New Iberia Manor South

Based on observation and interview, the facility failed to provide a sanitary and homelike environment for 1 (#9) out of 36 sampled residents.Resident #9. On 07/21/2025 at 10:23 a.m., the resident was observed siting up in bed in his room. During this observation, a suction canister was observed on the resident's dresser. There was drainage noted in the canister. The resident stated that the suction canister had been on the dresser for days. On 07/21/2025 at 10:24 am, S17LPN (Licensed Practical Nurse) entered the room and observed the canister on the dresser. S17LPN stated she did not know how long the canister had been on the dresser and that it should have been discarded. On 07/23/2025 at 10:33 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated the facility did not have a policy and procedure on suction equipment but stated the canister should have been changed out.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the residents right to be free from physical restraints imposed for purposes of discipline or convenience, for 1 (#2) of three (#1, #2, and #3) sampled residents. This deficient practice was evidenced by Resident #2's use of a wheelchair seat belt the resident was unable to remove. Findings: On 04/30/2025, a review of the facility's policy titled Facility Policy on PSDs (Personal Safety Devices) -Enablers-Side Rails & Restraints with a last revised date of 02/2025, read in part .Restraint Policy Intent: Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience and when not required to treat the patient's/resident's medical condition. Patients/Residents have the right to function at their highest practicable level in the least restrictive environment possible. Policy: 1. Restraints will not be used unless the facility's Interdisciplinary Team has completed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#3) out of 3 (#1, #2, and #3) residents sampled. Findings: A review of Resident #3's admission record revealed an initial admission date of 08/29/2024 and a re-admission date of 04/15/2025 with diagnoses that included but were not limited to, End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #3's nurse's notes revealed on 03/30/2025 at 11:45 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 04/15/2025 the resident returned from the hospital back to the facility. A review of the Emergency Transfer Log for March 2025 and April 2025 revealed Resident #3's transfer to the hospital on [DATE] was not identified on the list. On 04/30/2025 at 1:49 p.m., an interview and record review were conducted with S5SSD (Social Service Director). S5SSD stated she is responsible for completing and sending 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 interviews, the facility failed to ensure an assessment and ongoing communication with the dialysis facility by using dialysis communication forms for 1 (#3) out of 3 (#1, #2, and #3) residents sampled. Findings: A review of the facility's agreement with the Contracted Dialysis Agency with an effective date of 02/15/2019 read in part, Responsibilities of Long Term Care Facility (LTCF): LTCF healthcare staff will make an assessment of each patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis . This assessment and communication will occur prior to each and every transfer of a patient to the contracted dialysis agency for hemodialysis on an outpatient basis regardless of the number of time any particular patient may be transferred and dialyzed . A review of Resident #3's admission record revealed a re-admission date of 04/15/2025 with diagnoses that included but were not limited to, End Stage Renal Disease and Dependence 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 interview and record review, the facility failed to ensure a yearly performance review was completed on every Certified Nurse Assistant (CNA) for 1 (S8CNA) of 4 (S8CNA - S11CNA) CNAs personnel records reviewed. Findings: During an interview with S8CNA on 04/29/2025 at 5:25 a.m., the CNA stated she had not received a performance evaluation since she started working at the facility. Review of S8CNA's personnel records revealed a Personnel Action Form with a hire date of 06/06/2023. Further review of the CNA's personnel records revealed no performance evaluation. During an interview with S2DON (Director of Nursing) on 04/30/2025 at 12:04 p.m., she stated that S8CNA is a PRN (as needed) staff and had not received a performance evaluation because she did not receive raises. During an interview with S1ADM (Administrator) on 04/30/2025 at 3:55 p.m., she stated that she was not aware that performance evaluations were required for PRN staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure pain management was provided to residents complaining of pain for 1 (Resident #3) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This had the potential to affect the 82 residents that resided in the facility. Findings: On 03/25/2025 a review of the facility's policy titled, Pain Management Program Policy, with a revised and reviewed dated of 01/2025 read in part . The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices, related to pain management. If pain is identified, the following steps are initiated:-Created a Pain Care Plan using standardized pain assessment tools, obtain orders for pharmaceutical and/or non pharmaceutical interventions. Nurses will assess residents' pain every shift using the appropriate pain evaluation tool and document the effectiveness of interventions. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure pain medication was available for 1 (Resident #3) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This had the potential to affect the 82 residents that resided in the facility. Findings: Review of Resident #3's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: atrial septal defect as current complication following acute myocardial infarction, encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft (CABG), spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure and dysarthria following cerebrovascular disease. Review of Resident #3's March 2025 physician's orders revealed an order dated 03/11/2025 for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. 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 record review and interviews, the facility failed to ensure the resident's comprehensive plan of care was implemented for 2 (#1, #3) residents out of 6 (#1-#6) sampled residents. The facility failed to: 1. Monitor a hematoma and perform wound care for a laceration as ordered for Resident #1; and 2. Perform wound care as ordered for Resident #3's surgical incisions. Findings: Resident #1 Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, End Stage Renal Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Diabetes Mellitus, Severe Protein Malnutrition, and Muscle Wasting and Atrophy. Review of Resident #1's October 2024 physician's orders revealed the following orders dated 10/18/2024: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide care and services to prevent and treat pressure ulcers for 5 (#1, #2, #3, #4 and #5) residents of 5 (#1, #2, #3, #4 and #5) sampled residents investigated for pressure ulcers. The facility failed to provide wound care as ordered by the physician for Residents #1, #2, #3, #4 and Resident #5; and monitor proper functioning of a low air loss mattress for Resident #1 per the resident's plan of care. Findings: Resident #1 Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, End Stage Renal Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Diabetes Mellitus, Severe Protein Malnutrition and Muscle Wasting and Atrophy. October 2024 Review of Resident #1's October 2024 physician's orders revealed the following orders dated 10/07/2024: -Wound #1 Pressure Injury to the Left Ankle: Apply Gentian [NAME] daily every day…

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 post daily nursing staffing that included the facility name, date, census, and the total number and actual hours worked by staff responsible for resident care in a prominent place readily accessible to residents and visitors. Findings: On 07/22/2024 at 3:30 p.m., an observation was made throughout the entire facility, and there was no evidence that the daily nursing staffing was posted. On 07/22/2024 at 4:00 p.m., an interview was conducted with S6Corp (Corporate Nurse) who confirmed that the census should be posted daily. She stated that staff had been posting it on Hall B. At that time, an observation was conducted with S6Corp on Hall B. A white dry-eraser board was observed located under the TV against the back wall. A closer observation revealed that the board did not contain any information. S6Corp stated that the board should have the census, the number of staff, and the total number and actual hours worked. She also confirmed that the board was not and should have been in an area where it was visible for all residents…

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

Based on observation, and interviews, the facility failed to ensure that menus were followed for residents. This had the potential to affect a census of 80 residents. Findings: On 07/21/2024 at 12:05 p.m., an observation was made of the meal service during lunch. The residents were served [NAME] Pilaf, Glazed Ham, Baked beans, Pureed Ham, Chopped Ham, [NAME] Mashed Potatoes, Pork Chops with Gravy, Pureed [NAME] Beans, Dinner Rolls, and Lemon Cake. There was no pureed dinner rolls or cornbread available. Review of the facility's lunch menu revealed the residents should have received: Glazed Ham, Baked sweet potato, Braised cabbage, Cornbread, and Frosted cake. On 07/21/2024 at 1:10 p.m., an interview was conducted with S5Cook. She confirmed there was a difference in what was served from the scheduled menu. S5Cook also confirmed that she did not prepare and serve pureed bread for residents receiving pureed meals. S5Cook stated she should have checked the menu. On 07/22/2024 at 2:08 p.m., an interview was conducted with S8RD (Registered Dietician) who stated the kitchen staff should…

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

Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Clean the kitchen fryer, fryer baskets, floor beside fryer and oven; 2. Label refrigerated foods and discard expired foods in the refrigerator; 3. Monitor refrigerator and freezer temperatures; 4. Monitor dishwasher temperature and chemicals; and 5. Ensure staff wore hair restraints in the kitchen. This deficient practice had the potential to affect the 80 residents who consumed food from the kitchen. Findings: On 07/22/2024, a review of the facility's policy titled Sanitization with a revision date of 01/2024, read in part, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation .1. All kitchens, kitchen areas and dining areas shall be kept clean .11 B. Fixed Equipment .1. Fixed equipment will be routinely cleaned and maintained .3. Food contact equipment will be cleaned and…

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

Based on observation and interview, the facility failed to ensure the most recent survey results of the facility were posted in a place readily accessible to residents, family members, and legal representatives of residents. The facility's census was 80. Findings: On 07/21/2024 at 10:23 a.m., an observation was made of a clear plastic file holder mounted to the wall outside of the human resources office door near the facility's main entrance. A clear colored binder containing licensing surveys was observed inside the plastic file holder, and inside the binder were survey results and plan of corrections from the annual surveys and complaints conducted in 2018, 2019, 2020, and 2021. There was no evidence of the last three year's of annual or complaint surveys in the folder. On 07/23/2024 at 12:44 p.m., an interview was conducted with S1DON (Director of Nursing) and S11Adm (Administrator). They stated the results for the survey were posted at the entrance of the nursing home in a clear binder holder outside of the human resources office, but nowhere else. S11Adm confirmed the annual…

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 develop and implement a comprehensive person-centered plan of care for each resident as evidenced by: 1. failing to follow the plan of care to address Resident #33's elevated blood sugar; and 2. failing to ensure Resident #1 had enabler bars attached to the bed as ordered. Findings: 1. Resident #33. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included, but were not limited to, Type 2 Diabetes Mellitus. Review of the resident's physician's orders dated revealed an order for Humulin R inject as per sliding scale 60-150 mg/dL (milligram per deciliter): 0 units, 151-200 mg/dL: 2 units, 201-250 mg/dL: 4 units, 251-300 mg/dL: 6 units, 301-350 mg/dL: 8 units, 351-400 mg/dL: 10 units, 401 mg/dL: 12 units, recheck blood sugar in 2 hours if still greater than 400 call the physician. Review of the resident's June 2024 MAR (Medication Administration Record) revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, the facility failed to ensure that recipes were followed for 4 of 4 (#11, #34, #45, and #55) residents who received pureed diets, by failing to follow a recipe for mashed potatoes. Findings: On 07/22/2024, a review of the facility's policy titled Therapeutic diets with a revision date of 06/12/2024, read in part, Policy Statement: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care .Policy Interpretation and Implementation: 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example .d. Altered consistency diet. A review of Resident #11's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Hemiplegia and Hemiparesis Following Cerebral…

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 records reviewed the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help prevent and control the spread of an infectious communicable disease, COVID-19, as evidenced by staff: 1. Failing to remove Personal Protective Equipment (PPE) prior to exiting a positive COVID-19 room and perform hand hygiene upon removing PPE; and 2. Failing to ensure housekeeping staff used gloves and performed hand hygiene while handling a dirty mop. Findings: On 07/22/2024, a review of the facility's policy titled Infection Prevention and Control Program with a revision date of 01/01/2024, read in part, Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections .Policy Interpretation and Implementation .11. Prevention of Infection a. important facets of infection prevention include: 3. educating staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's dignity by failing to provide a covering for a urinary catheter bag for 1 resident (#428) out of 35 sampled residents. Findings: Review of Resident #428's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Heart Failure. On 07/21/2024 at 9:00 a.m., an interview and observation was made of Resident #428 with S12RNS (Register Nurse Supervisor). Resident #428's urinary catheter drainage bag was observed containing urine and there was no covering for the drainage bag. S12RNS confirmed that the catheter bag did not have a privacy cover. She was unsure of the policy on covering catheter drainage bags, but stated that she thought the bag should be covered. On 07/23/2024 at 11:42 a.m., an interview with S6Corp was conducted. She confirmed that a privacy cover should have been placed on Resident 428's urinary drainage bag.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#23) out of 2 (#23 and #33) residents investigated for a clean, comfortable and homelike environment. The final sample size was 35 residents. Findings: On 07/22/2024, a review of the facility's policy titled, Homelike Environment with a last reviewed date of 07/08/2024, read in part .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .e. clean bed and bath linens that are in good condition. Review of Resident #23's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Muscle Weakness, Unspecified Lack of Coordination and Need for Assistance with Personal Care. On 07/21/2024 at 11:04 a.m., an observation was made 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 Resident #1 Review of Resident #1's EMR revealed he was admitted to the facility on [DATE] and was diagnosed with Schizophrenia on 01/22/2018. Further review of Resident #1's EMR (electronic medical record) revealed a Level 1 PASARR screening dated 05/07/2018 that was completed at another facility. Section 3 titled Mental Illness, was checked yes, and only Major Depression Disorder was checked. On 07/22/2024 at 1:13p.m., an interview was conducted with S6Corp. She stated Resident #1 was diagnosed with Schizophrenia on 01/22/2018. S6Corp confirmed the Level 1 PASARR screening was not answered correctly because Schizophrenia was not checked. She confirmed no other PASARRs were found and was unable to confirm a corrected submission was sent. Based on record reviews and interviews, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level 1 screening was completed accurately for 2 (#1, #43) out of 2 (#1, #43) residents investigated for PASARR in a final sample of 35 residents.…

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 reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#428) of 35 sampled residents. This was evidenced by S18LPN (Licensed Practical Nurse) leaving Resident #428's medication at the bedside. Findings: On 07/08/2024, a review of the facility's policy titled, Medication Administration, with a review date of July 8, 2024, revealed in part .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Resident #428 was admitted to the facility on [DATE], with diagnoses that included Chronic Kidney Disease and Heart Failure. Review of the resident's BIMS (Brief Interview for Mental Status) performed on 07/18/2024 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.

Based on interviews and record reviews, the facility failed to provide pharmaceutical services that were in order and accounted for the drug record reconciliation of all controlled drugs during shift changes for 1(Medicine Cart 1) MC1 of 3 Medicine carts reviewed during their annual survey. This deficient practice had the potential to affect the 80 residents residing in the facility. On 07/23/2024, a review of the facility's policy titled, Controlled Substances, with a review date of July 8, 2024, revealed in part .4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. On 07/22/2024 at 09:09 a.m., an interview and review of the July 2024 Controlled Drugs-Count Record for MC1 was conducted with S19LPN (Licensed Practice Nurse) and S20ADON (Assistant Director of Nursing). Both S19LPN and S20ADON stated that the off going nurse for each shift should have reconciled the narcotics in each medicine cart with the oncoming nurse. Both S19LPN and S20ADON confirmed that there was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to properly store drugs as evidenced by 1. Loose pills found in the bottom drawers of 1(MC2 (Medicine Cart 2) out of 3 medication carts reviewed. 2. Failure to label a multi-use vial found in 1(MS1) out of 2 medicine storage rooms reviewed This deficient practice had the potential to affect the 80 residents residing in the facility. Findings: On 07/23/2024, a review of the facility's policy titled, Storage of Medications, with a review date of 07/08/2024, revealed, in part, the following: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner .3. Nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. On 07/22/2024 at 9:57 a.m., an interview along with an observation of MS1 (Medication Storage room [ROOM NUMBER], 100 hall) was conducted with S22LPN (Licensed Practical Nurse). A multi-use vial of flu vaccine was observed open, with no labeled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure the resident was adequately supervised and monitored while exiting off the transportation van's wheelchair ramp resulting in the residents sustaining injuries for 1 (#1) of 3 (#1, #2, #3) residents sampled for accidents. Findings: The facility did not have a policy or procedure for unloading residents from the facility's van wheelchair ramp. Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Bipolar, Depression, and Chronic Obstructive Pulmonary Disease. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 04/05/2024 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated he was cognitively intact. Review of the facility's incident report dated 06/10/2024, written by S6LPN (License Practical Nurse), read in part resident was lowered to the ground on ramp on van outside after returning from a doctor's appointment. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were treated with respect and dignity for 1 resident (#1) out of 3 (#1, #2, #3) sampled residents. Findings: On 06/25/2024 , a review of the facility's policy titled Quality of Life- Dignity with a last revised date of February 2020 read in part .1. Residents are treated with dignity and respect at all times .7. Staff speak respectfully to residents at all times . Review of Resident #1's EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] with diagnoses including Other Post Procedural Complications of Skin and Subcutaneous Tissue, Encounter for Attention to Colostomy, and Anxiety. Review of section C- Cognitive Patterns of Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating that her cognition was intact. Review of a facility investigation revealed that on 05/23/2024, Resident #1 gave 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 interviews and record review the facility failed to notify the Physician and Responsible Party, immediately after an accident involving the resident for 1(#1) of 3 (#1, #2, #3) sampled residents. This deficient practice had the potential to affect any of the 82 residents residing at the facility. Findings: On 03/26/2024 at 1:30 p.m., a review of the facility's policy titled Policy for Resident Incident and Visitor Accident Report with a review date of 01/2023, revealed in part: Policy. The facility will conduct an investigation of all incidents involving residents of the facility .B. Resident Incidents/Accidents: 1. If you witness an incident/accident, you must .2. Licensed nurse must .e. notify the physician, family, legal representative. Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Left Femoral Vein, Generalized Muscle Weakness, and Repeated Falls. On 03/21/2024, a review of a health standards intake form 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 observations, interviews and record reviews, the facility failed to implement a person centered care plan for 2(#1, #2) of 3(#1, #2, #3) sampled residents, by failing to ensure the residents received nutritional supplement as ordered by the physician. This deficient practice had the potential to affect the 27 residents who were ordered nutritional supplements. Findings: Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Acute Embolism and Thrombosis of Left Femoral Vein, Unspecified Severe Protein-Calorie Malnutrition, Generalized Muscle Weakness, and Repeated Falls. A review of Resident #1's physician's orders revealed an order written on 02/22/2024 at 12:06 p.m. for Ensure Plus before meals for Anorexia/Malnutrition. On 03/26/2024 at 9:17 a.m., an interview and observation of the rehab unit refrigerator was conducted with S2LPN (Licensed Practical Nurse). She stated that supplements were kept in the refrigerator. An observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interviews the facility failed to provide accurate documentation that the resident's nutritional supplement was offered for 1 (#3) out of 3 (#1, #2 and #3) sampled residents. This deficient practice has the potential to affect the 82 residents that resided in the nursing home. Findings: Review of Resident #3's admission record revealed she was admitted on [DATE]. Her diagnoses included in part, Cerebral ischemia, Dementia, Muscle Wasting and Atrophy, right upper arm, right and left shoulder, Pressure ulcer of sacral region-Stage 3, Pressure-induced deep tissue damage of left heel and Vitamin D deficiency. Review of the resident's order summary report of active orders as of 03/01/2024 revealed an order with an order date 02/14/2024 for staff to encourage intake of supplements brought by family in resident's room every shift. On 03/26/2024 at 9:50 a.m., an observation and interview was conducted with S5LPN (Licensed Practical Nurse). S5LPN was asked if she was aware that…

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 failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Remove expired food item from the refrigerator; 2. Label food items with the date and time they were opened; 3. Label cooked items with the date they were cooked; 4. Appropriately label food items taken out of original containers; 5. Remove dust buildup from the kitchen ceiling; 6. Remove dust from the refrigerator blower; and 7. Maintain kitchen equipment. This deficient practice had the potential to affect the 83 residents who consumed food from the kitchen. The facility's census was 89. Findings: A review of the facility's policy titled Refrigerators and Freezers read in part: Policy Interpretation and Implementation .7. All food shall be appropriately dated to ensure proper rotation by expiration dates .Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infections as evidenced by: 1. Failing to ensure hand hygiene was performed between distributing each resident's meal tray for 3 (#197, #198, #199) residents out of a final sample of 55 residents and ; 2. Failing to provide a lidded container to dispose used PPE (Personal Protective Equipment) used for a resident on Contact Precautions out of a final sample of 55 residents. Findings: 1. Review of the facility's policy titled, Handwashing - Hand Hygiene Policy and Procedures, 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: .b. before and after direct contact with residents. l. After contact with objects (e.g., medical equipment) in the immediate…

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 ensure the easy touch call light device was within reach for 1 (#71) investigated for accommodation of needs in a final sample of 55 residents. Findings: Review of the facility's policy, Answering The Call Light revealed, in part the following: Purpose: The purpose of this procedure is to respond to the resident's request and needs. Steps in the Procedure: . 11. Place the call light within reach of the resident. Review of Resident #71's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Epilepsy, Scoliosis, and Fusion of Spine. Review of Resident #71's comprehensive care plan dated 09/22/2021 revealed in part that the resident had an ADL (Activities of Daily Living) self-care performance deficit related to Cerebral Palsy with an intervention to keep call light within reach. On 08/28/2023 at 10:00 a.m., an observation was made of Resident #71 in bed. The resident's easy touch call…

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

Based on observations and interviews, the facility failed to maintain a clean and homelike environment by failing to clean the wall which had a dried brown and red splattered substance in Room A. Findings: Review of the facility's policy, Homelike Environment revealed, in part, the following: Policy Statement: Residents are provided with a safe, clean, comfortable 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 . Review of the facility's form titled, Housekeeping Job Routine revealed, in part, the following: complete this shift checklist daily . 6- Spot clean walls . Review of the Housekeeping Job Routine for Room A revealed all areas for the forms dated 08/25/2023 to 08/29/2022 were checked off as completed. Review of the Housekeeper Job Description revealed, in part, the following: Job Function: Clean walls . On 08/28/2023 at 8:47 a.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a Significant Change in Condition MDS (Minimum Data Set) Assessment was completed for 2 residents (#82, #83) out of a total sample of 55 residents. Findings: Resident #82 Review of the facility's policy tiled MDS Coding Policy read: Nexion affiliated facilities utilize the most up to date resident assessment instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Resident #82 was admitted to the facility on [DATE] with diagnoses including Non-Traumatic Intracerebral Hemorrhage in Brain Stem, Cerebral Infarction, Diabetes Mellitus, and Dysphagia. Review of Resident #82's EHR (Electronic Health Record) revealed a Significant Change MDS Assessment with an ARD (Assessment Reference Date) of 08/16/2023 that was in progress. Further review of the Significant Change MDS Assessment revealed section G was not completed. On 08/29/2023 at 11:00 a.m., an in interview was conducted with S17BOM…

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 ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the resident's dialysis status for 1 (#83) out of 55 sampled residents. Findings: A review of Resident #83's medical record revealed that he had diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis with an onset date of 06/29/2023. A further review of the medical record revealed Resident #83 received dialysis on 07/01/2023. A review of Resident #83's medical record revealed a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/02/2023. Section I for Active Diagnoses included in part: I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD) and I800 Dependence on Renal Dialysis. Further review of the MDS assessment revealed under Section O0100-J (Special Treatments, Procedures and Programs) the box for Dialysis While a Resident was not checked. On 08/29/23 at 2:52 p.m., an interview and a review of Resident #83's 07/02/2023 MDS was conducted 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 interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 resident (#82) out of 1 resident investigated for hospice services. This deficient practice occurred when the facility failed to collaborate with the hospice provider to obtain discharge orders at the time the resident was discharged from hospice care. Findings: Review of the facility's policy titled Hospice Program read in part: In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: b. changing the level of services provided when it is deemed appropriate .10. In general , it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative., and ensure that the level of care provided is appropriately based on the individual resident's needs. These…

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 physician orders were transcribed and followed for 1 (Resident #2) of 5 (Resident #1, #2, #3, #4, and #5) sampled residents. Findings: Review of Resident #2's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Scalp Contusion Status Post Fall, Acquired Absence Of Right Leg Below Knee, Acquired Absence Of Left Leg Above Knee, Peripheral Vascular Disease, and Atrial Fibrillation. Review of Resident #2's Q (Quarterly) MDS (Minimum Data Set) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 indicating his cognition was moderately impaired. Review of the hospital Discharge summary dated [DATE] at 3:15 p.m., revealed, in part, the following: Physician order Hold Eliquis for 48 hours. Review of Resident #2's July 2023 EMAR (Electronic Medication Administration Record) revealed the following Eliquis Oral Tablet 5 mg (milligram)…

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.