New Iberia Manor North

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure that their medication error rate was less than five percent, by failing to administer medications at the right time for 4 of 4 (#16, #41, #53, and #67) residents observed during morning medication pass. This deficient practice had the potential to affect a census of 74 residents. Findings: On 05/15/2024, a review of the facility's policy titled Administering Medications with a revision date of 04/05/2024, read in part: Policy heading: Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . A review of the facility's medication pass schedule revealed Med Pass Times: Culture Times .BID (twice a day): 6 a.m. (before noon) - 11 a.m., 7 p.m. (after noon) - 10 p.m. TID (three time a day): 6 a.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interview, the facility failed to ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep a resident's urine collection bag covered and private for 1 (Resident # 35) of 3 residents (# 35, # 52 and # 66) investigated for urinary catheter or urinary tract infection. Findings: Review of Resident # 35's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses, in part: Urinary Tract Infection, Other Retention of Urine, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Review of Resident # 35's current physician orders for May 2024 revealed, in part: 03/19/2024- Foley Catheter Care Q (every) Shift and PRN (as needed); Privacy bag or covering over urine collection bag for dignity every evening and night shift. Review of Resident # 35's care plan revealed the resident had an indwelling catheter with an intervention of privacy bag or covering over urine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#31) out of 35 sampled residents. Findings: Review of Resident #31's electronic clinical record revealed he was admitted to the facility on [DATE]. The resident's diagnoses included in part Hypertension, Angina Pectoris, Cerebral Infarction and Venous insufficiency (Chronic) (Peripheral). Review of the resident's quarterly MDS (Minimum Data Set) dated 02/14/2024 revealed under Section N-Medications, the resident was coded for the use of an anticoagulant (blood thinner). Review of the resident's active physician order as of 05/15/2024 revealed no order for an anticoagulant medication. On 05/15/2024 at 2:53 p.m., a review of Resident # 31's MDS dated [DATE] and current physician orders was conducted with S9RMDS (Regional MDS). S9RMDS stated that according to the physician orders, Resident #31 was not ordered any anticoagulant medications. She confirmed that the resident's MDS…

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

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 2 (Resident #37 and #57) of 2 (#37 and #57) residents investigated for PASARR in a final sample of 35 residents. Findings: Resident #37 A review of Resident 37#'s medical record revealed an admission date of 03/01/2024. Further review revealed he was diagnosed with Unspecified Psychosis on 03/13/2024. Further review of Resident #37's medical record revealed a Level 1 PASARR (Preadmission Screening and Resident Review) dated 03/01/2024. No PASARR Level II was noted in Resident #37's record. On 05/15/2024 at 12:43 p.m., an interview was conducted with S11SSD (Social Service Director) and S1ADM (Administrator) regarding resubmission for a Level II PASARR after a diagnosis of Unspecified Psychosis. S1ADM stated she would look into the matter, and would update when available. On 05/15/2024 at 3:45 p.m., an interview was conducted…

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 a resident with a qualifying mental disorder, was not admitted to the facility before a preadmission screening by the State Office of Behavioral Health (OBH) was completed or obtained for 1 (#33) of 4 (#31, #33, #37, and #57) residents investigated for PASARR (Preadmission Screening and Resident Review) out of 34 sampled residents. Findings: Resident #33 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Major Depressive Disorder and Psychotic Disorder with Delusions Due to Known Physiological Condition. A review of the resident's quarterly MDS (Minimun Data Set) with an ARD (Assessment Reference Date) of 03/18/2024 revealed under section I: Primary Medical Condition, that the resident had diagnoses which included Depression and Psychotic Disorder. A review of the resident's current plan of care revealed: 1)The resident was physically aggressive. On 05/03/2023 the resident had a physical fight…

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 reviews, and interviews, the facility failed to develop and implement a person-centered care plan for 2 (#37 and #66) out of 2 residents investigated for care plans out of a total sample of 35 residents by: 1. failing to follow physician's orders for completing wound care for Resident #37, 2. failing to request a urine C/S (culture and sensitivity) from the laboratory after order was received for Resident #66 Findings: 1. Resident #37 Review of Resident #37's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: Cerebral Infarction, Hemiplegia and Hemiparesis, Nontraumatic Intracerebral Hemorrhage, Contracture of Left Hand, and History of Falling. Review of Resident #37's nurse's notes revealed the resident had a fall on 04/21/2024 that resulted in a skin tear above his right eyebrow. Review of Resident #37's April 2024 physician's orders revealed the following order dated 04/25/2024: Skin tear 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to perform daily wound care as ordered by the physician and failed to provide weekly wound assessments for 1 (#48) of 3 (#17, #35 and #48) residents investigated for pressure ulcers. Findings: Review of Resident #48's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Ischemia, End Stage Renal Disease, Arteriovenous Fistula, Atherosclertoic Heart Disease of Native Coronary Artery, Moderate Protein Malnutrition, and Muscle Wasting and Atrophy. Review of Resident #48's May 2024 physician's orders revealed the following: orders dated 04/13/2024: Right big top of toe, clean with normal saline, pat dry, apply betadine, leave open to air, every day until healed; Right foot inner heel, clean with normal saline, pat dry, apply betadine and cover with dressing, every day until healed. Further review revealed the following orders dated 05/01/2024: DTI (deep tissue injury) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure that a resident (#62) with limited range of motion received the appropriate treatment and services by failing to implement recommendation by the physical therapy department for the restorative nursing program for 1 (#62) of 1 resident investigated for position/mobility in a total sample of 35 residents. Findings: Review of the resident's electronic record revealed she was admitted to the facility on [DATE]. Her admitting diagnoses in part: Cerebral Vascular Accident, Unspecified Myoneural Disorder, Muscle wasting and atrophy, right and left thigh and lower leg, and Lack of coordination. On 05/13/2024 at 10:52 a.m., Resident #62 stated she received 3 to 4 days of therapy after she was admitted , but she was no longer receiving therapy because her insurance would not pay for the therapy. When asked if she was on a restorative program, she replied No. Review of the resident's quarterly MDS (Minimum Data Set) dated 04/11/2024 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident was free from accidents for 1 (#37) of 2 (#37 and #61) residents investigated for accidents. Findings: Review of Resident #37's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Cerebral Infarction, Hemiplegia and Hemiparesis, Nontraumatic Intracerebral Hemorrhage, Contracture of Left Hand and History of Falling. Review of Resident #37's significant change MDS (Minimum Data Set) dated 04/11/2024, revealed he had a BIMS (Brief Interview for Mental Status) score of 8, indicating the resident had moderate cognitive impairment. A review of Resident #37's care plan revealed he was at risk for falls and for an actual fall. Further review of the plan of care revealed Resident #37 had actual falls on 03/02/2024, 03/05/2024, 03/09/2024 and 04/21/2024. Interventions included in part .staff assist back to bed when ready. A review of the facility's investigative…

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 reviews and interview, the facility failed to ensure a resident received necessary respiratory care and services as evidenced by: 1. Failing to ensure the resident was assessed for respiratory therapy and 2. Failing to obtain a physician's order for respiratory therapy. This deficient practice was evidenced for 1 (Resident # 35) of 3 residents (# 35, # 50 and # 71) investigated for respiratory care. Findings: On 05/14/2024 a review of the facility's Policy and procedure titled, Oxygen Administration, with a revision date of February 2023, revealed in part: The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order .Review the resident's care plan to assess for any special needs of the resident .Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: .4. Vital Signs . Documentation: After completing the oxygen setup or adjustment, the following information should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis facility as evidenced by failing to change the physician's order to reflect dialysis treatment days for 1 (#48) out 1 (#48) resident investigated for dialysis. Findings: Review of Resident #48's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to: End Stage Renal Disease (ESRD), Arteriovenous Fistula, and Dependence on Renal Dialysis. Review of Resident #48's care plan read in part . The resident needs hemodialysis r/t (related to) ESRD with Pulmonary Edema/Congestion .new order noted: Resident to receive dialysis 3 days a week on M, W, F (Monday, Wednesday, Friday) at dialysis center. Review of the Resident #48's nurses notes dated 05/10/2024 at 2:35 p.m. revealed, pt (patient) will have a new day and time starting 5/13/2024. Chair time will be at 11:15 MWF notified van driver. Review of Resident #48's May…

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

Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1, 2024 (October1 - December 31), revealed a One Star Staffing Rating. Review of Time Card Reports and RN (Registered Nurse) clock in hours for the months of October 2023 to December 2023 revealed an RN did not work a total of 8 hours for the following dates in October 2023: 10/13, 10/16, 10/17, 10/30, and 10/31. Further review revealed an RN did not work a total of 8 hours for the following dates in November 2023: 11/13, 11/14, 11/15, 11/20, and 11/22. On 05/14/2024 at 2:50 p.m., a phone interview was conducted with S1PBJ (Payroll Based Journal) who confirmed that the facility did not have an RN for 8 hours per day for the dates mentioned from October and November of 2023.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the menu was followed for 2 (#27, #37) residents out of 3 (#27, #30, #37) residents who received pureed diets. Findings: Resident #27 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Unspecified Dementia and Gastro-Esophageal Reflux Disease. Review of Resident #27's physician's orders revealed a diet order dated 08/04/2022 that read in part: Regular diet, pureed texture, thin consistency. Resident #37 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Other Sequelae of Cerebral Infarction, Type 2 Diabetes Mellitus, and Gastro-Esophageal Reflux Disease. Review of Resident #37's physician's orders revealed an order dated 04/03/2024 that read in part: Reduced Concentrated Sweets diet, pureed texture, nectar thickened consistency. Review of the facility's menu for 05/13/2024 revealed breakfast consisted of the following food items: Cereal Cream of Wheat, Scrambled Egg, Bacon Strip…

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 the resident received a mechanically soft chopped meats diet as ordered for 1 (# 61) of 3 (# 61, # 66, and # 71) residents investigated for food concerns in a final sample of 34 residents. Findings: Review of Resident # 61's record revealed he was admitted to the facility on [DATE] with diagnoses, in part . Sequelae Cerebral Infarction, Potential for Malnutrition, Other Speech and Language Deficits Following Cerebral Infarction. Review of the resident's physician orders for May 2024 revealed an order dated 02/01/2024, Mechanical soft texture, thin consistency, chop meats, no grapefruit products Review of the resident's care plan revealed Focus: Dietary Concern Speech Deficits, Protein Calorie Malnutrition Interventions included: Mechanical soft texture, thin consistency, chop meats, no grapefruit products. On 05/13/2024 at 8:55 a.m., an observation was made of Resident # 61 sitting up on the side of his bed feeding himself…

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 food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure cooked food items were not stored on the same shelf as raw food items; 2. Remove expired food items from the kitchen's walk in cooler. Findings: A review of the facility's policy titled, Food Receiving and Storage with a last reviewed date of January 2023 read in part: 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetable and other ready-to-eat foods. On 05/13/2024 at 6:30 a.m., an observation was made of the kitchen's walk in cooler with S5DM (Dietary Manager). Observation of the cooler revealed a bottom shelf to the right of the cooler. There were 2 rolls of uncooked ground beef defrosting in a pan on the bottom shelf, and uncooked sausage and raw chicken defrosting in a second pan. In between the two pans, was a large pan covered in foil labeled with a date of 5/11 and pinto beans. S5DM stated the…

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

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to ensure clean laundry and linen was not stored on the contaminated side of the laundry department. Findings: A review of the facility's environmental services policy with a last revised date of 10/2023, read in part: Laundry Flow .After washing, clean linens should be transported from the washing area to the drying area .Linen Storage .Clean linen must always be kept separate from contaminated linen through the use of separate rooms, closets, or other designated spaces with a closing door as the most secure methods for reducing the risk of accidental contamination. On 05/13/2024 at 10:29 a.m., an observation was made of the laundry department. S12Laundry was observed on the contaminated side of the laundry department placing soiled linen into the washing machines. She stated that clean laundry could not be stored on the contaminated…

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 records reviewed and interviews, the facility failed to have a plan in place to ensure how treatments were going to be completed when the treatment nurse resigned. This deficient practice had the potential to affect the 75 residents who resided in the facility. Findings: Upon entry to the facility on [DATE] at 9:00 a.m., S10LPN (Licensed Practical Nurse) stated she was a prn (as needed) staff and helped the facility with completing treatments. She pulled up the facility's list of resident's with current wound and skin treatments, which failed to include Resident #2. On 11/28/2023 at 9:30 a.m., S11LPN was asked to provide surveyor with names of current residents on her assigned hall who currently received wound and skin treatments. S11LPN stated Resident #2 had an unstageable pressure ulcer. Record review of sampled residents' October 2023 and November 2023 electronic Treatment Administration Records (eTARs) revealed there was no documentation to indicate the treatments were completed as ordered. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 6 (#1, and R1-R5) out of 8 (#1-#3, R1-R5) sampled residents as evidenced by: 1. Failing to ensure a floor mat was at the bedside for Resident #1 and; 2. Failing to ensure skin and wound treatments were completed as ordered for Residents R1, R2, R3, R4, and R5. Findings: Review of the facility's policy titled Care plans, Comprehensive Person-Centered read in part .A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses in part: Flaccid Hemiplegia Affecting Right Dominant Side, Unspecified Non-displaced Fracture of Surgical Neck of Right Humerus, Repeated Falls, and Generalized Anxiety. Review of Resident #1's November 2023 physician'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 and interview, the facility failed to ensure that a resident's care plan was accurately updated with the appropriately identified problem areas and interventions to reflect the resident's current wound status for 2 (#2, and #3) out of 8 (#1, #2, #3, R1, R2, R3, R4 and R5) sampled residents. Findings: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, read in part .8. The comprehensive, person centered care plan will: .g. Incorporate identified problem areas .further review of facility policy .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Resident #2 Review of the Resident #2's electronic medical record revealed he was admitted to facility on 08/20/2021 with the following pertinent diagnoses: Spinal Stenosis-Lumbar Region with Neurogenic Claudication, Spinal Stenosis-Thoracic Region, Neuromuscular Dysfunction of Bladder, Peripheral Vascular Disease (PVD), Lymphedema…

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 provide weekly wound assessments and failed to perform daily wound care as ordered for 2 (#2 and #3) out of 2 (#2 and #3) residents investigated for pressure ulcers out of a final sample of 8 residents (#1-#3 and R1-R5). Findings: Review of the facility's policy titled, Pressure Injury Prevention Program, revealed in part: Standard: All residents will be assessed for risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. 6. Weekly Wound Assessment a. Each identified skin issue/area is assessed weekly in electronic medical record for: Size Stage (staged by RN (Registered Nurse) or PT (Physical Therapist)) Location Drainage amount If odor is present Signs…

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 provide a safe and sanitary, environment to help prevent the development and transmission of communicable diseases and infections by failing to remove contaminated gloves and perform hand hygiene during wound care for 1 (#3) resident out of 7 (#2, #3, R1, R2, R3, R4, R5) residents investigated for wound/skin treatments. Findings: Review of the facility's policy titled, Hand Washing and Hand Hygiene, read in part .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . g. Before handling clean or soiled dressings, gauze pads, etc .i. After contact with a resident's intact skin. Resident #3 was admitted to the facility on [DATE] with diagnoses in part .Other Cord Compression, Myotonic Muscular Dystrophy, Unspecified Severe Protein Calorie Malnutrition, Pressure Ulcer of Right Hip Stage 3, and Pressure Ulcer of Sacral Region Stage…

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 interviews, the facility failed to maintain a clean and homelike environment by failing to ensure a resident's urine was properly disposed of in order to prevent the overly pungent odor of urine for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents. Findings: Review of the facility's policy, Homelike Environment revealed, in part, the following: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment . Policy Interpretation and Implementation .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment .pleasant, neutral scents . Review of Resident #2's record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses= Intervertebral Disc Degeneration Lumbar Region, Major Depressive Disorder-Recurrent, Type 2 Diabetes Mellitus,…

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 facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents. Findings: Record review of the policy titled, Filing Grievances/Complaints read in part, Our facility will assist residents, their representatives .in filing grievances .when such request are made .2. Grievances may be submitted orally or in writing .6. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer. 7. Upon receipt of a written grievance .the grievance officer will review and investigate the allegations and summit a written report of such findings to the administrator within 72 hours of receiving the grievance. 10. The Administrator will review the findings with the Grievance Officer to determine what corrective action .to be taken . 13. The results of all grievances filed, investigated…

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 store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure kitchen staff wore hair coverings while in the kitchen; 2. Ensure expired food items were removed from the cooler; 3. Ensure expired food items were removed from the dry goods storage room; 4. Ensure food items were labeled with the date and time it was opened; 5. Ensure the refrigerator was clean; 6. Ensure beverages that were not for residents were not stored the refrigerator; and 7. Ensure air conditioning vents were free of dust and debris. This deficient practice had the potential to affect the 70 residents who consumed food and beverages from the kitchen. The facility's census was 73. Findings: Review of the facility's policy titled Refrigerators and Freezers read in part .The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines .7. All food shall be appropriately…

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 interviews, the facility failed to maintain a comfortable and homelike environment by failing to ensure the window air conditioner (AC) unit was working for 1 (#3) of 5 (#3, #28, #33, #42 and #53) residents investigated for environment. Findings: Review of the facility's policy, Homelike Environment revealed, in part, the following: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting . h. comfortable temperatures. Review of Resident #3's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Epilepsy, Hypothyroidism, Shortness of Breath, Body Mass Index 45.0-49.9 and Peripheral Vascular Disease. Review of Resident #3's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, records reviewed and interviews the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 2 (#21 and #57) of 2 ( #21 and #57) residents investigated for grievances Findings: Record review of the policy titled, Filing Grievances/Complaints read in part, Our facility will assist residents, their representatives .in filing grievances .when such request are made .2. Grievances may be submitted orally or in writing .3. Actions on such issues will be responded to in writing, including a rational for the response .6. The Administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer. 7. Upon receipt of a written grievance .the grievance officer will review and investigate the allegations and summit a written report of such findings to the administrator within 72 hours of receiving the grievance. 10. The Administrator will review the findings with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to implement a comprehensive person-centered care plan by failing to follow physician order to document a resident's (#177) meal intake percentages for 1 (#177) of 2 (#64, #177) sampled residents for nutrition. Findings: Review of the facility document titled Charting and Documentation read in part, policy Interpretation and Implementation: .2. The following information is to be documented in the resident medical record: a. Objective observations .; f. Progress toward or changes in the care plan goals and objectives. Record review revealed Resident #117 was admitted on [DATE]. Further review of the record revealed, in part, diagnoses of Anorexia, Chronic kidney disease, Iron deficiency anemia, Vitamin deficiency, and Unspecified protein calorie malnutrition. Review of the resident's monthly weights revealed: 10/07/2022 - 179.0 11/07/2022 - 165.2 12/07/2022 - 159.4 01/07/2023 - 151.4 02/14/2023 - 154.4 03/07/2023 - 151.8 Review of physician orders…

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 a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#45) of 3 (#45, #53 and #71) residents reviewed for ADLs. The facility failed to provide toenail care for Resident #45. Findings: Review of Resident #45's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses of Type 2 Diabetes Mellitus, Cerebral infarction, Aphasia, and Flaccid hemiplegia affecting right dominant side. Review of physician orders dated 08/04/2022 read in part, podiatry consult for complaint of overgrown thick and painful toenails. Review of care plan dated 03/29/2023 read in part, nail care as needed; nurse to cut nails since diabetic. On 04/17/2023 at 11:27 a.m., an observation was conducted of Resident #45's toe nails. The resident's family stated that his toe nails were too long and needed to be cut. Upon Further observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure each resident with pressure ulcers received the necessary treatment and services to promote healing as evidenced by the staff failing to follow physician's orders for wound care for 2 (#51, #126) out of 4 (#20, #43, #51, #126) residents investigated with pressure ulcers out of a total sample of 36 residents. Findings: 1. Resident #51 Review of Resident #51's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Other Encephalitis and Encephalomyelitis, Osteomyelitis, Bacteria Infection, Type Two Diabetes Mellitus, and Unspecified Protein-Calorie Malnutrition. Review of Resident #51's current physician's orders list revealed an order on 03/21/2023 Left bottom of foot: Clean with wound cleanser, pat dry apply non-adherent dressing cover with ABD (abdominal) wrap with kerlix and secure with tape daily until resolved every day shift. A review of Resident #51's April…

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

Based on record review, observations and interview the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (#45) of 2 (#33, #45) resident reviewed for position and mobility. The facility failed to ensure resident #45 wore a splint 4 hours daily for a right hand contracture and received restorative services as ordered. Findings: Review of Resident #45's electronic medical record revealed an admit date of 10/22/2020 with diagnoses that included Cerebral vascular accident, Flaccid hemiplegia affecting right dominant side, and Aphasia. Review of Resident 45's physician orders dated 10/12/2022 read in part, restorative nursing program 6-7 days a week for bed mobility; active range of motion (AROM) related to muscle weakness. Review of Resident 45's care plan dated 3/29/2023 read in part, risk for loss of range of motion right dominant sided hemiplegia secondary to cerebral vascular accident. Intervention included the following: nursing staff to perform range of motion (ROM) with…

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 minimize the risk of contamination of a resident's tube feeding for 1 resident (# 73) investigated for tube feeding out of a total sample of 36 residents. This deficient practice had the potential to affect the 6 residents who received tube feedings in the facility. Findings: Review of the facility's policy titled Enteral Feedings- Safety Precautions read in part .2. The facility will remain current in and follow accepted best practices in enteral nutrition. Resident #73 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Aphasia, Dysphagia Following Cerebral Infarction, and Flaccid Hemiplegia Affecting Right Dominant Side. Review of Resident #73's MDS (Minimum Data Set) revealed she received 51% or more of total calories and 501 cc's (Cubic Centimeters) per day or more of fluid intake by tube feeding. Review of Resident #73's April 2023 physician's orders revealed an order dated 03/23/2023 that read:…

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 interviews the facility failed to ensure nasal cannulas were stored in plastic bags as required by their policy for 1 (#176) of 4 (#59, #70, #71, #176) residents investigated for respiratory care. Findings: Record review of policy titled, Departmental (Respiratory Therapy) Prevention of Infection read in part, Purpose .prevention of infection associated with respiratory therapy .8. Keep the oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use. Record review revealed Resident #176 was admitted to the facility on [DATE] with diagnoses of Lobar Pneumonia, Cardiac Arrest, Pneumonitis, Acute and Chronic Respiratory Failure, Hypoxia, Chronic Kidney disease, Chronic Systolic Heart Failure, Iron Deficiency Anemia, Atherosclerotic Heart Disease, and Transient ischemic Attack. Record review of Resident #176's active Physicians Orders read in part, 02 (Oxygen) at 2 liters per minute via nasal cannula PRN (as needed) Keep O2 sats (Saturation) > (greater…

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 attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#53) resident in a final sample of 36 residents. The facility failed to ensure nurses' medication administration documentation was accurate for Resident #53. Findings: Review of Resident #53's Electronic Health Record revealed resident was admitted to the facility on [DATE] with diagnoses in part: .[NAME] Syndrome, Ileostomy Status, Type 2 Diabetes Mellitus, Obesity, Rash and Other Nonspecific Skin Eruption. Review of March 2023 Medication Administration Record (MAR) revealed an order dated 03/30/2023 for Betamethasone Dipropionate Augmented External Gel 0.05%- Apply to back rash topically two times a day for rash for 14 days. Further review of the MAR revealed the medication was documented as administered on 03/31/2023 by S15LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to make an appointment with a dentist for 1 (#21) of 3 (#21, #45 and #176) residents investigated for dental care. Findings: Record review revealed Resident #21 was admitted to the facility on [DATE] with accumulative diagnoses including Dysphagia, Cognitive Communication Deficit, Symbolic Dysfunctions, Cochlear Implant, Major Depressive, Repeated Falls, Muscle weakness, Need for assistance with personal Care, Lack of Coordination, Anxiety and Parkinson's disease. Record review of Resident #21's Care plan read in part, The resident has oral/dental health problems r/t (Related to) has dentures but they are loose for resident .Coordinate arrangements for dental care .Document/Report PRN (as needed) any .dental problems needing attention .loose .in mouth. On 04/17/2023 at 10:21 a.m., an observation revealed Resident #21's upper dentures were loose and falling down while she spoke. At this time, Resident #21 stated her dentures were brand new…

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 employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 70 residents who consumed food from the kitchen. The facility's census was 73. Findings: On 4/17/2023 at 7:10 a.m., S6DM (Dietary Manager) was asked to provide her certification for food service management and safety. S6DM stated that she completed trainings but did not have a certification. She further stated that she has been the dietary manager for 2 years and was not certified. She stated the registered dietitian, who made rounds at the facility once a month, was supposed to schedule the class for her, but she did not. On 4/17/2023 at 8:44 a.m., an interview was conducted with S1Adm (Administrator) who stated that the facility was in the process of ensuring S6DM was certified. He stated S6DM completed online trainings, but failed the test. On 04/18/2023 at 10:04 a.m., an interview 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 interviews, the facility failed to maintain an accurate record in accordance with accepted professional standards and practices. The facility failed to accurately document temperatures on Resident # 3's Personal Refrigerator Temperature Log for April 2023. Findings: Review of the facility's policy, titled Charting and Documentation revealed, in part, the following: Policy Interpretation and Implementation: . 3. Documentation . will be objective (not opinionated or speculative), complete, and accurate. Review of Resident #3's Personal Refrigerator Temperature Log on 04/17/2023 revealed no temperatures documented on April 12, 13, 14, 15, and 16, 2023. Review of Resident #3's Personal Refrigerator Temperature Log on 04/18/2023 revealed 42 degrees documented on April 12, 13, 14, 15, 16, and 17, 2023 with S10CNA's (Certified Nursing Assistant) signature for those dates. On 04/18/2023 at 8:35 a.m., an interview was conducted with S10CNA. S10CNA stated she was the designated personnel to document on Resident #3's Personal Refrigerator Temperature…

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 collaborate with a hospice agency to ensure residents had a Hospice Plan of Care for 2 (#17, #378) out of 2 residents reviewed for hospice services in a total investigative sample of 36 residents. This deficient practice had the potential to affect the 2 residents receiving hospice services as documented on the facility's Resident Census and Conditions form (CMS-672). Findings Review of the facility's policy titled Hospice Program read in part .12. Our facility has designated .to coordinate care provided to the resident by our facility staff and the hospice staff.d. Obtaining the following information from the hospice: 1. the most recent hospice plan of care specific to each resident .13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility. Resident #17 Resident #17 was admitted to the facility on [DATE] with pertinent diagnoses…

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.