident investigated for neglect. Findings: Review of the facility's policy titled Abuse Prohibition last reviewed on 05/17/2024 revealed, in part, the facility will thoroughly investigate all alleged violations of neglect and take appropriate actions. Further review revealed the facility was to conduct interviews and/or obtain written statements from individuals, (residents, visitors, or staff) who may have firsthand knowledge of the incident. Review of the Health Standards Incident Report (HSIR) revealed, in part, there was an allegation of neglect involving Resident #2 for timely incontinence care. Resident #2 Review of S5Licensed Practical Nurse (LPN) 's witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, the witness statement was a photocopy of an alleged conversation between…

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 Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identification of residents not receiving incontinence care as needed. Findings: Review of the facility's policy title, Quality Assurance Policy and Procedure last revised on March 2023 revealed, in part, the Quality Assessment and Assurance (QAA) committee would regularly review and analyze data collected and make improvements. Further review revealed the QAA committee would develop and implement appropriate plans of action to correct identified quality deficiencies. Review of the facility's QAA Plan of Action and Implementation record revealed, in part, a plan of action was implemented for timely documentation for activities of daily living (ADL) on 04/18/2024 as a result of deficient practice cited on a prior complaint survey conducted on 03/14/2024. Review of Quality Assessment and Assurance Plan of Action and Implementation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to protect a resident's right to be free from verbal abuse by staff. This deficient practice was identified for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy review dated 05/17/2024 revealed, in part, verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to the residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of the facility's documentation related to an incident dated 07/26/2024 revealed an anonymous bystander from Resident #1's physician's office and staff from Resident #1's physician office reported to the facility that they witnessed S4Transportation Driver (S4TD) refuse to assist Resident #1 with filling out his paperwork and yelled nothing was wrong with his hands…

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 report the results of an investigation to the required state agency within 5 working days of a reportable incident for 1 (Resident #6) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect. Findings: Review of Resident #6's Facility Reported Incident entered on 05/30/2024 revealed an allegation of neglect. Review of the Facility Reported Incident log documentation revealed Resident #6 had an incident reported on 05/30/2024 and the investigation report was due to the state survey agency on 06/06/2024. In an interview on 06/13/2024 at 1:45 p.m., S4Corporate Clinical Specialist stated the results of Resident #6's investigation were submitted to the state survey agency on 06/07/2024 and should have been submitted by 06/06/2024. .

Based on record review and interviews, the facility failed to ensure an alleged incident of neglect was thoroughly investigated by the facility for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect. Findings: Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 revealed, in part, Resident #4 had a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #4's cognition was intact. Further review revealed Resident #4 required substantial/maximal assistance from staff for toileting and partial/moderate assistance from staff for toilet transfers. Review of the Resident #4's facility incident report dated on 05/29/2024 revealed, in part, an investigation was initiated for Resident #4 with an allegation of neglect. Further review revealed Resident #4 reported problems receiving timely care from the night staff. S1Administrator documented Resident #4 was not forthcoming with information and provided no specific date 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.

Based on record reviews and interviews, the facility failed to ensure a dependent resident received timely incontinence care for 1 (Resident #5) of 4 (Resident #1, Resident #4, Resident #5, and Resident #6) sampled residents investigated for incontinence care . Findings: Review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2024 revealed, in part, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated Resident #5 had moderately impaired cognition. Further review revealed Resident #5 was incontinent of bowel and bladder, and dependent on staff for toileting. Review of the facility's incident report dated 05/29/2024 revealed, in part, the report was initiated for an allegation of neglect. Further review revealed Resident #5 reported on 05/30/2024 she was not changed by the day shift Certified Nursing Assistant (CNA) on 05/29/2024. Further review revealed the facility identified S7CNA as the accused associate with the allegation and obtained a verbal statement from S7CNA on 05/31/2024. Further review revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to: 1. Protect a resident's right to be free from physical abuse by Resident #239 for 1 (Resident #75) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 2. Protect a resident's right to be free from physical abuse by Resident #43 and Resident #47 for 2 (Resident #43 and Resident #47) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 3. Protect a resident's right to be free from verbal abuse and neglect by S11Certified Nursing Assistant (CNA) for 1 (Resident #37) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; and, 4. Protect a resident's right to be free from neglect by S16CNA…

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

Based on record reviews, observations, and interviews, the facility failed to administer a resident's tube feeding water flush as ordered for 1 (Resident #50) of 1 (Resident #50) sampled residents investigated for tube feeding. Findings: Review of Resident #50's Minimum Data Set with an Assessment Reference Date of 02/10/2024 revealed, in part, Resident #50 had dysphagia (difficulty swallowing) and required nutrition and hydration through a feeding tube. Review of Resident #50's May 2024 physician's orders revealed, in part, an order for Resident #50's tube feeding water flush at 150 milliliters (mL) every 6 hours. Review of Resident #50's tube feeding care plan revealed, in part, an intervention for staff to administer Resident #50's tube feeding flush at 150mL every 6 hours. Observation on 05/13/2024 at 10:15 a.m. revealed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. Observation on 05/14/2024 at 10:57 a.m. revealed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. 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 record review and interviews, the facility failed to report an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Resident #47, Resident #75, and Resident #239) sampled residents investigated for abuse. Findings: Review of Resident #43's record revealed an admit date of 10/04/2023 with diagnosis of Alzheimer's disease with late onset. Review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 revealed, in part, Resident #43 had a Brief Interview for Mental Status (BIMS) of 6 which indicated she was severely cognitively impaired. Further review revealed there were no documented behaviors. Review of Resident #43's Progress Notes revealed a nurse's note written on 04/19/2024 at 10:15 a.m. by S6Licensed Practical Nurse (LPN) that revealed S10Certfied Nursing Assistant (CNA) informed S6LPN that Resident #43's left cheek and left corner of her lip was swollen and red. In an interview on 05/15/2024 at 10:00 a.m., S6LPN stated on 04/19/2024 upon assessment of Resident…

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

Based on record reviews and interviews the facility failed to investigate an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Resident #47, Resident #75, and Resident #239) sampled residents investigated for abuse. Findings: Review of Resident #43's record revealed an admit date of 10/04/2023 with diagnosis of Alzheimer's disease with late onset. Review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 revealed, in part, Resident #43 had a Brief Interview for Mental Status (BIMS) of 6 which indicated Resident #43's cognition was severely impaired. Review of Resident #43's Progress Notes revealed a nurse's note written on 04/19/2024 at 10:15 a.m. by S6Licensed Practical Nurse (LPN) that revealed S10Certfied Nursing Assistant (CNA) informed S6LPN that Resident #43's left cheek and the left corner of Resident #43's lip was swollen and red. In an interview on 05/15/2024 at 12:10 p.m., S10Certfied Nursing Assistant (CNA) stated on 04/19/2024 she notified S6LPN regarding…

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 a resident did not have an order for administration of a psychotropic medication (drugs that affect one's mental state) on an as needed basis (PRN) without a physician's documentation of the specified duration of the order for 1 (Resident #46) of 5 (Resident #16, Resident #46, Resident #47, Resident #64, and Resident #82) sampled resident investigated for unnecessary medications. Findings: Review of Resident #46's admission record revealed, in part, Resident #46 was admitted to the facility on [DATE] with diagnoses of unspecified mood disorder and bipolar disorder (a serious mental illness characterized by extreme mood swings of extreme excitement or extreme depressive feelings). Review of Resident #46's May 2024 physician's orders revealed, in part, an order with a start date of 11/20/2023 for Lorazepam (a psychotropic medication used to treat anxiety) 0.5 milligrams (mg) by mouth every 12 hours as needed for anxiety related to bipolar…

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 reviews, and interviews the facility failed to administer a medication for hypertension as ordered by the physician for 1 (Resident #14) of 22 (Resident #11, Resident #14, Resident #16, Resident #21, Resident #37, Resident #43, Resident #46, Resident #47, Resident #48, Resident #50, Resident #52, Resident #54, Resident #57,Resident #62, Resident #64, Resident #69, Resident #75, Resident #82, Resident #87, Resident #88, Resident #239, and Resident #440) residents investigated in the sample. Findings: Review of the manufacturers prescribing information for Clonidine revealed, in part, application of a new system to a fresh skin site at weekly intervals continuously maintains therapeutic plasma concentrations of clonidine. If the patch is removed and not replaced with a new system, therapeutic plasma clonidine levels will persist for about 8 hours and then decline slowly over several days. Over this time period, blood pressure returns gradually to pretreatment levels. Resident #14 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.

Based on record reviews and interviews, the facility failed to obtain a resident's most recent hospice Plan of Care, recertification of terminal illness, and documentation of hospice services provided for 1 (Resident #50) of 1 (Resident #50) sampled resident reviewed for hospice. Findings: Review of Resident #50's Minimum Data Set with an Assessment Reference Date of 05/12/2024 revealed, in part, Resident #50 had diagnoses which included stroke, seizure disorder, and malnutrition. Further review revealed Resident #50 received hospice care while a resident in the facility. Review of Resident #50's May 2024 physician's orders revealed, in part, an order to admit Resident #50 to the Contracted Hospice Agency on 02/23/2022. Review of the facility's agreement with the Contracted Hospice Agency dated 02/04/2022 related to Resident #50's hospice services revealed, in part, the following: -The hospice interdisciplinary team, in consultation with the facility, shall review and revise Resident #50's individualized Plan of Care as frequently as Resident #50's condition required, but no less…

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 Certified Nursing Assistant (CNA) completed hand hygiene during incontinence and catheter care for 1 (Resident #57) of 1 (Resident #57) residents reviewed for catheter care. Findings: Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, reviewed on 01/24/2024 revealed, in part, staff should perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with bodily fluids, and after removing gloves. Further review revealed the use of gloves does not replace hand washing/hand hygiene, and glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. Review of Resident #57's Minimum Data Set with an Assessment Reference Date of 02/27/2024 revealed, in part, Resident #57 had a urinary catheter (a device that sits in the bladder and collects urine), was always incontinent of bowel, and had a urinary tract…

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

Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of neglect for 6 (Resident #2, Resident #6, Resident #11, Resident #12, Resident #13, and Resident #17) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy with a revision date of 11/07/2023 revealed, in part, each resident had the right to be free from neglect and the facility will prohibit neglect of residents. Further review of the investigation component of the Abuse Prohibition policy revealed, in part, the facility will complete a thorough investigation to include where and when the incident occurred and interviews and/or written statements from individuals (residents, visitors, or staff), who may have firsthand knowledge of the incident. Further 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 record review and interview the facility failed to ensure staff answered call bells to assist residents timely with toileting and/or incontinence care for 6 residents (Resident #2, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #17) of 19 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled for incontinence care and toileting Findings: Resident #2 Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/2024 revealed, in part, a Brief Interview for Mental Status Score (BIMS) of 15. A BIMS score of 15 indicated Resident #5 was cognitively intact. Further review revealed Resident #2 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #2's Care Plan with a revision date of 02/13/2024 revealed, in part, Resident #2 had an Activity of Daily Living (ADL) self-care performance deficit with impaired mobility. Review of Resident #2's Care Plan…

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

Based on record reviews and interviews, the facility failed to ensure an incontinent resident dependent on staff for incontinence care received timely incontinence care for 1 (Resident #14) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) sampled residents investigated for incontinence care. Findings: Resident #14 Review of Resident #14's Minimum Data Set (MDS) with an assessment reference date of 01/12/2024 revealed, in part, Resident #14's cognition was intact, was incontinent of bowel and bladder, and dependent on staff for toileting. Review of the facility's investigation documentation for Resident #14 revealed, in part, on 02/11/2024, S13CNA reported Resident #14's bed linens were found wet with brown spots. Further review revealed the accused, S12CNA, reported Resident #14 never indicated she needed to be changed, and S12CNA did not check under the bed covers 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.

Based on record reviews and interviews, the facility failed to ensure a plan of care was developed for a resident identified as being at high risk for falls for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents in which the care plans were reviewed. Findings: Review of Resident #1's record, revealed an admit date of 12/06/2023, and had the following diagnoses: Displaced Bi-malleolar (ankle) fracture of right lower leg, and subsequent encounter for closed fracture with routine healing. Review of Resident #1's Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2023, revealed Resident #1 was mildly cognitively impaired, and was dependent on staff for toileting, sit to stand and transfers, putting on/taking off footwear, and lower body dressing. Review of Resident #1's Nurse's Notes revealed on 12/06/2023, Resident #1 was admitted to the facility after a stay at a local hospital due to a fall at home in which he sustained a broken right ankle. Further review revealed a late entry note written on 12/27/2023 that a fall…

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: 1. Ensure a dependent and incontinent resident with a history of urinary tract infections was provided incontinence care per the facility's policy and procedures for 1 (Resident #2) of 4 Residents (#1, #2, #3, #4) sampled. 2. Ensure a resident who completed self-catheterization was monitored for urine output and signs and/or symptoms of urinary tract infections for 1 (Resident #4) of 4 residents (#1, #2, #3, #4) sampled. Findings: 1. Review of facility's policy and procedure on Perineal Care revealed, in part, the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation. Further review revealed staff should use a wet wash cloth to clean perineal area and wash from front to back. Review of the Resident #2's EMR (electronic medical record) revealed, Resident #2 was admitted to the facility on [DATE] with a diagnosis of stress incontinence (the sudden, involuntary loss of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to: 1. Protect residents (Resident #10 and Resident #12) from resident to resident physical abuse; and, 2. Ensure a resident (Resident #5) was free from neglect by failing to provide incontinence care timely. This deficient practice was identified for 3 (Resident #10, Resident #12, and Resident #5) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for abuse and neglect. Findings: 1. Review of the facility's Abuse Prohibition Policy, revised 11/07/2023 revealed, in part, each resident has the right to be free from abuse. Resident #10 Review of Resident #10's record revealed, in part, diagnoses of personal history of transient ischemic attach, and unsteadiness on feet. Review of Resident #10's Quarterly Minimum Data Set with an Assessment Reference Date of 01/17/2024 revealed, in part, a Brief…

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 ensure residents were free from misappropriation of property/financial abuse/Exploitation for 1 (Resident #3) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for misappropriation of resident property. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, misappropriation of property/financial abuse/Exploitation was defined as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Review of Resident #3's Minimum Data Set with an Assessment Reference Data dated 12/01/2023 revealed, in part, Resident #3 had a Brief Interview of Mental Status score of 15 which indicated being cognitively intact. Further review revealed Resident #3 had a diagnosis of Syringomyelia and Syringobulbia (a disease affecting the spinal cord causing pain), Disease of the spinal cord, and Lower 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure allegations of resident neglect were reported to the state agency within 24 hours of the allegation for 2 (Resident #4 and Resident #10) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, the facility will report all allegations of neglect without serious bodily injury within 24 hours of the allegation. Resident #4 Review of Resident #4's Minimum Data Set with an Assessment Reference Date of 12/13/2023 revealed, in part, Resident #4 had diagnoses including Alzheimer's disease, stress incontinence and displaced bimalleolar (a bone in the ankle) fracture of the right lower leg. Further review revealed Resident #4 had a Brief Interview for Mental Status score of 08, which indicated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct a thorough investigation following allegations of neglect for 2 (Resident #4 and Resident #10) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, any allegations of neglect made by residents shall be reported to the Abuse Coordinator and investigated immediately. Resident #4 Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2023 revealed, in part, Resident #4 had diagnoses including Alzheimer's disease, stress incontinence and displaced bimalleolar (a bone in the ankle) fracture of the right lower leg. Further review revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 08, which indicated Resident #4 had moderate cognitive…

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 an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1(Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #R5) sampled residents reviewed for abuse. Findings: Review of Resident #4's S6Social Services Director's written notes or Review of Resident #4's written social service notes dated 11/30/2023 at 9:10 a.m. revealed, in part, BIMS assessment completed with no cues needed. Further review revealed, Resident #4 stated an aid treated me very badly. Review of Resident #4's nurse's note dated 11/30/2023 at 6:18 p.m. by S2Director of Nursing (DON) revealed, in part, head to toe skin check done by S3Assistant Director of Nursing. Further review revealed, Resident #4 was noted with a small discoloration to the left side temporal area with complaints that her head hit the wall and pain to the right rib area. Further review revealed the physician was notified and received new order for right…

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 ensure an allegation of abuse was thoroughly investigated for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #R5) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy revised 11/07/2023 revealed, in part, the facility will thoroughly investigate all alleged violations and take appropriate actions. Further review revealed, investigations will be prompt, comprehensive, and responsive to the situation. Further review revealed the procedure for the investigation will include interviews and/or written statements from individuals (residents, visitors or staff) who may have firsthand knowledge of the incident. Further review of the procedure for investigation revealed, examination of the resident alleged to have been abused for appropriate interventions (medical, psychosocial, etc.). Review of Resident #4's nurse's note dated 11/30/2023 at 6:18 p.m. by S2Director of Nursing (DON) revealed, in part, head to toe skin check done by S3Assistant…

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

Based on record reviews and interviews, the facility failed to immediately notify a resident's physician of a change in a resident's ability to tolerate an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine through a tube) for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents investigated for enteral feedings. Findings: Review of Resident #1's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 07/18/2023 revealed, in part, Resident #1 had a BIMS (brief interview mental status) score of 15 which indicated Resident #1 was cognitively intact. Further review revealed, Resident #1 received 51% or more of calories through a feeding tube (a medical device inserted into the stomach used to administer enteral feedings). Review of Resident #1's nutrition/dietary note dated 08/02/2023 revealed, in part, Resident #1's enteral feeding was Osmolite 1.5 Cal (a tube feeding formula that provides complete, balanced nutrition with high calories and protein) 300 milliliters (ml) four times a day (QID). Further review revealed,…

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

Based on record reviews and interviews, the facility failed to provide appropriate treatment and services to enhance a resident's tolerance of enteral feedings (a way of delivering nutrition directly to the stomach or small intestine through a tube) for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents investigated for enteral feedings. Findings: Review of the facility's Enteral Nutrition Policy revealed, in part, the dietitian would monitor residents who were receiving enteral nutrition and make appropriate recommendations for interventions to enhance a resident's tolerance of enteral feedings. Further review revealed, the nursing staff should monitor the resident for signs and symptoms of inadequate nutrition, altered hydration or electrolytes, and worsening conditions. Review of Resident #1's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 07/18/2023 revealed, in part, Resident #1 had a BIMS (brief interview mental status) score of 15 which indicated Resident #1 was cognitively intact. Further review revealed, Resident #1 received 51% 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 interviews, observations, and record review, the facility failed to ensure a resident who required assistance from staff with toileting received timely assistance to maintain personal hygiene per professional standards. This deficient practice was identified for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for activities of daily living. Findings: Review of the facility's Perineal Care Policy revealed, in part, the purpose of this procedure is to prevent infections and skin irritation. Review of steps in the procedure revealed, in part, wash hands and apply gloves; clean perineal area; change gloves; reposition; apply thin layer of skin barrier. Review of the facility's Hand Hygiene Policy and Procedure revealed, in part, hand hygiene is the primary means to prevent the spread of infections. Further review of the Policy Interpretation and Implementation of applying and removing gloves revealed, in part, perform hand…

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

Based on observation and interview, the facility failed to have the nurse staffing information posted on a daily basis. Findings: Observation on 08/08/2023 at 9:44 a.m. revealed no posted staffing in the facility. Observation on 08/09/2023 at 9:05 a.m. revealed no posted staffing in the facility. Observation on 08/09/2023 at 12:45 p.m. revealed no posted staffing in the facility. Observation on 08/09/2023 at 3:30 p.m. revealed no posted staffing in the facility. Observation on 08/10/2023 at 9:55 a.m. revealed posted staffing dated 08/09/2023. In an interview on 08/10/2023 at 10:20 a.m., S2Director of Nursing (DON) stated nurse staffing data should be posted daily. S2DON acknowledged nurse staffing data was not posted on 08/09/2023. S2DON further acknowledged nurse staffing data posted on 08/10/2023 was not current. In an interview on 08/10/2023 at 11:05 a.m., S6Human Resources (HR) stated she was responsible for posting staffing daily. S6HR confirmed she did not post staffing on 08/08/2023. S6HR also confirmed she posted staffing on 08/09/2023 at the end of the day on 08/09/2023.…

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.