Maison de Lafayette

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure expired foods were removed from the kitchen.This had the potential to affect the 166 residents that consumed food from the kitchen.Findings:On 08/12/2025, a review of the facility's policy titled, Food Receiving and Storage, with a last revision date of 11/2022, revealed in part. Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage.4. Dry foods that are stored in bins are removed from original packaging, label and dated ( used by date). Such foods are rotated using a first in-first out system. On 08/11/2025 at 8:30 a.m., an initial tour of the kitchen was conducted with S7DD (Dietary Director). During the tour, S7DD confirmed: 15 cups of prune juice on the shelf in the dry storage room, had an expiration date of 07/03/2025; 4 loafs of bread had a best use by date of 07/24/2025; 22 loafs of bread had a best by date of 08/06/2025; and 10 loafs of bread with a best by…

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, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. This was evidenced by staff failing to perform appropriate hand hygiene during the provision of care and services, and failing to appropriately dispose of medical waste.Findings:A. Review of the facility’s Handwashing/Hand Hygiene Policy and Procedure, with a review date of October 2023, read in part: “…Indication for Hand Hygiene: 1. hand hygiene is indicated: e. after touching the resident's environment…” Review of a document titled “Medical Waste, Handling of”, with a revision date of 09/2010, which read in part: “Purpose – is to provide a definition of and guidelines for the safe and appropriate handling of medical waste…General Guidelines – 1. Medical waste includes human blood and blood soiled articles contaminated items (i.e., soiled dressings)… 4. Disposable items, which are contaminated with excretions or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide the resident or RP (Responsible Party) with written notice which specifies the duration of the bed-hold policy at the time of transfer to the hospital for 1 resident (#2) out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy titled Transfer or Discharge, Preparing a resident for , with a last revised date of December 2016, read in part: The business office is responsible for .b. Informing the resident, or his or her representative (sponsor) of our facility's readmission appeal rights, bed- holding policies , etc; . Review of the facility's Emergency Transfer Log for March 2025 revealed Resident #2 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the Emergency Transfer Log revealed the written notification to resident portion of the log was blank. On 05/14/2025 at 9:04 a.m., a review of the Emergency Transfer Log was conducted with S12SSD (Social Services Director).…

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 that the minimum data set (MDS) assessment accurately reflected the status of 1 (Resident #3) of 3 (Residents #1 - #3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to metabolic encephalopathy, cerebral infarction, memory deficit following cerebral infarction, and hemiplegia and hemiparesis following infarction affecting right dominant side. During an interview with Resident #3 on 05/13/2025 at 9:09 a.m., she stated that she experienced pain from her pressure ulcer but had been receiving pain medication which helps with the pain. Review of Resident #3 Physician Orders, revealed an order written on 06/20/2024 for Tylenol 8 hour oral tablet extended release 650 milligram (mg) (Acetaminophen) Give 1 tablet by mouth two times a day. Review of Resident #3's quarterly MDS with an assessment reference date (ARD) of 03/19/2025, revealed in Section J0100 that 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 provide ADL (Activities of Daily Living) care for dependent residents by failing to ensure rounding was conducted every two hours for 1 (#2) resident out of 3 (#1,#2,#3) sampled residents. Findings: Review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and had diagnoses including unspecified dementia and urinary tract infection. Review of section GG- Functional Abilities of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident could not walk ten feet and required substantial or maximal assistance for toileting. Review of section H- Bowel and Blader revealed the resident was always incontinent of bowel and bladder. On 05/12/2025 at 8:05 a.m., a phone interview was conducted with Resident #2's family member. She stated that the CNAs were not rounding on the resident every two hours, and her mom was left soiled for several hours before being changed. On 05/12/2025 at 3:50 p.m., a follow up…

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 a comprehensive Minimum Data Set (MDS) assessment was completed timely for 1 (#1) out of 7 (#1, #2, #3, #R1, #R2, #R3, #R4) total sampled residents. Findings: A request was made on 04/03/2025 to S3RA (Regional Administrator) for a policy regarding MDS completion and submission time frames. A policy was not provided by the time of survey exit. Review of CMS's (Centers for Medicare and Medicaid Services) RAI Version 3.0 Manual- RAI OBRA (Omnibus Budget Reconciliation Act)-required Assessment Summary revealed that Assessment Reference Date for an admission Comprehensive Assessment should be completed no later than the 14th calendar day of the resident's admission. Findings: Review of Resident #1's progress notes revealed he was hospitalized on [DATE] and readmitted on [DATE]. Further review of Resident #1's progress notes revealed he was hospitalized again on 02/27/2025 and readmitted on [DATE]. Review of Resident #1's electronic clinical record…

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

Based on interview and record reviews, the facility failed to develop a plan of care after a fall for 1 (Resident #3) of 7 (#1, #2, #3, #R1, #R2, #R3, #R4) sampled residents. Findings: Review of Resident #3's Discharge Minimum Data Set with an Assessment Reference Date of 03/02/2025 revealed, in part, section J had yes to falls. Review of Resident #3's Nursing Progress note dated 02/13/2025 8:11p.m., read in part .Summoned to resident's room by CNA (Certified Nursing Assistant), who was doing rounds. Upon entering resident's room he was noted lying in supine position on floor next to bed. When assisted to bed facial grimace noted, although he denied pain. Review of Resident #3's Nursing Progress note dated 02/18/2025 8:19 p.m., read in part . I the writer was in the middle of going to give resident his HS (Hours sleep) medications, when I noticed Resident #3 on floor laying down in supine position , head beneath bed. I called another Agency Nurse to assisted resident back into bed. Resident was cover in feces and he stated he was going to use bathroom Review of Resident #3's Plan 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 and interviews, the facility failed to treat each resident with respect, dignity and care by: 1. the facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over Residents #122, #138, and #563 while assisting them to eat, 2. the facility failed to ensure that a resident with a urinary catheter had a privacy bag or covering over their urine collection bag for dignity for Resident #128. Findings: On 06/12/2024, a review of the facility's policy titled Assistance with meals with a revision date of 01/17/2024, read in part, Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals. Resident # 122 Review of the Resident #122's electronic medical record revealed she was admitted to the facility 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 observations, record reviews, and interviews, the facility failed to ensure recipes for pureed, and chopped diets were followed. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 7 residents who received pureed or chopped meals. Findings: On 06/11/2024 at 11:09 a.m., an observation was made of S23DS (Dietary Supervisor) preparing the lunch meal pureed dessert of a chocolate peanut butter bar. S23DS was observed taking an unmeasured amount of chocolate peanut butter bars and placing them in the food processor and blended the bars. She then stopped blending the mixture and added an unmeasured amount of milk from 1- half pint of milk, then blended the mixture and shortly after stopped blending. S23DS was observed manually breaking the large pieces of bars that had not processed into smaller pieces and then blended the mixture. She then added an unmeasured amount of milk from a half pint of milk, blended mixture, stirred mixture and added unmeasured amount of milk from a second…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview the Facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 2 (#25, #35) out 5 (#2, #25, #35, #63, and #106) residents investigated for choices as evidence by: 1. failure to remove completed food trays from resident's room for Resident #25; 2. failure to support food choices for Resident #35 Findings: Resident #25 Review of Resident #25's medical record revealed an admit date of 11/14/2018 with diagnoses which included in part, Type 2 Diabetes Mellitus, Major Depressive Disorder, recurrent severe without psychotic features. Review of Resident #25's annual Minimum Data Sets (MDS) assessment dated [DATE] revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. On 06/10/2024 at 7:35 a.m., an observation was conducted in Resident #25's room, which revealed two food trays. 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 and interviews, the facility failed to provide a homelike environment for 2 (#1 and #123) out of 9 (#1, #15, #22, #35, #89, #102, #106, #123 and #142) residents investigated for environment, out of a total sample of 59 residents. Findings: On 06/11/2024, a review of the facility's policy titled Homelike Environment with a revision date of 04/03/2024, read in part, Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment . Resident #1 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Atherosclerotic Heart Disease of Native Coronary Artery without Angina and Recurrent Depressive Disorders. On 06/10/2024 at 7:30 a.m., an observation was conducted of resident #1's bathroom. The left wall of the bathroom was scratched up and peeling, and there were four holes observed in the sheetrock of the wall across from the shower. On 06/10/2024 at 7:34 a.m., an interview and observation of Resident #1's bathroom was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer residents with newly identified mental disorders to the appropriate state designated authority for review for 2 residents (#16, #125) out of 4 residents (#16, #65, #102, #125) investigated for PASARR (Pre admission Screening and Resident Review). Findings: Resident #16 Review of Resident #16's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Pyschotic Disorder with Hallucinations and Unspecified Psychosis. Further review of Resident #16's EHR revealed a Level I PASARR screening dated 06/30/2006 that was completed at another facility. A diagnosis of mental retardation or other related conditions was not documented on the screening. A Review of the Level II Evaluation summary and determination notice dated 07/28/2023 revealed in part: Type of Referral - Resident Review . Evaluation Placement Recommendations - The individual does not have a serious mental illness and 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 observation, record review and interview, the facility failed to follow the care plan for Resident #72 as evidenced by failing to: 1. ensure the resident did not have cigarettes in her possession, 2. follow physician's orders to remove the resident's dialysis dressing for 1 (#72) out of 59 sampled residents. Findings: 1. Resident #72. Review of the resident's clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Encephalopathy, End Stage Renal Disease, Anxiety Disorder, Altered Mental Status, and Tobacco Use. Review of Resident #72's medical record revealed in Section O of her MDS that she received dialysis. Further review revealed a physician's order written on 05/20/2024: remove dressings/bandaids over dialysis cannulation site every Mon (Monday), Wed (Wednesday), Fri (Friday) before dinner. On 06/10/2024 at 8:36 a.m., the resident was observed sitting up in wheelchair in the hallway of the hall she resided on. The resident was observed holding…

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 Resident # 89 On 06/12/2024 at 2:32 p.m., a review of the facility's policy titled Advanced Directives with a last reviewed date of 04/03/2024 read in part: 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Review of Resident #89's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction due to Embolism of Left Posterior Cerebral Artery and Malignant Neoplasm of Cervix Uteri. Review of Resident #89's May 2024 physician's orders revealed an order dated 05/29/2024 that read DNR (Do Not Resuscitate). Review of the resident's Lapost (Louisiana Physician Orders for Scope of Treatment) signed and dated 05/29/2024 read in part: Cardiovascular Resuscitation - DNR/Do not attempt resuscitation (allow natural death). Review of Resident #89's plan of care revealed a focus that read: I am a Full Code; I have signed Advanced Directive, with an initiation dated 06/06/2023.…

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, observations and interview, the facility failed to provide appropriate and sufficient services, treatment and care according to standards of professional practice for 1 (#33) of 1 (#33) residents that were reviewed for urinary catheter or UTI (urinary tract infection) out of a total of 59 sampled residents. The facility failed to ensure Resident #33's urinary catheter bag was below the level of the resident's bladder. Findings: Resident # 33 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Bladder Disorder, and Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms A review of Resident #33's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/17/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 15, suggesting his cognition was intact. On 06/10/2024 at 8:32 a.m., an observation was conducted of the resident in his wheelchair with his urinary catheter bag hung on the right side on the arm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding by failing to ensure insertion site of the gastric tube was cleansed as ordered for 1 (#54) resident investigated for tube feeding, out of a total sample of 59 residents Findings: Resident #54 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Malignant Neoplasm of Overlapping Sites of Oropharynx and Carcinoma In Situ of Skin of Right Upper Limb. The resident had a PEG (Percutaneous Endoscopic Gastrostomy) tube for enteral feeding. A review of Resident #54's MDS (Minimum Data Set) revealed in section K that he had weight loss and was receiving 26-50% tube feeding. A review of Resident #54's June 2024 physician's orders revealed an order written on 10/23/2023: Cleanse the PEG site with soap and water, pat dry, apply split gauze qd (every day). On 06/10/2024 at 6:58 a.m., an observation and interview were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure medications were stored properly and not available for resident's use as evidenced by eye drops left at the beside for 1 (#2) out of 59 final sampled residents. The deficient practice had the potential to affect a census of 164. Findings: Resident #2 was admitted on [DATE] with diagnoses that included in part, Preglaucoma, and Occipital neuralgia. Review of Resident #2's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/28/2024 revealed a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderate cognitive impairment. On 06/12/2024 at 12:34 p.m., review of the facilities Medication Administration policy and procedure with a review date of 04/03/2024 read in part Policy Interpretation and Implementation: 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have 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 and interviews, the facility failed to provide a nourishing, palatable, well-balanced diet to meet the nutritional needs of 2 (#51 and #92) of 26 (#s 4, 5, 6, 14, 15, 17, 18, 28, 35, 49, 50, 51, 54, 62, 64, 83, 92, 104, 112, 122, 134, 138, 140, 142, 153, and 563) residents investigated for dining. Findings: On 06/12/2024, a review of the facility's policy titled, Frequency of Meals, with a revision date of 04/03/2024, read in part, Policy Statement: Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes .Policy Interpretation and Implementation 1. The facility will serve at least three (3) meals or their equivalent daily at scheduled times .Breakfast 7:30 a.m. Resident #51: Review of Resident #51's electronic record revealed an admission date of 09/23/2019 with diagnoses that revealed in part, Acute Kidney Failure, Vitamin D Deficiency, Chronic Congestive Heart Failure, Hypomagnesemia, Celiac Disease, Hypokalemia, Anemia, Unspecified…

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, observations and record review, the facility failed to ensure there was enough dietary staff to provide residents' meals within 45 minutes of the facility's scheduled meal times for 57 residents who consumed meals from Kitchen 3. Findings: On 06/12/2024, a review of the facility's policy titled, Frequency of Meals, with a revision date of 04/03/2024, read in part, Policy Statement: Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes .Policy Interpretation and Implementation 1. The facility will serve at least three (3) meals or their equivalent daily at scheduled times .Breakfast 7:30 a.m., Lunch 11:30 a.m . On 06/10/2024 at 8:15 a.m., an interview was conducted with S23DS (Dietary Supervisor) stated the facility has one main kitchen (Kitchen 1) where all of food was prepared and two other kitchens (Kitchen 2 and Kitchen 3) used to distribute meals. On 06/10/2024 at 8:30 a.m., an interview was conducted with S11DM (Dietary Manager) stated S12Cook was responsible for Kitchen 3. On 06/10/2024 at 8:41 a.m., an…

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

Based on observations, interviews, and record review, the facility failed to ensure environmental staff possessed the necessary qualifications or competencies as evidenced by failing to notify nursing staff when Resident #93 was heard yelling for help. Findings: Review of S9Hsk's (Housekeeping) training revealed the following onboarding training was completed upon hire on 06/06/2024: Stop and Watch In service Form revealed, in part .Environmental and Dining Services Employees do not provide direct patient care, but may come in contact with patients or residents while performing their duties, for example, while cleaning a resident's room or serving a resident's meal .Employees may come in contact with residents, it is important for them to be aware of the types of behavior that could indicate a serious change in a resident's health .It is important that you immediately notify a member of the nursing staff. The facility may have a form for you to complete if you notice a change in a resident's behavior, but the important thing is that you report the change to nursing so they are aware…

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

Based on observation and interviews, the facility failed to protect confidential information for Resident #6 by failing to enable the computer's privacy screen during a treatment being administered to Resident #153. This deficient practice had the potential to affect a total census of 164. Findings: On 06/11/2024 a review of the facility's Policy and Procedure titled, Confidentiality of Information and Personal Privacy, with a revision date of October 2017 and review date of January 2024, read in part . Policy: Our facility will protect and safeguard resident confidentiality of all resident personal and medical records. Policy Interpretation and Implementation: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . 4. Access to resident personal and medical records will be limited to authorized staff . On 06/11/2024 at 10:12 a.m., an observation was made of an unattended treatment cart located outside of Resident #153's room with the computer opened and the screen was visible. Private medical information was visible 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 observation, record review, and interviews, the facility failed to ensure residents were free from unnecessary physical restraints for 1 (#3) resident out of 3 residents investigated. Findings: On 04/04/2024, a review of the facility's policy titled Use of Restraints with a last reviewed date of 01/04/2024 read in part .Restraints shall only be used to treat the resident's medical symptom and never for discipline or staff convenience, or for the prevention of fall. Review of Resident #3's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE] with diagnoses including Traumatic Subdural Hemorrhage, Major Depressive Disorder, and Dementia. Review of Resident #3's plan of care revealed the following problem and intervention: Resident is at risk for falls r/t (related to) muscle weakness, difficulty walking, SDH (Subdural Hemorrhage), seizure, dementia, TIA (Transient Ischemic Attack), falls, dizziness. Intervention implemented on 03/21/2024- Fall Intervention- I need my…

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

Based on observations, interviews and record reviews, the facility failed to: 1. provide sufficient numbers of CNAs (Certified Nursing Assistant) to perform services on a 24- hour basis per the facility's assessment, and 2. timely respond to call bells for Resident #1's and Resident 2's who required assistance with care and needs. This had the potential to effect 165 residents who reside in the facility. Findings: 1. Review of the facility's Facility Assessment Tool Staffing Plan revealed the following including: Staffing Plan 3.2 - Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Nurse Aides - 46 (43 Floor, 2 [NAME] Clerks, 1 Activities). Review of the facility's 24 Hour CNA Staffing Sheet revealed the following days when there was not enough CNAs for the resident census as per the facility's assessment: 02/29/2024 - Facility Census: 164 - 41 CNAs worked in the 24 hour period. 03/01/2024 - Facility Census: 165 - 38 CNAs…

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 interview, the facility failed to develop and implement a person centered care plan for 1 resident (#3) out of a final sample of 3 residents as evidenced by failing to ensure a resident had a comprehensive care plan that addressed her refusal for CPAP (Continuous Positive Airway Pressure). Findings: Review of Resident #3's electronic medical record revealed Resident #3 was admitted to the facility on [DATE] with a diagnosis including in part, Asthma, COPD (Chronic Obstructive Pulmonary Disease) with Chronic Bronchitis, SOB (Shortness of Breath) Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2024 revealed, in part, Resident #3's Brief Interview for Mental Status Score (BIMS) was a 15 which indicated Resident #15 was cognitively intact. Review of Resident #3's Plan of Comprehensive Care Plan revealed, in part, Resident #3 I have episodes of dyspnea with potential for impaired oxygen exchange related to Asthma, COPD with Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a dependent resident was provided incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Review of Resident #1's Electronic Medical Record (EMR) revealed, in part, Resident #1 had Hemiplegia (paralysis to one side of the body) and Hemiparalysis following a Cerebral Infarction (disruption in blood supply to a part of the brain causing tissue to die) affecting the left non-dominant side. Review of Resident #1's Quarterly Minimum Date Set (MDS) dated [DATE] revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. Further review revealed Resident #1 required substantial/maximal assist from staff for toileting hygiene, partial/moderate assistance from staff for personal hygiene, and was frequently incontinent of bowel and bladder. Review of Resident #1's plan of care revealed, in part, an intervention that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the nurse informed the physician and RP (Responsible Party) in a timely manner of a change in the resident's condition for 1 (#2) out of 3 (#1, #2, #3) sampled residents. Findings: Resident #2. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's Disease, Impulse Disorder, and Schizoaffective Disorder. Review of the resident's nursing note dated 5/30/2023 at 9:16 a.m. revealed, CNA (Certified Nursing Assistant) was prompted to go to a resident room due to resident hollering to find (resident #2) walking around in her room only in a shirt . There was no evidence the physician or RP was notified of the resident's behavior. Review of the resident's nursing note dated 7/27/2023 at 17:40 (5:40 p.m.) revealed, Resident continuously wanders in and out of other resident's rooms. He bothers them in the dining room when others are trying to eat. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 2 (#18, #70) of 2 residents investigated for PASARR in a final sample of 44 residents. Findings: Review of Resident #18's diagnosis list revealed on 09/06/2021 he was diagnosed with Unspecified Psychosis, and Psychotic Disorder with Hallucinations. Review of Resident #18's records revealed no evidence a Level II PASARR had been submitted to the appropriate state-designated authority. On 05/17/2023 at 1:07 p.m., an interview was conducted with S7SSD. She confirmed Resident #18 had a new diagnosis of Unspecified Psychosis, and Psychotic Disorder with Hallucinations on 09/06/2021. S7SSD confirmed no Level 1 PASARR was completed after the new diagnosisResident #70 was admitted to the facility on [DATE].…

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 interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences as evidenced by failing to monitor for the presence of pain for 2 (96, 112) of 3 (96, 112, 130) residents sampled for pain, of a total sample of 44 residents. Findings: Review of Resident #96's Care Plan read in part .Pain: Potential for r/t (related to) Arthritis, Depression, Gout, GERD (Gastro Esophageal Reflux Disease) Pain to right foot ankle, right great toe infection, Osteoporosis with old compression fracture, left side back pain. Review of Resident #96's May 2023 physician's revealed the following orders: - Bio freeze Gel 4% -apply to lower back topically at bedtime for pain. - Acetaminophen ER (Extra Strength) Tablet 650 milligrams - three times daily for pain. --Neurontin Capsule 300 mg - give one at bedtime for Diabetic…

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 staff interviews, the facility failed to accurately code the residents' Minimum Data Set (MDS) assessments for 1(#12) for resident's vision out of 44 sampled residents. This deficient practice had the potential to affect a census of 162. Findings: Resident #12 was admitted on [DATE] with diagnoses that included in part: Major Depressive Disorder, Bradycardia, and Legal Blindness. Resident #12's Annual MDS assessment dated [DATE] was reviewed. Review of Section B- Hearing, Speech, Vision Status, revealed the resident was coded as 0, indicating he had adequate vision. On 05/15/2023, at 10:30 a.m., an observation was conducted of Resident #12's room. There were two signs posted that read vision impaired. On 05/16/2023 at 3:41 p.m., an interview was conducted with S25MDS. She stated she was very familiar with Resident # 12, and he was blind. A review of section B of Resident #12's MDS was conducted with S25MDS. S25MDS confirmed that the resident's vision was coded as adequate and should…

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 activities were provided based on comprehensive assessment , care plan, and preferences for 1 (#153) resident out of 1 resident investigated for activities out of a final sample of 44 residents. This deficient practice had the potential to affect the 17 residents that resided on Hall A. Findings: Review of the facility's policy titled Group Programs and Activities Calendar read in part .1. Both large and small group activities are part of our activity programs. 2. The activities calendar states all activities available for the entire month .6. Smaller monthly activity calendars are placed in each resident room at a height and location that is accessible to the resident .8. Modifications, time changes, cancellations or substitutions are reflected on all large [NAME] calendars as soon as possible. Resident #153 was admitted to the facility on [DATE] with diagnoses including but not limited to: Major Depressive Disorder 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 record review and interviews the facility failed to schedule a vision examination for 1 (#130) of 2 (#12, #130) residents reviewed for Communication and Sensory from 44 sampled residents. Findings: Review of Resident #130's electronic record revealed he was admitted to the facility on [DATE] with diagnoses of Rheumatoid Arthritis, Dementia, Gout, Osteoarthritis, Myalgia, Major Depressive Disorder, Pain, Benign Prostatic Hyperplasia, Anemia, and Essential Hypertension. Review of Resident #130's Social Services quarterly notes read in part, 12/02/2022 Resident has impaired vision without the use of corrective lenses at this time. 03/06/2023 Resident has impaired vision without the use of corrective lenses at this time. Review of Resident #130's MDS (Minimum Data Set) quarterly assessment read in part, 12/07/2022 Section B1000 Vision. 1. Impaired-sees large print but not regular print in newspapers/books. 03/08/2023 Section B1000 Vision. 1. Impaired-sees large print but not regular print 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 observation, interview, and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration and health for 1 (#3) resident diagnosed with a Urinary Tract Infection, of 2 (#3, #117) residents sampled for hydration, of a total sample of 44 residents. Findings: A review of Resident #3's annual MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score as 13, indicating that she was cognitively intact. A review of Resident #3's care plan revealed she was at risk for dehydration, bladder and bowel incontinence, and altered elimination related to dysuria (painful or difficult urination). Further review of the resident's care plan revealed she had a history of Urinary Tract Infections. A review of Resident #3's orders revealed an order with a start date of 05/09/2023 from S24NP (Nurse Practitioner) for the antibiotic Macrobid 100 mg (milligrams), one tablet twice daily for 7 days for a UTI (Urinary Tract Infection). The Macrobid was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to provide necessary respiratory care consistent with professional standards of practice for 1 (#121) of 2 (#121, #144) residents investigated for respiratory care. This deficient practice was evidenced by staff failing to clean Resident #121's CPAP (Continuous Positive Airway Pressure) machine per the facility's policy. Findings: A review of the facility's policy and procedure titled CPAP/BiPAP (Bi-level Positive Airway Pressure) Support revealed, in part, .General Guidelines for cleaning . 2. These guidelines are for single-resident use cleaning .5. Humidifier: a. Use clean, distilled water only in the humidifier chamber. b. clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly . A review of Resident #121's record revealed he was admitted to the facility on [DATE] with pertinent diagnoses of Unspecified Asthma, Sleep Apnea and Morbid…

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 implement a process to ensure 100% of the facility's staff were fully vaccinated as evidenced by failing to provide documentation of COVID-19 vaccination status for 1 (S20CNA-Certified Nursing Assistant) out of 1 staff listed as temporary delay/new hire. This deficient practice had the potential to affect the 30 residents who resided on Hall B. Findings: Review of policy: Mandatory COVID-19 Vaccination Policy and Procedure read in part . New Hires: All new employees are required to comply with the vaccination requirements outlined in this policy as soon as practicable and as a condition of employment. The candidate shall have at a minimum the first dose in a vaccine series if applicable completed prior to working in the facility with 30 days to complete the series or have an approved exemption request. Review of the facility's COVID-19 Staff Vaccination Status for Providers form, provided by S22HR (Human Resources), revealed a list of 129 total staff. The form also listed 1 staff with temporary delay/new hire, 113 staff…

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 there was evidence that CNAs (Certified Nursing Assistants), which included agency or contracted CNAs, received in-service training regarding abuse/neglect/exploitation, resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs for 4 (S26CNA, S27CNA, S28CNA, S29CNA) out of 5 (S26CNA, S27CNA, S28CNA, S29CNA, S30CNA) CNA personnel records reviewed. Findings: Review of S26CNA's personnel record revealed that she was an agency CNA. There was no date of hire noted in the CNA's personnel record. Further review of the CNA's personnel record revealed that there was no evidence of training on abuse/neglect/exploitation, resident rights, dementia care, infection control, communication, behavioral health, and specific resident needs. Review of S27CNA's personnel record revealed that she was an agency CNA. There was no date of hire noted in the CNA's personnel record. Further review of the CNA's personnel record revealed that there was no evidence of training on 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.