Twin Oaks Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to ensure a resident with a new diagnosis of bipolar disorder (a mood disorder that can cause intense mood swings) was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #3) of 2 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for PASARR. Findings: Review of Resident #3's electronic medical record (EMR) revealed, in part, Resident #3 was admitted to the facility on [DATE] with a Level I PASARR which was approved for a temporary period from 01/22/2024 through 04/20/2024 for skilled therapies. Further review revealed Resident #3 received another Level I PASARR screening dated 04/21/2024 indicating Level II services were not required. Review of Resident #3's psychiatric assessment completed on 02/07/2025 revealed, in part, Resident #3 received a new diagnosis of bipolar disorder. Review of Resident #3's EMR revealed no documented evidence, 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 record reviews and interviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for neglect. Findings: Review of the facility's Policy for Prohibition of Abuse, Neglect and Misappropriation of Property revised on 08/05/2024 revealed, in part, the facility will have evidence of a thorough investigation of all alleged violations. Review of the facility's records revealed a report dated 08/21/2024 revealed, in part, in which the allegation of neglect was reported and investigated for Resident #1. Further review revealed Resident #1 was sent to the hospital due to a drop in blood pressure on 08/21/2024. In the emergency room Resident #1 was found to have gauze and an empty ketchup packet lodged in the back of his throat. Further review of the report revealed the lunch meal on 08/21/2024 included French fries served with ketchup. Further review revealed the camera footage was reviewed by the facility and the footage showed multiple…

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 provide nail care for 2 (Resident #28 and Resident #40) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) sampled residents investigated for activities of daily living (ADLs). Findings: Resident #28 Resident #28 was admitted to the facility on [DATE] with diagnoses of hemiplegia affecting the right side. Review of Resident #28's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/16/2024 revealed she had impairment on one side of her upper and lower extremities. Review of Resident #28's Care Plan revealed Resident #28 required assistance with ADLs with a goal to be kept clean, dry and well-groomed. Observation on 08/06/2024 at 2:20 p.m. revealed Resident #28's toe nails extended past the tips of her toes. Observation on 08/07/2024 at 9:40 a.m. with S13Certified Nursing Assistant (CNA) and S6MedRecords/CNA Supervisor revealed Resident #28's bilateral toe nails and bilateral…

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 develop a plan of care for 1 (Resident #3) of 1 resident (Resident #3) receiving respiratory care by nasal cannula. Findings: Observation on 08/05/2024 at 9:40 a.m. revealed Resident #3 received oxygen at 2 liters per minute (LPM) by nasal cannula. Review of Resident #3's Minimum Data Set (MDS) with an assessment reference date of 04/29/2024 revealed, in part, a brief interview mental status of 13 which indicated cognitively intact. Review of Resident #3's Physician Orders dated August 2024 revealed, in part, no orders for oxygen per nasal cannula. Review of Resident #3's Care Plan revealed, in part, most current target date listed for problems identified was dated 10/01/2024. Further review of the care plan revealed no plan of care was developed for oxygen care by nasal cannula. Observation on 08/06/2024 at 11:40 a.m. revealed Resident #3's received oxygen at 4 LPM per NC. In an interview on 08/06/2024 at 11:58 a.m., S10Licensed Practical Nurse (LPN) indicated Resident #3 received oxygen at 2 LPM by NC.…

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 the nursing staff signed a verification of an accurate medication count at the beginning and end of each shift for 2 [Medication Cart (a) and Medication Cart (b)] of 2 [Medication Cart (a) and Medication Cart (b)] Medication Carts (Med Cart) observed and reviewed for accurate dispensation of controlled medications. Findings: Review of the facility's undated Controlled Substances Policy revealed, in part, the nursing staff must count controlled drugs at the end of the shift with the nurse coming on duty and the nurse going off duty. Further review revealed the nurse coming on duty and the nurse going off duty must make the count together. Further review revealed the nursing staff must document and report any discrepancies to the Director of Nursing (DON) or designee immediately. Review of Med Cart (a)'s controlled substance binder dated 05/31/2024 to 08/07/2024 revealed, in part, no documentation of signatures of the nurse coming on duty and the nurse going off duty on the following dates and shifts: 06/03/2024 the…

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

Based on observation and interview, the facility failed to protect client confidentiality for 1 resident (Resident #8) of 32 sampled residents (Resident #1, Resident #3, Resident #8, Resident #11, Resident #15, Resident #25, Resident #21, Resident #24, Resident #28, Resident #29, Resident #40, Resident #43, Resident #47, Resident #53, Resident #54, Resident #56, Resident #57, Resident #60, Resident #6, Resident #67, Resident #68, Resident #70, Resident #73, Resident #78, Resident #80, Resident #88, Resident #86, Resident #87, Resident #89, Resident #340, Resident #34, and Resident #342). Findings: Observation on 08/06/2024 at 11:02 a.m. revealed Resident #8's closed exterior side of the door facing the hallway revealed written sign titled, Appointment Sheet. Further observation revealed, in part, Resident #8's written name with Tuesday, Thursday and Saturday goes to dialysis with a pick up time of 5:30 a.m. In an interview on 08/06/2024 at 12:15 p.m., S10Licensed Practical Nurse (LPN), after reading Resident #8's sign on exterior side of the door that was facing the hallway,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed correctly for 1 (Resident #56) of 1 (Resident #56) residents reviewed for PASARR. Findings: Resident #56 was admitted to the facility on [DATE] with diagnoses, in part, of Major Depressive Disorder, Anxiety, and Schizophrenia. Review of Resident #56's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/23/2024, revealed, in part, diagnosis of Major Depressive Disorder, Anxiety, and Schizophrenia. Further review revealed Resident #56 received antipsychotics on a daily basis. Review of Resident #56's record revealed a Level- 1 PASARR completed on 10/21/2021. Further review revealed Section 3: Mental Illness was marked yes. Further review revealed a referral was not made to appropriate state designated authority for Level II PASARR evaluation and determination. In an interview on 08/07/2024 at 2:05 p.m., S3Social Services indicated Resident #56's Level-…

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 a resident was referred for dental services for 1 (Resident #25) of 3 (Resident #25, Resident #68, and Resident #21) sampled residents reviewed for dental services. Findings: Review of Resident #25's medical record revealed, in part, Resident #25 was admitted on [DATE]. Review of Resident #25's care plan with a goal date of 08/21/2024 revealed, in part, the potential for dental issues. Further review revealed care plan approaches to include arranging for dental appointments and periodic dental visits. Review of Resident #25's records revealed, in part, no documented evidence, and the provider could not provide any documented evidence, Resident #25 was evaluated for dental services. Review of Facility's resident dental treatment schedule dated 08/19/2024 revealed, in part, Resident #25 was not listed on the schedule for dental services. Observation on 08/05/2024 at 9:57 a.m. revealed Resident #25 did not have any upper teeth.…

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 ensure: 1. Ensure clean items in the facility's laundry room were not kept in the contaminated laundry area, and 2. Ensure staff wore proper protective equipment and performed hand hygiene during incontinence care for 1 (Resident #24) of 6 (Resident #24, Resident #28, Resident #40, Resident #47, Resident #61, and Resident #78) residents investigated for activities of daily living. Findings: 1. Observation on 08/05/2024 at 9:15 a.m. revealed the facility's clean mop heads were hung on wall hooks directly over soiled linen barrels in the facility's contaminated laundry area. Observation on 08/06/2024 at 10:52 a.m. revealed 15 of the facility's clean mop heads were hung on wall hooks in the facility's contaminated laundry area. In an interview on 08/06/2024 at 10:52 a.m., S2Laundry Supervisor confirmed the facility's clean mop heads were stored on the wall of the contaminated area of the facility's laundry room. In an interview on 08/06/2024 at 10:53 a.m., S1Administrator confirmed the facility's clean mop…

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 an allegation of verbal and physical abuse was reported to the required state survey agency for 1 (Resident #1) of the 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's policy and procedure titled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property with a revision date of 09/26/2017 revealed, in part, all alleged violations and all substantiated incidents should be reported to the required state agency, and any employee who becomes aware of an allegation of abuse should report the incident to a supervisor, Director of Nursing, or Administrator immediately. Further review of the policy revealed the facility will report all allegations of abuse to the state agency. Review of Resident #1's closed medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses, in part, Alzheimer's disease, schizophrenia, depressive…

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 conduct a thorough investigation following an allegation of physical abuse for 1(Resident #1) of the 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's policy and procedure titled Policy for Prohibition of Abuse, Neglect and Misappropriation of Property with a revision date of 09/26/2017 revealed, in part, the facility will thoroughly investigate all alleged violations of abuse and take appropriate actions. Review of Resident #1's Physician's Emergency Certificate (PEC) dated 06/03/2024 revealed Resident #1 alleged claimed S1Administrator pushed her. Review of the police report document case with a disposition/completion date and time of 06/04/2024 at 1:41 p.m. revealed, in part, Resident #1 stated S1Administrator pushed her. There was no documented evidence, and the facility did not present any documented evidence Resident #1's allegation of abuse by S2Administrator was investigated. In an interview on 06/25/2024 at 1:42 p.m., S1Administrator stated…

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 training program for 1 (S1Administrator) of 6 (S1Administrator, S6Sunshine Aide, S7Social Services, S8Cerified Nursing Assistant [CNA], S9CNA, and S10CNA) sampled personnel files reviewed for training. Findings: Review of S1Administrator's Personnel File revealed a date of hire of 07/22/2015. Further review revealed, no documented evidence and the facility presented no documented evidence, S1Administrator received training on Quality Assurance and Performance Improvement (QAPI) program, behavioral health training, ethics training, and resident rights. In an interview on 06/27/2024 at 3:05 p.m., S2Regional Administrator indicated the facility did not have documented evidence S1Administrator had received trainings for QAPI, behavioral health, ethics, abuse, and resident rights.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from verbal and physical abuse by other residents. This deficient practice was identified for 6 (Resident #4, Resident #5, Resident #6, Resident #8, Resident #9, and Resident #10) of 10 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) reviewed for abuse. Findings: Resident #4 Review of facility documents related to an incident dated 03/17/2024 revealed, in part, Resident #3 struck Resident #4 in the face in the facility dining room. In an interview on 05/01/2024 at 10:30 a.m., S4Food and Nutrition Manager stated she witnessed Resident #3 approach Resident #4, who had his eyeglasses on and was sitting in his wheelchair. Resident #3 then stated that was her glasses. Resident #3 removed Resident #4's eyeglasses and pulled her hand back and struck Resident #4 in the face. In an interview on 05/02/2024 at 11:26 a.m., S1Administrator stated she reviewed the facility video tape 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.

Based on record review and interviews, the facility failed to ensure an allegation of resident-to-resident abuse was: 1. Reported to the State Survey Agency for 1 (Resident #10) of 10 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) sampled residents reviewed for abuse; and, 2. Reported timely to the State Survey Agency for 2 (Resident #6 and Resident #9) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) sampled residents reviewed for timeliness of reporting of abuse allegations. Findings: #1 Review of Resident #1's medical record reveal, in part, a nurse's note dated 04/01/2024 documenting Resident #1 verbally threatened Resident #10 by shouting I'm gonna kill you if you don't shut up! Review of Morning Leadership Meeting minutes dated 04/01/2024 revealed an incident of Resident #1 yelling at Resident #10 and had been discussed by the leadership team. In an interview on 05/01/2024 2:51 p.m., S1Administrator indicated 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 record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of verbal abuse between 2 (Resident #1 and Resident #10) of 10 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10) sampled residents investigated for abuse. Findings: Resident #1 was admitted on [DATE] with diagnoses which included fractured left femur, pressure ulcer of right heel, hyperlipidemia, hypertension, chronic kidney disease, type 2 diabetes, cerebral infarction, depression, left BKA, lack of coordination/muscle weakness, repeated falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 04/17/2024 revealed, in part, Resident #1's cognition was moderately impaired. Further review revealed Resident #1 did not have physical or verbal symptoms directed toward others. Resident #10 was admitted on [DATE] with diagnoses which included closed skull fracture,…

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 notify a resident's physician of a significant change of condition for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings: Review of the policy: Change in a Resident's Condition or Status, revealed in part, the following Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Review of Resident #1's record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, in part, Gastro-Esophageal Reflux with Esophagitis with Bleed and Gastrointestinal Hemorrhage unspecified. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/2023 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. Further review revealed Resident #1 needed extensive assistance by two…

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

Based on interviews, and record review, the facility failed to administer medications per a physician's order for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) resident's records reviewed. Findings: Resident #2 Review of Resident #2's December 2023's physician's orders revealed, in part, an order dated 12/11/2023 to administer Levofloxacin (a medication used to treat infections) 750 milligrams (mgs) daily for 14 days, was discontinued on 12/20/2023. Further reviewed revealed an order dated 12/21/2023 to administer Levofloxacin 750 mgs daily for 14 days, was discontinued on 12/22/2023. Further review revealed, an order dated 12/27/2023 to administer Clonidine (a medication used to treat high blood pressure) 0.1 mg as needed for blood pressure reading greater than 170/90. Review of Resident #2's December 2023 electronic medication administration record (eMAR) revealed, in part, Resident #2 was administered Levofloxacin 750 mg daily from 12/12/2023 to 12/22/2023 for a total of 11 days. Further review revealed Resident #2 had a blood pressure (B/P) 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.

Based on interviews and record review, the facility failed to have accurate orders and nursing notes for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) resident's records reviewed for accuracy. Findings: Review of Resident #3's January 2024 physician's orders revealed, in part, an order dated 01/03/2024 for Glucerna 1.5 calorie 10 milliliters (ml) per hour with goal of 55ml per hour. Further review revealed an order dated 01/03/2024 for Glucerna 1.5 calorie 20 milliliters ml per hour. Further review revealed an order dated 01/03/2024 for Glucerna 1.5 calorie 30 milliliters ml per hour. Further review revealed an order dated 01/03/2024 for Glucerna 1.5 calories 40 ml per hour. Review of Resident #3's progress notes dated 01/04/2024 at 5:31 a.m. for a late entry on 01/03/2023 at 7:00 a.m. revealed, in part, S3RN (Registered Nurse) received a clarification order from S6Nurse Practitioner (NP) to increase Resident #3's enteral feedings every 1-2 hours by 10 ml increments, or as tolerated, up to a goal of 55 ml per hour. Further review revealed S3RN increased the…

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

Based on observation and interviews, the facility failed to allow residents access to their personal funds for 1 (Resident #29) of 4 (Resident #4, Resident #29, Resident #44, and Resident #69) sampled residents investigated for personal funds. Findings: In an interview on 10/30/2023 at 10:34 a.m., Resident #29 stated she had money held in an account by the facility; however, she can only get her money at a certain time on Mondays through Fridays. Observation on 11/01/2023 at 10:45 a.m. of S3Business Office Manager's (BOM) office door revealed signage which revealed, Banking hours Monday - Friday 8:30 a.m. to 9:30 a.m. and 12:30 p.m. to 1:30 p.m. In an interview on 11/01/2023 at 10:50 a.m., S3BOM confirmed Resident #29 participated in the facility's resident trust fund. S3BOM stated approximately a month ago, S1Administrator implemented banking hours from 8:30 a.m. to 9:30 a.m. and 12:30 p.m. to 1:30 p.m. S1BOM further stated when she was not in the facility and on the weekends there was no system to ensure the residents could access money from their trust fund. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident's code status matched and was maintained throughout the clinical record for 1 (Resident #44) of 16 (Resident #4, Resident #5, Resident #6, Resident #13, Resident #18, Resident #19, Resident #25, Resident #29, Resident #38, Resident #44, Resident #53, Resident #57, Resident #58, Resident #59, Resident #69, and Resident #81) residents reviewed for code status. Findings: Review of Resident #44's medical record revealed, in part, Resident #44 was admitted to the facility on [DATE]. Review of Resident #44's [DATE] physician orders revealed, in part an order dated [DATE] the read Resident #44's code status was full code. Review of Resident #44's Louisiana Physician Orders for Scope of Treatment (LaPOST) dated [DATE] revealed, in part, Resident #44 desired to have a code status of do not resuscitate (DNR). Review of Resident #44's comprehensive care plan revealed, in part, Resident #44's code status was full code. Observation…

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 implement a resident's care plan and administer a resident's insulin per physician's order for 1 (Resident #11) of 5 (Resident #11, Resident #13, Resident #53, Resident #57, and Resident #58) sampled residents reviewed for unnecessary medications. Findings: Review of Resident #11's Comprehensive Care Plan revealed, in part, Resident #11 was care planned for the potential of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) related to Diabetes with an intervention to have insulin administered as ordered. Review of Resident #11's October 2023 Physician's Orders revealed, in part, an order dated 06/29/2023 for Novolog (a medication used to lower blood sugar levels) 100 units per milliliters (units/mL) subcutaneously (injection under the skin) sliding scale for a blood glucose of 0-60 milligrams/deciliter (mg/dL) administer 0 units and give orange juice or milk; for a blood glucose of 61-200 mg/dL administer 0 units; for a blood glucose of 201-250 mg/dL administer 2 units; for a blood glucose of 251-300…

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: 1. Ensure a resident with a history of falls received increased supervision to prevent further falls for 1 (Resident #59) of 2 (Resident #18 and Resident #59) sampled residents reviewed for falls; and 2. Ensure a resident with a known history of unsafe smoking in his room did not have smoking materials in his possession for 1 (Resident #25) of 6 (Resident #6 and Resident #25) sampled residents reviewed for safe smoking. Findings: 1. Review of Resident #59's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/2023 revealed, in part, Resident #59 had a Brief Interview for Mental Status score of 0, which indicated Resident #59 had a severe cognitive impairment. Review also revealed Resident #59 required maximal assist for transfers. Review of Resident #59's Fall Risk assessment dated [DATE] revealed, in part, Resident #59 was assessed as being at high risk for falls. Further review revealed Resident #59 had intermittent…

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: 1. Ensure a resident's physician's order for dialysis was accurate for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for dialysis services; and, 2. Maintain ongoing communication regarding a resident's condition with the dialysis facility for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for dialysis services. Findings: 1. Review of Resident #13's Dialysis Care Plan revealed, in part, an intervention for Resident #13 to attend dialysis per the physician's order. Review of Resident #13's October 2023 Physician's Order's revealed, in part, an order with a start date of 03/27/2023 for Resident #13 to attend dialysis on Tuesdays, Thursdays, and Saturdays at Dialysis Center A. In an interview on 11/02/2023 at 11:30 a.m., S8Licensed Practical Nurse (LPN) stated Resident #13 attended Dialysis Center B. S8LPN confirmed Resident #13's dialysis location in the October 2023 Physician's Order with a start date of 03/27/2023 was incorrect. In an interview on 11/02/2023 at 12:35 p.m.,…

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

Based on record review and interview, the facility failed to ensure side effect monitoring for the use of anticoagulant medication was completed for 1 (Resident #53) of 5 (Resident #11, Resident #13, Resident #53, Resident #57, and Resident #58) sampled residents reviewed for unnecessary medications. Findings: Review of Resident #53's Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/29/2023 revealed, in part, Resident #53 received anticoagulant medication (a medication to prevent blood clots) 7 days of the 7 day look back period. Review of Resident #53's physician's orders dated August 2023, September 2023, and October 2023 revealed, in part, an order with a start date of 06/28/2023 for Eliquis (an anticoagulant medication) 5 milligrams by mouth twice daily. There was no documented evidence and the facility did not present any documented evidence of a side effect monitoring for Resident #53's anticoagulant use. Review of Resident #53's Medication Administration Record (MAR) dated August 2023, September 2023, and October 2023 revealed, in part, no documented…

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: 1. Ensure the nurse performed hand hygiene during insulin (a medication used to lower blood sugar) administration for 3 (Resident #9, Resident #53, and Resident #286) of 3 (Resident #9, Resident #53, and Resident #286) residents observed for glucose monitoring and insulin administration; and 2. Ensure a Certified Nursing Assistant (CNA) performed hand hygiene while passing ice to 7 residents (Resident #1, Resident #8, Resident #26, Resident #50, Resident #66, Resident #67, and Resident #286) of 7 residents (Resident #1, Resident #8, Resident #26, Resident #50, Resident #66, Resident #67, and Resident #286) observed for hand hygiene while passing ice. Findings: 1. Review of the facility's Hand Hygiene Policy revealed, in part, hand hygiene should be performed before and after preparing or handling medications. Further review revealed staff were to perform hand hygiene before applying non-sterile gloves. Observation on 10/31/2023 at 11:55 a.m. revealed S5Treatment Nurse entered Resident #286's room, applied…

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

Based on record reviews, observations, and interviews, the facility failed to ensure a resident had access to the air conditioner thermostat controls in order to set the temperature in her room per her preference for 1 (Resident #13) of 1 (Resident #13) sampled residents investigated for environment. Findings: Review of Resident #13's face sheet revealed, in part, Resident #13 had diagnoses including end stage renal disease and anemia. Review of Resident #13's Minimum Data Set with an Assessment Reference Date of 09/29/2023 revealed, in part, Resident #13 had a Brief Interview for Mental Status score of 10, which indicated Resident #13 was moderately, cognitively intact. Further review revealed Resident #13 weighed 85 pounds. Review of Resident #13's Resident [NAME] of Rights revealed, in part, each resident has the right to reside and receive services in the facility with reasonable accommodations of an individual's needs and preferences, except when the health or safety of the individual or other residents would be endangered. Observation on 10/30/2023 at 10:10 a.m. 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 reviews and interviews, the facility failed ensure necessary supervision was provided to ensure a resident did not verbally and physically abuse another resident for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for abuse. Findings: Review of the facility's policy for Abuse, Neglect, and Misappropriation of Property revealed, in part, residents had the right to be free from abuse. Review of the facility's Incident Report dated 09/05/2023 at 11:00 a.m. revealed, in part, Resident #19 hit another resident. Review of Resident #19's care plan for Resident #19 exhibiting behaviors and hit another resident with a target date of 12/14/2023 revealed, in part, Resident #19 was told to keep hands to self. In an interview on 11/01/2023 at 2:32 p.m., S11Dietary Manager stated on 09/05/2023 Resident #15 ambulated in her wheelchair next to Resident #19, who was sitting in her gerichair in the dining room. Resident #19 attempted to hit Resident #15 in the back, missed, then swung again and hit Resident #15 in the back.S11Dietary Manager further stated Resident #19…

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

Based on record review and interviews, the facility failed to ensure an allegation of physical abuse and verbal abuse was reported to the state survey agency within 2 hours of the allegation for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for abuse. Findings: Review of the facility's policy for Abuse, Neglect, and Misappropriation of Property revealed, in part, all alleged violations involving abuse should be reported immediately to the administrator of the facility and to other officials in accordance with state law. Review of the facility Incident Report dated 09/05/2023 revealed, in part, Resident #19 hit another resident in the back. Review of Resident #19's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/01/2023 revealed, in part, Resident #19 had a Brief Interview for Mental Status score of 10, which indicated Resident #19 had moderate cognitive impairment. In an interview on 11/01/2023 at 2:32 p.m., S11Dietary Manager stated on 09/05/2023 Resident #15 ambulated in her wheelchair next to Resident #19, who was sitting in her gerichair in…

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

Based on record review and interview, failed to ensure an allegation of resident to resident physical abuse was thoroughly investigated for 1 (Resident #19) of 1 (Resident #19) sampled residents reviewed for abuse. Findings: Review of the facility's policy for Abuse, Neglect, and Misappropriation of Property revealed, in part, the facility should have had evidence of thoroughly investigating an incident of alleged physical abuse. Review of the facility's Incident Report dated 09/05/2023 at 11:00 a.m. revealed, in part, Resident #19 hit another resident. Review of Resident #19's care plan for Resident #19 exhibiting behaviors and hit another resident with a target date of 12/14/2023 revealed, in part, Resident #19 was told to keep hands to self. There was no documented evidence and the facility did not present any documented evidence that an investigation was conducted after the above mentioned incident. In an interview on 11/01/2023 at 2:32 p.m., S11Dietary Manager stated on 09/05/2023 Resident #15 ambulating in her wheelchair next to Resident #19, who was sitting in her gerichair…

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, interview, and observation, the facility failed to ensure only licensed personnel administered medications for 1 (Resident #43) of 1 (Resident #43) sampled residents observed for medicated cream administration in a total sample of 18. Findings: Review of Resident #43's medical record revealed, in part, Resident #43 was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of the buttock. In an interview on 10/31/2023 at 9:27 a.m., S9Certified Nursing Assistant (CNA) stated she used cream on Resident #43's buttocks as needed. S9CNA presented the surveyor with two tubes of creams she used on Resident #43 buttocks. Observation revealed a tube of Miconazole Nitrate 2% cream (an antifungal ointment) and a tube of silicone cream (a moisture barrier). S9CNA further stated she used both creams and asked the wound care nurse which cream should be used. In an interview on 11/02/2023 at 9:37 a.m., S5Treatment Nurse stated the CNAs were allowed to apply silicone cream as a moisture…

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, observations, and interviews the facility failed to ensure: 1. Maintain accurate reconciliation records of controlled medication for 2 (Medication Cart b and Medication Cart c) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) medication carts observed; 2. Maintain accurate reconciliation records of controlled medication for 5 (Resident #3, Resident #5, Resident #R6, Resident #R7, and Resident #R8) residents who received controlled medication; and 3. Medication records were accurately documented for 3 (Resident #3, Resident #4, and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: 1. Observation on 08/22/2023 at 1:05 p.m. revealed Medication Cart c did not have two signatures for the Schedule Drug Count on 08/01/2023 7:00 a.m. to 3:00 p.m. shift, 3:00 p.m. to 11:00 p.m. shift, and 11:00 to 7:00 p.m. shift; on 08/02/2023 7:00 a.m. to 3:00 p.m. shift; 08/03/2023 7:00 a.m. to 3:00 p.m. shift and 3:00 p.m. to 11:00 p.m. shift; on 08/05/2023 11:00 p.m. to 7:00 a.m. shift; 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 observation and interview the facility failed to ensure: 1. Resident's medications were not left unattended on top of the medication cart for 1 (Medication Cart a) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) medication carts observed, and 2. Medication Carts were locked when unattended for 1 (Medication Cart b) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) medication carts observed. Findings: 1. Observation on 08/22/2023 at 8:50 a.m. revealed Fluoxetine (medication to treat depression) 20 milligram (mg) capsule card, Divaloproex Sodium (medication used to treat seizures) 250 mg tablet card, Potassium Chloride Extended Release (medication used to replace potassium) 10 milliequivalent (meq) tablet card, Furosemide (medication used to treat edema) 40 mg tablet card, and Cyproheptadine (medication used to treat allergy symptoms) 4 mg tablet card was left on the top Medication Cart a unattended. In an interview on 08/22/2023 at 8:55 a.m., S8Licensed Practical Nurse (LPN) acknowledged she left Fluoxetine 20 mg capsule card, Divaloproex…

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.