Jefferson Healthcare Center

Based on observations, interviews, and record review, the facility failed to maintain a sanitary environment in a resident's room for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for environment. Findings: Review of Housekeeper Aide Job Description, dated 04/15/2015, revealed, in part, the primary purpose of the Housekeeper Aide was to perform the day-to day activities of the housekeeping department in accordance with current federal, state, and local standards. Further review revealed the housekeeper aide was responsible for cleaning walls by washing, wiping, dusting, spot cleaning, disinfecting, and deodorizing. Observation on 04/28/2025 at 10:25AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. Observation on 04/29/2025 at 10:31AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. Observation on 04/30/2035 at 10:42AM of Resident #36's room, revealed there was an unknown dried brown substance on two…

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: 1. An injury of unknown origin was reported to the State Survey Agency as required after discovery of a bruise to a resident's right eye (Resident #146); and, 2. An allegation of resident to resident physical abuse was reported to the State Survey Agency as required (Resident #154). This deficient practice was identified for 2 (Resident #146, Resident #154) of 3 (Resident #56, Resident #146, Resident #154) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy and procedure, dated 09/30/2019, revealed, in part, the facility must ensure all alleged violations involving injuries of unknown origin and abuse were reported immediately, but no later than 2 hours after the allegation was made to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with state law through established procedures. 1. Review of Resident #146's Minimum Data Set…

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 an injury of unknown origin was thoroughly investigated for 1 (Resident #146) of 3 (Resident #56, Resident #146, Resident #154) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy and procedure dated 09/30/2019, revealed, in part, for an allegation of abuse, the administrator was to complete a thorough investigation, including interviews of employees who were working in the resident's room during the time in question, and obtaining signed statements from these employees. Further review revealed the investigator would interview the resident if the resident was cognitively able to answer questions, and if not able to interview, the investigator would interview the resident's roommate. Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/16/2025 revealed, in part, Resident #146 had a Brief Interview for Mental Status (BIMS) score of 02 (00-07 indicated Resident #146 had a severe cognitive impairment). 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 interviews and record reviews, the facility failed to ensure: 1. A referral was made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for a resident with a onset of mental illness since admission (Resident #121); and, 2. A referral was made to the Louisiana Office of Behavioral Health's PASRR program for a resident identified with a mental illness upon admission (Resident #17). This deficient practice was identified for 2 (Resident #17, Resident #121 of 3 (Resident #17, Resident #57, Resident #121) sampled residents investigated for PASRR. Findings: 1. Review of Resident #121's Electronic Medical Record (EMR) revealed, in part, Resident #121 was admitted to the facility on [DATE]. Further review revealed Resident #121 had a diagnosis of moderate, recurrent, Major Depressive Disorder with an onset date on 09/02/2022. Further review revealed no documented evidence a PASRR Level II evaluation was completed for Resident #121 and/or a referral was made…

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 Level I Pre-admission Screening and Resident Review (PASRR) was accurately completed to reflect a resident's mental illness for 1 (Resident #17) of 3 (Resident #17, Resident #57, Resident #121) sampled residents investigated for PASRR requirements. Findings: Review of Resident #17's medical record revealed, in part, Resident #17 was admitted to the facility on [DATE] with diagnoses, which included, major depressive disorder and bipolar II disorder. Review of Resident #17's incomplete and undated Level I PASRR revealed, in part, Resident #17 was documented to not have been diagnosed with a mental illness. Further review revealed no psychiatric diagnosis was selected/identified on the above mentioned assessment. In an interview on 04/30/2025 at 1:35PM, S4Administrator Assistant (AA) indicated Resident #17 was admitted with diagnoses of major depressive disorder and bipolar II disorder. S4AA further indicated Resident #17's undated preadmission…

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 ensure a dependent resident received nail care for 1 (Resident #22) of 2 (Resident #21, Resident #22) sampled residents investigated for activities of daily living (ADLs). Findings: Review of Resident #22's April 2025 Care Task log revealed, in part, Resident #114's nail care task was documented as not applicable on 05/01/2025 at 5:59AM. Observation on 05/01/2025 at 8:28AM revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22's fingertips. In an interview on 05/01/2025 at 8:28AM, Resident #22 indicated that he would like his fingernails cut. In an interview on 05/01/2025 at 8:39AM, S25CNA indicated Resident #22 required total assistance with ADLs. Observation on 05/01/2025 at 10:40AM revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half…

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, interviews, and record review, the facility failed to ensure a carton of nutritional supplement was stored per a manufacturer's guideline and was not available for resident consumption. Findings: Review of Med Plus 2.0 nutritional supplement's directions revealed, in part, the product should be used within 4 hours of opening if not refrigerated. Observation on 05/01/2025 at 8:30AM revealed an opened unrefrigerated carton of Med Plus 2.0 nutritional supplement on Medication Cart d. Further observation revealed the above mentioned carton had an opened date of 04/30/2025. In an interview on 05/01/2025 at 8:45AM, S13Licensed Practical Nurse (LPN) confirmed the above mentioned supplement was opened on 04/30/2025, not refrigerated, and available for resident consumption. S13LPN further indicated he did not know the supplement should have been used within 4 hours of opening if not refrigerated. In an interview on 05/01/2025 at 11:00AM, S2Director of Nursing (DON) confirmed nursing staff should have ensured the carton of Med Plus 2.0 nutritional supplement was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident's electronic Medication Administration Record (eMAR) was accurately documented for 2 (Resident #14, Resident #99) of 4 (Resident #14, Resident #17, Resident #67, Resident #99) sampled residents reviewed for accurate medical record documentation. Findings: Review of the facility's Employee Handbook Code of Conduct dated 10/01/2024 revealed, in part, all employees were required to be truthful in all communication and written records to ensure resident records were accurate. Review of the facility's Licensed Practical Nurse (LPN) job description dated 10/2024 revealed, in part, it was the responsibility of the LPN to have knowledge of federal and state laws and regulations related to resident care and to carry out the assigned duties and responsibilities in accordance with current existing federal and state regulations. Resident #14 Review of Resident #14's electronic medical record revealed, in part, Resident #14 was admitted to the…

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

Based on record reviews and interviews, the facility failed to administer medications per the physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident's records reviewed for pharmaceutical services. Findings: Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/11/2024 revealed, in part, Resident #1 received application of an ointment or medication other than to feet. Review of Resident #1's October 2024 Physician Orders revealed, in part, Nystatin powder (an antifungal medication) was to be applied to Resident #1's right abdominal fold twice a day and as needed until resolved. Further review revealed the nystatin powder was originally ordered on 07/09/2024. Review of Resident #1's September 2024 electronic Medication Administration Record (eMAR) revealed, in part, Nystatin powder was scheduled to be applied at 8:00 a.m. and 4:00 p.m. daily. Further review of the September 2024 eMAR revealed nystatin powder was not applied at 8:00 a.m. on 09/07/2024 and at 4:00 p.m. on 09/03/2024, 09/04/2024,…

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

Based on record reviews and interviews, the facility failed to ensure a Licensed Practical Nurse displayed competency to clarify a physician's order related to a medication change for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident's records reviewed for pharmaceutical services. Findings: Review of Louisiana Revised Statue, Title 37, Section 961 revealed, in part, the licensed practical nurse must practice under the direction of a licensed physician, optometrist, or dentist acting individually or as a member of the medical staff, registered nurse or physician assistant. Review of Resident #1's record revealed, in part, a diagnosis of Diabetes. Review of Resident #1's current Care Plan revealed, in part, Resident #1 has a diagnosis of Diabetes with an intervention which included to administer medications as ordered by the physician. Review of Resident #1's October 2024 Physician Orders with a start date of 10/11/2024 revealed an order to administer Tresiba (a long acting insulin used to control high blood sugar) 30 Units (U) every day at 7:00 p.m. 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.

Based on record reviews and interviews, the facility failed to ensure medication administration records were complete and/or accurately documented for 2 (Resident #1 and Resident#2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for pharmacy. Findings: Review of the Licensed Practical Nurse's job description dated 04/15/2015 revealed, in part, the following responsibilities: 1. Prepare and administer medications according to procedure; and, 2. Record nursing information on resident's care plan and clinical record, including medication records. Resident #1 Review of Resident #1's October 2024 Physician's Orders revealed, in part, the following: 1. Gabapentin tablet (a medication used to treat seizures and neuropathic pain) give 600 milligrams (mg) three times a day; 2. Artificial tears (a medication used to treat dry eyes) ophthalmic solution instill one drop in the left eye four times a day, and 3. Prednisolone-Moxifloxacin-Bromfenac eye drops (an eye drop used for inflammation, infection, and pain after surgery) instill one drop three times a day.…

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 assess a resident for self-administration of medications for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents observed. Findings: Review of the facility's Med Pass Guidelines policy and procedure dated 12/04/2017 revealed, in part, the nurse administering medications were not to leave residents with medications in a cup. Further review revealed the nurse should make sure to see the resident take their medications. Review of Resident #1's Annual Minimum Data Set with an Assessment Reference Date of 07/03/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. Review of Resident #1's record revealed no documented evidence, and the facility did not present any documented evidence Resident #1 was assessed and/or care planned to self-administer medications. Observation on 10/10/2024 at 9:47 a.m. revealed a medicine cup containing 9 pills was on Resident #1's bedside table. In an interview 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.

Based on record reviews and interviews, the facility failed to ensure a dependent resident was provided a bath for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for activities of daily living (ADLs). Findings: Review of the facility's Bed Bath Policy and Procedure dated 08/01/2017 revealed, in part, bed baths were to be provided to residents as scheduled and/or as needed. Review of Resident #1's Annual Minimum Data Set with an Assessment Reference Date of 09/25/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had limitations in range of motion in his bilateral upper and lower extremities and required partial to moderate staff assistance with bathing. Review of Resident #1's Care Plan with a start date of 04/26/2023 revealed, in part, Resident #1 was care planned to require staff assistance with ADLs with an intervention for staff to assist Resident #1 with bathing. In an interview on 10/07/2024 at 11:59…

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 resident's bath type was accurately documented for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for activities of daily living. Findings: Review of Resident #1's Annual Minimum Data Set with an Assessment Reference Date of 09/25/2024 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had limitations in range of motion in his bilateral upper and lower extremities and required partial to moderate staff assistance with bathing. Review of Resident #1's Care Plan with a start date of 04/26/2023 revealed, in part, Resident #1 was care planned to require staff assistance with ADLs with an intervention for staff to assist Resident #1 with bathing. Review of Resident #1's August 2024 Bath Log revealed, in part, documentation that Resident #1 was provided a shower on the following dates: -08/04/2024; -08/10/2024; -08/12/2024; -08/15/2024; -08/16/2024;…

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 reviews, observations, and interviews, the facility failed to ensure: 1.) Ensure a resident's fall mat was at the bedside for 2 (Resident #44 and Resident #98) of 3 (Resident #12, Resident #44, and Resident #98) sampled residents reviewed for accident hazards; and, 2.) Ensure a resident's dycem was in his wheelchair for 1 (Resident #44) of 3 (Resident #12, Resident #44, and Resident #98) sampled residents reviewed for accident hazards. Findings: Review of the facility's policy dated 10/22/2014 and titled, Fall Prevention Program Policy and Procedure revealed, in part, residents who are classified as a high risk for falls would have a careplan addressing their goals and approaches to prevent falls. Resident #44 Review of Resident #44's electronic medical record (EMR) revealed, in part, Resident #44 was admitted to the facility on [DATE]. Review of Resident #44's Minimum Data Set with an Assessment Reference Date of 03/20/2024 revealed Resident #44's Brief Interview for Mental Status score was 8,…

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, observation, and interview, the facility: 1. Failed to sanitize the thermometer when internal temperatures of foods were measured; and, 2. Failed to perform hand hygiene during meal service. Findings: 1. Review of the 2022 Food Code United States Food and Drug Administration revealed, in part, temperature measuring device probes must be sanitized to prevent contamination of products when internal temperatures are measured. Observation on 04/16/2024 at 11:27 a.m. revealed S7Culinary [NAME] did not sanitize the thermometer before she inserted the thermometer into the pureed cauliflower to obtain the temperature. S7Culinary [NAME] then used a dishtowel, located on the food preparation table, to wipe the thermometer. S7Culinary [NAME] inserted the thermometer into the pureed lasagna, obtained a temperature, and wiped the thermometer with a paper towel. S7Culinary [NAME] then inserted the thermometer into the regular consistency lasagna, obtained the temperature, and wiped the thermometer with a paper towel. S7Culinary [NAME] then inserted the thermometer into the…

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

Based on observations and interviews, the facility failed to ensure a resident's room and equipment was kept clean for 1 (Resident #124) of 4 (Resident #21, Resident #32, Resident #46, and Resident #124) residents reviewed for environment. Findings: Observation on 04/15/2024 at 12:00 p.m. revealed large areas of a dried tan substance on the floor near Resident #124's tube feeding pole and on the base of the tube feeding pole. Observation on 04/16/2024 at 10:07 a.m. revealed large areas of a dried tan substance on the floor near Resident #124's tube feeding pole and on the base of the tube feeding pole. Observation on 04/17/2024 at 11:49 a.m. revealed large areas of a dried tan substance on the floor near Resident #124's tube feeding pole and on the base of the tube feeding pole. Observation further revealed Resident #124's wheelchair had 2 law labels (a legally required label on new items describing the fabric and filling usually saying This tag may not be removed under penalty of law except by the consumer) that were covered in a dark brown substance. In an interview on 04/17/2024…

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 observations, interviews, and record reviews, the facility failed to check a resident's peg tube placement prior to administration of an enteral nutritional therapy feeding (nutritional supplementation supplied through a tube that enters the stomach) for 1 (Resident #146) of 2 ( Resident #94 and Resident #146) residents investigated for nutrition. Findings: Review of the facility's Enteral Nutritional Therapy (Tube Feeding) Policy and Procedure dated 01/14/2016 revealed, in part, check position of tube by placing the stethoscope over the stomach and instill a small amount of air into enteral feeding tube and listen for air to enter the stomach. Review of Resident #146's electronic Medical Record (EMR) revealed, in part, Resident #146 was admitted to the facility on [DATE] with diagnosis of dysphagia 9difficulty in swallowing) and gastrostomy status. Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/2024 revealed, in part, Resident #146 was dependent 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.

Based on record reviews and interviews, the facility failed to ensure Licensed Practical Nurses (LPNs) did not work without their designated on-site supervisor per their Consent Agreement/Orders from the Louisiana State Board of Practical Nurse Examiners for 2 (S4LPN and S5LPN) of 2 (S4LPN and S5LPN) Licensed Practical Nurses reviewed for compliance with Louisiana State Board of Practical Nurse Examiners probation requirements. Findings: S4LPN Review of S4LPN's Louisiana State Board of Practical Nurse Examiners Employer's agreement with a start date of 10/17/2023 revealed, in part, S4LPN would work a 7-3 shift at the facility and S2DON would be S4LPN's designated on-site supervisor. Further review revealed the on-site supervisor must be physically present at the facility at all times while the probated licensed practical nurse was present and working. Review of S4LPN and S2DON's time sheets for November 2023 revealed, in part, S4LPN worked in the facility 6 evening shifts when S2DON was not present. S5LPN Review of S5LPN's Louisiana State Board of Practical Nurse Examiners Consent…

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 protect a resident's right to be free from resident to resident physical abuse by Resident #6 and Resident #R1. This deficiant practice was identified for 2 (Resident #R2 and Resident #5) 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 #R1, and Resident #R2) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse-Prevention and Prohibition Policy and Procedure revealed, in part, each resident has to right to be free from abuse. Further review revealed, abuse is the willful infliction of injury and physical abuse included hitting and slapping. Resident #6 Review of the facility's incident report dated 09/21/2023 revealed, in part, Resident #6 hit Resident #R2 on the left side of the face and on the right shoulder with a closed right hand. Review of Resident #6's nurse's notes dated 09/21/2023 revealed, 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 record review and interviews, the facility failed to: 1. Ensure an allegation of resident to resident sexual abuse and resident to resident physical abuse involving 3 (Resident #R1, Resident 5, 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 #R1, and Resident #R2) sampled residents reviewed for abuse was reported to the state survey agency within 2 hours of the allegation and; 2. Ensure an allegation of staff to resident physical abuse for 1 (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 #R1, and Resident #R2) sampled residents reviewed for abuse was reported to the state survey…

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 allegations of resident to resident sexual abuse and allegations of resident to resident physical abuse was thoroughly investigated for 2 (Resident #5 and Resident #R1) 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 #R1, and Resident #R2), and failed to initiate an appropriate corrective action plan for 1 (Resident #5) of the 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 #R1, and Resident #R2) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse - Prevention and Prohibition Policy and Procedure revealed, in part, the Administrator will complete a thorough investigation, including interviews of employee…

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 medications were maintained in a secure manner. Findings: Observation on 11/13/2023 at 12:49 p.m. revealed S4Licensed Practical Nurse (LPN) opened the over the counter (OTC) medication storage closet and S4LPN opened the OTC medication storage closet without the use of a key. Further observation revealed obtained a medication, closed the OTC medication storage closet door, did not lock the door, and returned to her medication cart. The surveyor remained within eyesight of the OTC medication storage closet until 12:59 p.m., at which time, S3Regional Quality Improvement Nurse approached the surveyor. In an interview on 11/13/2023 at 12:59 p.m., S3Regional Quality Improvement Nurse stated the OTC medication storage closet should be locked at all times, and he confirmed the door was unlocked when S3Regional Quality Improvement Nurse accompanied the surveyor to the OTC closet and found the door to be unlocked. S3Regional Quality Improvement Nurse confirmed there were 57 different OTC medications stored in the unlocked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to have accurate and complete documentation for oral care and bath care 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: Resident #1: Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed, in part, assessments of Brief Interview for Mental Status (BIMS) was a 3, which was severely impaired cognition. Review of Functional Status revealed personal hygiene and bathing required one person physical assist. Review of Resident #1's Personal Hygiene Roster revealed, in part, from 07/09/2023 to 07/20/2023 there was no documentation of oral care being provided twice a day. Review of the Bath Day Roster revealed, in part, from 08/20/2023 to 08/28/2023 and from 09/14/2023 to 09/18/2023 revealed no documentation of a bath. In an interview on 09/20/2023 at 10:40 a.m., S1Director of Nursing (DON) confirmed for Resident #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to administer a resident's medication as ordered. This deficient practice was identified for 1 (Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for medication administration. Findings: Review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of, in part, History of Stroke, Hypertension, and Diabetes Mellitus Type 2. Review of Resident #2's July 2023's Physician's Orders revealed, in part, an order for Ozempic (diabetic medication) 1 milligrams (mg) Sub Q (Subcutaneous) injection every Tuesday with a start date of 07/11/2023. Review of Resident #2's August 2023's Physician's Orders revealed, in part, an order for Ozempic 2 mg Sub Q injection every Tuesday. Review of Resident #2's September 2023's Physician's Orders revealed, in part, an order for Ozempic 2 mg Sub Q injection every Tuesday. Review of Resident #2's July 2023…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure that a resident received an assistive device to maintain vision abilities for 1 (Resident #2) of 5 ( Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents. FINDINGS: Review of Resident #2's diagnosis revealed, in part, a history of cataracts (a cloudy area in the lens of the eye that leads to decreased vision) and Diabetes. Review of Resident #2's MDS (Minimum Data Sheet) with ARD (Assessment Reference Data) dated 06/28/2023 revealed, in part, Section B (Hearing Speech, Vision )- corrective lenses; and Section C (Cognition) - BIMS (Brief Interview for Mental Status) Score of 15 which indicated Resident #2 was cognitively intact. Review of progress notes dated 02/09/2023 revealed, in part, Resident #2 had surgery to her left eye. Review of progress note dated 04/06/2023 revealed, in part, Resident #2 had surgery to her right eye. Review of the physician's post-operative cataract surgery visit note…

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.