Belle Teche Nursing & Rehab Center

Based on observations, interviews and policy review, the facility failed to ensure dietary staff prepared, distributed and served food in accordance with professional standards for food service safety as evidenced by 2 dietary assistants (S13DA and S14DA) without a beard restraint. Findings: On 05/21/2025 a review of facility's policy titled, Employee Sanitation Practices reviewed on 01/15/2025, revealed in part: 3. Proper Work Attire .b. The food service employee observes the following dress standards: i. Wears a clean hat or other hair restraint. Employees with facial hair wear a beard restraint . On 05/19/2025 at 8:44 a.m., an initial observation was made of S13DA (Dietary Assistant) assisting with prepping sandwiches with his facial hair not covered. On 05/19/2025 at 10:35 a.m., a follow up visit in the kitchen was made. S13DA was observed assisting with food preparation for the lunch meal service with his facial hair not covered. On 05/19/2025 at 10:56 a.m., an observations was made of S14DA assisting with the lunch meal service preparation with his facial hair exposed and not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to obtain the most recent recertification of terminal illness and most recent hospice POC (plan of care) for 1 (#31) out of 1 (#31) resident reviewed for hospice care. Findings: A review of the facility's agreement with the Contracted Hospice Agency dated 08/26/2015 read in the part, the following, Compilation of Records: Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient . Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Resident Hospice Patient . Each such record shall be readily accessible and systematically organized to facilitate retrieval by either party. A review of Resident #31's record revealed he was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Encounter for Palliative Care and Parkinson's disease with Dyskinesia. A 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 interviews and record reviews, the facility failed to ensure it employed a qualified social worker on a full-time basis. The facility had 150 licensed beds. Findings: Record review of S5SSD's resume revealed, in part, education: Bachelors of Science in health Studies (Marketing/Management), Associate of Science and Certificate of General Studies (Health Care Management). S5SSD's resume failed to show a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and one year of supervised social work experience in a health care setting working directly with individuals. On 05/20/2025 at 1:30 p.m., an interview was conduct with S5SSD, she confirmed she was serving as the facility social service director, with a BS (Bachelor of Science) degree in business health administration. S5SSD also confirmed she did not have a bachelor degree related to sociology, gerontology, special education, rehabilitation counseling, and psychology. On…

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

Based on observation, interview and policy review, the facility failed to maintain an effective infection and control program, by failing to ensure laundry staff wore appropriate personal protective equipment (PPE) while sorting soiled laundry. Findings: On 05/21/2025, a review of the facility's policy titled Infection Control, with a last reviewed date of 01/15/2025, indicated, Policy: To establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection .Procedure .14. linens must be handled .to prevent the spread of infection. a. Soiled linens must be handled to contain and minimize aerosolization and exposure to any waste products. During a tour of the facility's laundry room on 05/21/2025 at 9:00 a.m., S12LS (Laundry Staff) was observed removing laundry from a large yellow barrel and placing the laundry in the washing machine. S12LS was wearing only a pair of gloves during the procedure. She stated the laundry came from resident's rooms and 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 observations and interviews, the facility failed to maintain electrical patient care equipment in safe operating condition by failing to replace an electrical outlet plate for 1 (Resident #7) out of a finalized sample of 47 residents. Findings: On 05/19/2025 at 12:30 p.m., an observation of resident #7's room revealed an electrical outlet near the resident's bed, and within arm's reach of the resident. The outlet did not have a safety plate. On 05/20/2025 at 9:21 a.m., a second observation of resident #7's room revealed the outlet was still without a safety plate. On 05/20/2025 at 3:30 p.m., an observation and interview was conducted with S7LPN (Licensed Practical Nurse) who stated that a work order had been submitted to maintenance to have the plate replaced. On 05/20/2025 at 3:31 p.m., review of the maintenance log was conducted with S11M (Maintenance), S10CN (Charge Nurse) and S7LPN from present day to 01/2025. The log revealed that a no work order had been submitted for the electrical plate to be replaced. S7LPN and S10CN confirmed that a work order had not been…

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 maintain professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. Rust along the wall in the dishwashing area 2. Food residue on the ledge and front of the stove. 3. Two dented cans of Cream of Mushroom in the dry foods storage room 4. Build-up of grease and residue on the lids of storage bins in the dry foods storage room 5. Thick layer of dust along the ceiling tiles. 94 residents receive food and beverages from the kitchen. Findings: On 04/15/2024 at 8:44 a.m., an initial tour of the facility's kitchen was conducted with S7CDMLPN (Certified Dietary Manager, Licensed Practical Nurse). S7CDMLPN confirmed the two cans of Cream of Mushroom were dented at the rim and should not have been. S7CDMLPN confirmed the findings of rust along the wall in the dishwashing area, food residue on the ledge and front of the stove, build-up of grease and residue on the lids of storage bins in the dry foods storage room, and thick layer of dust along the ceiling tiles. She…

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

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice for 1 (#93) out of 1 (#93) residents sampled for dialysis services as evidenced by: 1. Failing to conduct comprehensive post dialysis assessments; and 2. Failing to ensure that communications were received from the dialysis provider. Findings: Review of the facility's policy titled, Fistula Maintenance: Post Dialysis Care, with a last reviewed date of 02/07/2024, read in part .A. 2. Check for signs of infection: a. Redness b. Warmth c. Pain/tenderness d Swollen e. Drainage of pus B. Documentation: 1. Documentation in the medical record regarding the fistula site may occur on the medication administration record, flowsheets, in the nurses' notes or any other part of the medical record. The following are examples of items to include in the documentation: b. condition of site c. presence /absence of bleeding and/or any other abnormalities noted. d. complaints from resident regarding site. The facility did not…

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, interviews and record review, the facility failed to ensure residents who smoked were free from accident hazards, by failing to ensure that 1 (#23) resident who was assessed as an unsafe smoker received a protective device. The total sample size was 34 residents. Findings: On 04/16/2024, a review of the facility's smoking policy, with a revision date of 02/07/2024, read in part .The intent of this policy is to establish fair and equitable smoking policies that are in the best interest of the employee and facility alike. However, restrictions within the facility will apply . Furthermore, it may be necessary to place smoking restrictions on individual residents because of safety and medical reasons. Should this become necessary, such information will be noted on the resident's Care Plan . Resident #23 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease; Shortness of Breath; Chronic Cough; Peripheral Vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to develop a person centered care plan for 1 (#2) of 3 (#1, #2, #3) sampled residents assessed for wandering that resided on the Dementia Unit in the facility. Findings: Record review revealed Resident #2 was admitted to the facility on [DATE] to the Dementia Unit (Long term memory care). Her diagnoses were as follows: Alzheimer 's disease, Dementia, Alcohol dependence, Opioid dependence, History of repeated falls, Major Depressive Disorder, Anxiety Disorder. She had a BIMS (Brief Interview for Mental Status) of 9, indicating moderate cognitive impairment. Record review of Resident #2's assessment document titled, Wander Data Collection, dated for 05/26/2023 (Admission), 09/07/2023, and 12/07/2023 revealed six yes's on the evaluation factors, meaning Resident #2 was a Definite Risk for wandering and/or elopement. Record review of Resident #2's care plan with a start dated of 5/26/2024 (admission Date) under the category of Cognition and Psychosocial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure the facility-wide assessment included an accurate evaluation of its resident population the resources required to provide care and services for those residents who resided on the secured special care unit. This deficient practice affected 1 resident (#3) with a potential to affect the 21 residents who currently resided on the secured special care unit. Findings: A record review of the facility's undated policy and procedure titled, Facility Assessment Policy, was conducted on 03/19/2024 and read in part .This assessment will be used to make decisions about direct care staff needs, as well as, the facility's capabilities to provide services to the residents in the facility .The intent of the facility assessment is for the facility to evaluate its' resident population and identify the resources needed to provide the necessary person-centered care and services the residents require .The facility has adopted a Facility Assessment Tool to assist in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observations, and interviews the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases, COVID-19, and infections by failing to ensure: 1. Required chemicals were being added to laundry water while washing residents' clothing. 2. Appropriate PPE (Personal Protective Equipment) was available and utilized by staff while handling soiled linens in the laundry facility. 3. Laundry staff transported soiled isolation linen appropriately to the laundry room, and removed dirty gloves prior to exiting an isolation room. 4. nursing staff performed hand hygiene when indicated when providing care. There were 91 residents in the facility. Findings: 1. Review of facility document titled Soiled Laundry and Linen Pick up Operational Procedures read in part. Operational Procedures: b. soiled laundry and linens are placed in laundry hampers. Hampers are kept covered 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that charges were not imposed against the personal funds of a resident for any items or services no longer needed by failing to discontinue the charges for disposable brief for 1 (#64) out of 42 sampled residents. Findings: Review of Resident #64's record revealed he was admitted to the facility on [DATE] with diagnoses including Alcoholic Hepatic Failure Without Coma, Generalized Anxiety Disorder, and Diabetes Mellitus Type 2. Review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating his cognition was intact. Toilet use score of 2, indicating limited assistance resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance. Reviewed a document titled Statement Register from 03/15/2022 to 03/15/2023. Resident #64 was charged for disposable briefs on the following dates:…

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 On 03/13/23 at 09:15 a.m., a small brown roach was observed crawling on the baseboard in the activity room where surveyors were setup for the survey. S13AIT was summoned to observe roach. S13AIT confirmed the crawling roach then smashed it with his foot. On 03/13/23 at 10:36 a.m., S31AD (Activity Director) stated that the activity room was currently used for small events like dominoes and family visits on occasion. Observations on Wing C revealed: On 03/13/23 at 09:44 a.m., an observation of Resident #35's room revealed the rolling bedside table frame was rusty and corroded. The wheels of the table had dust and brown debris on it. The bed frame and foot control pedals had areas of rust, dust, and crumbs. Crumbs were also observed under the bed. The room door did not completely close shut. It got stuck on the frame due to cracked portion of raised tile at the door frame. A missing section of baseboard was observed under the AC unit. The handwashing sink in the room did not paper towel dispenser. On 03/13/23 09:58…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview, the facility failed to follow the physician's orders and residents' plan of care for 4 (#2, #3, #62, and #82) 42 sampled residents. This deficient practice is evidenced by failing to: 1. Failing to check the resident's blood sugar timely for Resident #82 as ordered; 2. Failing to have an abdominal binder in place for Resident #2; 3. Have anit-slip strips in front of the toilet for Resident #3; and 4. Failing to ensure heel boots were in place and hand roll applied to the left hand for Resident #62. Findings: Resident #82 Review of the resident's record revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus. Review of the resident's physician orders revealed Novolin R Regular U-100 Insluin 100 unit/mL (milliliter) injection solution subcutaneous before each meal and at bedtime every day. Special requirements of the order indicated the medication should be administered per a sliding scale dependent on the 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 reviews and interviews the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 (#16, #42, and #80) residents in a final sample of 42 residents. The facility failed to ensure: 1. nurse's medication administration documentation was accurate for Resident #80 2. nurses did not administer expired insulin to Resident #42 3. resident was not NPO (nothing by mouth) without an order for Resident #16 Findings: Review of Resident #80's Electronic Medical Record (EMR) revealed that she was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Herpes Zoster, Acute and Chronic Respiratory Failure with Hypoxia, Acute and Chronic Respiratory Failure with Hypercapnia, Respiratory Failure, Dependence on upplemental oxygen, and Shortness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure its medication rate was not 5 percent or greater as evidenced by a calculated medication error rate of 63.33%. Findings: Review of the facility's medication administration policy titled General Guidelines read in part: Medications are administered within 60 minutes of scheduled time. Resident #16 Resident #16 was admitted to the facility on [DATE] with diagnoses in part: Heart Failure, Major Depressive Disorder, Dysphagia, and Acquired Absence of Larynx. Review of Resident #16's March 2023 physician's orders revealed an order that read: Crush all crushable meds and open capsules. Mix with a small amount of applesauce or pudding. Further review of Resident #16's March 2023 physician's orders and March 2023 eMAR revealed the following medications were scheduled to be administered at 8:00 p.m ., but were administered at the following times: -Trazadone 50 mg tablet (milligram): 10:55 p.m. -Zoloft 50 mg tablet: 11:01 p.m. -Amitiza 8 mcg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure safe and secure storage of all medications as evidenced by: 1. medication cart observed unlocked and unattended; and 2. expired insulin in 1 (MedCart A) of 3 medication carts reviewed. Findings: 1. Review of the facility's policy titled, Medication Storage in the Facility read in part: Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. On [DATE] at 08:38 a.m., S16LPN (Licensed Practical Nurse) was observed administering Resident #82's medications and checking his blood sugar. S16LPN exited the resident's room at 08:45 a.m., walked over to the medication cart, then cleaned and put away supplies. She walked away from the medication cart to the nurses' station to wash her hands. At this time, the medication cart was observed parked in front Resident #82's room with the locking mechanism disengaged. After some time, she was paged to return to her medication cart for interview. By…

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 be administered in a manner that enable it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure its medication rate was not 5 percent or greater as evidenced by a calculated medication error rate of 63.33%. The facility's administration failed to put measures in place to prevent medication errors. Findings: Cross reference F759 Review of the facility's medication administration policy titled, General Guidelines read in part: Medications are administered within 60 minutes of scheduled time. Thirty observations conducted of nursing staff administering medications during medication pass. A total of 19 errors were counted. The facility had a medication error rate of 63.33%. On 03/15/23 at 10:57 a.m., an interview was conducted with S2DON (Director of Nursing) who stated that she was aware nurses were not administering medications on time. She stated that it had been a problem with nurses…

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 and implement appropriate plans of action after multiple medications were administered late. This deficient practice had the potential to affect a census of 91 residents that receive medications. Findings: Review of the facility's QAPI (Quality Assurance Performance Improvement) Program Policy and Overview read in part, .The QAPI program includes evaluating clinical care issues, adverse resident events, the residents' quality of life, and residents' choices in the ongoing program .Once issues are identified, corrective actions are implemented to address problems or gaps in current systems. Clear expectations are to be stated in the corrective action plans to reflect safety, quality, resident rights, resident choice, and respect of the residents as priorities in solving or managing identified issues . Definitions: Adverse Event is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses . Review of facility's QAPI meeting dated 1/23/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident's physician when there was a 5 pound weight gain of 1 (#16) of 42 sampled residents out of a total census of 91 residents. Findings: Review of Resident #16's medical record revealed she was admitted to the facility on [DATE]. She had diagnoses including Other Specified Nutritional Anemias, Mild Protein Calorie Malnutrition, Hypertension, Cellulitis, Heart Failure, Aphasia, Aphonia, and Hypoxemia. Review of Resident # 16's physician orders revealed an order dated on 12/18/22 notify MD (Medical Director) or NP (Nurse Practitioner) of weight gain 5 pounds or greater. Review of the weight and vital signs grid revealed a weight on 03/12/23 of 165 pounds, and on 03/13/23 170 pounds. On 03/14/23 at 11:14 a.m., S2DON confirmed the resident had a 5 pound weight gain. S2DON stated the nurse should have followed the physician's orders to notify the provider of the weight gain of 5 pounds or greater. She stated she does not see that the nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews the provider failed to ensure that a resident's assessment accurately reflected the resident's status by failing to ensure that the resident's MDS (Minimum Data Set) included that the resident was on an antipsychotic medication for 1(#85) of 1 sampled resident investigated for Resident Assessment out of a total sample of 42. The total facility census was 91. Findings: Resident #85 was admitted to the facility on [DATE] with diagnoses of Psychotic Disorder With Hallucinations Due To Known Physiological Condition, Visual Hallucinations, Dementia In Other Disorder Classified Elsewhere, Mild, With Agitation. Review of the resident's Physician Orders List revealed an order with a start date of 02/14/2023 for Nuplazid, an antipsychotic medication, to be administered daily at bedtime. Review of the resident's admission MDS (Minimum Data Set) dated 02/21/2023 revealed under Section N: Medications, the resident was not assessed that he received an antipsychotic…

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 obtain a Level II PASARR (Pre-admission Screening And Resident Review) screening after a new diagnosis of Psychotic Disorder With Hallucinations was added to the resident's list of diagnoses for 1(#85) of 1 (#85) sampled resident reviewed for PASARR out of a total census of 91. Findings: The resident was admitted to the facility on [DATE] with diagnoses of Psychotic Disorder With Hallucinations Due To Known Physiological Condition, Visual Hallucinations, Dementia In Other Disorder Classified Elsewhere, Mild, With Agitation. Review of Resident #85's admission MDS (Minimum Data Set) dated 02/21/23 revealed a BIMS (Brief Interview of Mental Status) of 3, severe cognitive impairment. Further review of the MDS revealed under Section E- Behavior that the resident exhibited the following behaviors: Physical and verbal behavior symptoms directed towards others. Behavioral symptoms that put resident at risk for illness/injury, interfered with the 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 observations, interviews, and record review, the facility failed to ensure that a resident was offered sufficient fluid intake to maintain proper hydration for 1 (Resident #35) out of 1 (Resident #35) residents investigated for hydration out of a total of 42 sampled residents. Findings: Record review revealed Resident #35 was admitted to the facility on [DATE] and had diagnoses that included in part: Urinary Tract Infection, Hemiplegia, Anemia, Traumatic Brain Injury and Constipation. Review of Resident #35's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C- Brief Interview for Mental Status (BIMS) score of 15 meaning she was cognitively intact. Review of Resident #35's plan of care revealed she was at risk for Urinary Tract Infections, Potential for Fluid Volume Deficit and Potential for Constipation with interventions to offer fluids every 2 hours while awake, water pitcher in reach and resident has personal cup in room that she prefers her ice to be put in. Review of the 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 observations, record review and interview, the facility failed to ensure nursing staff labeled the resident's tube feeding per the facility's policy and administered the resident's water flushes per the physician's order for 1 (#2) of 2 (#2, #37) residents investigated for tube feeding in a final sample of 42 residents. This deficient practice had the potential to affect a total of 4 residents in the facility receiving tube feedings according to the facility's Resident Census and Conditions form. Findings: Review of the facility's policy titled, Nasogastric/Gastrostomy Tube Feedings read in part: Purpose: to provide nourishment and hydration through intermittent or continuous feedings directly into the stomach as prescribed by MD (Medical Doctor) through a nasogastric or gastrostomy tube. Labels should be completed with resident's name, date, start time, initials of nurse and rate. Review of Resident #2's record revealed she was admitted to the facility on [DATE] and had diagnoses and conditions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure respiratory equipment was properly stored and labeled per the facility's policy for 2 (#9 and #80) of 4 (#9, #16, #52 and #80) residents investigated for respiratory care out of a total sample of 42 residents. Findings: Review of the facility's policy titled, Oxygen Administration (Concentrator or Tank) read in part, .Humidifier bottles, cannulas and O2 (oxygen) tubing will be changed at least once weekly and dated. Concentrator filter should be cleaned weekly or as needed as well. When not in use, cannula or mask should be placed in a plastic bag . Resident #9 Review of Resident #9's record revealed she was admitted to the facility on [DATE] with diagnoses including Acute Bronchitis, Obstructive Sleep Apnea, and Dependence of Supplemental Oxygen. Review of Resident #9's current physician's orders read in part, 10/21/2022 Oxygen 2 lpm (Liters Per Minute) via nasal cannula PRN (As Needed) SOB (Shortness of Breath) or to keep Oxygen…

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

Based on observations and interviews, the facility failed to ensure food items were stored in accordance with professional standards for food service safety. The facility failed to maintain the integrity and cleanliness of the walk-in food storage refrigeration and freezer units. This deficient practice had the potential to affect a total of 90 residents who consumed food prepared and served from the kitchen in a facility with a census of 91. Findings: Review of the facility's policy and procedure titled Storage of Refrigerated Food revealed in part, Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedures: .4. All non-hazardous, opened foods are labeled with name of food and date stored. 5. All hazardous foods are labeled with name of food and date to be discarded or the date stored. Cooked foods not to be held longer than 48 hours . Review of the facility's policy and procedure titled Storage of Frozen Food revealed in part, Policy: The facility ensures the quality and safety of frozen food through accepted storage…

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 store garbage and refuse properly as evidenced by debris scattered outside of the 3 dumpsters on the ground. The facility had a census of 92 residents. Findings Review of the facility's policy and procedure titled Waste Disposal revealed in part, Policy: Garbage and trash is removed from the food preparation area to prevent contamination of food. Procedure: .4. Outside storage areas are: .d. kept clean of garbage and debris. On 03/13/2023 at 9:10 a.m., a joint observation and interview was conducted with S28DM (Dietary Manager) of the facility's 3 dumpsters located outside near the back parking lot. On the ground, scattered amongst the 3 dumpsters, were remains of boiled crawfish which S28DM stated the facility had not boiled crawfish at all. Further observation revealed paper straw wrappers and other unidentifiable paper items scattered on the ground. S28DM confirmed that the items were not disposed of properly and the crawfish remains increased the risks of rodents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review the facility failed to ensure the accuracy of a resident's clinical record when the nurse administered an enteral feeding before its scheduled time and inaccurately documented in the record the time she administered the feeding for 1 (#37) of 2(#2, #37) sampled residents investigated for tube feeding out of total sample of 42. The facility census was 91. Findings Review of the facility's policy titled Pharmacy read in part, Only the licensed or legally authorized personnel who prepares a medication may administer to it. This individual records the administration on the resident's MAR at the time the medication is given. Medications are administered within 60 minutes of scheduled time. Review of Resident #36 record revealed she was admitted to the facility on [DATE] with following diagnoses, but not limited to, Unspecified Severe Protein-Calorie Malnutrition, Other Cerebrovascular Disease, Dysphagia Following Other Cerebrovascular Disease, Encounter For Attention To…

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

Based on record review and interview, the facility failed to notify 11 (#2, #15, #16, #18, #32, #52, #60, #62, #80, #84, #89) of 11 residents, representatives and families of the facility's staff that were positive for COVID-19 infections of the records reviewed for notification. This deficient practice had the potential to affect a census of 91 residents. Findings: A review of the facility's log of Employee COVID-19 Test Tracking Log revealed that on 01/16/2023, the facility received positive COVID-19 test results for1 employee. Further review revealed that on 01/31/2023, positive COVID-19 test results were received for 1 additional employee. On 02/06/2023 1 employee received positive COVID-19 results. 02/14/2023 1 employee received positive COVID-19 test results, and on 03/11/2023 1 employee received positive COVID-19 results. A review of 11 (Residents #2, #15, #16, #18, #32, #52, #60, #62, #80, #84, #89) randomly selected resident departmental notes were reviewed and failed to reveal documentation on or around the dates of 01/16/2023, 01/31/2023, 02/06/2023, 02/14/2023, 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.