Cypress at Lake Providence

Based on observation and interview, the facility failed to ensure that required dementia management and abuse prevention training was completed for 2 (S11Certified Nursing Assistant [CNA], S12CNA) of 5 (S8CNA, S9CNA, S10CNA, S11CNA, S12CNA) personnel records reviewed. Additionally, the facility failed to ensure that competencies and skills training was provided for 4 (S8CNA, S9CNA, S10CNA, S12CNA) of 5 (S8CNA, S9CNA, S10CNA, S11CNA, S12CNA) personnel records reviewed. Findings: Review of S11CNA's personnel record revealed no documented evidence of required dementia management, abuse prevention training, or competencies and skills training. Review of S12CNA's personnel record revealed no documented evidence of required dementia management and abuse prevention training. Review of S8CNA's personnel record revealed no documented evidence of competencies and skills training. Review of S9CNA's personnel record revealed no documented evidence of competencies and skills training. Review of S10CNA's personnel record revealed no documented evidence of competencies and skills training. 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 record review and interview, the facility failed to ensure the rights of Residents to receive written notice, including the reason for the change, before the Resident's room in the facility is changed for 1 (#41) of 1 Residents reviewed for rights. Findings: Review of the facility's Resident Rights - Right to Share a Room with Person of Choice Policy dated 02/2023 revealed in part: Purpose: Clarify the Resident's rights regarding sharing a room with a roommate of choice. 4. When a Resident is being moved at the request of the facility, the Resident, or family and/or Resident representative receives an explanation in writing as to why the room change is required. Review of the medical record for Resident #41 revealed an admission date of 08/20/2020. Resident #41 had diagnoses including diabetes mellitus, chronic venous hypertension, pain, cognitive communication deficit, reduced mobility, lack of coordination, hypertension, lymphedema, depression and obesity. Review of the Quarterly 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 record review and interview, the facility failed to ensure a Resident with a facility initiated discharge with Medicare Part A skilled service with days remaining was provided with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage from Centers for Medicare and Medicaid Services CMS-10055 and Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for 1 (#16) of 3 (#8, #16, #322) Residents reviewed for termination of Medicare Part A services. Findings: Record review revealed Resident #16's Medicare Part A skilled services episode start date was 01/05/2025. The last covered day of Part A services was 02/03/2025. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. Resident #16 remained in the facility. Further review revealed no documented evidence Resident #16 was provided CMS-10055 and CMS-10123 prior to being discharged from Medicare Part A Services. On 05/20/2025 at 11:02 a.m. an interview with S14Clinical Reimbursement Specialist confirmed she was not able to locate the completed forms CMS-10055 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.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 3 (#35, #41 and #63) of 8 (#15, #20, #35, #41, #52, #61, #63, #321) Residents reviewed for environment. Findings: Resident #41 On 05/19/2025 at 9:47 a.m., and 05/21/2025 at 8:30 a.m., observations of Resident #41's room revealed the air/heating unit had grime and debris on the air vents. Resident #63 On 05/19/2025 at 8:45 a.m., and 05/20/2025 at 11:00 a.m., observations of Resident #63's room revealed the air/heating unit had grime and dust on the air vents. On 05/21/2025 at 8:40 a.m. an interview with S2Director of Nursing (DON) confirmed the air/heating units in Residents #41 and #63's room needed to be cleaned. On 05/21/2025 at 8:30 a.m. an interview with S16Maintenance Director confirmed the air/heating units in Residents #41 and #63's room needed to be cleaned. Resident #35 Observations of Resident #35's room on 05/19/2025 at 7:43 a.m. and 05/21/2025 at 8:40 a.m. revealed numerous dead flying insects noted stuck to the bathroom walls, heavy lint buildup…

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 resident's drug regimen was free from unnecessary medications by failing to monitor for side effects and behaviors of psychotropic medications for 1 (#61) of 5 (#3, #32, #36, #61, and #63) residents reviewed for unnecessary medications. Findings: Review of Resident #61's record revealed an admission date of 08/08/2024 with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, and chronic kidney disease. Review of Resident #61's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed Resident #61 required assistance with activities of daily living.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to implement the plan of care for 2 (#13, #62) of 37 total sampled residents. The facility failed to: 1. place a smoking apron on Resident #13 while smoking as stated in the care plan and 2. place a fall mat by Resident #62's bedside as stated in the care plan. Findings: Review of the Physical Environment Facility with Independent and Supervised Smokers revised date 03/2019 revealed in part: Purpose: To provide a safe environment for residents. 2. The Facility will furnish the designated smoking area with a fire extinguisher and proper receptacle for extinguishing smoking materials. Smoking blankets or aprons will be furnished for Residents who are assessed to require a smoking blanket or apron. Resident #13 Review of the medical record for Resident #13 revealed diagnoses including heart disease, chronic obstructive pulmonary disease (COPD), depressive disorder, diabetes mellitus, paranoid schizophrenia, muscle wasting, wasting, cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure Residents who required respiratory care received the care and services consistent with professional standards by failing to properly store nebulizer mouth pieces and post oxygen use signage for 3 (#27, #15, #171) of 3 Residents reviewed for respiratory care. Findings: Resident #15 Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included diabetes and shortness of breath. Review of the current physician orders revealed Resident #15 was to receive Ipratropium/Albuterol, 1 application, inhaled orally four times a day for shortness of breath. On 05/19/2025 at 9:25 a.m., observation of the nebulizer mouth piece for Resident #15 was on a bedside dresser open to the air and not contained in a bag. Observation on 05/20/2025 at 7:45 a.m., the nebulizer mouth piece for Resident #15 was on his bed and not contained in a bag. On 05/20/2025 at 10:45 a.m., interview with S2Director…

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, record reviews and interviews, the facility failed to ensure it provided pharmaceutical services to meet the needs of the Residents by failing to have medications available for administration for 2 (#33, #8) of 3 (#33, #8, #30) Residents observed for a medication pass. Findings: Resident #33 On 05/19/2025 at 7:35 a.m., a medication pass was observed for Resident #33 with S3Licensed Practical Nurse (LPN). During the medication pass, S3LPN reported Vitamin D-2 400 units was not on the cart. Review of the physician's orders revealed Resident #33 was to receive Vitamin D-2 400 units daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. On 05/19/2025 at 12:50 p.m. observation of the medication room revealed Resident #33's Vitamin D-2 was not in the medication room. On 05/19/2025 at 1:00 p.m., interview with S2Director of Nursing (DON) confirmed Resident #33's Vitamin D-2 was not available in the facility for administration. Resident #8 On 05/19/2025 at 7:40 a.m., a medication pass was observed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for edema while resident was on a diuretic for 1 (#61) of 5 (#3, #32, #36, #61, and #63) residents reviewed for unnecessary medications. Findings: Review of Resident #61's record revealed an admission date of 08/08/2024 with diagnoses including chronic obstructive pulmonary disease, acute/chronic combined systolic and diastolic heart failure, acute kidney failure, unspecified dementia unspecified severity with other behavioral disturbance, cellulitis, hypokalemia, cocaine abuse, hypertension, hyperlipidemia, myocardial infarction, chronic kidney disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review of the MDS revealed resident required assistance with activities of daily living. Review of the May 2025…

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, interview, and record reviews, the facility failed to ensure it did not have a medication error rate of 5 percent or greater by having 2 errors in 27 opportunities resulting in a medication error rate of 7%. Findings: Resident #33 On 05/19/2025 at 7:35 a.m., a medication pass was observed for Resident #33 with S3Licensed Practical Nurse (LPN). During the medication pass, S3LPN reported Vitamin D-2 400 units was not on the cart. Review of the physician's orders revealed Resident #33 was to receive Vitamin D-2 400 units daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for administration. This resulted in an error by omission. Resident #8 On 05/19/2025 at 7:40 a.m., a medication pass was observed for Resident #8 with S3LPN. During the medication pass, S3LPN reported Farxiga 10 milligrams (mg) was not on the cart. Review of the physician's orders revealed Resident #8 was to receive Farxiga 10 mg daily. On 05/19/2025 at 9:10 a.m., S3LPN reported that the medication was not available in the facility for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored properly in a locked compartment by leaving medication at resident's bedside for 2 (#55, #64) of 2 (#55, #64) residents reviewed for medication storage. Findings: Review of the facility Pharmacy Services Medication Administration policy dated (03/2023) revealed the following: 2. Medications will be prepared and administered in accordance with: a. Prescriber's order 15. Medications will be administered within (1) hour before or after the scheduled administration time. Resident #64 Review of Resident #64's medical record revealed an admit date of 01/14/2025 and diagnoses which include in part: depression, bipolar disorder, non-traumatic subarachnoid hemorrhage, cerebral infarction, hypertension, and hypothyroidism. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated…

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 have quarterly Quality Assessment and Assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s lack of documentation of QAA meetings being held since the previous annual survey. Findings: On 05/22/2025 at 2:40 p.m., an interview with S1Administrator revealed the facility was unable to locate documentation of any quarterly QAA meetings held since the prior annual survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure it maintained an infection control program designed to provide a sanitary environment by having staff store used tube feeding syringes improperly for 1 (#44) of 1 (#44) residents reviewed for tube feeding. Findings: Resident #44 Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction and dysphasia. Review of the physician orders revealed an order to crush crushable medications and to flush with 30 cubic centimeters (cc) of water before and after medications. On 05/20/2025 at 10:11 a.m., observation revealed the tip of the syringe used to administer medications was filled with an orange colored liquid and the plunger of the syringe was in the plunger. On 05/20/2025 at 10:45 a.m., interview with S2Director of Nursing (DON) revealed the syringe should have been rinsed and disassembled before being stored for later use.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to the State Survey Agency in accordance with State law for 2 (#1, #5) of 4 (#1, #3, #5, #6) residents investigated for possible abuse or neglect. The failed practice was evidenced by the facility failing to report: 1.) an injury of unknown source to the State Survey Agency within 2 hours of the incident which involved resident #1 and 2.) abuse to the administrator and State Survey Agency within 2 hours of an incident involving resident #5. Findings: Policy/Procedure Review of abuse policy with a revision date of 05/15/2023 revealed the following in part: Response to Allegations and Suspicions 1. Allegations may be verbal or in writing and will be reported to the administrator of the facility and other…

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 protect the resident's right to be free from verbal abuse by S6Certified Nursing Aide (CNA) for 1 (#5) of 3 (#1, #3, and #5) sampled residents reviewed for abuse. Findings: Review of the facility's Freedom from Abuse, Neglect, and Exploitation, revised 03/2023, revealed the following, in part: Purpose: To keep residents free from abuse, neglect, and corporal punishment of any kind by any person. Policy: The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. This protection extends to abuse by staff, consultants, contractors, volunteers, students, and visitors (collectively staff). Guidelines: 4. Staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents recieved the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management for 1 (#4) of 2 (#3, #4) sampled residents reviewed for pain management. Findings: Review of the record revealed an admission date of 05/03/2024 with diagnoses including paresthesia of skin, morbid obesity, bipolar disorder, hypertension, cellulitis of groin, lumbar radiculopathy, sleep apnea, aggressive behavior, open fracture of first lumbar vertebra, stenosis of lateral recess of lumbar spine, prolapsed lumbar intervertebral disc, and secondary kyphosis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of the April 2025 Physician's Orders revealed an order dated 02/27/2025 for Oxycodone-Acetaminophen oral tablet 10-325 milligrams (mg) give 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 interviews and record reviews, the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This deficient practice was identified for 1 (#7) of 9 (#1, #2, #3, #4, #5, #6, #7, #8, #9) residents reviewed for allegations of abuse. Findings: Review of the facility`s abuse policy with a revision date of 05/15/2023 revealed in part: Responsibilities of Facilities and covered individuals 2. Reporting responsibilities for reasonable suspicion of a crime in accordance with state law: d. assault and battery Response to Allegations and Suspicions 2. Report any reasonable suspicion of a crime to a resident that involves serious bodily injury immediately, but not later…

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 and record review, the facility failed to maintain an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 4 (#48, #60, #18, #38) of 4 (#48, #60, #18, #38) sampled residents and had the potential to affect all 82 residents that resided in the facility. Findings: Review of the facility's policy titled, Physical Environment Safe, Functional, Sanitary Environment dated March 2023 read in part . Purpose: To provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Guidelines: The facility will maintain an effective pest control program to control pests and rodents. Observations on all days of the survey (05/06/2024 - 05/08/2024) revealed there were multiple flies flying around throughout the facility, including the dining room, all resident hallways, and in common areas of the facility. On 05/07/2024 at 3:40 p.m. an observation revealed resident #48 was in his room in bed and there was a fly noted on the resident's sheet near his head. On 05/07/2024…

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.

Resident #186: On 05/07/2024 at 10:53 a.m. review of the record for resident #186 revealed an admit date of 04/22/2024. Further review of the record revealed no documentation of an advance directive indicating the resident's code status. On 05/08/2024 at 9:57 a.m. S2DON (Director of Nursing) was informed there was no documented evidence of resident #186's advance directive. S2DON revealed that social services usually obtains the residents' advance directive upon admit. On 05/08/2024 at 2:56 p.m. an interview with S19SSD revealed resident #186's advance directive was in the social folder in her office and was not available to staff. S19SSD said she is new and just started and is in the process of going through each resident's record and social folder. On 05/08/2024 at 6:00 p.m. interview with S2DON and S18Regional Director of Clinical confirmed resident # 186's advanced directive should have been obtained upon admit and entered into the resident's electronic record available for staff to review. Based on record reviews and interviews, the facility failed to ensure the residents' code…

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

Based on observation and interview the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#64, #74, #44, #83) of 4 ( #64, #74, #44, #83) residents' rooms observed with environmental concerns. Findings: Review of the facility's policy for Physical Environment dated March 2023 revealed in part: Purpose: To provide a safe, functional, sanitary and comforable environment for resident. Resident #44 Observations of resident #44's room on 05/06/2024 at 2:25 p.m. and on 05/07/2024 at 11:13 a.m. revealed a metal fluorescent light fixture, approximately 3.5 feet long by 5 inches wide by 5 inches deep, was only secured to the wall on the very left side of the light fixture and the light fixture was leaning down to the right. On 05/08/2024 at 4:35 p.m. an observation of resident #44's room with S1Administrator and S20Maintenance Supervisor revealed the metal fluorescent light fixture was only secured to the wall on the left side and was leaning down to the right. Interview with S1Administrator and S20Maintenance Supervisor confirmed the light fixture 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 observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene for 5 (#26, #44, #60, #64 and #71) of 5 (#26, #44, #60, #64 and #71) residents sampled for Activities of Daily Living. Findings: Resident #26 On 05/07/2024 at 4:02 p.m. record review for resident #26 revealed diagnoses in part of: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease (COPD), type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease, and congestive heart failure. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #26 had a Brief Interview of Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Review of the functional assessments…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 (#60) of 2 (#10 & #60) residents reviewed for positioning/mobility and 2 (#26 & #39) of 3 (#26, #39, & #83) residents reviewed for skin conditions. The facility failed to: 1) identify non-pressure related wounds to resident #26, 2) provide a right hand roll to resident #60 and 3) provide treatment to resident #83's scrotal wound. Findings: Resident #26 Record review for resident #26 revealed the resident was admitted on [DATE] with diagnoses in part of: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, type 2 diabetes, vascular dementia with behavioral disturbance, hypertension, end stage renal disease, and calciphylaxis wounds (known as calcific uremic arteriolopathy, it is characterized by painful skin lesions caused by cutaneous arteriolar calcification leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nurses had documentation of medications administered for 1 (#16) of 5 (#16, #26, #53, #61, and #64) residents reviewed for unnecessary medications. Findings: Review of the facility's Pharmacy Services Medication Administration Policy dated 03/2023 revealed: Purpose: To provide residents with safe, accurate medication administration. 2. Medications will be prepared and administered in accordance with: a. Prescriber's order; b. Manufacturer's specifications (not recommendations); c. Accepted professional standards and principles. Review of the medical record for resident #16 revealed diagnoses of major depressive disorder, intracranial injury without loss of consciousness, cervical root…

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

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services of 8 consecutive hours a day on 12/23/2023, 12/25/2023, 12/26/2023 and 12/30/2023. Findings: Review of the facility's Payroll Based Journal (PBJ) Data time sheets for the dates of 12/23/2023, 12/25/2023, 12/26/2023 and 12/30/2023 revealed that there was no staffing hours for the RN. There was no evidence the RN worked 8 consecutive hours on those dates. Review of the time sheets revealed no documented evidence a RN worked for 8 hours on the dates listed above. On 05/08/2024 at 8:20 a.m., an interview with S1Administrator revealed she was unable to find the documentation or time sheet to prove a RN worked for 8 hours on the dates listed above.

Based on record reviews and interviews, the pharmacist failed to report any irregularities to the attending physician and the facility's medical director and director of nursing for 3 (#26, #53, and #62) of 5 ( #16, #26, #53, #61, and #64) records reviewed for unnecessary medication review. Resident #26 On 05/07/2024 at 4:02 p.m. review of the record for resident #26 revealed, in part, the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease (ESRD), congestive heart failure (CHF), and left great toe amputation. Review of May 2024 physician orders revealed current orders for the following laboratory tests:: Chemistry 14, Glycated Hemoglobin (A1C) every 3 months due in July, October, January and April. Further lab orders revealed to have liver function test (LFT) every 6 months in July and January and for complete blood count (CBC),…

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 each resident's drug regimen must be free from unnecessary drugs for 3 ( #26, #53 and #64) of 5 (#16, #26, #53, #61 and #64) sampled residents reviewed for unnecessary medications. The facility failed to 1) perform edema checks for residents #53 and #64 while taking a diuretic, and 2) obtain labs as ordered for resident #26. Findings: Resident #26 On 05/07/2024 at 4:02 p.m. review of the record for resident #26 revealed in part the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, aphasia, dysphagia, chronic obstructive pulmonary disease, type 2 diabetes, anxiety disorder, vascular dementia with behavioral disturbance, hypertension, end stage renal disease (ESRD), congestive heart failure (CHF), and left great toe amputation. Review of May 2024 physician orders revealed current orders for the following laboratory tests:: Chemistry 14, Glycated Hemoglobin (A1C) every 3 months due in July, October, January and April. Further lab orders…

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, record review and interview the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety. This failed practice had the potential to affect all residents who receive meals from the kitchen. Findings: On 05/06/2024 at 8:28 a.m. observation of the kitchen environment with S11DM (Dietary Manager) revealed the front of ice machine was open exposing inside of machine and electrical components. Observation of the stand-up refrigerator revealed the temperature reading was 48 degrees Fahrenheit. Observation of the temperature logs hanging on the 3 refrigerators and the 2 freezers in the kitchen revealed there were no temperature logs maintained. Interview at that time with S11DM confirmed the temperature logs had not been maintained. Observation of the walk-in refrigerator revealed a temperature reading of 61 degrees Fahrenheit. Further observation revealed there were vegetables and multiple food items stored in the refrigerator. S11DM said they would have to take everything out of the refrigerator.…

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 it operated and provided services in compliance with Federal, State, and local laws by 1) not providing a sufficient number of nursing service personnel to provide nursing care to all residents, and 2) not ensuring residents received nursing care in accordance with resident care plans 24 hours per day for 2 (#38 & #39) of 2 (#38 & #39) sampled residents. Findings: The current Long Term Care Minimum Licesning Standards, statute 9823, A. states the nursing facility shall provide 2.35 hours of care per patient per day. Review of the Nursing/Ancillary Personnel Staffing Pattern Reporting Form dated 03/01/2024 through 05/04/2024 revealed the facility did not meet the required hours according to the State statue noted above. The staffing form showed the facility was short on the hours provided to the resdient census on 11 out of 65 days. On 05/08/2024 at 2:50 p.m., an interview with S1Administrator confirmed the facility did not meet the required…

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 inform each resident as soon as possible of changes in Medicare covered services as evidenced by the facility's failure to provide: 1.) the Form Centers for Medicare and Medicaid Services (CMS) 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage and Form CMS 10123 Notice of Medicare Non-Coverage as required for 1 resident (#84) and 2.) the Form CMS 10123 Notice of Medicare Non-Coverage as required for 1 resident (#236) of 3 (#57, #84, and #236) residents reviewed for Beneficiary Notification who required the notification. Findings: Resident #84 Review of the list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months completed by the facility revealed resident #84 was discharged from Medicare Part A Services on 04/04/2024 with benefit days remaining. Further review of the records revealed Form CMS-10055 and Form CMS-10123 had not been provided to resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately to the facility administration for 1 (#16) of 4 (#10, #16, #63 and #73) residents reviewed for abuse. Findings: Review of the facility's policy and procedure for Abuse with a revised date of 05/15/2023 revealed: Intent: To promote a safe environment for residents, visitors, and employees through prompt and appropriate response and follow up to abuse allegations and events. Review of the medical record for resident #16 revealed diagnoses of major depressive disorder, intracranial injury without loss of consciousness, cervical root disorder, insomnia, anoxic brain damage, delusional disorder, psychotic disorder with delusions due to known physiological condition, dementia with behavioral disturbance, impulse disorder, and anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #16 had severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to conduct a comprehensive assessment which included the resident's safe smoking assessment for 1 (#18) of 1 (#18) residents reviewed for smoking. Findings: Review of the facility policy and procedures for Physical Environment: Smoking - Supervised Smokers dated March 2023 revealed in part: Guidelines: Smoking assessments will be completed on admission, quarterly, with significant change of condition and as needed for residents who wish to smoke. Smoking assessment will include a return demonstration of ability to safely manage smoking paraphernalia. Review of resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. Review of resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. 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.

Based on record reviews and interview, the facility failed to ensure the State Adverse Actions Website checks were completed for Certified Nursing Assistants (CNA) monthly for 3 (S23CNA, S24CNA, and S25CNA) of 5 (S23CNA, S24CNA, S25CNA, S26CNA, and S27CNA) personnel files reviewed. Findings: Review of S23CNA's personnel file revealed a hire date of 12/08/2023. Further review of S23CNA's personnel file revealed there was a State Adverse Actions check on 05/03/2024. There was no documentation of monthly State Adverse Actions checks prior to 05/03/2024. Review of S24CNA's personnel file revealed a hire date of 08/28/2023. Further review of S24CNA's personnel file revealed there was a State Adverse Actions check on 05/03/2024. There was no documentation of monthly State Adverse Actions checks prior to 05/03/2024. Review of S25CNA's personnel file revealed a hire date of 02/05/2024. Further review of S25CNA's personnel file revealed there was a State Adverse Actions check on 05/03/2024. There was no documentation of monthly State Adverse Actions checks prior to 05/03/2024. An interview…

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

Based on observation and interview the facility failed to maintain all resident care equipment in safe operating condition for 2 (#26, #48) of 2 (#26, #48) residents observed with resident care equipment concerns. This failure had the potential to affect the 82 residents in the facility. Findings: Resident #48 Review of the record for resident #48 revealed in part the following diagnoses: traumatic subarachnoid hemorrhage, primary generalized osteoarthritis, generalized muscle weakness, unsteadiness on feet, other abnormalities of gait and mobility, other lack of coordination, and unspecified dementia. Further review of the record revealed resident #48 had a Brief Interview for Mental Status (BIMS) of 3 indicating he was severely cognitively impaired and required the use of a wheelchair for locomotion. On 05/07/2024 at 03:40 p.m. observation of resident #48's wheelchair revealed the rubber protective cover on the resident's right wheelchair handle was missing. On 05/08/2024 at 3:30 p.m. S22Licensed Practical Nurse (LPN) confirmed resident # 48's right wheelchair handle's rubber…

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 protect residents' right to be free from physical abuse by another resident for 7 (#1, #2, #3, #5, #6, #7, #10) of 10 (#1 - #10) sampled residents reviewed for abuse. The facility failed to protect residents #1, #2, #3, #5, #6, #7, and #10 from being physically abused. Findings: Review of the current facility's Abuse Prevention Policy revealed: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Resident #1 Review of the medical record for resident #1 revealed the resident was admitted on [DATE] with diagnoses including complete intestinal obstruction, colostomy, hypertension, reflux, and convulsions. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent with cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident receiving a psychotropic medication was monitored for effectiveness and side effects for 1 (#2) of 10 (#1 - #10) sampled residents. Findings: Review of the medical record for resident #2 revealed the resident was admitted on [DATE] with diagnoses including diabetes, heart failure, myocardial infarction, cognitive communication deficit, dementia with behavioral disturbances, alcohol dependence, hypertension and disorientation. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #2 was independent with transfers and ambulation. Review of the physician orders revealed orders dated 01/27/2024 for Rexulti 1 milligrams (mg) one tablet one time a day and Zoloft 50 mg one time a day. Review of the care plan revealed the resident used psychotropic medications. Further review revealed an approach to monitor for side effects 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 reviews and interviews the facility failed to implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health care and services that is appropriate and effective as determined by the facility assessment. The facility failed to ensure all staff (direct, indirect, and contract) were trained on the behavioral health care needs and services for all 80 residents residing in the facility. The facility failed to ensure the following staff received behavioral management health care training: 1) 1 staff providing direct care to the residents (S4Licensed Practical Nurse (LPN), 2) 4 (S6OccupationalTherapist (OT), S7PhysicalTherapistAssistant (PTA), S8CertifiedOccupationalTherapistAssistant (COTA), S9SpeechTherapist (ST)) and 3) 6 (S10LPN, S11Certified Nursing Assistant (CNA), S12LPN, S13CNA, S14LPN, S15CNA) contract staff. Findings: Review of the current facility assessment dated [DATE] revealed the facility had residents that have…

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 documented evidence that allegations of physical abuse were thoroughly investigated for 4 (#5, #6, #8, #9) of 10 (#1 - #10) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Policy with a revision date of 05/15/2023 revealed in part: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Investigation: 1. The facility Administrator/designee will conduct thorough investigations of alleged violations and report the findings to the State agency within 5 working days of the allegation. 2. The facility will immediately protect the resident from further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. This includes: d. Conducting interviews with other…

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

Based on record review and interviews the facility failed to inform the resident's responsible party of a resident's change in condition for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure responsible party was notified of Resident1's fall and emergency room visit. Resident1 was admitted to the facility 01/23/2020 with diagnoses that include but not limited to the following: Cerebral Palsy, anxiety disorder, anemia, major depressive disorder, epilepsy unspecified, Crohn's disease, and pain unspecified. Review of Resident #1's incident report dated 09/12/2023 at 9:10 p.m. revealed Resident #1 was found on floor beside bed by a CNA (Certified Nursing Assistant). Resident was assessed by S3LPN (Licensed Practical Nurse) and no apparent injury was noted. Resident denied hitting head. Resident complained of hurting all over. Resident reported she did not remember falling. Resident's vital signs were the following: tempurature 98.6, pulse 80, respirations 20, blood pressure 133/87, and pain scale 7. Physician was notified on 09/12/2023 at 9:23 p.m. 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 interview the facility failed to protect the resident's right to be free from physical and verbal abuse by S3 CNA (Certified Nursing Assistant), when she used profanity and cursed at the resident and overturned a tray full of his belongings into his lap. The incident involved 1 (#1) of 5 (#1-5) sampled residents reviewed for abuse. Findings: Review of the facility`s policy on abuse revealed the facility would provide protections for the health, welfare and rights of each resident to prevent resident abuse. The policy also called for the facility to establish coordination with the quality assurance and performance improvement (QAPI) program. Review of facility incident report revealed an incident on 08/03/2023 occurred between resident #1 and S3 CNA. The completed facility incident report substantiated that Resident #1 sustained physical and verbal abuse by S3 CNA. Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes, major…

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 that residents or the resident's responsible representative were provided written Advance Directive information for 3 (#12, #28, and #68) of 3 (#12, #28, and #68) residents reviewed for advance directives. Findings: Resident #12 Review of the Facility's Resident' Rights Regarding Treatment and Advance Directives revealed in part: Policy Explanation and Compliance Guidelines: On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate and advance directive. Review of the medical record revealed resident #12 was admitted to the facility on [DATE] with diagnoses including bariatric surgery, hypomagnesium, Parkinson's disease, obesity, anxiety, depression, hypertension, sleep apnea, peripheral vascular disease, bipolar, diabetes mellitus, reflux, hyperlipidemia, and overactive bladder. Review of resident #12's MDS (Minimum Data Set) dated 04/04/2023…

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.

Based on observation and interview the facility failed to maintain a safe, clean, comfortable and homelike environment by having a dirty whirlpool room, dirty resident bathrooms, not having paper towels or soap available in resident bathrooms, and by having large holes in resident bathroom wall. Findings: On 05/21/2023 at 08:45 a.m. observation of room (a) revealed: Shower stall had a dirty brief lying on the floor, dirty towel and dirty washcloth lying on the floor. On the floor next to the whirlpool tub was a dirty towel. Observation of the bathroom area in the whirlpool room revealed the tank cover was missing to the toilet and there was mold in the toilet. Further observation of the bathroom revealed there was a broken toilet seat in the trash can. Observation of the floor by the entrance and exit door to the 100 hall whirlpool room revealed there was a used glove on the floor by the door, and a used cigarette butt on floor by door. Interview at the same time with S3 WC (Wound Care Nurse) revealed they don't do showers on Sundays, she further confirmed all of the observations…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to provide care and treatment in accordance with professional standards for 2 (#12, 32) of 3 (#12, 32, 59) residents reviewed for pressure ulcers. The failed practice was evidenced by the facility having: 1) no record of weekly RN (Registered Nurse) wound assessments for Residents #12 and #32 and, 2) no record of weekend wound care provided on Saturdays and Sundays in April and May 2023 for Resident #12 and #32. Resident #12 Review of the medical record revealed resident #12 was admitted to the facility on [DATE] with diagnoses including bariatric surgery, hypomagnesium, Parkinson's disease, obesity, anxiety, depression, hypertension, peripheral vascular disease, bipolar, diabetes mellitus, hyperlipidemia, and overactive bladder. Review of resident #12's MDS (Minimum Data Set) dated 04/04/2023 revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating independent cognition for daily decision making. Further review revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents. The facility failed to have documented evidence of the wanderguards being monitored for proper placement and functioning for 2 (#9 and #68) of 2 (#9 and #68) residents reviewed for elopement. Findings: Review of the Facility's Elopement Prevention System policy revealed in part: Policy Interpretation and Implementation 6. Wanderguard should be checked for placement every shift, to monitor for resident removing device. 7. Wanderguard should be checked for functioning q (every) day. Resident #9 Review of the medical record for resident #9 revealed an admission date of 01/16/2008 with diagnoses including cognitive communication deficit, pain, schizophrenia, abnormal gait, lack of coordination, depressive disorder, delusional disorder, bipolar disorder and psychosis. Review of the care plan dated 04/12/2023 revealed the resident was at risk for elopement and 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 Resident #68 Resident #68 was admitted on [DATE] with diagnoses including unspecified psychosis, dementia, anxiety, anemia, hypertension, chronic pain, metabolic encephalopathy, unspecified convulsions, Alzheimer's disease, other nontraumatic intracerebral hemorrhage, and depression. Review of resident #68's May 2023 Physician's Orders revealed an order dated 02/27/2023 for Klonopin 0.25 mg (milligrams) tablet administer 1 tablet po (by mouth) at noon and administer Klonopin 0.5 mg 1 tablet po at bedtime. Review of resident #68's April 2023 and May 2023 MAR (Medication Administration Record) revealed no documentation of monitoring side effects and behaviors for resident #68 while taking antianxiety medication (Klonopin). Review of the Pharmacy Consultant Reports for resident #68 from January 2023- April 2023 revealed the pharmacy consultant failed to identify that facility was not monitoring for side effects and behaviors of antianxiety medication while resident was taking Klonopin. An interview on 05/23/2023 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that each resident was free from unnecessary medication use for 1 (#68) of 5 (#13, #32, #38, #68, and #72) 5 residents reviewed for unnecessary medications. The facility failed to ensure resident #68 was monitored for side effects and behaviors while on an antianxiety medication. Findings: Resident #68 was admitted on [DATE] with diagnoses including unspecified psychosis, dementia, anxiety, anemia, hypertension, chronic pain, metabolic encephalopathy, unspecified convulsions, Alzheimer's disease, other nontraumatic intracerebral hemorrhage, and depression. Review of resident #68's May 2023 Physician's Orders revealed an order dated 02/27/2023 for Klonopin 0.25 mg (milligrams) tablet administer 1 tablet po (by mouth) at noon and administer Klonopin 0.5 mg 1 tablet po at bedtime. Review of resident #68's April 2023 and May 2023 MAR (Medication Administration Record) revealed no documentation of monitoring side effects and behaviors for resident…

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

Based on interview the facility failed to maintain an effective QAPI (Quality Assurance Performance Improvement) system to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators. Findings: On 05/23/2023 at 6:15 p.m. a request was made to review the facility QAPI (Quality Assurance Performance Improvement) plan and documentation of the implementation of the QAPI. At that time, S1 Administrator revealed he had not done any QAPI for the past year or for the identified deficiencies cited on the annual survey. S1 Administrator said the only thing he had was the quarterly QA (Quality Assurance) committee sign in sheets. He said he did not even have any minutes from the quarterly QA meetings.

Based on interview the facility failed to coordinate and evaluate activities under the QAPI (Quality Assurance Performance Improvement) program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. Findings: On 05/23/2023 at 5:32 p.m. an interview with S1 Administrator revealed he only had sign in sheets for the QA (Quality Assurance) meetings and did not have any meeting minutes. S1 Administrator also confirmed that he did not have any items or problems that identified the facility was in the process of monitoring.

Based on record review and interview the facility failed to notify the resident representative when a resident had a fall for 2 (#13, #63) of 3 (#13, #63, #65) residents with falls. Findings: Resident #13 Review of the medical record revealed resident #13 had falls on 01/26/2023, 02/16/2023, 03/26/2023, and 04/07/2023. Review of incident and accident report for resident #13 dated 03/26/2023 revealed the resident was reaching for items and fell onto the floor mat at the bedside. Further review of the incident and accident report and the nurses' notes revealed there was no documentation of notification to the resident representative after the fall. On 05/23/2023 at 9:31 a.m., an interview with S2 RN (Registered Nurse) Manager revealed there was no documentation of notification to the resident representative after the fall. Resident #63 Review of the incident and accident report for resident #63 dated 04/20/2023 at 12:46 p.m. revealed resident #63 was noted on the floor in front of his wheelchair in the dining room. Resident #63 stated he didn't know what he was doing, he was just 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 record review and interview the facility failed to provide written notice of transfer or hospitalization to the Ombudsman and resident`s representative for 2 (#20, and #79) of 2 (#20, and #79) residents reviewed for hospitalizations. Findings: Resident #20 Review of the record for resident #20 revealed admit date [DATE] with diagnosis of left knee osteoarthritis, hypertension, schizophrenia, depression, shortness of breath, abnormality of gait, cardiomegaly, aftercare following joint replacement surgery, cognitive communication deficit, insomnia, discitis lumbar region, spondylodiscitis in addition to moderate malnutrition, metabolic acidosis, epidural abscess, acute kidney injury, bipolar disorder, Alzheimer's disease, dementia, schizophrenia, and paraspinal abscess. Resident #20 had a BIMS (Brief Interview Mental Status) of 9 indicating Resident #20 had moderate mental impairment. Record review revealed resident #20 was sent to the emergency room on [DATE] due to an abdominal hernia and returned to…

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

Based on observation, interview and record review the facility failed to update the plan of care with appropriate approaches after a resident fall for 1 (#63) of 3 (#13, #63, #65) residents investigated for falls. Resident #63 On 05/21/2023 observation of resident #63's bed revealed there was a mattress on the floor. Interview with S2 RN (Registered Nurse) Manager revealed they put his mattress on the floor a long time ago because he was having behaviors such as pulling things off the tables, hitting the walls, and falling out of a regular bed onto the floor. Review of the incident and accident report for resident #63 dated 04/20/2023 revealed resident #63 had a fall in the dining room from his wheelchair. Review of the plan of care update approaches for the fall on 04/20/2023 revealed: 1/2 side rails put on bed, bed mattress placed on side of bed. During observations on 05/21/2023 and 05/22/2023 the resident's mattress was on the floor and not on a frame. On 05/22/2023 at 3:46 p.m., an interview with S8 MDS (Minimum Data Set) Coordinator revealed she gets the updated interventions…

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

Based on observation and interview the facility failed to provide the necessary services for a resident who was unable to carry out activities of daily living to maintain good personal hygiene for 1 (#36) of 1 (#36) residents reviewed for activities of daily living out of a sample of 18. The failed practice was made evident by the facility failing to provide clean bed linen for Resident #36. Findings On 05/21/2023 at 10:49 a.m., resident #36 reported she needed help making her bed and she needed clean linens. Resident #36 reported her bed sheets had not been changed in a week. The bed sheets were dingy and dirty and the draw sheet had a brown smear on the left hand side. Resident # 36 reported she did not have a left femur so she needed help changing her bed sheets. On 05/22/2023 at 1:33 p.m., resident #36 reported the bed sheets had not been changed. The bed sheets remained dingy and dirty. The draw sheet had a brown smear on the left hand side. On 05/23/2023 at 8:43 a.m., an observation and interview with S1 Administrator was conducted in resident #36's room. The bed sheets…

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 State Registry verifications were obtained prior to hire of 2 (S13 CNA (Certified Nursing Assistant) and S16 CNA) of 5 (S12 CNA, S13 CNA, S14 CNA, S15 CNA and S16 CNA) personnel files reviewed. Findings: Review of the facility's policy for Abuse, Neglect and Exploitation revealed in part: The components of the facility abuse prohibition plan are discussed herein: I. Screening A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 3. The facility will maintain documentation of proof that the screening occurred. Review of the personnel file for S13 CNA revealed a hire date of 04/19/2023. Further review of the personnel file revealed no documented evidence of a CNA state registry verification obtained. Review of the personnel file for S16 CNA revealed…

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

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (#38) of 5 (#13, 32, 38, 68, 72) residents reviewed for unnecessary medications. The facility failed to obtain a lipid panel and a liver function test for resident #38. Findings: Review of the medical record for resident #38 revealed diagnoses of diabetes mellitus, pain, mood disorder, heart disease, hyperlipidemia, hypertension, anxiety, insomnia, and depressive disorder. Review of the careplan revealed at risk for medication side effects and for the pharmacist consultant to review the medications every month, obtain lab work as ordered and report results. Review of the quarterly MDS (Minimum Data Set) dated 04/17/2023 revealed the resident had independent cognition for daily decision making and required supervision with set up help for activities of daily living. Review of the physician's orders revealed an order dated 01/09/2023 for Gemfibrozil 600 milligrams (cholesterol lowering medication) to be given every day. Further review of 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 observation and interviews the facility failed to ensure all drugs and biologicals are stored in locked compartments. The facility failed to ensure medications were not left unattended at the bedside for 1 (#12) of 1 (#12) residents. Findings: Review of the facility's Medication Storage policy revealed in part: Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering mediations or locked in the medication storage area/cart. Review of the medical record revealed resident #12 was admitted to the facility on [DATE] with diagnoses including bariatric surgery, hypomagnesium, Parkinson's disease, obesity, anxiety, depression, hypertension, peripheral vascular disease, bipolar, diabetes mellitus, hyperlipidemia, 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.