Villa Feliciana Chronic Disease

Based on record review, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Unit 2B) of 2 (Unit 1A and Unit 2B) resident units reviewed for staffing. This had the potential to affect the 20 residents residing on Unit 2B. Findings: Review of the facility's Nursing Staffing Pattern revealed the facility required 2 CNA's assigned per shift for Unit 2B. Review of the facility's census dated 03/03/2025 revealed there were 20 residents residing on Unit 2B. Review of the facility's Daily Assignment Sheet dated 03/03/2025 revealed the following, in part: 6:00 a.m. to 6:00 p.m.: S9CNA - Unit 2B Further review revealed no other CNA assigned to Unit 2B. Review of the facility's Daily Assignment Sheet dated 03/05/2025 revealed the following, in part: 6:00 a.m. to 6:00 p.m.: S10CNA - Unit 2B Further review revealed no other CNA assigned to Unit 2B. An observation was made on 03/03/2025 at 9:00 a.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents' Medication Administration Record (MAR) were accurately documented for 2 (#1 and #2) of 3 (#1, #2, and #3) residents reviewed for pharmaceutical services. This deficient practice had to the potential to affect any of the 153 residents residing in the facility. Findings: Review of the facility's policy titled Medication Administration with revision date of August 2018 revealed the following, in part: Procedure: M. The nurse must document medication administration on the resident's MAR/electronic MAR immediately after administering the medications. N. If a resident refuses a medication, indicate on MAR/electronic MAR noting the specific date/time, document in resident's clinical record on the nurses' notes, and notify physician. Resident #1 Review of Resident #1's Clinical Record revealed an admission date of 03/04/2021, with diagnoses which included Schizoaffective Disorder, Dementia, Epilepsy, Hypertension, Diabetes Mellitus-Type 2,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to prevent misappropriation of resident property by S4RN for 2 (#1 and #2) of 3 (#1, #2, and #3) sampled residents. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in an Immediate Jeopardy situation on 02/01/2025 when S4RN withheld Resident #1 and Resident #2's 7:00 p.m. 01/31/2025 medications. Two staff members observed both Resident #1 and Resident #2's 7:00 p.m. 01/31/2025 dose of medications inside of S4RN's personal bag after S4RN verbalized the resident's refused the medications. These medications included cardiac, hypertension, seizure, diabetic, and psychiatric medications. Residents are likely to suffer serious harm, impairment, or death as a result of staff misappropriating of residents' property. S1DON was notified of the Immediate Jeopardy on 03/10/2025 at 4:50 p.m. Findings:…

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 neglect/misappropriation of property were reported in the required timeframe for 2 (#1 and #2) of 5 (#1, #2, #3, R1, and R2) sampled residents. Findings: Review of the facility's policy titled Abuse and Neglect Policy revised on 03/2023, revealed in part, the following: 5. Exploitation: Some examples include taking money or other personal property from a resident for one's own use, taking residents medication for own personal use. 7. Neglect: Acts of omissions by a person responsible for providing care of treatment which placed the resident at risk for harm, or which deprived a resident of sufficient or appropriate services, treatment or basic care. Civ. Procedure to Report Neglect-Any Employee: 1. To the Immediate Supervisor: Immediately, but in no case later than one hour after knowledge or suspicion. 5. If unable to report face to face or by phone to supervisor or any supervisor, report immediately by phone or face to face to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff utilized appropriate PPE during care with residents who required EBP (Enhanced Barrier Precautions) for 3 (#35, #52, and #54) of 3 (#35, #52, and #54) of 3 (#35, #52, and #54) residents observed during chronic wound care and use of indwelling medical devices. This deficient practice had the potential to affect any of the 20 residents residing in the facility on Enhanced Barrier Precautions. Findings: Review of the facility's policy titled Implementation of PPE use in LTC (Long Term Care) setting to prevent the spread of MDROs (Multi-Drug Resistant Organisms) Dated 10/24/2022, revealed the following, in part: Residents for whom EBP applies to include any resident with an indwelling medical device or wound. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing, Providing Hygiene, Device care or use: feeding tube, and tracheostomy, and wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an environment which promotes quality of life through dignity and respect for 1 (#94) of 5 (#10, #16, #94,#107, and #150) residents reviewed for resident rights. The facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over Residents #94 while assisting him to eat. Findings: Review of the facility's policy titled Feeding a Resident with an effective date of November 1999 revealed the following, in part: Procedure: R. If possible, sit facing the resident while feeding is taking place A review of Resident #94's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction and Acquired Absence of Right Fingers. A review of Resident #94's Quarterly Minimum Data Set with an Assessment Reference Date of 10/22/2024 revealed functional limitation in range of motion to bilateral upper extremities and dependent on staff for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure an effective system was in place to incorporate Level II PASARR determination recommendations in the resident's care planning for 1 (#106) of 3 (#33, #106, and #145) residents reviewed for PASARR. This deficient practice had the potential to affect any of the 58 residents residing in the facility with a PASARR Level II as determined by the facility. Findings: Review of Resident #106's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Schizoaffective Disorder - Bipolar Type. Review of Resident #106's Level II PASARR Determination dated 08/08/2024 revealed the following, in part: Specialized Services Recommendations: Individual outpatient therapy - checked Other - checked Other specialized services: schedule a psychiatric evaluation - include treatment recommendations Review of Resident #106's current Care Plan revealed no documented evidence of a Level II PASARR or any recommended interventions.…

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 services provided met professional standards of quality by failing to ensure nursing staff accurately documented Pressure Ulcer treatment as performed for 1 (#52) of 4 (#45, #52, #65, and #139) residents reviewed with Pressure Ulcers. This deficient practice had the potential to affect any of the 13 residents residing at the facility with Pressure Ulcers. Findings: Review of the facility's undated policy titled, Wound Care Policy and Procedures revealed the following, in part: Documentation: A. Treatment Documentation: Treatments will be initiated per physician orders. Treatments will be documented .as ordered. Review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Pressure Ulcers and Paraplegia. Review of Resident #52's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS summary score of 15, which indicated he was cognitively intact. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident with Pressure Ulcers received treatment and services consistent with professional standards by failing to implement the physician ordered treatment for 1 (#52) of 2 (#52 and #62) residents reviewed with wound vacuums. This deficient practice had the potential to affect any of the 13 residents with Pressure Ulcers as listed on the facility's CMS-802. Findings: Review of the facility's undated policy titled, Wound Care Policy and Procedures revealed the following, in part: Documentation: A. Treatment Documentation: Treatments will be initiated per physician orders. Treatments will be documented .as ordered. Review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Pressure Ulcers and Paraplegia. Review of Resident #52's Quarterly MDS with an ARD of 10/22/2024 revealed a BIMS summary score of 15, which indicated he was cognitively intact. 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 observations, interviews, and record reviews, the facility failed to protect residents' right to be free from physical abuse by another resident for 3 (#3, #7, and #9) of 12(#1, #2, #3, #4, #5, #6, #7, #8, 9, 10, 12, and 13) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 was free from physical abuse by Resident #4; 2. Resident #7 was free from physical abuse by Resident #8; and 3. Resident #9 was free from physical abuse by Resident #10. Findings: Review of the facility's policy titled, Abuse and Neglect Policy, with a revision date of March 2023, revealed the following, in part: Purpose: It is the policy of this facility and the state agency, to prohibit the abuse of patients/residents (henceforth referred to as resident). This facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents by other residents of this facility are prohibited. Definitions: Physical abuse - physical contact such as hitting,…

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 provider failed to ensure physician's orders were implemented for 1 (#13) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents sampled. Findings: Review of Resident #13's clinical record revealed he was admitted on [DATE] with diagnoses which included Epilepsy, Bipolar Disorder, and Alcohol Abuse. Review of Resident #13's quarterly MDS with an ARD of 06/28/2024, revealed Resident #13 had a BIMS of 13, which indicated he was cognitively intact. Review of Resident #13's physician's orders dated 04/09/2015, revealed the following, in part: Phenobarbital 64.8 mg, 1 tablet by mouth twice daily. Review of Resident #13's Medical Administration Record (MAR) dated 08/01/2024 to 09/25/2024 revealed no documentation Phenobarbital 64.8 mg was administered on 09/04/2024 at 7:00 p.m. Review of Resident #13's Individual Patient Controlled Drug Record revealed no documentation Phenobarbital was administered on 09/04/2024 at 7:00 p.m. On 09/26/2024…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure a resident did not receive a medication he was allergic to for 1 (#10) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) sampled residents. Findings: Review of the facility policy titled Allergy Alert with a revision date of 10/2019 revealed the following, in part: I. Purpose: a. To prevent anaphylaxis b. To prevent allergic reactions II. Scope : Allergy alerts should be checked by all direct care staff who provide care to a resident. It is the responsibility of nurses, therapist and physicians to check resident's charts for allergies before giving a medication. III. Policy: Allergy alerts are to be placed on charts and all direct care staff who provide care to residents are to be advised of their allergies and check them prior to administering care, administering meds or feeding. Review of Resident #10's clinical…

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 PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 1 (#8) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) residents reviewed for medications. Findings: Review of the facility's policy titled Antipsychotic/Psychotropic Medication Policy with no revision date revealed the following, in part: 1. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. Review of Resident #8's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Unspecified Dementia, Unspecified Psychosis, and Schizophrenia. Review of Resident #8's September 2024 Physician's Orders revealed an order written on 12/11/2023 for Ativan 1mg tablet by mouth every six hours as needed (PRN) for agitation. Further review revealed the PRN medications had no stop date or duration.…

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 notify the physician when a residents had a change in condition for 3 (#12, #13, and #14) of 16 residents reviewed for abuse. Findings: Resident #12 Review of Resident #12's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury, Anoxic Brain Damage, and Impulse Disorder. Review of Resident #12's most recent MDS with an ARD of 05/15/2024, revealed that the resident had a BIMS (Brief Interview for Mental Status) of 0 which indicated the resident was severely impaired for cognition. Further review revealed the resident was independent with mobility and walking. Review of the facility's state agency reportable incidents for Resident #12 revealed the following: Abuse type in Review: Abuse Date: 06/25/2024 Incident Description: Allegation of nurse drugging resident #12. Review of Resident #12's Nurse's Notes revealed the following, in part: 06/25/2024 at 7:12 a.m., Resident #12…

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 abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the state survey agency for 2 (#7 and #16) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse and Neglect Policy with a revision date of 03/2023 revealed the following, in part: iv. Procedure to Report Abuse/Neglect-Any employee 1. To the Immediate Supervisor: Immediately, if at all possible, but in no case later than one hour after knowledge or suspicion, the written report shall be submitted to the RN supervisor as soon as possible, but no later than two hours after the verbal report. 9. Ensure that all reporting requirements are followed. vi. Client Rights Officer-The function of the Client Rights Officer is as follows: 2. At the direction of the Administrator, report allegations of abuse 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 interviews and record reviews, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 4 (#4, #8, #13 and #14 ) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for unnecessary medications. Findings: Review of the facility's policy titled Antipsychotic/Psychotropic Medication Policy with no revision date revealed the following, in part: Purpose: Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period, and are subject to gradual dose reduction, and re-review by Physicians and mid-level providers to ensure appropriate use, evaluation and monitoring. Procedures: 1. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Resident #4 Review of Resident #4's clinical record revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to protect each residents' right to be free from physical abuse for 3 (#3, #5, and #9) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 ,#13, #14, #15, and #16) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 and Resident #9 were free from physical abuse by Resident #4; and 2. Resident #5 was free from physical abuse by Resident #6. Findings: Review of the facility's policy titled, Abuse and Neglect Policy, with a revision date of March 2023, revealed the following, in part: Purpose: It is the policy of this facility and the state agency, to prohibit the abuse of patients/residents (henceforth referred to as resident). This facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents by other residents of this facility are prohibited. Definitions: Physical abuse - physical contact such as hitting, slapping, pinching, kicking,…

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 the residents plan of care was revised by failing to update behavior interventions after a verbal altercation for 1 (#1) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for care plans. Findings: Review of the facility's policy titled, Care Plans-Nursing with a revision date of 05/2015 revealed the following, in part: II. Purpose: A. To provide an individualized nursing care plan to guide the resident's care . IV. Policy: B. The care plan for each resident must include: 2. Interventions: that describe the services you will employ to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. M. Document: 1. All pertinent .expected outcomes, nursing interventions, and evaluations of expected outcomes. Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnosis which included Multiple Myeloma Not…

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

Based on interviews and record review, the facility failed to ensure a resident received necessary services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive care plan by failing to implement and document increased behavior monitoring for 1 (#9) of 5 (#3, #4, #5, #6, and #9) residents reviewed for increased monitoring for behaviors. Findings: Review of facility's policy titled, Observation Precautions, dated 08/08/2023, revealed, in part: Purpose: Observation precautions are instituted for situations where the resident's condition/behavior presents as a clear and present risk to himself, others or the environment. Definitions: Increased Observation-staff members are assigned to observe an individual resident more frequently than traditional rounds. Increased observation may be completed in 15 minute intervals. Procedure: Documentation and Reporting: a. A form specific to the documentation of observation precautions shall be maintained with entries noted every 15 minutes by assigned staff and every 2 hours…

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

Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays for 3 (#62, #120, and #132) of 7 (#47, #62, #99, #112, #117, #120, and #132) residents reviewed for mail during the resident council meeting. This deficient practice had the potential to affect 144 residents residing in the facility. Review of the facility's Policy titled, Mail revealed the following, in part: Purpose: To ensure residents receive their mail in a timely manner. Procedure: 1. Weekend and holiday mail will be picked up by the Nursing Department .Any packages received on weekends and holidays shall be distributed by the nursing department. During the resident council meeting on 11/13/2023 at 1:38 p.m., Resident #62, Resident #120, and Resident #132 all stated mail was not delivered on Saturdays and was held until the following Monday. An interview was conducted with S5SSC on 11/14/2023 at 11:00 a.m. He stated he, S6SSC and S7SSC were responsible for delivering the residents' mail. He stated there was no one present to deliver mail on Saturdays. He stated mail 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 observations, interviews, and record review, the facility failed to ensure resident equipment was maintained in a safe and orderly manner by failing to ensure geri-chairs were in good repair for 1 (#4) of 2 (#4 and #94) residents reviewed for environment. Findings: Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Non-Traumatic Intracranial Hemorrhage. Review of Resident #4's current Care Plan revealed the following, in part: Problem Onset: 09/25/2023 Problem: I need assist with transfers because of my decreased mobility (geri-chair), hemiparesis, poor posture (scoliosis), impaired vision (cataracts), and poor cognition Traumatic Brain Injury. Approaches: Assist me in my geri-chair. Review of facility's Durable Medical Equipment Monthly Maintenance Logs, dated 11/01/2023 -11/14/2023, revealed no entries for Resident #4's geri-chair. On 11/13/2023 at 9:23 a.m., an observation was made of Resident #4's room. A geri-chair was noted in…

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 report an allegations of physical abuse to the state survey agency within 2 hours for 2 (#75 and #89 ) of 4 (#75, #89, #132, and #338) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse and Neglect Policy revealed the following, in part: 9. Ensure that all reporting requirements are followed. Resident # 75 Review of the clinical record revealed Resident #75 was admitted to the facility on [DATE]. Review of Resident #75's Incident Investigation dated 10/30/2023 revealed the following, in part: At 6:50 a.m., Resident #75 was punched in his left cheek and kicked by Resident #338. Resident #75's mouth was bleeding. It appears he bit his cheek. Signed by S9RN. Review of the Incident Report submitted to the state survey agency for Resident #75 revealed the following, in part: Victim: Resident #75 Accused: Resident #338 Incident Occurred: 10/30/2023 at 6:50 a.m. Incident Discovered: 10/30/2023 at 6:50 a.m. Incident…

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 implement a person-centered plan of care by failing to ensure weekly restorative nursing assessments were completed for 1 (#99) of 2 (#9 and #99) residents reviewed for limited range of motion. Findings: Review of the medical record for Resident #99 revealed the resident was admitted to the facility on [DATE]. Resident #99 had diagnoses which included: Neuromyelitis Optica (Devic's Disease), Monoplegia of Upper Limb, Right Wrist Drop, and Incomplete Paraplegia. Review of the MDS with ARD of 11/02/2023 revealed Resident #99 had a BIMS of 15, which indicated he was cognitively intact. Review of the current Care Plan for Resident #99 revealed the following, in part: Problem: need for Restorative Nursing to prevent contractures and maintain current mobility. Approaches: Provide Passive Range of Motion to my bilateral lower extremities every shift; evaluate my Restorative Care every week on Wednesdays. Review of Physician Order dated 08/08/2023 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 observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure: 1. Oxygen tubing was labeled and the oxygen humidifier bottle was properly changed for 1 (#4) of 3 (#4, #81, and #84) residents; and 2. Oxygen orders were initiated for 1 (#81) of 3 (#4, #81, and #84) residents reviewed for oxygen therapy. Findings: 1. Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Hypoxemia, and Coronavirus Disease. Review of Resident #4's Physician Orders dated November 2023 revealed the following, in part: Oxygen at 2 liters per nasal cannula to maintain oxygen saturations less than 88%. Review of Resident #4's current Care Plan for Resident #4 revealed the following, in part: Problem Onset: 09/25/2023 Problem: I am at risk for not breathing well,…

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 implement a person-centered plan of care by failing to ensure weekly restorative nursing assessments were completed for 1 (#99) of 2 (#9 and #99) residents reviewed for limited range of motion. Findings: Review of the medical record for Resident #99 revealed the resident was admitted to the facility on [DATE]. Resident #99 had diagnoses which included: Neuromyelitis Optica (Devic's Disease), Monoplegia of Upper Limb, Right Wrist Drop, and Incomplete Paraplegia. Review of the MDS with ARD of 11/02/2023 revealed Resident #99 had a BIMS of 15, which indicated he was cognitively intact. Review of the current Care Plan for Resident #99 revealed the following, in part: Problem: need for Restorative Nursing to prevent contractures and maintain current mobility. Approaches: Provide Passive Range of Motion to my bilateral lower extremities every shift; evaluate my Restorative Care every week on Wednesdays. Review of Physician Order dated 08/08/2023 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.