Pontchartrain Health Care Center

Based on observations and interviews, the facility failed to ensure the facility was a functional, sanitary, and comfortable environment for residents. The facility failed to ensure: 1.) The floor tiles were cleaned and without debris, the wall adjacent to the bed was without chipped/missing paint, the shower was functional and sanitary, and the bed's mechanical parts were cleaned in Room a; and 2.) The air conditioner units in Room b and Room c were cleaned. This deficient practice had the potential to effect the 113 residents residing in the facility. Findings: 1. On 03/31/2025 at 12:10 p.m., an observation was made of Room a. There was a scattered brown/black substance on the floor tiles near the window and air conditioner unit. There was missing/chipped paint behind the bed. There was a dried brown substance on the bottom left foot control of the bed which was missing a cover. The shower was missing a shower head, and not functional. There was a dried orange substance along the bottom left shower tiles with chipped/missing shower tiles and no shower curtain. On 04/01/2025 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.

Based on observations, and interviews the facility failed to ensure a safe, functional, sanitary and comfortable environment. The facility failed to ensure: 1.) Ceiling tiles were in good repair for Room b, Room c, Room d, Room f, and Hall b; 2.) The vent above the ice machine on Hall c was clean; 3.) The gutters of the building remained intact; and 4.) Hall a's bathroom toilet was maintained in a sanitary and functional condition. This deficient practice had the potential to effect the 114 residents residing in the facility. Findings: 1. On 03/03/2025 at 9:45 a.m., a tour of the facility was conducted. In Room b there were 2 ceiling tiles which had a brown substance on them. In Room c there were 18 sagging ceiling tiles, a tan substance on the ceiling tile above a resident's bed, and a tear in 1 ceiling tile. In room d there was a baseball sized brown substance on 1 ceiling tile. In room f there were 3 ceiling tiles with a brown substance on them. On Hall b there were 4 ceiling tiles with tears, and 2 ceiling tiles had a brown substance on them. 2. On 03/03/2025 at 10:00 a.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure an allegation of physical abuse was reported to the state agency in the required time frame for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Property with a revision date of 09/26/2017, revealed, in part, the following: Policy: Reporting/Response: 1.Report all alleged violations of abuse to the state agency 2.Any employee who becomes aware of an alleged abuse .shall report the incident to a supervisor, DON or Administrator immediately. 3.The facility will report all allegations of abuse to the state agency within 24 hours of discovery . Review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE]. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024, revealed a Brief Interview for Mental Status (BIMS) of 00 which indicated Resident #1 was severely…

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 a resident's comprehensive plan of care was implemented for 1(#1) of 3(#1, #2 and #3) residents reviewed in the sample. The facility failed to ensure Resident #1 had daily meal intake percentage documented. Findings: Review of the Clinical Record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses, which included Non-Alzheimer's Dementia, Malnutrition and Dysphagia. Review of Care Plan for Resident #1 revealed the following, in part: 09/24/2024- Potential for altered nutrition. I am fed by staff. Goal: I will have adequate nutrition. Intervention: Observed meal intake and document percentage. Review of Nutrition Intake for Resident #1 dated February 2025, revealed no percentage of meal intake documented on the following dates: 02/02/2025, 02/09/2025, 02/10/2025, 02/12/2025, 02/13/2025, 02/14/2025, 02/15/2025, 02/16/2025, 02/21/2025, 02/22/2025, 02/24/2025 and 02/25/2025. On 03/05/2025 at 1:19 p.m., 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 observations and interviews, the facility failed to ensure housekeeping and maintenance services were provided and maintained a safe, clean, comfortable, and homelike environment for the residents for 3 of 3 (Hall A, Hall B, Hall C) areas observed for environmental concerns. This deficient practice had the potential to affect a census of 110 residents currently residing in the facility. Findings: Hall A An observation was conducted on 11/12/2024 at 9:00 a.m. of Hall A. Observations were conducted on Hall A near the double doors of two busted and cracked floor tiles with exposed concrete subflooring. Further observations were conducted across from the shower room and revealed a busted and cracked floor tile with exposed concrete subflooring. Hall B An observation was conducted on 11/12/2024 at 9:00 a.m. of Hall B. Observations were conducted at the beginning of Hall B of a cracked and uneven tile. Further observations were conducted on Hall B and revealed two more cracked tiles with missing parts. Hall C An observation was conducted on 11/12/2024 at 9:00 a.m. of Hall C.…

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 an effective pest control program to ensure residents had a pest free environment. The deficient practice affected 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents and had the potential to affect all 110 residents that resided in the facility. Findings: Observations on all days of the survey (11/12/2024 - 11/13/2024) revealed flies flying around throughout the facility, including hallways and resident rooms. On 11/12/2024 at 3:30 p.m., an observation revealed Resident #1 was in his room in bed and there were two flies flying around his room. A blue and green fly trap device was observed hanging from the left side of the curtain track near Resident #1's window, as well as a fly swatter on his bedside table. On 11/12/2024 at 3:45 p.m., an observation revealed Resident #3 was in his room in bed and there was a fly flying around his room. On 11/13/2024 at 5:55 a.m., an interview was conducted with S4CNA. He stated there were flies in and out of resident rooms and in the hallways daily. He confirmed the facility…

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 maintain accurate records in accordance with accepted professional standards for 2 (#2 and #3) of 3 (#1, #2, and #3) sampled residents reviewed for baths. Findings: Resident #2 Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident#2's Bath/Shower Logs revealed Resident #2 should receive a bath three days a week. Review of Resident #2's September 2024 and October 2024 Bath/Shower Logs revealed no documentation for a bath or shower given on 09/21/2024, 09/24/2024, and 10/10/2024. Resident #3 Review of Resident #3's clinical record revealed the resident was admitted to the facility on [DATE]. Review of Resident #3's Bath/Shower Logs revealed Resident #3 should receive a bath three days a week. Review of Resident #3's September 2024 Bath/Shower Logs revealed no documentation for a bath or shower given on 09/07/2024, 09/10/2024, 09/12/2024, 09/14/2024, 09/19/2024, 09/19/2024, 09/21/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 2 ( #2 and #3) of 2(#2 and #3) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing peri-care and catheter care to residents who were on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions, dated 04/01/2024, revealed the following, in part: Guideline: 1. Gown and gloves will be used during high-contact resident care activities for residents .who are at increased risk of multidrug-resistant organisms acquisition (e.g., residents with wounds or indwelling medical devices). Resident #2 Review of Resident #2's Clinical Record revealed she was re-admitted to the facility on [DATE]. A review of Resident 2#'s admission MDS…

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 a resident's assessment accurately reflected the resident's status for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for resident assessment. The facility failed to code the resident's Minimum Data Set (MDS) correctly for antipsychotic and antidepressant use. Findings: Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Depression and Hallucinations. Review of Resident #3's Physician's Orders revealed: Start date: 07/01/2024, Quetiapine Fumarate Tablet 25 mg Give one tablet by mouth at bedtime. Start date: 08/03/2024, Venlafaxine Extended Release Tablet 150 mg Give one tablet by mouth one time a day. Review of Resident #3's Medication Administration Record (MAR) dated 08/01/2024 to 10/11/2024 revealed Resident #3 received Quetiapine Fumarate and Venlafaxine in accordance with Physician's Orders for the dates reviewed. Review of Resident #3's Quarterly MDS with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to ensure physician's orders were accurately transcribed for 1 (#2) of 3 (#1, #2 and #3) residents reviewed for physician's orders. Findings: Review of Resident #2's Clinical Record revealed she was re-admitted to the facility on [DATE] with diagnoses, which included Gastrostomy Status and Colostomy Status. Review of Resident #2's Physician's Orders dated October 2024 revealed there were no orders for Gastrostomy Care. Further review revealed an order for Colostomy Care, dated 09/19/2024, had no start date. Review of Resident #2's MAR dated October 2024 revealed no Gastrostomy Care and no Colostomy Care. On 10/11/2024 at 3:05 p.m., an interview was conducted with S7QAN. S7QAN reviewed Resident #2's current October 2024 Physician's Orders and October 2024 MAR, and confirmed there were no orders for Gastrostomy care or Colostomy care written after Resident #2 was readmitted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure: 1. Oxygen tubing and humidifier bottle were properly labeled for 1 of 1 (#3) resident; and 2. Oxygen was administered at the ordered rate for 1 of 1 (#3) resident reviewed for oxygen therapy. Findings: 1. Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Dyspnea. Review of Resident #3's Physician's Orders revealed the following, in part: Start date: 07/01/2024: Oxygen at 2 Liters per nasal cannula. On 10/11/2024 at 9:45 a.m., an observation was made of Resident #3's oxygen tubing and humidifier bottle which were not properly labeled with date of last changed. On 10/11/2024 at 10:03 a.m., an observation was made of Resident #3's oxygen tubing with S4LPN. S4LPN confirmed the oxygen tubing was not labeled with the date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 3 of 3 (#1, #2 and #3) sampled residents reviewed for activities of daily living. The facility failed to ensure staff documented completed baths or showers in the Residents' record. Findings: Resident #1 Review of Resident #1's current Clinical Record revealed the resident was re-admitted to the facility on [DATE]. Review of Resident #1's July 2024 Tuesday, Thursday, and Saturday Shower Lists revealed no documentation of a completed bath or shower for the resident on 07/18/2024 and 07/20/2024. An interview was conducted on 07/31/2024 at 4:00 p.m. with S3CNA. S3CNA stated on 07/18/2024 and 07/20/2024 she was the shower aide for Resident #1. S3CNA stated on the aforementioned dates she completed a bath or shower for Resident #1 but did not document and should have. Resident #2 Review of Resident #2's current Clinical Record revealed the resident was admitted…

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 interview, the facility failed to store food under sanitary conditions by failing to do the following: 1. Ensure food was properly labelled and stored in unit refrigerators; and 2. Ensure kitchen equipment was maintained in safe operating condition. This deficient practice had the potential to affect 101 residents who were capable of storing and consuming food in the facility's unit refrigerators. Findings: 1. On 05/06/2024 at 3:25 p.m., a tour was conducted of Medication Storage Room A. An observation wad made of a sign posted to the front of the refrigerator stating, STOP- all items must be labeled and dated. Further observations revealed the following: Unit Refrigerator - 3- to-go boxes with no label and date; Unit Freezer - 1- frozen coffee drink with no label and date; and 1- frozen fast food ice cream with no label and date. On 05/07/2024 at 9:29 a.m., a tour was conducted of Medication Storage Room B. An observation was made of a sign posted to the front of the refrigerator stating, Before putting anything in this refrigerator make sure it's labeled…

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 have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This deficient practice had the potential to affect 101 residents who were capable of storing and consuming food in the facility. Findings: Review of the facility's policies revealed no policy on ensuring safe and sanitary storage, handling, and consumption of foods brought to residents by family and other visitors. On 05/07/2024 at 11:00 a.m., an interview was conducted with R. [NAME], S2ADON. She stated the facility did not have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. On 05/07/2024 at 11:40 a.m., an interview was conducted with S2DON. She confirmed the facility did not have a policy regarding use and storage of foods brought to residents by family and other visitors 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 and interviews, the facility failed to dispose of garbage and ensure waste was properly contained in the outdoor dumpster Findings: On 05/06/2024 at 8:40 a.m., an observation and interview was conducted with S5DM. An observation was made of the outside area immediately to the left of the entrance/exit door of the kitchen which revealed a pool of grey stagnant water containing loose trash and one deteriorating mop head. Further observation revealed one metal cooking pan filled with black water and spoiled food. S5DM verified the entryway was used for food deliveries and was unsanitary. On 05/06/2024 at 8:45 a.m., an observation and interview was conducted with S5DM. An observation of the area surrounding the facility's two dumpsters revealed multiple bedframes and mattresses. S5DM stated the bedframes and mattresses were trash and were waiting to be disposed of. he stated the trash company came once this week and did not pick up the bedframes and mattresses. On 05/06/2024 at 9:45 a.m., an observation and interview was conducted with S1ADM. S1ADM confirmed all of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 3 (#50, #54, and #78) of 22 sampled residents reviewed for MDS. Findings: Resident #50 Review of Resident #50's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #50 was diagnosed with Alzheimer's. Review of Resident #50's admission MDS with an ARD of 03/11/2024 revealed Alzheimer's was not coded as an active diagnosis in Section I. Resident #54 Review of Resident #54's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #54 was diagnosed with Depression. Review of Resident #54's quarterly MDS with an ARD of 04/29/2024 revealed Depression was not coded as an active diagnosis in Section I. Resident #78 Review of Resident #78's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #78 was diagnosed with Post Traumatic Stress…

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 were given the right to rescind the arbitration agreement within 30 calendar days for 3 (#50, #109, and #114) of 3 (#50, #109, and #114) residents reviewed for arbitration. Findings: Review of the facility's form titled Resident [NAME] of Rights on page 5 of 5 revealed an arbitration agreement was included in the admission packet. Further review revealed no documentation of the resident's right to rescind the agreement within 30 calendar days. Resident #50 Review of Resident #50's Clinical Record revealed she was admitted to the facility on [DATE]. Further review of Resident #50's Clinical Record revealed a signed form titled, Resident [NAME] of Rights. Resident #109 Review of Resident #109's Clinical Record revealed she was admitted to the facility on [DATE]. Further review of Resident #109's Clinical Record revealed a signed form titled, Resident [NAME] of Rights. Resident #114 Review of Resident #114's Clinical Record revealed she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a PASARR Level II evaluation as required for 1 (#72) of 4 (#34, #49, #72, and #114) sampled residents records reviewed for PASARR Level II. Findings: Review of the Clinical Record revealed Resident #72 was admitted to the facility on [DATE]. Further review of the Clinical Record revealed Resident #72 was diagnosed with Schizoaffective Disorder, Bipolar Type on 10/23/2023. An interview was conducted on 05/08/2024 at 2:50 p.m. with S6BOM. She stated she was responsible for submitting Resident Reviews for all residents in the facility. She confirmed Resident #72 acquired a new diagnosis of Schizoaffective Disorder, Bipolar Type on 10/23/2023. She stated a Resident Review for PASARR Level II was not submitted after Resident #72 received the new diagnosis. An interview was conducted on 05/08/2024 at 3:00 p.m. with S2DON. She confirmed a Resident Review for PASARR Level II should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 2 (#19 and #51) of 6 (#9, #12, #19, #34, #51 and #58) residents reviewed for unnecessary psychotropic medications. The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days. Findings: Resident #19 Review of the Clinical Record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorders, Hallucinations and Senile Degeneration of the Brain. Review of Resident #19's active Physician Orders revealed the following, in part: Start Date: 04/29/2024 -Lorazepam 2mg/ml oral concentration, 0.25ml by mouth/sublingual every 4 hours PRN for anxiety/agitation until death for standard of hospice care. Further review revealed the order did not have a documented stop date. Resident #51 Review of Resident #51's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff used appropriate hand hygiene after incontinent care for 1 (#101) of 1 (#101) residents observed for incontinent care. Findings: Review of the facility's policy revised on 08/2015 titled, Handwashing/Hand Hygiene, revealed, in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub . or alternatively, soap and water for the following situations: b. Before and after direct contact with residents. j. After contact with .bodily fluids. m. After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine…

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 residents, who were unable to carry out ADLs, received the necessary services to maintain personal hygiene for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for ADLs. Findings: Resident #1 Review of the clinical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses, which included Unspecified Fracture of Second Lumbar Vertebra, Subsequent encounter for Fracture with Routine Healing, Muscle Weakness, Difficulty in Walking, Unspecified Lack of Coordination, Cognitive Communication Deficit, Ankylosing Spondylitis Lumbar Region, Dementia in Other Diseases Classified Elsewhere, Unspecified Intellectual Disabilities, Bilateral Primary Osteoarthritis of Knee, and Legal Blindness. Review of Resident #1's admission MDS with an ARD of 12/29/2023 revealed she had a BIMS of 1 indicating she was severely cognitively impaired. Further review revealed she required maximal assistance to complete the activity of 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 observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 2 (Resident #2, Resident #3) of 3 (Resident #2, Resident #3 and R2) residents reviewed for incontinent care. Finding: A review of the policy labeled Handwashing/Hand Hygiene revealed the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the…

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

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 2 (a and b) of 3 (a, b, and c) Medication Carts observed for medication storage. Findings: Review of the facility's policy titled Storage of Medications revealed in part, the following: 2. The nursing staff shall be responsible for maintaining medication storage. 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication Cart a An observation was made on 04/24/2023 at 9:55 a.m. of Medication Cart a. One bottle of Lorazepam 2mg/mL for Resident #66 was observed in the narcotic lock box drawer of the medication cart. The Lorazepam bottle revealed a label which read Refrigerate. An interview was conducted on 04/24/2023 at 9:56 a.m. with S4LPN. S4LPN confirmed the bottle of Lorazepam's label read Refrigerate and should have been placed back into the refrigerator after each dose. She stated the bottle of Lorazepam for Resident #66 was in the medication cart for an unknown…

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 store and prepare food under sanitary conditions by failing to ensure food was properly stored in the refrigerator of the facility's kitchen. This had the potential to effect all residents served out of the kitchen. This had the potential to effect 95 residents served out of the kitchen. Review of the facility's policy entitled Preventing Foodborne Illness-Food Handling revealed in part, the following: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 1. This facility recognizes that the critical factors implicated in foodborne illness are: d. Unsafe food sources. Observations were made on 04/24/2023 at 9:20 a.m. of the facility's walk-in cooler with S8DM. The following observations were made: 1. 1 opened ten pound box of unsealed smoked ham located on the 4th shelf, directly above a box of sliced cheese and a crate of skim milk. 2. 1 opened twelve pound box of unsealed roast beef located on the 4th shelf, directly above a box of dinner rolls and a crate of skim milk. 3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#66) of 32 residents reviewed in the initial screening for advanced directives. Findings: Review of Resident #66's clinical record revealed he was admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction and Metabolic Encephalopathy. Review of the Significant Change MDS with an ARD of [DATE] revealed Resident #66 was unable to complete the BIMS due to an inability to be interviewed. Review of Resident #66's [DATE] Physician Orders revealed: [DATE] Code Status: CPR [DATE] Admit to hospice Diagnosis: CVA; DNR Code Status Review of Resident #66's Advance Directive dated [DATE] revealed the following, in part: 4. Does the resident have a DNR (no code)? Box checked: No 5. Do you have a LaPost? Box checked: No Document signed by Resident #66's Health Care Representative on [DATE]. Review of Resident #66's current…

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 resident assessments accurately reflected the resident's status. The facility failed to ensure 1 (#66) of 4 (#14, #48, #66 and #82) residents reviewed for resident assessment had an accurate MDS (Minimum Data Set) that reflected the resident's active treatment of hospice. Findings: A review of Resident #66's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Cerebral Infarction and Metabolic Encephalopathy. Review of the Significant Change MDS with an ARD of 04/10/2023 revealed Resident #66 was unable to complete the BIMS due to an inability to be interviewed. Further review of Resident #66's MDS revealed the following: Section O-Special Treatments, Procedures, and Programs K. Hospice care: Unchecked A review of Resident #66's Physician Orders dated April 2023 revealed the following, in part: 04/06/2023-Admit to hospice Diagnosis: CVA (Cerebral Vascular Accident); DNR (Do Not Resuscitate) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to implement a comprehensive care plan for 1 (#51) of 4 (#15, #46, #50 and #51) residents reviewed for nutrition. The facility failed to ensure Resident #51 was weighed on a monthly basis as ordered by the physician. Findings: Review of the facility's Weight Management Policy revealed, in part: 2. New admits and readmits will be weighed for the first four weeks to establish baseline weights, after which they will be placed on the monthly weight schedule, if there is not a significant weight loss or gain. Review of the medical record for Resident #51 revealed she was admitted on [DATE] with the following diagnosis, in part: Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. Review of the Care plan for Resident #51 revealed the following, in part: Problem onset 10/02/2022: I am at risk for altered nutrition. I will be free from significant weight loss/gain. Interventions: Monitor my weights per MD (Medical Doctor) orders. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days and indicate the duration for PRN orders for 2 (#66 and #82) of 6 (#11, #12, #15, #60, #66 and #82) residents reviewed for unnecessary medications. Findings: Review of the facility's policy titled Psychotropic Medication Use revealed the following: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosis specific condition that is documented in the clinical record. a. PRN orders psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to implement appropriate infection control practices by failing to ensure staff appropriately changed gloves and performed hand hygiene for 1 (#108) of 2 (#30 and #108) residents reviewed in the final sample for incontinence care. Findings: Review of the Clinical Record for Resident #108 revealed she was admitted to the facility on [DATE], with diagnoses which included: Pressure Ulcer of Left Buttocks-Stage 4, Difficulty Walking, Diarrhea, Ulcerative Colitis, and Chronic Cystitis Without Hematuria. Review of the Admit MDS with an ARD of 03/28/2023 revealed Resident #108 had a BIMS of 6, which indicated she was severely cognitively impaired. Further review revealed Resident #108 was always incontinent of bowel and had an indwelling catheter. On 04/27/2023 at 2:00 p.m., an observation/interview was conducted with S1LPN performing incontinence care for Resident # 108. S1LPN washed her hands with soap and water, then applied gloves. S1LPN then set up a basin…

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.