Heritage Healthcare of Hammond

Based on observations, interviews, and record reviews, the facility failed to have a measurable evaluation system in place to ensure nursing staff were trained and competent to perform wound treatments as ordered prior to being allowed to independently perform them. This deficient practice was evidenced by failure to ensure: 1. The nurse documented the date and their initials on the dressing of each treatment performed for 1 (#3 and #4) of 4 (#3, #4, #5, and #6) residents present in the facility who were reviewed for wounds; and 2. The nurse applied a dressing large enough to fully cover and protect the wound for 1 (#4) of 4 (#3, #4, #5, and #6) residents present in the facility who were reviewed for wounds. This deficient practice had the potential to affect any of the facility's 31 wounds with active treatment orders. Findings: Review of the facility's Wound Care Policy and Procedure, effective 11/26/2014, revealed, in part, the following:Treatment Orders: After observation/evaluation of the affected skin area, implement standing orders. Applying Treatment: 1. Date and Initial…

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 have a system in place to ensure the safe disposition and administration of resident medications for 1 (#2) of 3 (#2, #4, and #5) residents present in the facility who were reviewed for medications. This deficient practice was evidenced by Resident #2, who was not assessed for and did not have a physician's order for self-administration of medications, having an inhaler left at bedside.Findings: Review of the facility's Self Administration of Medication Policy and Procedure, effective 12/05/2014, revealed, in part, the following:Policy: Each resident will be assessed on admission, quarterly, annual, any significant change in condition and as needed for self-administration of medication if applicable. Procedure: 1. A Self-Administration of Medication Assessment will be completed as indicated. 2. Interdisciplinary Team (IDT) will review assessment and determine if resident is safe to administer medication. 3. IDT will determine who will be…

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

Based on record reviews and interviews, the facility failed to ensure that each resident's comprehensive and non-comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 5 of 20 (#24, #29, #37, #57, and #60) resident records reviewed in the final sample. The facility failed to submit Resident assessments within 14 calendar days as required. Findings: Resident #24 Review of Resident #24's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2025, revealed a complete by date of 05/07/2025. Further review of the MDS revealed the MDS had a status of in progress. Resident #29 Review of Resident #29's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/2025, revealed a complete by date of 05/10/2025. Further review of the MDS revealed the MDS had a status of in progress. Resident #37 Review of Resident #37's Discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2025, revealed a complete by date of 05/08/2025. 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 observations, interviews, and record reviews, the facility failed to provide sufficient nursing staff to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure: 1. Staff assisted resident's request for assistance with ADLs timely for 3 (#6, #31, and #60) of 13 residents reviewed on Hall B; and 2. S7LPN was aware Resident #32 was at the facility for a time period of 3-4 hours when she refused to go to dialysis. Findings: Review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 1 revealed a one-star staffing rating. Review of the facility's census dated 05/18/2025 revealed there was a total census of eighty-four residents and seven halls. Further review revealed there were thirteen residents residing on Hall B. Review of the facility's Daily Assignment Sheet dated 05/20/2025 revealed the following, in part: 6:00 a.m. to 2:00 p.m.: S17CNA - Hall B Further review revealed no other CNA's assigned to Hall B. 1.…

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

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was properly stored in the walk-in cooler and walk-in freezer; 2. Food was properly stored in the dry food storage room; 3. Dietary employees wore effective hair restraints while engaged in the handling and preparation of food; 4. Ceiling vents in the kitchen were properly cleaned and free of black and grey substances; and 5. Meals carts were properly cleaned and free of debris. This deficient practice had the potential to affect the 79 residents who were served food from the kitchen. Findings: Review of the facility's policy titled, Storage of Refrigerated Food with a revision date of 10/2018, revealed the following, in part: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: Food taken out of original containers is put in a clean sanitized container with a tight fitting lid. No food is left uncovered.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure: 1. Nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 2 (#19 and #69) of 3 (#19, #69, and #391) residents reviewed for insulin administration; and 2. Nursing staff donned proper Personal Protective Equipment (PPE) during direct resident care for 2 of 2 (#1 and #76) residents whom required EBP (Enhanced Barrier Precautions). Findings: Review of the facility's policy titled, Infection Prevention and Control Program, with an effective date of 09/30/2022, revealed the following, in part: Purpose: The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent 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 complete a significant change MDS within 14 calendar days after determining there was a significant change in residents status for 2 of 20(#6 and #29) sampled resident's. Findings: Resident #6 Review of Resident #6's Significant Change MDS with an ARD of 03/06/2025 revealed an admission date of 11/24/2021. Further Review of Resident #6's Significant Change MDS with an ARD of 03/06/2025 revealed assessment was completed on 03/26/2025. Resident #29 Review of Resident #29's Significant Change MDS with an ARD of 05/05/2025 revealed an admission date of 10/09/2023. Further review of Resident #29's clinical record revealed a Significant Change MDS with an ARD of 05/05/2025 with a submission status of in progress. On 05/21/2025 at 12:56 p.m. an interview was conducted with S13MDS. She reviewed Resident #6 and Resident #29 most recent significant change assessments. S13MDS confirmed Resident #6 Significant Change assessment dated [DATE] was not completed within…

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 a baseline care plan was developed within 48 hours of admission to the facility for 1 (#290) of 20 sampled residents. Findings: Review of Resident #290's medical record revealed an admit date of 05/08/2025 with diagnoses which included Type II Diabetes Mellitus, Atrial Fibrillation and Major Depressive Disorder. Review of Resident #290's medical record revealed a baseline care plan was initiated on 05/19/2025. On 05/21/2025 at 12:56 p.m. an interview was conducted with S19MDS. She reviewed Resident #290's care plan and confirmed she initiated it on 05/19/2025. S19MDS confirmed baseline care plans should be implemented within 48 hours of admission and Resident #290's was not. On 05/21/2025 at 2:10 p.m. an interview was conducted with S2RNSUP. She reviewed Resident #290's baseline care plan and confirmed it was initiated on 05/19/2025. S2RNSUP confirmed she would expect all residents to have a baseline care plan within 48 hours of Admission. S2RNSUP confirmed Resident #290's baseline care was not implemented in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents who required assistance to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene for 1 (#240) of 2 (#37 and #240) residents reviewed for ADLs. Findings: Review of the facility's policy titled Bath, Bed Policy and Procedure, dated 08/01/2017, revealed the following, in part: Policy: Bed Baths are to be given as scheduled and/or as needed. Review of Resident #240's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Complete Traumatic Amputation of Left Foot and Fracture of Right Shoulder. Review of Resident #240's admission MDS with an ARD of 05/10/2025 revealed he had a BIMS of 15, which indicated he was cognitively intact. Further reviewed revealed he was dependent on staff for bathing/showering. Review of Resident #240's Nurses Notes dated 05/06/2025 - 05/20/2025 revealed no documentation of Resident #240 refusing baths or showers. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to provide wound care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#240) of 3 (#19, #76, #240) sampled residents reviewed for wound care. Findings: Review of facility's Dressing Change (Wound Care), Clean Policy and Procedure policy dated 10/30/2024 revealed, in part: Policy Complete dressing changes as ordered by the physician. Review of Resident #240's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Complete Traumatic Amputation of Left Foot and Fracture of Right Shoulder. Review of Resident #240's admission MDS with an ARD of 05/10/2025 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #240's current Care Plan revealed the following, in part: Problems: Laceration to left knee, Laceration to right forearm, Surgical incision related to left below knee amputation (LBKA), Abrasion to left knee,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled properly in accordance with current accepted professional principles. The facility failed to ensure medications for Resident #190 were labeled properly, not expired and not available for administration. Findings: Resident #190 Review of Resident #190's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses of Unspecified Elevated [NAME] Blood Cell Count, Acute Kidney Failure, and Chronic Kidney Disease Stage 4. Review of Resident #190's current Physician Orders revealed the following, in part: Order date: 05/16/2025 Cefazolin Sodium Injection Solution Reconstituted 1 gram use 1 gram intravenously one time a day every Tuesday, Thursday, and Saturday to be given at dialysis related to Unspecified Acute Kidney Failure. On 05/19/2025 at 9:45 a.m., an observation was made of Med a room with S2RNSUP and S3ADON. A large clear plastic bag was observed containing seven…

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 garbage and waste were properly contained in the outdoor trash dumpster. Findings: On 05/18/2025 at 8:45 a.m., an observation was made of the facility's outdoor trash dumpster with S9CK. The outdoor trash dumpster was observed containing several bags of trash with the lid open. On 05/18/2025 at 8:50 a.m., an interview was conducted with S9CK. She observed the outdoor dumpster lid and stated it should have been closed by the night shift kitchen staff. She stated the dumpster lid was open upon arrival for her shift. She attempted to close the dumpster lid with a broom stick, but was unsuccessful. She further stated she thought the dumpster lid may be broken. On 05/18/2025 at 9:47 a.m., an interview was conducted with S8DM. She was made aware of the above finding. She stated the dumpster lid was not broken, but was hard for staff to close. She confirmed the outdoor trash dumpster lid should be kept closed at all times.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented and complete for 2 (#32 and #60) of 20 residents reviewed in the final sample. Findings: Resident #32 Review of Resident #32's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses with included Presence of Cardiac and Vascular Implant and Graft, and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of Resident #32's admission MDS with an ARD of 03/10/2025 revealed a BIMS of 12, which indicated she was moderately cognitively impaired. Review of Resident #32's Current Physician Orders revealed the following, in part: Dialysis every Monday, Wednesday, Friday Review of Resident #32's MAR dated May 2025 revealed the following, in part: 05/19/2025- Checked that Resident #32 went to dialysis, initialed by S7LPN Review of Resident #32's Nurse's Notes revealed the following, in part: 05/19/2025-Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to maintain accurate documentation for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure: 1. Resident #1's daily wound care was accurately documented; and 2. Resident #3's oxygen use was accurately documented. Findings: Resident #1 Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Unspecified Fracture of Left Femur, Subsequent Encounter For Closed Fracture with Routine Healing. Review of Resident #1's December 2024 - January 2025 Physician Orders revealed in part, the following: Clean surgical incision to left hip with normal saline/wound cleanser, pat dry, apply dry dressing of choice daily and as needed until healed, start date: 12/18/2024. Review of Resident #1's January 2025 TAR (Treatment Administration Record) revealed in part, the following: Wound care to surgical incision wound on 01/01/2025 was blank. An interview was conducted 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 observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 1 (#3) of 2 (#2 and #3) residents reviewed for oxygen therapy. Findings: Review of Resident #3's clinical record revealed resident was admitted to the facility on [DATE] with diagnoses, which included Congestive Heart Failure and Chronic Respiratory Failure. Review of Resident #3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2025 revealed he had a BIMS of 14, which indicated Resident #3 was cognitively intact. Review of Resident #3's February 2025 Physician Orders revealed the following: 01/24/2025: Oxygen at 2 Liters (L) via nasal cannula. On 02/25/2025 at 9:45 a.m., an observation was made of Resident #3 resting in his bed with no oxygen in use. At that time an interview was conducted with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure accurate weekly skin assessments were completed for 2 (#2 and #3) of 2 sampled residents. The deficient practice had the potential to affect any of 88 residents residing in the facility. Findings: Resident #2 Review of Resident #2's clinical record revealed resident was admitted to the facility on [DATE]. Review of Resident #2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/2025 revealed she had a risk of pressure ulcers. Review of Resident #2's current Physician Orders revealed the following: 12/31/2024: Weekly Body Audit. Resident #3 Review of Resident #3's clinical record revealed resident was admitted to the facility on [DATE]. Review of Resident #3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2025 revealed he had a risk of pressure ulcers. Review of Resident #3's current Physician Orders revealed the following: 01/24/2025: Weekly Body Audit. On 02/24/2025 at 1:45…

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 residents' assessments accurately reflected the resident's status by failing to ensure a resident's Minimum Data Set was accurately coded for an indwelling catheter for 1 (#2) of 2 (#1 and #2) residents reviewed for catheters. Findings: Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] and was readmitted on [DATE] from a local hospital. Review of Resident #2's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/2024 revealed the Brief Interview for Mental Status (BIMS) could not be completed because the resident was rarely/never understood. Further review revealed Resident #2 was not coded for an indwelling catheter. The MDS had a status of Accepted. Review of Resident #2's Clinical admission Screener, with an effective date of 10/30/2024, revealed the resident returned to the facility from the hospital with an indwelling catheter. On 11/12/2024 at…

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

Based on record review and interviews, the facility failed to initiate and resolve grievances voiced for 1 (#17) of 33 sampled residents reviewed for grievances. Findings: Review of the facility's policy titled, Grievance Policy and Procedure, dated 10/10/2022 revealed the following, in part: Follow Up/Resolution: 1. The grievance official/compliance liaison or designee will follow up with the complainant with a resolution within 5 business days of the date that the grievance was filed. Review of Resident #17's admission MDS with an ARD of 03/18/2024 revealed BIMS of 14 which indicated she was cognitively intact. Further review revealed she was dependent on staff for bathing. Review of the Completed Care record dated 04/01-04/31/2024 revealed Resident #17 only had a bath on 04/04/2024 and 04/15/2024. Completed Care Record dated 05/01-05/31/2024 revealed Resident #17 only had a bath on 05/08/2025 and 05/22/2023. Review of the facility's grievance logs dated December 2023-current revealed on 04/03/2024 Resident #17 had a complaint for nursing. Further review revealed, Resident #17…

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

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure: 1. S3LPN and S4LPN practiced proper hand hygiene for 3 of 3 (#11, #129, #130) residents observed for medication administration; and 2. S4LPN disinfected blood glucose meters between resident use for 1of 1 (#130) residents observed for blood glucose monitoring. This deficient practice had the potential to affect any of the 79 residents currently residing in the facility. Findings: Review of the facility's policy titled, Hand Hygiene Policy and Procedure dated 07/01/2020, revealed the following, in part: Policy: 3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 1. On 06/03/2024 at 2:05 p.m., an observation was made of S3LPN administering medication to Resident #129. S3LPN did not sanitize her hands prior to putting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident's assessment accurately reflected the resident's status for 1 (#10) of 33 residents reviewed in the final sample. Findings: Review of the facility's policy MDS Policy and Procedure, with an effective date of 6/25/2015, revealed, in part, the following: Policy: All MDS are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Procedure: The Interdisciplinary Team will assess the resident and document during the 7 day look back and accurately complete the MDS according to the RAI manual. Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #10 had a diagnosis of Localized Edema with an onset date of 08/23/2011. Review of Resident #10's current Physician Orders revealed the following: Start Date: 02/19/2024 Lasix 40 mg tablet by mouth daily for localized edema Review of Resident #10's MAR for March 2024, April…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan to meet the needs of 1 (#1) of 33 residents reviewed in the final sample. The facility failed to develop a care plan with interventions for a resident with diabetes who frequently refuses blood glucose monitoring. Findings: Review of the facility's policy Care Plan Policy and Procedure, with an effective date of 05/22/2017, revealed, in part, the following: Policy: A comprehensive plan of care will be used to communicate and address care issues that are relevant to the resident's individual needs. Procedure: 4. The care plan will be revised on an ongoing basis to reflect changes in the resident and the care the resident is receiving. 6. Consider: f) Respecting the resident's right to decline treatment. Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Unspecified Complications and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure resident's received the necessary services to maintain personal hygiene for 1 (#17) of 2 (#17 and #45) residents reviewed for Activities of Daily Living. Findings: Review of the facility's policy titled, Bath, Tub Policy and Procedure, dated 09/04/2014 revealed the following, in part: Policy: Tub Baths are to be given as scheduled and/or as needed. Procedure: 5. Assist resident into tub and assist with bath as needed. Review of the facility's policy titled, Bath, Shower Policy and Procedure, dated 09/04/2014 revealed the following, in part: Policy: Showers are to be given as scheduled and/or as needed. Procedure: 1. Place resident in shower chair and cover with appropriate drape. 4. Wash face and shampoo hair; rinse well. Review of Resident #17's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Morbid Obesity and Chronic Diastolic Heart Failure. Review of Resident #17's admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 2 (#4 and #7) of 6 (#1, #4, #7 #10, #35 and #43) residents reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #4 and Resident #7 had PRN orders for psychotropic drugs that were limited to 14 days. Findings: Resident #4 Review of the clinical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses, which included Dementia, Unspecified Severity with Agitation, Anxiety Disorder, Major Depressive Disorder with Severe Psych Symptoms, Unspecified Mood Defective Disorder, and Alzheimer's Disease, Unspecified. Further review revealed Resident #4 was admitted to Hospice Services on 09/16/2023. Review of Resident #4's active Physician Orders revealed the following, in part: Start Date: 12/14/2023- Ativan 1mg tablet give one tablet by mouth every 4 hours as needed for Agitation. Start Date: 06/03/2024-…

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.