Chateau Napoleon Caring, LLC

Based on interview and record review, the facility failed to ensure routine medication was available for administration for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for medication administration. Findings: Review of the facility's Medication Administration policy revised on 03/01/2023 revealed, in part, medications are administered by licensed nurses as ordered by the physician in accordance with professional standards or practice. Further review revealed to correct any discrepancies related to medication orders and report the discrepancies to the nurse manager. Review of Resident #2's Physician's Orders for May 2025 revealed, in part, an order for Brivaracetam oral tablet 75 milligram (mg) every 12 hours with a start date of 05/03/2025. Review of Resident #2's May 2025 Medication Administration Record (MAR) revealed the following was documented related to the administration of Resident #2's Brivaracetam 75mg oral tablet: -9 was documented at 8:00AM and 8:00PM doses on 05/03/2025, 05/04/2025, 05/05/2025, and 05/06/2025; -2 was…

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

Based on interviews and record reviews, the facility failed to ensure staff notified a physician regarding a change in a resident's skin condition for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for notification of change. Findings: Review of Resident #1's progress note dated 02/10/2025 at 9:30AM revealed, in part, the Certified Nursing Assistant (CNA) reported a red/purple discoloration to Resident #1's right neck/chest area. Further review revealed, upon assessment, Resident #1 presented with a small red/purple discoloration to Resident #1's right neck/chest area and Resident #1's physician was made aware. In an interview on 02/20/2025 at 2:10PM S6Former LPN indicated she attempted to notify Resident #1's physician's nurse of Resident #1's skin alteration, but the text message was not sent successfully. S6Former LPN further indicated she had not realized the text message did not send successfully until S5StaffDevelopement Nurse called her later in the day when she (S5Staff Development Nurse) was sending Resident #1 to the emergency room.…

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 ensure administrative staff (S2Director of Nursing [DON]) followed the facility's abuse prevention policy and did not indicate to a staff member (S6Former Licensed Practical Nurse) that she should not have admitted to seeing Resident #1's injury of unknown origin. Findings: Review of the facility's undated DON Job Description revealed, in part, the facility's DON was responsible for ensuring the facility's nursing service personnel understood and followed departmental policies and procedures. Review of the facility's Freedom from Abuse, Neglect, and Exploitation-Preventing and Prohibiting Abuse policy, last revised in 03/2023 revealed, in part, a sign of abuse was a suspicious injury. Further review revealed staff would immediately report allegations or suspicions of abuse to the Administrator, state agency, adult protective services, and other required agencies. In an interview on 02/20/2025 at 10:32AM, S4Former Admissions Nurse indicated S8LPN had sent her a recording of a conversation between S8LPN and S2DON in 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.

Based on interviews and record reviews, the facility failed to revise a plan of care with an intervention after a fall for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for resident centered care plans. Findings: Review of the facility's incident/accident log dated 11/2024 to 02/2025 revealed, in part, Resident #2 had unwitnessed falls on 11/24/2024 12/18/2024, and 02/13/2025. Review of Resident #2's Minimum Data Set with an Assessment Reference Date of 12/10/2025 revealed, in part, Resident #2 had a Brief Interview for Mental Status assessment score of 9, which indicated moderate cognitive impairment. Further review revealed Resident #2 had one fall with no injury since Resident #2's last assessment. Review of Resident #2's nursing progress note dated 02/13/2025 at 9:10PM revealed, in part, a Certified Nursing Assistant (CNA) reported to the nurse Resident #2 was found lying on the floor near Resident #2's bed. Review of Resident #2's Plan of Care with a target date of 03/11/2025 revealed, in part, Resident #2 was at risk for falls…

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

Based on interviews and record reviews, the facility failed to ensure a licensed nurse (S7Licensed Practical Nurse [LPN]) did not leave the facility without ensuring another nurse assumed responsibility of her resident assignment. This deficient practice had the potential to affect all 28 residents (Resident #1, Resident #R4, Resident #R5, Resident #R8, Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R15, Resident #R16, Resident #R17, Resident #R18, Resident #R19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, Resident #31, Resident #32) who resided on the facility's Hall y and Hall z on 02/09/2025. Findings: Review of the facility's LPN schedule dated 02/09/2025 revealed, in part, S7LPN was the scheduled nurse for Hall y and Hall z on the 6:00AM to 6:00PM shift and S18Agency LPN was the scheduled nurse for Hall y and Hall z on the 6:00PM to 6:00AM shift. Review of the facility's time sheets dated 02/09/2025 revealed, in part,…

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 records reviews, the facility failed to ensure wound care was completed as ordered for 8 (Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R17, Resident #R28, Resident #R29) of 10 (Resident #R8 and Resident #R9, Resident #R10, Resident #R11, Resident #R12, Resident #R13, Resident #R14, Resident #R17, Resident #R28, Resident #R29) residents reviewed for completed wound care. Findings: Review of the facility's time sheet for 02/09/2025 revealed, S19Wound Care Nurse (WCN) worked on 02/09/2025 from 6:27AM to 2:15PM. Further review of the facility's time sheet for 02/09/2025 revealed, in part, there was no documented evidence S20WC Nurse worked on 02/09/2025. In an interview on 02/20/2025 at 11:52AM, S19WC Nurse indicated she did not perform the resident's wound care on 02/09/2025 because she was still in training. Review of Resident #R10's February 2025 electronic Treatment Administration Report (eTAR) revealed, in part, documentation S20WCN cleaned Resident #R10's right shin non-pressure ulcer with wound cleanser/normal…

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

Based on interviews and record reviews, the facility failed to ensure a resident's assistive device was available for a resident's use to decrease the risk of falls for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents reviewed for accident/hazards. Findings: Review of Resident #1's Electronic Medical Record revealed, in part, Resident #1 had diagnoses, which included, unspecified dementia, abnormal posture, difficulty in walking, muscle weakness, and lack of coordination. Review of S9Former Certified Nursing Assistant (CNA) witness statement dated 02/13/2025 revealed, in part, on 2/8/2025 S9Former CNA indicated she found Resident #1 lying in the bed with Resident #1's upper half of his body in the bed and the lower half of Resident #1's body in his wheelchair. Further review of S9Former CNA witness statement revealed S9Former CNA placed Resident #1 back in the bed and removed Resident #1's wheelchair from the bedside. Resident #1 was upset S9Former CNA removed his wheelchair. In an interview on 02/21/2025 at 11:46AM, S1Administrator indicated…

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

Based on interview and record reviews, the provider failed to ensure a Registered Nurse (RN) worked at least 8 hours for 1 (02/09/2025) of 14 (02/02/2025, 02/03/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/11/2025, 02/12/2025, 02/13/2025, 02/14/2025, 02/15/2025) days reviewed for staffing requirements. Findings: Review of the Nursing/Ancillary Personnel Staffing Pattern Report Form submitted by the facility revealed, in part, there was no documented evidence an RN worked on 02/09/2025. Review of the facility's time sheets dated 02/09/2025 revealed, in part, there was no documented evidence an RN worked on 02/09/2025. There was no documented evidence, and the provider was unable to present any documented evidence, an RN worked at least 8 hours as required on 02/09/2025. In an interview on 02/20/2025 at 1:50PM, S16Medical Director indicated an RN should have worked on 02/09/2025 as required.

Based on interviews and record reviews, the facility failed to maintain a system to reconcile controlled drugs for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart b, Medication Cart c) medication carts reviewed for the reconciliation of controlled substances. Findings: Review of the facility's surveillance footage on 02/09/2025 from 6:00PM until 8:37PM revealed, in part, Medication Cart c (the medication cart that held the controlled drugs for the residents that resided on Hall y and Hall z) was in view of the surveillance camera. Further review revealed no evidence S7LPN reconciled Medication Cart c's controlled drugs with any nurse before she left the facility at 6:15PM on 02/09/2025. In an interview on 02/24/2025 at 9:50AM, S7LPN indicated she did not reconcile the controlled drugs in Medication Cart c with another nurse before leaving the facility. In an interview on 02/25/2025 at 9:15AM, S2Director of Nursing acknowledged the facility's off going and oncoming nurses should reconcile controlled drugs at shift change.

Based on interview and record review, the facility failed to ensure the facility assessment included active involvement from direct care staff, a governing body member, residents, and residents' representatives in its development. Findings: Review of the facility's facility assessment, last updated on 08/26/2024 revealed, in part, there was no documented evidence the facility assessment included a Registered Nurse (RN), a Licensed Practical Nurse (LPN), a Certified Nursing Assistant (CNA), and a resident and/or a resident's representative was involved in the development of the facility's facility assessment. Further review revealed there was no documented evidence a member of the facility's governing body was involved in the development of the facility's facility assessment. The facility was unable to present documented evidence the above mentioned staff, a resident and/or a resident's representative, and a member of the facility's governing body were involved in the development of the facility's assessment. In an interview on 02/21/2025 at 11:46AM, S1Administrator indicated he was…

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

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) received 12 hours of in-service training annually for 1 (S12CNA) of 5 (S11CNA, S12CNA, S13CNA, S14CNA and S15CNA) CNAs' personnel files reviewed for in-service trainings. Findings: Review of S12CNA's personnel file revealed, in part, a date of hire of 07/17/2014. Further review of S12CNA's personnel file revealed no documented evidence, and the facility was unable to present any documented evidence S12CNA completed 12 hours of in-service trainings annually as required. In an interview on 02/21/2025 at 9:17AM, S2DON indicated the facility did not have any documented evidence S12CNA completed 12 hours of in-service trainings annually as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for care planning. Findings: Review of the facility's 2023 policy titled, Clinical Services Policy and Guidelines For Implementation, Quality of Care, Skin Integrity, revealed, in part, a resident identified as having risk for developing pressure ulcers would have individualized interventions implemented to attempt to prevent pressure ulcers from developing, interventions would be monitored for effectiveness, and the resident's care plan would reflect the interventions. Review of Resident #1's Electronic Medical Record (EMR) revealed, in part, Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024 revealed, in part, Resident #1 was at risk for developing pressure ulcers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were available for use for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for pharmacy services. Findings: Resident #1 Review of Resident #1's clinical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, hypertension (high blood pressure), and gout (a condition that causes swelling and tenderness in joints). Review of Resident #1's November 2024 physician's orders revealed, in part, orders for potassium chloride 20 milliequivalent (mEq) (a medication used to treat chronic kidney disease) to be administered twice a day; allopurinol 100 milligram (mg) (a medication used to treat swelling and tenderness in joints) to be administered once a day; and, lisinopril-hydrochlorothiazide 10-12.5 mg (a medication used to treat high blood pressure) to be administered once a day with a start date of 11/16/2024 at 8:00 a.m. Review…

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

Based on observations and interviews, it was determined the facility failed to ensure shower rooms were maintained in a clean and sanitary manner for 2 (shower room y and shower room z) of 2 shower rooms reviewed for physical environment. Findings included: Observation of shower room y on 12/02/2024 at 8:50 AM revealed, an unknown black/gray substance on the floor and base moldings in all 4 shower stalls. Further observation revealed several cracked tiles had an unknown black/gray substance along the cracked tile on the back wall of shower room y. Further observation revealed and unknown black/gray substance on the tiled floor around the toilet in shower room y. Further observation revealed 4 shower curtains had an unknown black/gray substance on both sides of the bottom of the shower curtains. Further observation of shower room y revealed two areas had missing tile molding which exposed sheet rock. Further observation of shower room y revealed an unknown orange/red substance on the metal ceiling supports. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment…

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

Based on interviews and record reviews, the facility failed to immediately ensure a resident's physician was notified of a resident's change of condition in a timely manner 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) residents investigated for Quality of Care. Findings included: Review of the facility's policy titled, Resident Rights: Notification of Change of Condition and Room Changes, dated 03/2023, revealed, in part, the facility would promptly inform the resident, consult with the resident's physician, and notify the resident representative, consistent with his or her authority, when there was an accident that involved the resident, which resulted in injury, and had the potential for requiring physician interventions. Review of the facility's Incident Audit Report, dated 05/02/2024, revealed, in part, on 04/27/2024, Resident #2's wife reported Resident #2 had a blister to his left hand index finger from a cigarette burn. Review of the facility's electronic facsimile sheet dated 04/27/2024 revealed, in part, a faxed communication was sent to Resident #2's…

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, record reviews, and facility policy review, the facility failed to assist a resident and/or provide transportation for a residents podiatry (physician which treats disorders of the feet) appointment for 1 (Resident #1) of 3 sampled residents reviewed for foot care. Findings included: Review of the facility's undated Resident [NAME] of Rights Louisiana, revealed, in part, residents have the right to receive adequate and appropriate health care and support services consistent with rules promulgated by the Louisiana Department of Health. Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had diagnoses of, in part, chronic osteomyelitis (bone infection) to right ankle/foot and diabetes mellitus with polyneuropathy (high…

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, facility policy, and record reviews, it was determined facility failed to ensure a resident was seen by a physician in a timely manner for 1 (Resident #1) of 3 sampled residents reviewed for physician visits. Findings included: Review of the facility's policy titled, Physician Services Physician Visits and Physician Delegation of Visits, dated 03/2023 revealed, in part, a physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. Further review revealed the requirement for physician visits can be satisfied in accordance with stated law by a Non Physician Practitioner (NPP). Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Review of Resident #1's medical record revealed, in part, Resident #1 was seen…

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, it was determined the facility failed to obtain laboratory services per physician's order for 1 (Resident #1) of 3 sampled resident's records reviewed for pharmaceutical services. Findings included: Resident #1 Review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/2024 revealed, in part, Resident #1 was admitted to the facility on [DATE] and had diagnoses of, in part, chronic myeloid leukemia not having achieved remission (blood cancer), chronic osteomyelitis (bone infection) to the right ankle/foot, diabetes mellitus with polyneuropathy (high blood sugar levels that can cause nerve damage to feet and toes), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident #1's Physician Orders, for the month of 12/2024 revealed, in part, an order dated 09/23/2024, for Complete Blood Count (CBC) (a blood test which measures the number and size of the different cells in your blood) 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, observations, interviews the facility failed to ensure privacy was provided for residents during activities of daily living (ADL) care and incontinence care provided in their rooms (Room A and Room B) for 4 (Resident #16, Resident #27, Resident #45, and Resident #46) of 4 (Resident #16, Resident #27, Resident #45, and Resident #46) sampled residents investigated for privacy. Findings: Review of the facility's Resident [NAME] of Rights revealed, in part, each resident has the right to have privacy in treatment and during care of personal needs. Further review revealed privacy of the resident's body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene. Room A Review of the facility's daily census dated 09/30/2024 revealed, in part, Resident #16 and Resident #46 were roommates in Room A. An observation of Room A on 09/30/2024 at 9:10 a.m. revealed there was no curtain to provide privacy between Resident #16 bed and Resident #46 bed. Review of Resident #16's Quarterly Minimum Data Set (MDS) and State…

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 an interview, the facility failed to ensure the Certified Nurse Aide (CNA) Registry was verified upon hire for 1 (S11CNA) of 6 (S4CNA Coordinator, S8CNA, S9CNA, S10CNA, S11CNA, and S12CNA) personnel records reviewed. Findings: Review of S11CNA's personnel record revealed, in part, a hire date of 01/09/2024. Further review of S11CNA's timesheet revealed S11CNA worked with residents on 01/09/2024, 01/10/2024, 01/11/2024, 01/12/2024, 01/14/2024, and 01/15/2024. Review of S11CNA'S personnel record revealed, in part, a CNA Registry verification dated 01/15/2024. Further review of S11CNA's personnel record revealed there was no documented evidence, and the provider did not present any documented evidence a CNA certification check on S11CNA was completed before hire. In an interview on 10/02/2024 at 2:15 p.m., S13Human Resources (HR) Business Partner confirmed the facility did not complete a CNA certification check on S11CNA before hire to ensure S11CNA was active and should have.

Based on record reviews and interviews, the facility failed to ensure an allegation of staff to resident verbal abuse was reported to the required State Survey Agency for 1 (Resident #64) of 1 (Resident #64) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Policy and Procedure last revised March 2023, revealed, in part, when the facility identified abuse the facility should take appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately, which included to report the allegation to appropriate authorities within required timeframes, conduct a thorough investigation of the allegation, document and report the result of the investigation of the allegation, and take appropriate corrective action. Further review of the facility's Abuse Policy and Procedure revealed, in part, staff were expected to be in control of their behavior, were to behave professionally, and understood how to work with the facility population. Review of the facility's Grievance Log dated 09/25/2024 revealed, in part, Resident #64 filed 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.

Based on interviews and record review, the facility failed to conduct a thorough investigation following an allegation of staff to resident verbal abuse for 1 (Resident #64) of 1 (Resident #64) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Policy and Procedure last revised March 2023 revealed, in part, when the facility identified abuse, the facility should take the appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately. Further review of the facility's Abuse Policy and Procedure revealed the facility should conduct a thorough investigation of the allegation, document, and report the results of the investigation of the allegation. Review of Resident #64's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/06/2024 revealed, in part, Resident #64 required supervision with toilet transfer. Review of Resident #64's Plan of Care revealed, in part, Resident #64 required assistance of one staff member with toilet transfer. In an interview on 09/30/2024 at 9:21 a.m., Resident #64…

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 with a diagnoses of Major Depressive Disorder and Bipolar Disorder was referred to the appropriate State Survey Agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #64) of 5 (Resident #17, Resident #21, Resident #50, Resident #62, and Resident #64) sampled residents reviewed for PASARR. Findings: Review of Resident #64's Electronic Medical Record (EMR) revealed, in part, Resident #64 was admitted to the facility on [DATE] with a diagnosis that included Major Depressive Disorder. Further review revealed on 05/10/2023 a new diagnosis of Bipolar Disorder. Further review of Resident #64's EMR revealed, in part, no documented evidence that a Level II PASARR evaluation was completed. In an interview on 10/01/2024 at 12:05 p.m., S3Director of Social Services indicated a Level II PASARR evaluation was not completed on Resident #64. S3Director of Social Services further indicated…

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

Based on record reviews and interviews, the facility failed to ensure a medication was available for resident use as ordered by the physician for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for quality of care. Findings: Review of Resident #1's Physicians Order dated 09/03/2024 revealed, in part, Tramadol 50 milligram (mg) (a medication used for pain) to be administered two times a day. Review of Resident #1's September 2024 electronic Medication Administration Record (eMAR) revealed the following was documented, in part, 09/03/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9 (9 indicated other and see progress notes); 09/04/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9; 09/04/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9; 09/05/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9; 09/05/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9; 09/06/2024 at 8:00 a.m. Tramadol 50mg was documented as a 9; 09/06/2024 at 5:00 p.m. Tramadol 50mg was documented as a 9; and, 09/09/2024 at 8:00 a.m. Tramadol 50mg was…

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

Based on record review and interview, the facility failed to ensure a resident received adequate assistance with a transfer for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents who were reviewed for the use of mechanical lifts. Findings: Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2024 revealed, in part, Resident #1 required extensive assistance from two or more persons with transfers. Review of Resident #1's Care Plan with an initiation date of 01/05/2024 revealed, in part, Resident #1 required the mechanical lift which required the assistance of 2 staff persons for transfers. Review of Resident #1's Nurses Notes dated 08/25/2024 revealed, in part, Resident #1 indicated he had an abrasion to his leg which occurred on 08/23/2024 when S4Certified Nursing Assistant (CNA) transferred him without the assistance of a second staff person using the mechanical lift. In an interview on 09/09/2024 at 10:40 a.m., Resident #1 indicated he hurt his leg on 08/23/2024 when S4CNA transferred him with 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 interview, the facility failed to electronically submit payroll information for direct care staffing as required. Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30) revealed, in part, the facility failed to submit staffing data for Quarter 4. Review of the facility's record titled CMS (Centers for Medicare and Medicaid Services) Submission Report dated 11/14/2023 revealed, in part, a file was submitted for Fiscal Quarter 4 and the entire file was rejected. Further review revealed the file was not structured properly and therefore could not be processed and the facility should contact the software vendor, make appropriate corrections to the record, and resubmit. Record review revealed no documented evidence and the facility did not present any documented the facility submitted the PBJ Staffing Data for FY Quarter 4 2023 (July 1 - September 30). In an interview on 02/27/2024 at 10:00 a.m., S1Administrator stated the facility was unable to submit 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 interviews and record reviews, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of the facility's Freedom from Abuse, Neglect and Exploitation Policy revealed, in part, abuse was defined as the willful infliction of injury resulting in physical harm, pain, or mental anguish. Further review revealed, willful was defined as the individual must have acted deliberately, and in determining abuse such action will be considered regardless of whether the individual intended to inflict injury or harm. The policy also revealed physical abuse included but was not limited to, hitting, slapping, punching, biting, and kicking. Resident #1 and Resident #2 Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status Score (BIMS) of 03 which indicated Resident #1…

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

Based on record reviews and interviews, the facility failed to ensure residents received psychiatric evaluations in a timely manner after an incident of resident to resident abuse. This deficient practice was identified for 2 (Resident #1 and Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for behavioral healthcare services. Findings: Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/22/2023 revealed, in part, Resident #1 had a Brief Interview Mental Status Score (BIMS) of 03 which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 had a diagnosis of Alzheimer's disease. Review of Resident #2's MDS with a ARD of 12/21/2023 revealed, in part, Resident #2 had a BIMS score of 15 which indicated Resident #2 was cognitively intact. Review of facility's incident report dated 01/16/2024 at 1:55 p.m. revealed, in part, Resident #1 and Resident #2 were involved in an incident of resident to resident abuse in which Resident #2 approached Resident #1 and they swung…

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 staff were provided abuse and neglect training; and 2. Ensure staff were provided dementia management training. This deficient practice was identified for 3 (S3Social Worker, S4Activities Director, and S6Cook) of 7 (S3Social Worker, S4Activities Director, S5Certified Nursing Assistant, S6Cook, S7Occupational Therapy, S8Certified Nursing Assistant, and S9Certified Nursing Assistant) personnel records reviewed. Findings: Review of S3Social Worker's personnel record revealed, in part, a hire date of 09/08/2023. Further review of S3Social Worker's personnel record revealed no documented evidence and the facility did not present any documented evidence S3Social Worker completed annual dementia training. Review of S4Activities Director's personnel record revealed, in part, a hire date of 04/06/2022. Further review of S4Activieties Director's personnel record revealed no documented evidence and the facility did not present any evidence S4Activities Director completed annual abuse training. Review of S6Cook's…

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 electronically submit payroll information for direct care staffing as required. Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 3 2023 (April 1 - June 30) revealed, in part, the facility failed to submit staffing data for Quarter 3. In an interview on 11/28/2023 at 2:50 p.m., S1Regional Director of Operations stated he was unable to produce documented evidence the facility had submitted the PBJ Staffing Data for FY Quarter 3 2023 (April 1 - June 30).

Based on record reviews, observations, and interviews, the facility failed to: 1. Ensure staff placed a hand roll in a resident's contracted hand and elbow pads in a resident's contracted arms as ordered by the physician for 1 (Resident #1) of 2 (Resident #1 and Resident #61) sampled residents investigated for positioning and mobility; and, 2. Ensure a resident with contractures received restorative nursing services per their plan of care for 1 (Resident #1) of 2 (Resident #1 and Resident #61) sampled residents investigated for positioning and mobility. Findings: 1. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. Further review revealed Resident #1 had diagnoses of traumatic brain injury, stroke, and hemiparesis (a condition of weakness or paralysis on one side of the body)/hemiplegia (a condition of paralysis on one side of the body). Review also revealed Resident #1 was documented as total dependent on…

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

Based on observations, interviews, and record review the facility failed to: 1. Ensure a resident remained free from falls by failing to develop and/or implement a care plan to prevent falls, and/or failed to develop new individualized interventions after following a fall for 1 (Resident #15) of 1 (Resident #15) sampled residents reviewed for falls; and 2. Ensure smoking paraphernalia was secure according the facility's policy and the residents care plan 1 (Resident #2) of 1 (Resident #2) sampled residents reviewed for smoking. Findings: 1. Review of the facility's Accident Hazards/Supervision/Devices Policy revealed, in part, the facility would initiate and implement a comprehensive, resident-centered fall prevention plan for residents at risk for falls or with a history of falls. Review of Resident #15's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/2023 revealed, in part, Resident #15's Brief Interview of Mental Status (BIMS) score was 5, which indicated severe cognitive impairment. Review of the facility's incident report log May 2023 through November…

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: 1.Ensure a licensed pharmacist completed monthly medication reviews (MMR) for 3 (Resident #2, Resident #8 and Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications; and, 2.Ensure the attending physician acted upon the pharmacist's identified irregularities for 1 (Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications. Findings: Review of the facility's Pharmacy Services policy revealed, in part, residents will have a Medication Regimen Review (MRR) conducted at least monthly by a licensed pharmacist and includes a review of the resident's medical record. Further review revealed the pharmacist will report any irregularities on a separate written report provided to the attending physician, medical director and the director of nursing. Review also revealed irregularities will then be reviewed and a response will be provided in a timely manner.…

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

Based on record reviews and interviews, the facility failed to ensure a resident was free from unnecessary medications by failing to: 1. Ensure each resident medication had an adequate indication for use for 1 (Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications; and, 2. Ensure adverse reactions and behavior monitoring was completed for a resident receiving antipsychotic and hypnotic medications for 1 (Resident #51) of 5 (Resident #2, Resident #8, Resident #19, Resident #51, and Resident #61) sampled residents reviewed for unnecessary medications. Findings: 1. Review of the facility's September 2023 Pharmacy Log revealed, in part, documentation that Resident #51's pharmacy consult identified Resident #51 had no diagnoses for medications. Further review revealed Resident #51's pharmacy consult was marked as outstanding. Review of Resident #51's Consultant Pharmacist Recommendations to Nursing Staff dated 09/25/2023 revealed, in part, the pharmacist identified Resident #51 had no clear or…

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

Based on interviews and record reviews, the facility failed to maintain documentation that the resident or resident representatives received education regarding the benefits and potential side effects of the influenza vaccine for 5 (Resident #28, Resident #40, Resident #42, Resident #56 and Resident #63) of 5 (Resident #28, Resident #40, Resident #42, Resident #56 and Resident #63) sampled residents reviewed for influenza vaccines. Findings: Review of the facility's policy titled, Influenza Vaccination, revealed, in part, the following: 1. Prior to the administration of the influenza vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of CDC's current vaccine information statement relative to the influenza vaccination, and 2. Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. Review of Resident #28's influenza vaccine consent form revealed, in part, Section 3: Consent for vaccination, I have read or had explained to me…

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 observations the facility failed to have a have a comfortable mattress for a resident. This deficient practice was for 1 (Resident #34) of 18 (Resident #1, Resident #2, Resident #8, Resident #11, Resident #15, Resident #19, Resident #25, Resident #28, Resident #34, Resident #40, Resident #42, Resident #51, Resident #57, Resident #61, Resident #66, Resident #67, Resident #72, and Resident #73) sampled residents investigated. Findings: Resident #34 In an interview on 11/28/2023 at 1:12 p.m., Resident #34 stated that his mattress was sunken down in the middle and was uncomfortable. Observation on 11/29/2023 at 9:28 a.m. revealed Resident #34's bed was sunken down in the middle towards the head of the bed. In an interview on 11/29/2023 at 9:35 a.m., S14Licensed Practical Nurse (LPN) confirmed Resident #34's mattress should not be sunken down. S14LPN further stated the bed was changed out about two weeks ago. In an interview on 11/29/2023 at 9:36 a.m., Resident #34 stated that his mattress was changed out two weeks ago, it was sunken down in the middle. In an…

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

Based on observations and interviews, the facility failed to have a failed to maintain a resident's wheelchair in a sanitary manner. This deficient practice was for 1 (Resident #1) of 18 (Resident #25, Resident #34, Resident #28, Resident #67, Resident #66, Resident #57, Resident #61, Resident #8, Resident #19, Resident #51, Resident #1, Resident #40, Resident #2, Resident #15, Resident #72, Resident #73, Resident #11, and Resident #42) sampled residents investigated. Findings: Observation on 11/28/2023 at 9:41 a.m. revealed Resident #1 was reclined in her wheelchair which had stains of an unknown white substance covered the seat, the back, and the wheels and a wad of hair caught in the right and left front wheels. Observation on 11/28/2023 at 11:45 a.m. revealed Resident #1 was reclined in her wheelchair which had generalized stains of an unknown white substance and a wad of hair caught in the right and left front wheel. Observation on 11/29/2023 at 9:15 a.m. revealed Resident #1 was reclined in her wheelchair which had stains of an unknown white substance and a wad of hair caught…

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, interviews, and observation, the facility failed to ensure a resident's injury of unknown origin was reported for 1 (Resident #1) of 18 (Resident #1, Resident #2, Resident #8, Resident #11, Resident #15, Resident #19, Resident #25, Resident #28, Resident #34, Resident #40, Resident #42, Resident #51, Resident #57, Resident #61, Resident #66, Resident #67, Resident #72, and Resident #73) sampled residents investigated. Findings: Review of the facility's Abuse policy and procedure revealed, in part, an injury was classified as an injury of unknown source when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Further review revealed reporting of an injury of unknown source was required no later than 24 hours after forming the suspicion. Review of Resident #1's Minimum Data Set 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.

Based on record reviews and interviews, the facility failed to thoroughly investigate a resident's injury of unknown origin for 1 (Resident #1) of 18 (Resident #25, Resident #34, Resident #28, Resident #67, Resident #66, Resident #57, Resident #61, Resident #8, Resident #19, Resident #51, Resident #1, Resident #40, Resident #2, Resident #15, Resident #72, Resident #73, Resident #11, and Resident #42) sampled residents investigated. Findings: Review of the facility's Abuse policy and procedure revealed, in part, an injury was classified as an injury of unknown source when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. Further review revealed a thorough investigation should be completed within 5 working days of the allegation. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 10/25/2023…

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

Based on record review and interview, the facility failed to develop a plan of care with measureable objectives and timeframes for a resident receiving hospice services. This deficient practice was identified for 1 (Resident #28) of 1 (Resident #28) sampled residents reviewed for hospice services. Findings: Review of Resident #28 record revealed, in part, an admission date of 10/11/2022. Review of Resident #28's November 2023 Physician Orders revealed, in part, an order with a start date of 09/22/2023 to admit to hospice care services. There was no documented evidence and the facility did not present any documented evidence that a plan of care was developed related to Resident #28 receiving hospice services. In an interview on 11/30/2023 at 10:00 a.m., S25Licensed Practical Nurse (LPN) acknowledged Resident #28 did not have a care plan implemented for Hospice Care when Resident #28 was admitted to Hospice Care on 09/22/2023. In an interview on 11/30/2023 at 10:05 a.m., S27Corporate Minimum Data Set Nurse stated they were not auditing the current Care Plans to ensure they were…

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

Based on record reviews, observations, and interviews, the facility failed to clarify a physician's order for a nutritional supplement prior to administration for 1 (Resident #57) of 2 (Resident #11 and Resident #57) sampled residents reviewed for nutrition. Findings: Review of the May 2023 Louisiana Administrative Code, Title 46, Part XLVII revealed, in part: the registered nurse retained the accountability for the total nursing care of the individual, and was responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she received, regardless of whether the care was provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. Review also revealed the registered nurse must clarify any order or treatment regimen believed to be inaccurate, or contraindicated by consulting with the appropriate licensed practitioner and by notifying the ordering practitioner when the registered nurse made the decisions not to administer the medication or treatment. Review of Resident…

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

Based on record reviews, observations, and interview, the facility failed to ensure a dependent resident received nail care for 1 (Resident #1) of 2 (Resident #1 and Resident #42) sampled residents investigated for activities of daily living. Findings: Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 10/25/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status score of 04, which indicated Resident #1 had severe cognitive impairment. Further review revealed Resident #1 was dependent on facility staff for all self-care and did not display rejection of care behaviors in the lookback period. Review of Resident #1's care plan revealed, in part, Resident #1 had impaired cognitive function and contractures to her right upper and lower extremities. Further review revealed interventions included staff were to assist Resident #1 as needed to complete all activities of daily living, including personal hygiene. In an interview on 11/28/2023 at 9:42 a.m., S5Certified Nursing Assistant (CNA) stated Resident #1 was a totally dependent on staff for…

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

Based on observation, interview, and record review the facility failed: 1. Ensure an indwelling catheter bag was not lying on the floor and/or held above the waistline while emptying the catheter bag (Resident #19); and 2. Ensure catheter care was performed correctly (Resident #66). This deficient practice was identified for 2 (Resident #19 and Resident #66) of 2 (Resident #19 and Resident #66) sampled residents reviewed for catheter care. Findings: Resident #19 Review of Resident #19 clinical record revealed, in part, diagnosis of Urinary Tract Infection and Urinary Retention. Review of Resident #19's Care Plan revealed, in part, Resident #19 had an indwelling catheter. Observation on 11/27/2023 at 9:58 a.m. revealed Resident #19's catheter bag was held by a Certified Nursing Assistant (CNA) above Resident #19's waistline. Further observation revealed cloudy, yellow, urine with sediments back-flowed towards Resident #19's bladder. Observation on 11/29/2023 at 9:25 a.m. revealed Resident #19's catheter bag was lying on the floor. Observation on 11/29/2023 at 11:25 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 observation, interview and record review the facility failed to ensure a resident's dialysis access site was assessed for a thrill (palpable vibration of blood through access to test patency) and a bruit (audible sound of blood passing through access to test patency) on every shift as ordered by the physician for 1 (Resident #11) of 1 (Resident #11) sampled residents reviewed for dialysis. Findings: Review of Resident #11's record revealed, in part, diagnoses of chronic kidney disease, end stage renal disease, dependence on renal dialysis. Review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/27/2023 revealed, in part, Resident #11's Brief Interview Mental Status score was 15, which indicated he was cognitively intact. Review of Resident #11's November 2023 Physician Orders revealed, in part, monitor dialysis fistula access site every shift for thrill and bruit with a start date of 10/24/2023. Review of dialysis monitoring documentation revealed, in part, a monitoring order was in place stating monitor dialysis fistula every shift for thrill 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 interview, the facility failed to complete an annual performance review of every certified nurse aide (CNA) at least once every 12 months for 2 (S7CNA and S9CNA) of 2 (S7CNA and S9CNA) personnel records reviewed. Findings: Review of S7CNA's personnel record revealed, in part, a hire date of 08/10/2021. Further review revealed S7CNA's last annual performance review had been completed on 11/02/2022. Review of S9CNA's personnel record revealed, in part, a hire date of 10/28/2021. Further review failed to reveal evidence an annual performance review had been completed for S9CNA in the last 12 months. In an interview on 11/28/2023 at 11:26 a.m., S10Human Resources/Payroll confirmed S7CNA and S9CNA did not have an annual performance review completed in the last 12 months. S10Human Resources/Payroll stated the head of the nursing department was responsible for the completion of annual performance reviews for the certified nurse's aides. S10Human Resources/Payroll stated the facility was aware annual performance evaluations had not been completed timely. There…

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 ensure eye drops were labeled per facility policy. This deficient practice was identified for 1 medication cart (Cart x) of 2 medication carts ( Cart x, and Cart y) observed for medication storage task. Findings: Review of the facility's policy titled Pharmacy Services Labeling and Storage of Drugs and Biologicals revealed, in part: for medications designed for multiple administration (inhalers, eye drops), the label identifies the specific resident for whom it was prescribed. Observation on 11/29/2023 at 10:16 a.m. of Cart x revealed, in part, an opened bottle of Artificial Tears Ophthalmic Solution (eye drops used for dry eye relief and lubricant). Further observation revealed there was no way to identify which resident the eye drops belonged to. In an interview on 11/29/2023 at 10:16 a.m., S23Agency Nurse acknowledged the opened bottle of Artificial Tears Ophthalmic Solution should have had the resident's name but it was not labeled. S23Agency Nurse further stated she was unable to identify which resident…

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

Based on record reviews and interviews, the facility failed to obtain laboratory services for 3 (Resident #1, Resident #3, and Resident #5) of 5 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) Findings: Resident #1 Review of Resident #1's Physician's Orders with a start date of 05/10/2023 revealed, in part, CBC (complete blood count), CMP (comprehensive metabolic panel), Keppra (a medication used to treat seizures), Dilantin (a medication used to treat seizures), and Valproic Acid (a medication used to treat seizures) level on admit and every 3 months in the morning. Review of Resident #1's Office Visit Report dated 05/15/2023 and completed by Resident #1's Physician revealed, in part, need Depakote level drawn soon after the patient is administered medication, need Keppra level drawn, need phenytoin level drawn, obtain CBC, CMP, TSH (thyroid stimulating hormone), Lipid Panel and Vitamin D. Review of Resident #1's record revealed no documented evidence, and the facility did not present any documented evidence, the above documented labs were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to: 1.Ensure the ordering physician was promptly notified of laboratory results for 1(Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and 2.Ensure there was a physician's order for completed labs for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: 1. Review of Resident #2's July 2023 physician's orders revealed, in part, an order dated 07/05/2023 to obtain a Magnesium (a mineral that helps the heart work properly) level. Review of Resident #2's lab report revealed, in part, labs that were drawn on 07/05/2023 and reported to facility on 07/06/2023, resulted in a critical Magnesium level of 0.9 mg (milligrams)/dL (deciliter) (Normal Range 1.6 mg/dL-2.3 mg/dL). Review of Resident #2's progress notes revealed, in part, no documentation that the ordering physician was notified of the critical Magnesium level 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.