Natchitoches Nursing and Rehabilitation Center, LL

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident received reasonable accommodation of needs for 1 (#R2) of 9 sampled residents. The facility failed to ensure Resident #R2 had an appropriate call light within reach to call for assistance.Findings:Review of Resident #R2's medical record revealed an admission to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Quadriplegia, Body Mass Index 19/9 or less, Adult, Depression, and Pressure Ulcer to Sacral Region, Stage 4. Review of Resident #R2's admission MDS with ARD of 01/06/2026 revealed a BIMS score of 13, indicating intact cognition. Resident #R2 has impairment on both the left and right side and requires assistance with all ADL's. An observation on 02/19/2026 at 11:35 a.m. Resident #R2 is observed lying in bed. The call bell is observed situated between the bed and side rail, out of reach to resident. Resident #R2 stated that he is unable to utilize the call bell system, and at times has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide incontinent care in a timely manner for 1 (#2) of 9 residents reviewed for ADL care. Findings:Review of the Facility's 01/26/2026 policy titled Supporting Activities of Daily Living read in part.Policy Statement: Residents will be provided with care, treatment and services to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Review of Resident #2's medical records revealed an admission to the facility on [DATE] with the following Diagnoses: Type 2 Diabetes Mellitus, Quadriplegia, Essential Hypertension, Major Depressive Disorder, Cognitive…

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

Based on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to: 1. Ensure Resident #7's Suprapubic Indwelling Catheter was changed monthly according to physician's orders; and 2. Input and follow physician wound care clinic orders for wound care for 1 (#7) of 7 sampled residents.3. Follow physician wound care orders for wound care for 1 (#6) of 7 sampled residents. Findings: #1. Review of Resident #7's medical record revealed an admission date of 04/25/2024, with diagnoses that included in part .Type 2 Diabetes Mellitus with Diabetic Mononeuropathy, UTI, Anxiety, Cellulitis of Right Lower Limb and Left Lower Limb, Edema, Venous Insufficiency (Chronic, Peripheral), and Neuromuscular Dysfunction of Bladder. Review of Resident #7's Quarterly MDS with an ARD of 12/19/2025 revealed a BIMS score of 14, which indicated intact cognition. Resident #7 required partial/moderate assistance with hygiene, was incontinent for bladder and bowel, and had an infection of the foot (cellulitis, purulent…

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.

Findings:Review of Resident #8's Clinical Record revealed an admit date of 10/12/2022 with diagnoses which included: Other Muscle Spasm; Quadriplegia, C5-C7 Complete; and Other Chronic Pain.Review of Resident #9's Clinical Record revealed an admit date of 11/19/2025 with diagnoses which included: Contracture, Right Shoulder; Contracture, Right Elbow; Limitation of Activities due to Disability; Quadriplegia; Other Muscle Spasm; Contracture, Left Shoulder; Chronic Pain Syndrome; Age-Related Nuclear Cataract, Unspecified Eye; Myopia, Unspecified Eye, Primary Generalized (Osteo) Arthritis. Review of Resident #10's Clinical Record revealed an admit date of 12/26/2025 with diagnoses which included: Unspecified Dementia; Muscle Weakness (Generalized); Unspecified Lack of Coordination; Other Symbolic Dysfunctions; Dysphagia; (Idiopathic) Normal Pressure Hydrocephalus. Observation on 01/12/2026 at 12:39 p.m. revealed S7 CNA standing while feeding Resident #8 during meal service.In an interview with S7 CNA on 01/12/2026 at 2:06 p.m. S7 CNA stated Resident #8 was total care and he had to be…

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.

Findings: A review of Resident #4's Quarterly MDS with an ARD date of 11/24/2025 revealed Resident #4 had a BIMS of 15 which indicated the resident was cognitively intact. In an interview with Resident #4 on 01/13/2026 at 9:25 a.m., he revealed he was unable to get his money out of his trust fund. He stated he had been asking S11 Administrative Assistant/Office Manager for it since October 28, 2025, and was repeatedly told tomorrow. In an interview with S11 Administrative Assistant/Office Manager on 01/13/2026 at 9:55 a.m., she revealed Resident #4 wanted money from his trust fund to reimburse his family for wheelchair parts and other purchases made in October 2025. In an interview with S11 Administrative Assistant/Office Manager on 01/13/2026 at 10:05 a.m., she revealed Resident #4 submitted his receipts for the purchased items on 12/02/2025 and she emailed it to the regional financial consultant for approval. In an interview with S11 Administrative/Office Manager on 01/13/2026 at 10:15 a.m., she confirmed she did not give Resident #4 the reimbursement checks within 3 days after…

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 develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #7) resident of 7 sampled residents. The facility failed to develop and/or initiate a care plan for Resident #7's suprapubic indwelling catheter.Findings: Review of a facility's policy on 01/14/2026 at 3:18 p.m. titled, Comprehensive Person Centered Care Plans with a review date of 01/2025 revealed the following in part . Policy: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. 7. The Comprehensive Person-Centered Care Plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change, and annual assessments per the RAI manual. Review of Resident #7'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 observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff followed proper infection control practices during wound care for 1 (#7) of 1 resident observed during wound care. Findings:Review of the facility's policy on 01/14/2026 at 3:11 p.m., titled Standard Precaution with a review date of 09/2019 revealed, in part.Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel. Definition: implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel. These include: hand hygiene, use of gloves, gown, mask, eye protection, and/or face shield…

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

Based on observation, record review and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure x-ray results were followed up on in a timely manner for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #1's clinical record revealed an admit date of 09/08/2020, with diagnoses which included Alzheimer's Disease with Late Onset; Vitamin Deficiency, Pain in Left Hip; Unspecified Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Abnormalities of Gait and Mobility; Lack of Coordination, Muscle Weakness, Fracture of Unspecified Part of Neck of Left Femur, Presence of Left Artificial Hip Joint, and Dementia. Review of Resident #1's Care Plan dated 01/12/2025 revealed in part At risk for falls/injuries. 2/28/24; 3/16/24; 5/30/25: Unwitnessed fall with interventions to include . Contact MD with abnormal findings. Review of Resident #1's Progress notes revealed in part . Nursing note dated 05/30/2025 at 5:18 p.m. by S2 LPN: around 3:45pm Aid notified this…

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 the Quality Assessment and Assurance (QAA) committee meetings included the required staff members for the facility's quarterly committee meetings. The facility failed to ensure the Infection Preventionist (IP) was in attendance at each quarterly committee meetings. This deficient practice had the potential to affect all 58 residents residing in the facility. Findings: Review of the facility's policy on 03/12/2025 at 2:40 p.m. titled Quality Improvement Program, with a revision date of 10/2022, revealed the following in part .Procedure 2. Committee team members shall consist of the DNS, Medical Director or designee, and three other staff; at least one of who must be the Administrator, Owner, a Board Member, or other individual in a leadership role; and the Infection Preventionist. Review of the facility's QAA Committee list revealed the following in part .The QAA Committee meets once monthly and as needed. The committee is comprised of: Executive Director, Director of Nursing, Medical Director, Social Services,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #23 Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, and mental and psychosocial needs for 1 (#23) of 24 sampled residents. The facility failed to ensure Resident #23 was care planned for discharge planning. Findings: Review on 03/12/2025 of the facility's policy titled Comprehensive Person Centered Care Plans last revised on 01/2025 revealed in part .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .The Comprehensive Person-Centered Care Plan contains services provided, preference, ability, goals for admission and desired outcomes, and care level guidelines. Review of Resident #23's medical record revealed an admit date of 02/19/2024 with diagnoses that included in part .Schizophrenia, Diabetes Mellitus, and Chronic Pain Syndrome. Review of Resident #23's Quarterly…

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 all services provided met professional standards of quality. The facility failed to notify the physician of 3+ edema for 1 (#26) of 58 sampled residents. Findings: Review of Resident #26's medical record revealed an admission date of 03/17/2020, with a diagnosis of Edema. Review of Resident #26's current Physician Orders dated 10/31/2024 revealed . Monitor edema every shift. Indicate any edema with 0, 1+, 2+, 3+, or 4+. Notify physician if 3+ or 4+. Review of Resident #26's 01/2025 Progress Notes revealed Resident #26 had 3+ edema on 01/03/2025. Review of Resident #26's 01/2025 MAR revealed 3+ edema was documented on 01/09/2025. Review of Resident #26's 02/2025 MAR revealed 3+ edema was documented on 02/02/2025, 02/03/2025, 02/05/2025, 02/06/2025, 02/15/2025, 02/19/2025, 02/20/2025, 02/21/2025, 02/22/2025, 02/23/2025, 02/24/2025, 02/25/2025, 02/26/2025, 02/27/2025, and 02/28/2025. Review of Resident #26's 03/2025 MAR revealed 3+ edema was documented on 03/02/2025, 03/03/2025, 03/04/2025, 03/05/2025, 03/06/2025,…

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

Resident #59 Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 (#59) of 1 resident reviewed for ADLs (Activities of Daily Living). Findings: Review of Resident #59's medical record revealed an admit date of 01/13/2025 with diagnoses that included in part .Polyosteoarthritis, Type 2 Diabetes Mellitus, and Hypertension. Review of Resident #59's admission MDS with an ARD of 01/20/2025 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #59 was independent with eating and required partial to moderate assistance with rolling left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed to chair transferring. Review of Resident #59's care plan revealed a focus area initiated on 01/17/2025 of The resident has an ADL self-care performance deficit related to activity intolerance, fatigue,…

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 provide an ongoing activities program to support residents in their choice of activities based on comprehensive assessments, care plans and preferences for 3 (Resident #23, Resident #25, and Resident #41) of 24 sampled residents. The facility failed to ensure an activities program occurred on the weekend. This deficient practice has the potential to effect all 58 residents currently residing in the facility. Findings: Review of a facility policy on 03/11/2025 at 2:00 p.m. titled, Activities and Social Events with a reviewed date of 10/2009, revealed the following in part .Procedure: 4. Daily activities, including those on the weekends and holidays, are provided, as well as scheduled religious and social activities .9. Individualized and group activities are provided that: B. are offered at hour of convenient to the residents, including evenings, holidays, and weekends. Review of the facility's March 2025 activities calendar revealed the following scheduled activities in part . 03/08/2025: 11:00 a.m. Ring Toss and 2:00 p.m.…

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

Based on record review and interview, the facility failed to ensure the Medical Director was notified when a hospice resident had an accident resulting in injury and pain that could not be relieved for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility waited 14 hours for hospice to come assess Resident #1 before sending the resident to the emergency room. Findings: Review of facility's policy on 01/07/2025 titled Notification of Change in a Resident's Status dated 11/2017 revealed in part . 1. Guideline for notification of physician/responsible party: j. Abnormal complaints of pain, ineffective relief of pain from current regimen. Review of Resident #1's medical record revealed an admit date of 05/15/2020 with diagnoses that included in part .Alzheimer's Disease, Major Depressive Disorder, Pressure Ulcer of Sacral Region, and Edema. Review of Resident #1's Quarterly MDS with an ARD of 12/12/2024 revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Review of the MDS revealed Resident #1 was dependent with eating, rolling left 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 review and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive care plan for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility failed to ensure Resident #1, who reported pain after a fall, and displayed nonverbal indicators of pain, received pain medication as ordered to alleviate pain. Findings: Review of facility policy on 01/07/2025, dated 01/2025, and titled Pain Evaluation/Management, revealed the policy did not address the administration of pain medication, as ordered. Review of Resident #1's medical record revealed an admit date of 05/15/2020, with diagnoses that included in part .Alzheimer's Disease, Major Depressive Disorder, Pressure Ulcer of Sacral Region, and Edema. Review of Resident #1's Quarterly MDS with an ARD of 12/12/2024, revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. Review of the MDS revealed Resident #1 was dependent with eating, rolling left and right,…

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

Based on observation, record review, and interview, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (#R1 and #R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) sampled residents. The facility failed to maintain privacy for residents by allowing the shower door to remain open during resident care. Findings: Review of the facility's policy dated (01/2023) titled Resident [NAME] of Rights revealed in part .Each resident has a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion including those rights specified herein. Review of the facility's policy dated (08/2011) titled Bath/Shower-…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure physician's orders were implemented as ordered. The facility failed to administer a medication (antibiotic) when ordered for 1 (#3) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) sampled residents. Findings: Review of the Facility's Policy titled Medication Administration General Guidelines dated (8/2016) revealed in part . Responsibility: All Licensed Nursing Personnel. Procedure: Medications are administered in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. Review of Resident #3's clinical record revealed an admit date of 09/28/2024 with diagnoses that included in part . Urinary Tract Infection, Vitamin Deficiency, Dementia and Osteoarthritis. Review of Resident #3's State Optional MDS with an ARD of 11/09/2024 revealed a BIMS of 6, 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 observation and interview the facility failed to dispose of garbage and refuse properly. The total facility census was 63 residents. Findings: Review of the facility's undated policy titled, Garbage and Rubbish Disposal on 11/21/2024 at 12:20 p.m. read in part . Guideline: All outside dumpsters will be maintained in a clean and sanitary condition. Procedure: 5. Storage areas will be kept clean to discourage pests. Storage areas should be routinely inspected by the facility pest control operator. 6. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. Observation on 11/21/2024 at 8:51 a.m. of the area outside of the facility's kitchen revealed one blue dumpster located inside a wooden fenced area. The dumpster receptacle was observed with the sliding door left open, and a cat jumped out of the dumpster. Observation revealed there was trash on the ground, in front of dumpster. A torn mattress and two walkers was outside of the dumpster area. Signage observed on the sliding door read in part .dumpster door to be closed at all times.…

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

Based on observation and interview the facility failed to ensure a safe, functional and comfortable environment for residents. The facility failed to: 1. Repair a toilet base in Room A; and 2. Repair the shower room door on X hall. Findings: Observation of Room A's restroom on 11/21/2024 at 8:58 a.m. revealed broken pieces of a solid material underneath the toilet. Observation of Room A's restroom on 11/25/2024 at 3:28 p.m. revealed broken pieces of a solid material under the toilet. Interview with Resident #R2 on 11/25/2024 at 3:28 p.m. revealed the toilet in his room (Room A) had been in disrepair since he moved into the room last year. Review of Resident #R2's Quarterly MDS with an ARD of 11/07/2024 revealed a BIMS of 15. Observation of the shower door on X Hall on 11/25/2024 at 09:28 a.m. revealed a hole near the bottom of the door that was approximately 6 inches in width. Observation and Interview with S3 Maintenance on 11/25/2024 at 3:32 p.m. confirmed there was a hole and cracked area at the bottom of the shower door on X Hall, and there should not be. S3 Maintenance revealed…

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

Based on record review, observation, and interview, the facility failed to provide a private space for the Resident Council Meeting held 10/07/2024 and failed to act promptly upon the grievances voiced by the residents during monthly resident council meetings. The deficient practice had the potential to affect a total of 66 residents residing in the facility. Findings: Review of the facility's policy titled Resident Council dated 02/2017 revealed in part . 1. The Resident Council structure and process will be established by the residents with the Social Services staff. 2. Monthly meetings will be scheduled in an area that promotes privacy or per Resident request. Review of the facility's policy titled Complaint/Grievance/Missing Property dated 01/2015 revealed in part . A.1. Resident Council meetings are to allow time for residents to address concerns or complaints. Minutes are to reflect the issues and the direction taken. Respective Department Heads and/or Executive Director will follow up on issues noted. In an observation of the Resident Council meeting on 10/07/2024 at 1:30…

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 residents were provided with a diet specific for his special dietary needs and preferences. The facility failed to ensure that an artificial sugar sweetener was available for use for Resident #1 who required a diabetic precautions diet. The total facility census was 62 residents. Findings: Review of Resident #1's Medical Record revealed an admission date of 02/19/2024 with diagnoses that included Diabetes due to underlying condition with Diabetic Neuropathy, Unspecified, Hyperlipidemia, Essential Primary Hypertension, Schizophrenia and Mood Disorder due to known Physiological condition and other Intellectual Disabilities. Review of Resident #1's Physician Orders for September 2024 revealed an order dated 02/19/2024 for Regular diet with DM Precautions Diagnosis: Diabetes due to underlying condition with Diabetic Neuropathy, Unspecified. Review of Resident #1's Quarterly MDS with an ARD of 09/05/2024 revealed a BIMS score of 15, indicating intact cognition. Review of Resident #1's Care Plan with a Target…

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 act promptly upon grievances and recommendations of the resident council concerning issues of resident care and life in the facility; and failed to demonstrate their response and rationale for such response. The facility census was 58. Findings: Review of the facility's Resident Council Policy revealed the following including: The Social Services Director or designee will facilitate the organization and maintenance of a facility Resident Council. Responsibility: Social Service Director or designee. Review of the facility's Grievance Policy reveal the following in part, A. 1. Respective Department Head, Executive Director and/or Grievance Official will follow-up on issues noted. a. Grievances may be presented to any staff member who will then report the issue utilizing the Grievance Form to his/her supervisor and/or department head. b. The supervisor will discuss the concerns/grievances and appropriate solutions with the department direction. Review of the facility's Resident Rights Policy revealed the following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #26 Review of Resident #26's medical record revealed Resident #26 was admitted to the facility on [DATE]. Resident #26 had diagnoses that included in part . Dementia, Kidney Failure, Urinary Incontinence, Anxiety, Dizziness and Giddiness, and Unsteadiness on feet. Review of Resident #26's Quarterly MDS with ARD of 12/07/2023 revealed Resident #26 had a BIMS of 13 (intact cognition). Resident required Substantial/Maximal assistance for toileting, showering/bathing, and dressing. Resident was always incontinent of Bowel/Bladder. Observation on 01/10/2024 at 9:41 a.m. of Resident #26's room revealed a strong urine odor within room. There was a heavily soiled pull up that contained urine lying on the floor beside the right side of Resident's bed. Interview with Resident #26 at time of observation revealed she called for help, but had to wait too long for assistance. Resident #26 stated she had to go to the restroom on her own, and pointed to her bathroom. Observation of the bathroom revealed the toilet seat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 (Resident #10, Resident #12, Resident #16, Resident #26, and Resident #28) of 24 sampled residents. Findings: Review of the facility's policy titled, Care Plans read in part . Policy: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care. Responsibility: Nurse will be monitored by ED. Procedure: 1. The Care Plan will be developed within 2 days. Subsequent meetings will take place yearly and as needed. 2. The team along with the resident and/or family members will identify services needed, preferences, and ability and care level guidelines. 3. The Care plan will be reviewed and/or revised yearly with the completion of the Admission/ Readmission/Yearly Evaluation and with changes in resident'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 record review, observation, and interview, the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 5 (#5, #11, #12, #17, & #53) of 7 (#5, #11, #12, #17, #22, #30, & #53) residents reviewed for ADLs. Findings: Resident #5 Review of the medical record for Resident #5 revealed an admit date of 11/06/2020 with diagnoses that included: Schizoaffective Disorder, Chronic Kidney Disease, Muscle Weakness, and Type 2 Diabetes Mellitus. Review of Resident #5's Quarterly MDS with an ARD of 11/23/2023 revealed a BIMS score of 13, indicating intact cognition. Review of the MDS revealed Resident #5 was dependent with showering/bathing, dependent with toileting hygiene, and dependent with tub/shower transferring. Review of Resident #5's care plan revealed a problem of incontinent of bowel and bladder and requires assistance with dressing, grooming and hygiene tasks, bed mobility 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 observation, interview and record review, the facility failed to provide sufficient numbers of CNAs to perform services on a 24-hour basis to provide nursing care to all residents in accordance to the resident care plans for all 58 residents in the facility; Findings: Review of the Facility's Facility Assessment Tool Staffing Plan revealed the following including: Staffing Plan 3.2 - Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Nurse Aides - 20 per day (8 hour shift); Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any time - Nursing Assistants - 1:7 Residents on Days (6 CNAs/2 Restorative Aides); 1:12 Residents on evenings (3-4 CNAs); and 1:19 Residents on nights (3 CNAs). Review of the Facility's Staffing Pattern Report Form revealed the following days when there was not enough CNAs based on the Facility Assessment: 11/25/2023 - 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.

FACILITY Based on observation and interview the facility failed to dispose of garbage and refuse properly. This could affect all 58 residents in the facility. The total facility census was 58 residents. Findings: Review of the facility's policy titled, Garbage and Rubbish Disposal read in part . Guideline: Garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen does not encourage infest or rodents. All outside dumpsters will be maintained in a clean and sanitary condition. Procedure: 6. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. Observation on 01/08/2024 at 09:20 a.m. revealed the slide door of the facility dumpster open. Observation of several pieces of paper trash on the ground surrounding the facility's dumpster and one broken bed frame outside of the kitchen door on the ground. Interview at this time with S15 Dietary Manager confirmed the above findings. S15 Dietary Manager stated she was unaware of when the broken bed frame was put outside. S15 Dietary Manager confirmed that the facility's dumpster slide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections. The facility failed to ensure the following: 1. Proper hand hygiene during wound care for Resident # 17. 2. Proper staff training of chemicals used for cleaning and disinfection of environment. 3. Proper handling of medical equipment during wound care for Resident # 28. This failed practice had the potential to affect all staff and the residents residing at the facility. The facility census was 58. Findings: Review of the facility's policy titled, Standard Precautions read in part . Policy: Standard Precautions will be utilized to provide a primary strategy for the prevention of HAI agents among patients and healthcare personnel. Definitions in part . Standard Precautions applies to all persons regardless of their diagnosis or presumed infectious…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure cognitively impaired residents were treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 2 (#17, #59) of 4 (#17, #22, #53, and #59) Residents reviewed for dignity in a total sample of 24. The facility failed to: 1. Ensure Resident #17's hair was maintained in a manner of her preference. 2. Ensure Resident #59 was dressed appropriately. Findings: Resident #17 Review of Resident #17's medical record revealed an admit date [DATE] of with diagnoses that included in part . Hemiplegia, Dysphasia, Schizoaffective Disorder-Bipolar Type, Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Malnutrition, Major Depressive Disorder, Generalized Anxiety Disorder, Atherosclerotic Heart Disease, Diverticulitis, Osteoarthritis, Urinary Tract Infection, Epilepsy, and Chronic Obstructive Pulmonary Disorder. Review of Resident #17's Quarterly MDS with an ARD of 11/30/2023 revealed a BIMS score of…

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

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #28) of 1 resident reviewed for environment. The facility failed to ensure Resident #28 had an adaptive call light in reach in order to call for assistance. The total facility census was 58 residents. Findings: Review of Resident #28's Medical Record revealed an admission date of 10/12/2022 with diagnoses that included Quadriplegia, C5-C7 Complete, Chronic Kidney Disease, Neuromuscular dysfunction of bladder, Anxiety disorder, Pressure Ulcer of Left Hip, Unstageable, Pressure Ulcer of Sacral Region, Unstageable, Chronic Pain, Depression and Essential Primary Hypertension. Review of Resident #28's Physician's Orders revealed: 10/12/2022 - Admit to (facility) under the care of _____ Hospice 10/12/2022 - O2 Nasal Cannula at 2 liters prn SOB 10/12/2022 - Morphine Sulfate 100mg/5 ml concentrate give 0.25ml po every 2 hours prn pain 10/12/2022 - Ondansetron HCl 4mg give 1 tablet po every 6 hours prn…

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 their grievance policy and procedure was followed. The facility failed to inform the resident/resident's RP (responsible party) of investigation findings and actions taken to correct the identified problems for 1 (#17) of 24 sampled residents. Findings: Review of the facility policy titled Grievance/Missing Property revealed in part . Grievances may be presented to any staff member; the staff member may resolve the issue immediately. If unable to resolve immediately, follow the Grievance Procedure. 1. Respective Department Head, Executive Director and/or Grievance Official will follow-up on issues noted. 2. Supervisory personnel or department heads are responsible for reviewing the Grievance form within 10 working days. Department heads are responsible for reviewing, signing and forwarding the completed complaint form to the Executive Director and/or Grievance Official. 3. Social Service is responsible for notifying resident representative, family/next of kin and Ombudsman, as appropriate, of resolution. Supervisory…

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 provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 (Resident #10) of 1 sampled resident reviewed for foot care. Findings: Review of the Facility's Preventive Skin Care Policy revealed the following including: 4. Provide Preventive skin care to all residents .a. Keep skin clean, dry, and cleansed at the time of soiling and at routine intervals. Observation on 01/09/2024 at 4:22 p.m. revealed Resident #10 sitting in his wheelchair in his room asleep. He had a dressing intact to his right foot. Observation on 01/11/2024 at 8:45 a.m. revealed Resident #10 sitting in his wheelchair in the front lobby. He had a dressing intact to his right foot. He confirmed that he had asked one of the nurses to change his dressing to his right foot because it was dirty from drainage. Resident #10 stated the nurse refused to do the treatment because it was not her job. Review of Resident #10's EHR revealed an admit…

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 residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #10) of 1 sampled resident receiving dialysis. Findings: Review of the facility's Dialysis Information Update Transfer Policy revealed the following: Policy: A Dialysis Information Update Transfer Form is completed each time a resident receives outpatient dialysis. This ensures enhanced communication between the two facilities. Procedure: 1. The top section of the Dialysis Information Update Transfer Form is completed by the nurse responsible for sending the resident to the dialysis unit/facility.3. The bottom section of the form is completed by personnel responsible for the resident at the dialysis facility and returned to the nursing home with the resident. 4. Once the form is completed in its entirety, the most recent form should be filed under Consultant Reports in the medical record. 5. As…

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

Based on observations, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1(Resident #2) of 3 (Resident #1, Resident #2, & Resident #3) sampled residents. The facility failed to ensure Resident #2's call light was answered within a timely manner after calling for assistance. Findings: Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/28/2023 revealed she had a BIMS (Brief Interview for Mental Status) of 14 (cognitively intact). Observation on 11/06/2023 at approximately 1:10 p.m. while in Resident#1's room, this surveyor heard a beeping sound. After exiting Resident #1's room, the beeping sound became louder. The sound was noted to be coming from the call light panel located behind the nurses' station. Resident #2's room was illuminated in red on the call light panel. Observation by this surveyor revealed the light over Resident#2's room door was noted to be on, and the beeping sound was audible from 1:10 p.m. -2:30 p.m. without any staff responding to Resident #2's call…

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 that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide incontinent care to a dependent resident for 1(Resident #2) of 3 (Resident #1, Resident #2, & Resident #3) residents sampled for ADL's. Findings: Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 07/09/2020 with diagnoses which included Fibromyalgia; Pressure Ulcer of sacral region, unspecified stage; Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified; Iron Deficiency Anemia, unspecified; and Hyperlipidemia, unspecified. Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/28/2023 revealed a BIMS (Brief Interview for Mental Status) of 14 (cognitively intact). Resident #2 required 2 person physical assist with bed mobility, dressing, and toilet use and 1 person physical assist with eating and bathing. Resident #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 observation, record review and interview, the facility to provide appropriate and sufficient services, treatment and care according to standards of professional practice for Resident #2 who was reviewed for urinary catheter or UTI (urinary tract infection) out of a total of 3 sampled residents. The facility failed to ensure Resident #2's Foley catheter care was performed as ordered by the physician. Findings: Review of the Facility's Policy titled Catheter Care read in part: Policy: Catheter care is performed to keep the catheter insertion site clean. Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 07/09/2020 with diagnoses which included Fibromyalgia; Pressure Ulcer of sacral region, unspecified stage; Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified; Iron Deficiency Anemia, unspecified; and Hyperlipidemia, unspecified. Review of the November 2023 Physician orders revealed: Foley catheter care with soap and water q (every) shift Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure restorative nursing services were implemented according to the resident's person-centered plan of care for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Review of the facility's policy titled Nursing Rehabilitation/Restorative Care read in part . Rehabilitative or restorative care refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. A restorative program should be started when a resident is admitted with restorative needs, but not a candidate for therapy, or when the need arises during the course of the stay. 2. Each restorative service is then recorded in the Approaches Section of the Rehabilitation Nursing Program form with the minutes per shift documented as required.…

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

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 (Resident #1, Resident #2, and Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Resident #1 Review of Resident #1's medical record revealed an admit date of 08/22/2023, with diagnoses that included: Acute and Chronic Respiratory Failure, Metabolic Encephalopathy, Fracture of the Mandible, Unspecified Displaced Fracture of Fifth Cervical Vertebra, and Traumatic Subdural Hemorrhage. Review of Resident #1's admission MDS with an ARD of 09/05/2023 revealed a BIMS score of 99, indicating Resident #1 was unable to complete the interview. The MDS revealed Resident #1 had severely impaired cognitive skills for daily decision making, and was totally dependent requiring 2+ person physical assist with bathing, and extensive 1 person physical assist with personal hygiene. 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.

Based on interview and record review, the facility failed to ensure nursing staff were able to demonstrate competency in the skills and techniques necessary to provide tracheostomy care for 2 (S6 LPN and S7 LPN) of 3 (S6 LPN, S7 LPN and S8 LPN) facility staff, and 2 (S5 Agency LPN and S9 Agency LPN) of 3 (S5 Agency LPN, S9 Agency LPN, and S10 Agency LPN) agency staff. The facility had a total of 4 residents with tracheostomies. Findings: Interview on 10/24/2023 at 10:17 a.m. with S1 DON revealed the facility did not have a Respiratory Therapist. S1 DON reported the nurses provide all tracheostomy care as ordered. S1 DON stated all nurses, including agency nurses, received training on tracheostomy care and demonstrated competency as documented on a skills checklist, before providing care in the facility. Interview on 10/24/2023 at 10:51 a.m. with S1 DON revealed all nurses were required to complete the Tracheostomy Care Competency and Skills Evaluation on hire and annually. Review of S6 LPN's Tracheostomy Care Competency and Skills Evaluation revealed a date of 05/04/2022. Interview…

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

Based on observation, record review and interview, the facility failed to provide pharmaceutical services, to include the accurate administration of medication, for 1 (#R2) random sampled resident. The facility failed to reorder a blood pressure medication timely for #R2. The total sample was 7 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7), and 4 random sampled residents (#R1, #R2, #R3 and #R4). Findings: Review of the facility's policy titled Medication Administration - General Guidelines read in part . 14. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (e.g. resident not in facility at scheduled dose time, initial dose of antibiotic), the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If several doses of a vital medication are withheld or refused, the physician and responsible party are notified and documentation of…

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

Based on interview and record review, the facility failed to maintain accurately documented resident medication administration records for 3 (Resident #1, Resident #2, Resident #3) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents and 2 (#R1 and #R2) of 4 (#R1, #R2, #R3, and #R4) random sampled residents. Findings: Review of the facility's policy titled Medication Administration - General Guidelines read in part . 9. Only licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's MAR or TAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and al administered doses were documented. 11. The resident's MAR/TAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration. 14. If a dose…

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

Based on observation, record review and interview, the facility failed to ensure a resident's right to be treated with respect and dignity, for 1 (#R1) of 4 (#R1, #R2, #R3, and #R4) random sampled residents, in a total sample of 7 residents (#1, #2, #3, #R1, #R2, #R3, and #R4). Findings: Review of #R1's Quarterly MDS with an ARD of 09/14/2023 revealed a BIMS score of 11, indicating #R1 was cognitively intact. Observation on 10/24/2023 at 8:32 a.m. revealed #R1 informed S12 CNA that she was wet and needed to be changed. #R1 stated her bottom was burning. S12 CNA informed #R1 that they were passing breakfast trays, and she would have to wait until the trays were passed to be changed. Observation on 10/24/2023 at 8:39 a.m. revealed S12 CNA brought #R1's breakfast tray into her room and began feeding #R1. S12 CNA did not change #R1's incontinent brief prior to feeding #R1 breakfast. Observation on 10/24/2023 at 8:50 a.m. revealed S12 CNA exited #R1's room with breakfast tray in her hand. Interview with #R1 on 10/24/2023 at 8:52 a.m. revealed she still needed to be changed, and stated…

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

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences, by failing to ensure the resident had a call light within reach for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Review of Resident #4's medical record revealed an admit date of 04/19/202, with diagnoses that included: Morbid Obesity, Type 2 Diabetes Mellitus, Bed Confinement Status, Chronic Pain, and Other Sequelae of Cerebral Infarction. Review of Resident #4's Quarterly MDS with an ARD of 09/28/2023 revealed a BIMS score of 13, indicating intact cognition. The MDS revealed Resident #4 required extensive 2+ person physical assistance with bed mobility, dressing, and toilet use. Review of Resident #4's care plan with a target date of 12/2023 revealed a problem of Routine Care Needs related to Morbid Obesity, Paraplegia, and CVA, with interventions that included: keep call light within easy reach, and respond to call light promptly.…

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

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #1 and Resident #5) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents' rooms. Findings: 1. Observation of Resident #1's room on 10/19/2023 at 12:54 p.m., and 10/20/2023 at 9:39 a.m. revealed a green wall that was in need of repair. The green wall had four areas of missing paint which exposed the white underneath. Three of the areas were approximately two to three inches in length, one was approximately eleven inches in length, and all were approximately two inches wide. Observation on 10/20/2023 at 9:56 a.m. of Resident #1's room accompanied by S2 RN, and interview of S2 RN at that time confirmed that the green wall that had four areas of missing paint which exposed the white underneath. Three of the areas were approximately two to three inches in length, one was approximately eleven inches in length, and all were approximately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide services to meet professional standards of practice for 1 (Resident #2) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) sampled residents. The facility failed to perform Neurological checks on Resident #2 after finding the resident on the floor with a laceration to his head. Findings: Review of a facility policy titled Neurological Checks after head injury revealed neurological checks should be performed every 15 minutes X 4, every 30 minutes X 2, every hour X 4 and every shift X 24 hours. The resident's condition should be documented in the nurses' notes every shift X 72 hours. Review of an investigation conducted by the facility revealed Resident #2 sustained a laceration/injury of unknown origin on 10/07/2023. The facility investigation revealed Resident #2 was found on the floor with a laceration to the middle of his head/scalp. Resident #2 was evaluated in ER and returned to 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.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice of 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. Findings: Review of Resident #1's medical record revealed an admit date of 08/22/2023, with diagnoses that included: Acute and Chronic Respiratory Failure, Fracture of the Mandible, Unspecified Displaced Fracture of Fifth Cervical Vertebra, and Traumatic Subdural Hemorrhage. Review of Resident #1's admission MDS with an ARD of 09/05/2023 revealed a BIMS score of 99, indicating Resident #1 was unable to complete the interview, and had severely impaired cognitive skills for daily decision making. The MDS revealed Resident #1 required extensive 2+ person physical assistance with bed mobility. Review of Resident #1's 10/2023 Physician Orders revealed orders for full code, ipratropium bromide/albuterol sulfate (used to control asthma, chronic bronchitis, emphysema) 0.5-3(2.5) mg/3 mL neb q 4 hours, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide baths, shaving, and nail care to dependent residents for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) residents sampled for ADL's. Findings: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Peripheral Vascular Disease, Type II Diabetes Mellitus, and Alzheimers. Review of Resident #1's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/22/2023 revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 11, indicating mild cognitive impairment. The MDS review revealed Resident #1 required the physical assistance of one person for toileting, bathing and hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure their grievance policy and procedure was followed by failing to provide prompt efforts of an effective resolution to the resident's complaints for 1 (Resident #2) of 7 sampled residents (Resident #1, Resident #2,Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7). The facility had a total census of 58 residents. Findings: Review of the facility policy titled Complaint/ Grievance/ Missing Property revealed in part . a. Complaints may be presented to any staff member who will then report the issue utilizing the Complaint/Grievance Form to his/her supervisor and/or department head. 2. Supervisory personnel or department heads are responsible for reviewing the Complaint/Grievance form within 10 working days. Review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Resident #2 had diagnoses to include Schizophrenia, Major Depressive Disorder severe with Psychotic Symptoms, Generalized Anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident assessments were completed accurately for 1 (Resident #1) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) residents sampled. Findings: Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Peripheral Vascular Disease, Type II Diabetes Mellitus, and Alzheimers. Review of Resident #1's Discharge MDS with an ARD of 06/23/2023 revealed Resident #1 had a BIMS score of 9, indicating severe cognitive impairment. The MDS review revealed Resident #1 required extensive assistance for bed mobility, transfers, toileting and personal hygiene. Review of the MDS Assessment section P, Restraints, revealed Restraints were documented as 0. Not used, for all categories. Review of Resident #1's CPOC with a target date of 08/09/2023 revealed in part . Socially inappropriate behavior related to diagnosis of Impulse…

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.