Ferncrest Manor Living Center

Based on observations, interviews, and record reviews, the facility failed to maintain a resident's wheelchair in a safe working condition for 1 (Resident #91) of 5 residents reviewed for environment.Findings:Review of Resident #91's records revealed, in part, an admit date of 05/19/2025. Review of Resident #91's diagnoses revealed, in part, Resident #91 was diagnosed with lack of coordination, morbid (severe) obesity, right heart failure, and shortness of breath. Review of Resident #91's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/2026 revealed, in part, Resident #91 required the use of a manual wheelchair. In an interview on 05/18/2026 at 9:00AM, Resident #91 indicated his wheelchair tires were extremely damaged with the rubber peeling off of the wheels. Resident #91 further indicated due to the damaged wheels on his wheelchair, the wheels on the wheelchair did not properly lock.Observation on 05/19/2026 at 12:00PM revealed Resident #91's wheelchair had multiple areas of rubber missing off the wheelchair's wheels. In an interview on 05/19/2026…

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

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A resident was positioned as ordered while receiving enteral feedings (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) (Resident #2); 2. An enteral feeding administration set (tubing used to administer a resident's enteral feeding) for a resident's enteral feeding was changed every 24 hours per the facility policy and physician's order (Resident #2); and, 3. Only qualified staff placed a resident's enteral feeding on hold and/or restarted a resident's enteral feeding (Resident #R4). This deficient practice was identified for 2 (Resident #2, Resident #R4) of 3 (Resident #1, Resident #2, Resident #R4) residents reviewed for enteral feeding maintenance. Findings: Review of the facility's Enteral Feedings-Safety Precautions, last revised on 10/01/2024 revealed, in part, Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) were the personnel responsible for preparing, storing, and administering enteral feedings. Further review…

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

Based on interview and record reviews, the facility failed to maintain accurate records for 1 (Resident #2) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for accurate documentation. Findings: Review of the facility's Charting and Documentation policy, last revised on 10/01/2024, revealed, in part, all services provided to a resident shall be documented in the resident's medical record. Review of Resident #2's June 2025 physician's orders revealed, in part, an active order dated 01/22/2025 for staff to check the residual amount of Resident #2's enteral feeding (a type of liquid nutritional supplement that is typically given through a tube directly inserted into the stomach) every 4 hours at 12:00AM, 4:00AM, 8:00AM, 12:00PM, 4:00PM, and 8:00PM. Further review revealed an active order dated 05/22/2025 for staff to administer Jevity 1.5 (an enteral feeding) to Resident #2 at a rate of 40 milliliters/hour (ml/hr) continuously. Further review revealed an additional active order dated 05/26/2025 for staff to administer Jevity 1.5 at a rate of 20 ml/hr…

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

Based on observation and interview, the facility failed to ensure a resident's privacy during incontinence care for 1 (Resident #R4) of 4 (Resident #1, Resident #2, Resident #3, Resident #R4) residents observed for residents' rights. Findings: Observation on 06/24/2025 at 9:43AM revealed S3Certified Nursing Assistant (CNA) was providing incontinence care to Resident #R4 and did not announce that she was providing care to Resident #R4 when the surveyor knocked on the door to Resident #R4's room before entering. Further observation revealed Resident #R4's limbs and incontinence brief could be visualized from the doorway of Resident #R4's room. Further observation revealed that the privacy curtain in Resident #R4's room was not drawn to obstruct visualization of Resident #R4 from Resident #2 (Resident #R4's roommate) while S3CNA provided incontinence care to Resident #R4. In an interview on 06/24/2025 at 11:23AM, S2Dirctor of Nursing (DON) indicated S3CNA should have pulled Resident #R4's privacy curtain and/or provided privacy to Resident #R4 when she provided incontinence care to…

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

Based on observations, interviews, and record reviews the facility failed to ensure: 1. The facility's dining room was kept in a clean/sanitary manner; and, 2. The facility's hallways were kept in a clean/sanitary manner and in good repair for 3 (Hallway a, Hallway b, Hallway c) of 3 (Hallway a, Hallway b, Hallway c) hallways observed for physical environment. Findings: Review of the facility's Maintenance Service policy and procedure, with a revision date of 05/2024 revealed, in part, the functions of the facility's maintenance personnel included maintaining the building in good repair. Review of the facility's Environmental Services policy and procedure, with a revision date of 05/2024 revealed, in part, floors shall be maintained in clean, safe and sanitary manner. 1. Observation of the dining room on 05/27/2025 at 11:30AM revealed the following: - 16 windows had a total of 85 dead insects, between them, on the window sills; - five of the output air vents, on the ceiling above the area where the dining room tables were, had an unknown light gray substance surrounding them; 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 interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS) Assessment was transmitted within the required timeframe after completion for 1 (Resident #69) of 1 (Resident #69) sampled resident reviewed for assessment transmission. Findings: Review of Resident #69's annual MDS Assessment Section Z - Assessment Administration revealed, in part, Resident #69's annual MDS Assessment was completed and electronically signed by the Registered Nurse (RN) Assessment Coordinator on 04/17/2025. Review of the Final Validation Report dated 05/29/2025 revealed, in part, Resident #69's annual MDS Assessment was not submitted to the Centers for Medicare & Medicaid Services (CMS) database until 05/29/2025. In an interview on 05/29/2025 at 8:24AM, S11Registered Nurse (RN) indicated Resident #69's annual MDS Assessment was completed on 04/17/2025 but was not transmitted until 05/29/2025. S11RN further indicated that the assessment should have been transmitted within 7 days of the completion date but was not as required.

Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) of 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's May 2025 Medication Cart a Narcotic Nurse Sign on/off log revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart a's controlled substances with the oncoming nurse on: - 05/01/2025 for the 7:00PM to 7:00AM shift; and, - 05/22/2025 for the 7:00AM to 7:00PM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart a's controlled substances with the off going nurse on 05/01/2025 for the 7:00PM to 7:00AM shift. Further review on 05/29/2025 at 1:57PM revealed S13Licensed Practical Nurse's (LPN)…

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

Based on observation and interview, the facility failed to ensure a nurse secured medications when unatteneded for 1 (Medication Cart b) of 6 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e, Medication Cart f) medication carts reviewed for medication storage. Findings: Observation on 05/27/2025 at 12:22PM, revealed Medication Cart b was left unlocked and unattended. Further observation revealed the following medications were present on the top of Medication Cart b and unsecured: 55 tablets of metoprolol tartrate (a medication used to treat high blood pressure and chest pain) 25 milligrams (mg) and two vials of Zosyn (a medication used to treat infections) 4.5 grams. Further observation revealed S16Licensed Practical Nurse (LPN) (the nurse responsible for Medication Cart b) was sitting at the nursing desk with her back turned to Medication Cart b. Further observation revealed Medication Cart b was left unattended by S16 LPN for 10 minutes. In an interview on 05/27/2025 at 12:33PM, S16LPN acknowledged she should not have the above…

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: 1. ensure food stored in the facility's walk in cooler was properly dated and labeled, 2. ensure the dishwasher temperature and sanitizer log was properly maintained. Findings: 1. Review of the facility's policy for Food Receiving and Storage, with a revision date of 05/2024 revealed, in part, refrigerated foods are covered, labeled, and dated. An initial kitchen observation on 05/27/2025 at 8:25AM revealed the following: - 1 container of cooked carrots in a container covered with saran wrap not dated, - 1 container of barbeque sauce covered with saran wrap not dated and, - 14 styrofoam containers of chicken noodle soup were not dated In an interview on 05/27/2025 at 8:28AM, S7Dietary Manager confirmed the above mentioned containers of food should have been labeled and dated but were not. 2. Review of the facility's policy titled Dishwashing Machine Use, with a revision date of 10/01/2024 revealed, in part, a supervisor will check the dishwashing machine for proper concentrations of sanitizer solution…

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: 1. Ensure the Quality Assurance and Assessment (QAA) committee met at least quarterly; and 2. Ensure the designated Infection Preventionist participated in the quarterly QAA meeting. Findings: 1. Review of the facility's QAA meeting sign-in sheet revealed the most recent QAA committee meeting was held on 04/09/2025. Further review revealed the prior QAA committee meeting was held on 10/09/2024. There was no documentation of a QAA meeting being conducted during the 1st quarter of 2025 (January-March) and the facility did not present any documented evidence a QAA meeting was held for the period of Jan-[DATE]. 2. Review of the Quarterly QAA meeting minutes dated 04/09/2025 revealed the Infection Preventionist (IP) was not documented on the sign-in sheet as being in attendance at the meeting. In an interview on 05/28/2025 at 3:01PM, S3Director of Nursing (DON) indicated the Infection Preventionist did not attend the 04/09/2025 QAA meeting. S3DON further…

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

Based on observations, interviews, and records reviews, the facility failed to: 1. Store clean mop heads in the clean linen area of the facility's laundry room; 2. Store clean linen in a sanitary manner; and, 3. Ensure residents' suction canisters were changed on the scheduled change date for 2 (Resident #62, Resident #82) of 2 (Resident #62, Resident #82) sampled residents reviewed for infection control. Findings: 1. Observation on 05/27/2025 at 10:00AM revealed, the facility's clean mop heads were stored in an open container next to an open container of dirty mop heads, and adjacent to containers of dirty laundry in the facility's contaminated laundry area. In an interview on 05/27/2025 at 10:01AM, S9Housekeeper indicated the mop heads stored in the above mentioned open container in the facility's contaminated laundry area were clean and ready to be used. In an interview on 05/27/2025 at 10:03AM, S10Housekeeper indicated the clean mop heads were normally stored in the above mentioned open container next to the dirty mop heads in the facility's contaminated laundry area. In an…

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

Based on observations, interviews, and record reviews, the facility failed to ensure call lights were within reach for 2 (Resident #24, Resident #101) of 3 (Resident #24, Resident #64, Resident #101) sampled residents investigated for accommodation of needs. Findings: Review of the facility's Answering the Call Light policy dated 04/01/2021 with revised date of 10/01/2024 revealed, in part, it is the policy of the facility to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Resident #24 Review of Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/2025 revealed, in part, Resident #24 required substantial and/or maximal assistance for self-care from staff, partial/ moderate assistance for activities of daily living (ADL) from staff and was dependent on staff for transfers. Observation on 05/28/2025 at 11:55AM revealed Resident #24 was lying in bed. Further observation revealed Resident #24's call light was on the floor, at the head of the bed, 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 interview and record reviews the facility failed to ensure a resident's Minimum Data Set (MDS) assessment reflected the resident's accurate discharge status for 1 (Resident #111 ) of 3 (Resident #109, Resident #110, Resident #111 ) sampled residents investigated for closed records. Findings: Review of Resident #111's Discharge MDS with an Assessment Reference Date (ARD) of 03/12/2025 revealed, in part, Resident #111 was discharged to a short term general hospital. Review of Resident #111 progress note dated 3/12/2025 revealed Resident #111 had a planned discharge to home. In an interview on 05/29/2025 at 11:26AM, S11Registered Nurse (RN), MDS Coordinator confirmed Resident #111's discharge MDS with ARD of 03/12/2025 indicated Resident #11 was discharged to a short term general hospital and was incorrect. S11RN, MDS Coordinator indicated Resident #111 was discharged to home.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to administer a medication per a physician's orders for 1 (Resident #91) of 5 (Resident #2, Resident #29, Resident #91, Resident #101, Resident #162) residents reviewed for unnecessary medication review. Findings: Review of the scope of Practice of Practical Nursing defined in Section 961 of Chapter 11, Louisiana Revised Statues revealed the licensed practical nurse must practice under the direction of, in part, a licensed physician. Review of Resident #91's Electronic Medical Record (EMR) revealed, in part, Resident #91 was admitted on [DATE] with diagnoses, which included, cerebrovascular vasospasm and vasoconstriction; diabetes mellitus; essential (primary) hypertension; malignant melanoma of skin of breast; anxiety disorder, unspecified; morbid (severe) obesity due to excess calories; and major depressive disorder. Review of Resident #91's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2025 revealed, in part,…

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

Based on interview and record reviews, the provider failed to ensure a Registered Nurse (RN) worked at least 8 hours for 1 (04/19/2025) of 22 (04/19/2025, 04/20/2025, 04/26/2025, 04/27/2025, 05/03/2025, 05/04/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/24/2025, 05/25/2025) days reviewed for staffing requirements. Findings: Review of the facility's weekend Nursing/Ancillary Personnel Staffing Pattern Reporting Form, dated 04/19/2025 through 05/252/2025, signed as complete and accurate by S1Administrator on 05/27/2025 revealed, in part, one RN worked on 04/19/2025. Review of the facility's time sheets dated 04/19/2025 revealed, in part, S2Direcor of Nursing (DON) was the only RN with a time clock entry for 04/19/2025. Further review revealed, S2DON clocked in at 9:01AM and clocked out on 11:13AM. In an interview on 05/29/2025 at 10:45AM, S2DON confirmed she was the only RN that worked on 04/19/2025. S2DON further indicated she was unable to provide any…

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

Based on interview and record review, the facility failed to ensure the facility assessment included specific nursing staffing needs for day, night, and weekend shifts. Findings: Review of the facility's facility assessment, last updated on 05/07/2025 revealed, in part, there was no documented evidence the facility assessment included specific staffing needs of its resident population for Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA) for day, night, and weekend shifts. In an interview on 05/29/2025 at 11:00AM, S1Administrator was presented with the above mentioned findings and could offer no explanation as to why the facility assessment did not include specific LPN and CNA staffing needs for day, night, and weekend shifts.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and facility document review, it was determined that the facility failed to ensure staff members received behavioral health training for 5 (S2Maintenance, S3Smoking Aide, S4Social Worker, S6Certified Nursing Assistant [CNA], and S7CNA) of 5 personnel records reviewed for required trainings. Findings Included: Review of the Facility's assessment dated [DATE] revealed, in part, the facility had 58 residents with Psychiatric Diagnoses and 14 residents required behavior management. Review of S2Maintenance's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S2Maintenance received behavioral health training. Review of S3Smoking Aide's personnel record revealed, in part, no documented evidence, and the facility did not present any documented evidence, S3Smoking Aide received behavioral health training. Review of S4Social Worker's personnel record revealed, in part, no documented evidence, and the facility did not present any…

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, facility document reviews, and facility policy review, it was determined that the facility failed to ensure an allegation of physical abuse was reported to the Louisiana Department of Health no later than 2 hours after the allegation was made for 1 (Resident #1) of 3 residents investigated for abuse. Findings Included: Review of the facility's policy titled, Reporting, Abuse, Neglect, Misappropriation of Property, last revised on 07/25/2023 revealed, in part, the Director of Nursing, the Assistant Administrator, and/or the Administrator shall immediately notify the designated representatives through the State Incident Management System (SIMS) within 2 hours if an allegation involved physical abuse or resulted in bodily harm or injury. Review of the provider's investigative report for physical abuse dated 11/21/2024 revealed, in part, S1Administrator received a report an altercation between S2Maintenance and Resident #1 had occurred outside in the smoking area. Further review revealed S2Maintenance stood up over Resident #1, who was sitting in a wheelchair, 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 record reviews and interviews, the facility failed to ensure adequate respiratory staff were available to provide respiratory care and services as ordered for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for respiratory care. Findings: Review of the facility's undated policy and procedure titled, Ventilator Assessment / Monitoring, revealed, in part, complete physical and mechanical assessments should be made on the first ventilator round of both the resident and the ventilator. Further review revealed ventilator rounding was every 4 hours. Review of the Facility assessment dated [DATE] revealed, in part, the facility's Technology Dependent Unit (TDU) staff needs required 2 respiratory therapists (RT) per shift. Further review revealed, minimum staffing requirements included 2 RTs twenty-four hours a day, every day. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 09/05/2024 revealed, in part, Resident #1 had diagnoses of…

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

Based on record reviews and interviews, the facility failed to ensure Nurse Staffing Agency (NSA) Certified Nursing Assistants (CNAs) were trained on tracheostomy (a surgical opening in the neck to allow air to enter the lungs) and ventilator (a machine that moves air in and out of a person's lungs) safety prior to being assigned to the facility's Technology Dependent Unit (TDU) (unit at the facility that houses the tracheostomy and ventilator residents) for 2 (S6CNA and S7CNA) of 2 (S6CNA and S7CNA) NSA CNAs sampled for tracheostomy and ventilator competency. Findings: Review of the facility's nursing staff in-service records dated 02/22/2024 through 09/17/2024 revealed, in part, no documented evidence, and the facility could not provide any documented evidence, S6CNA and/or S7CNA were in-serviced on tracheostomy and ventilator safety. Review of the facility's staff assignment log dated 08/31/2024 revealed, in part, S6CNA and S7CNA were assigned to the [NAME] unit (TDU) during the 7:00 p.m - 7:00 a.m. shift. Review of S6CNA's NSA record revealed, in part, no documented evidence,…

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 a resident's medication was available for use and administered as ordered for 1 (Resident #6) of 1 (Resident #6) sampled residents reviewed for infection control. Findings: Review of Resident #6's electronic medical record (EMR) revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of Gastrostomy status. Further review revealed, Resident #6 returned to the facility on [DATE] after an emergency room visit with a diagnosis of Contact Dermatitis. Review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/2024 revealed, in part, Resident #6's Brief Interview for Mental Status Score (BIMS) was a 99 which indicated Resident #6 was rarely understood and unable to complete the interview. Review of the Resident #6's After Visit Summary dated 05/07/2024 revealed, in part, Resident #6 was discharged from the hospital with an order for Cephalexin (a medication used to treat infections) 250…

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 interviews, the facility failed to: 1.) Ensure enhanced barrier precautions were implemented for a resident with an indwelling device or wound for 5 (Resident #6, Resident #51, Resident #111, Resident #474 and Resident #475) of 5 (Resident #6, Resident #51, Resident #111, Resident #474 and Resident #475) residents reviewed for enhanced barrier precautions; 2.) Ensure resident care items were identified and contained. 3.) Ensure nursing staff removed their gloves and completed hand hygiene while performing gastrostomy dressing changes for 1 (S10Registered Nurse (RN) of 1 (S10RN) RNs and 1 (S17Licensed Practical Nurse (LPN)) of 1 (S17LPN) LPNs observed for gastrostomy tube dressing changes; and, 4.) Ensure the wound care nurse properly contained and disposed of a residents visibly soiled dressing for 1 (S9Wound Care Nurse/ Licensed Practical Nurse (WCLPN) of 1 (S9Wound Care Nurse/ Licensed Practical Nurse (WCLPN) nurses observed for wound care. Findings: Review of 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, observations, and interviews, the facility failed to: 1.) Ensure a careplan with measureable interventions was developed for a resident receiving oral antibiotics and wound care for contact dermatitis for 1 (Resident #6) of 4 (Resident #6, Resident #51, Resident #474, and Resident #475) sampled residents reviewed for infection control; 2.) Ensure a careplan with measureable interventions was developed for a resident receiving hospice services for 1 (Resident #474) of 2 (Resident #12 and Resident #474) sampled residents reviewed for hospice services; and, 3.) Ensure a careplan with measureable interventions was developed for a resident with an indwelling urinary catheter for 1 (Resident #474) of 2 (Resident #92 and Resident #474) sampled residents reviewed for urinary catheters. Findings: Resident #6 Review of Resident #6's electronic medical record (EMR) revealed Resident #6 was admitted to the facility on [DATE] with a diagnosis of Gastrostomy status (a surgical inserted tube in 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 and interviews the facility failed to have a resident with clean and trimmed fingernails for 1 (Resident #74) of 2 sampled residents reviewed for activities of daily living care (Resident #50 and Resident #74) in a total sample of 41 residents. Findings: Review of Resident #74's Minimum Data Set (MDS) dated [DATE] revealed, in part, Resident #74 was assessed as having a brief interview for mental status score as a 5 which indicated Resident #74 was severely impaired. Further review of the MDS revealed Resident #74 required substantial/maximal assistance for shower/bathing. Observation on 05/13/2024 at 10:15 a.m., revealed Resident #74's fingernails had an unknown black substance below his fingernails and some fingernails were approximately 3/16 inches long or longer. Observation on 05/14/2024 at 11:11 p.m., revealed Resident #74's fingernails had an unknown black substance below his fingernails and some fingernails were approximately 3/16 inches long or longer. In an interview on 05/13/2024…

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 interviews, the facility failed to ensure a resident's indwelling urinary catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) was secure to prevent pulling for 1 (Resident #475) of 4 (Resident #6, Resident #51, Resident #474, and Resident #475) sampled residents reviewed for infection control. Findings: Review of Resident #475's electronic medical record revealed, in part, Resident #475 was admitted to the facility on [DATE]. Review of Resident #475's Minimum Data Set with an Assessment Reference Date of 04/29/2024 revealed, in part, Resident #475 was dependent on staff for toileting. Review of Resident #475's May 2024 Physicians Orders revealed, in part an order dated 02/26/2024 for staff to assure a securement device such as a Stat Lock (a device used to secure an indwelling urinary catheter to a residents lower extremity) with Resident #475's indwelling urinary catheter was in place to her lower extremity every…

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: 1. Ensure a residents gastrostomy tube (a tube inserted directly into the abdomen to provide nutrition) site was cleaned as ordered by the physician for 2 (Resident #1 and R5) of 4 (Resident #1, Resident #2, Resident #3, and R5) residents reviewed for gastrostomy site care. Findings: Resident #1 Review of Resident #1's Quarterly Minimum Data Set with an Assessment Reference Date of 03/28/2024 revealed, in part, Resident #1 had a gastrostomy tube. Review of Resident #1's April 2024 physician's orders, in part, revealed an order with a start date of 03/10/2024 for cleanse gastrostomy site with wound cleanser, pat dry and cover with drain sponge every day and as needed. Review of Resident #1's Electronic Medication Administration Record (EMAR) revealed, in part, Resident #1' did not receive gastrostomy site care on 03/11/2024, 03/13/2024, 03/15/2024, 03/17/2024, 03/19/2024, 03/21/2024, 03/23/2024, 03/25/2024, 03/27/2024, 03/29/2024, 03/31/2024,…

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 interviews, the facility failed to maintain an environment that was free from pests as evidence by: 1. Maggots were identified in a residents gastrostomy tube (a tube that is inserted into a person's stomach to provide nutrition) site; 2. A fly was observed on the gastrostomy tube of 1 (Resident #3) of 2 (Resident #2 and Resident #3) residents observed for gastrostomy tube site care; 3. A fly was observed in the facility's kitchen; 4. Flies were observed in the facility's dining room; and, 5. Flies were observed on a residents bed linens for 1 (R4) of 3 (Resident #2, Resident #3, and R4) resident rooms observed for pests. Findings: Review of the facility's Root Cause Analysis Template dated 04/24/2024 revealed, in part, the description of event was a resident's gastrostomy tube site was found to have maggots. Further review revealed there were flies in the building. 1. Review of Resident #1's nurse note dated 04/19/2024 at 9:36 p.m. revealed, in part, S3Licensed…

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 ensure documentation was complete and accurate for residents' activities of daily living (ADLs) and residents' 2 hour rounding for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Resident #1 Review of Resident #1's face sheet revealed Resident #1 had diagnoses of cerebrovascular vasospasm and vasoconstriction (a narrowing of the arteries in the brain), unspecified convulsions (a medical condition where the body muscles contract and relax rapidly and repeatedly), and altered mental status. Review of Resident #1's care plan revealed Resident #1 was care planned to have an ADL deficit related to a cerebrovascular accident (stroke) and required intervention from staff to provide assistance with ADLs. Review of Resident #1's nurse's note dated 12/20/2023 at 7:42 a.m. revealed Resident #1 was transferred out of the facility to the hospital. Review of Resident #1's November 2023 ADL…

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

Based on record review and interview, the facility failed to electronically submit payroll information for direct care staffing as required. Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report [NAME] Report 1705D Fiscal Year (FY) Quarter 4 2023 (July 1 - September 30) revealed, in part, the facility failed to submit staffing data for Quarter 4. In an interview on 01/09/2024 at 3:30 p.m., S20Human Resources stated she was unable to produce documented evidence the facility had submitted the PBJ Staffing Data for FY Quarter 4 2023 (July 1 - September 30). In an interview on 01/12/2024 at 2:50 p.m., S1Administrator stated the facility's PBJ Staffing Data was not submitted for FY Quarter 4 2023.

Based on record review, observations, and interviews, the facility failed to ensure 12 controlled drugs were accurately reconciled for 1 (Medication Cart y) of 2 (Medication Cart x and Medication Cart y,) medication carts observed for controlled drug reconciliation. Findings: Review of the facility's Controlled Substances Policy and Procedure revealed, in part, when a controlled substance was administered, the nurse administering the medication was responsible for recording: the name of the resident receiving the medication; the name, strength and dose of the medication; the time of the medication was administered; the method in which the medication was administered, the quantity of medication remaining; and the signature of the nurse administering the medication. Observation on 01/10/2024 at 5:58 a.m. of Medication Cart y revealed the following: - Resident #3's controlled medication cards had 2 tablets of Lacosamide (a controlled medication used to prevent and control seizures) 200 milligram (mg) and 49 tablets of Phenobarbital (a medication used to prevent and treat seizures)…

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

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater by having a medication error rate of 14.8%. This deficient practice was identified for 1 [S6Licensed Practical Nurse (LPN)] of 3 nurses (S6LPN, S7LPN, and S8Registered Nurse) who were observed during medication administration. Findings: Observation on 01/10/2024 at 10:05 a.m. revealed S6LPN administered Cetirizine (medication used to treat allergies) 10 milligrams (mg) 1 tablet per gastric tube, Sennosides (medication used to treat constipation) 8.6 mg 2 tablets per gastric tube, Iron 325 mg 1 tablet per gastric tube, and Refresh Lacri-Lube (medication used for dry, irritated eyes) 56.8-42.5% ointment 1 application to both eyes to Resident #3. Review of Resident #3's current physician orders revealed, in part, an order with a start date of 12/17/2023 for Loratadine (medication used to treat allergies) 10 mg via gastric tube daily. Further review revealed, an order with a start date of 01/05/2024 for Senna- S (medication used to treat constipation) 8.6…

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.

The facility failed to ensure Respiratory Therapist staff had completed annual respiratory therapy competencies completed for 10 (S9Respiratory Therapist, S10Respiratory Therapist, S11Respiratory Therapist, S12Respiratory Therapist, S13Respiratory Therapist, S14Respiratory Therapist, S15Respiratory Therapist, S16Respiratory Therapist, S17Respiratory Therapist, S18Respiratory Therapist) of 11 (S4Respiratory Therapist, S9Respiratory Therapist, S10Respiratory Therapist, S11Respiratory Therapist, S12Respiratory Therapist, S13Respiratory Therapist, S14Respiratory Therapist, S15Respiratory Therapist, S16Respiratory Therapist, S17Respiratory Therapist, S18Respiratory Therapist) Respiratory Therapist files reviewed. Findings: Review of the facility's training and competency records revealed, S9Respiratory Therapist had annual respiratory therapy competencies completed on 12/11/2022. There was no documented evidence and the facility did not present any documented evidence that respiratory therapy competencies was completed for the year 2023. Review of the facility's training and competency…

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 a resident's representative/power of attorney(POA) was immediately notified of a significant change in his medical condition for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of the facility's Notification of Changes policy, revealed, in part, a notification of change included a significant change in the resident's physical, mental, or psychological status, such as deterioration in health, mental, or psychological status, in life-threatening conditions or clinical conditions. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room on [DATE] from approximately 11:48 p.m. through [DATE] at approximately 12:03 a.m. revealed, in part, Resident #1 lying supine with his tracheostomy (a device surgically inserted into the trachea to allow air to fill the lungs) lying on Resident #1's right side on top of his blanket. S4RT entered…

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

Based on record review and interview, the facility failed to ensure a resident remained free from neglect by failing to ensure staff made rounds/checked on a resident every two hours for a resident who was cognitively impaired, had an active tracheostomy status diagnosis, and who was dependent on staff for all activities of daily living. This deficient practice was identified for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) sampled residents. Findings: Review of the facility's Reporting Abuse, Neglect, Misappropriation of Property Policy, revised March 2023, revealed, in part, all residents have the right to be free from abuse, neglect, and misappropriation of property as well as the fear of being abused or neglected. Further review revealed, in part, the Director of Nursing, Assistant Administrator, or Administrator should immediately notify the State Survey Agency within 2 hours after the allegation. Review of the facility's Reinsertion of Tracheostomy Tube policy revealed, in part, the respiratory care staff would be held responsible and…

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

Based on record review and interview, the facility failed to report an allegation of neglect timely to the State Survey Agency and Certification Agency as required for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of the facility's Reporting Abuse, Neglect, Misappropriation of Property Policy, revised March 2023, revealed, in part, all residents have the right to be free from abuse, neglect, and misappropriation of property as well as the fear of being abused or neglected. Further review revealed, in part, the Director of Nursing, Assistant Administrator, or Administrator should immediately notify the State Survey Agency within 2 hours after the allegation. Review of Resident #1's Power of Attorney's (POA) video camera footage of Resident #1's room revealed on 12/15/2023 at 7:43 p.m., S4RT exited Resident #1's room and did not return until 11:48 p.m., at which time S4RT discovered Resident #1 with his tracheostomy tube removed and to be pulseless and breathless. In an interview on 01/12/2024 at 4:00…

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, record review, and interviews, the facility failed to ensure tube feedings were administered as ordered for 1 (Resident #3) of 5 (Resident #1, Resident #2, and Resident #3, Resident #4, and Resident #5 ) sampled residents. Findings: Review of Resident #3's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 12/07/2023 revealed, in part, Resident #3's was severely impaired and dependent on staff with eating. Review of Resident #3's January 2024 physician orders revealed, in part, an order with a start date of 11/30/2023 for Jevity 1.2 calorie (cal) (a tube feeding formula that provides complete and balanced nutrition) at 70 milliliters (ml)/hour (hr). Observation on 01/10/2024 at 10:06 a.m. revealed Resident #3 was receiving Jevity 1.5 cal tube feeding at 70 ml/hr via percutaneous endoscopic gastrostomy (PEG) In an interview on 01/10/2024 at 10:23 a.m., S6Licensed Practical Nurse (LPN) stated Resident #3 was receiving Jevity 1.5 cal tube feeding at 70ml/hr. Observation on 01/10/2024 at 1:10 p.m. revealed Resident #3 was receiving Jevity 1.5 cal…

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

Based on record review, observation, and interview, the facility failed to: 1) Ensure an order was obtained and/or clarified if a compression device to a resident's legs was to be applied or not with a resident's physician (Resident #3); 2) Ensure nursing staff monitored and/or assessed a resident's compression device (Resident #3); and, 3) Ensure a physician's order for a medication was implemented in a timely manner (Resident #3). This deficient practice was identified for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for quality of care. Findings: Review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2023 revealed, in part, Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #3's cognition was intact. Further review revealed, in part, Resident #3 had a diagnosis of lymphedema (swelling caused by circulatory blockage), end stage renal disease (ESRD), and dependent on renal dialysis. 1. Review of Resident #3's care plan revealed, in part,…

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

Based on record review and interview the facility failed to ensure a resident's physician orders for medication administration was coordinated with a resident's dialysis schedule and the resident's physician (Resident #2). This deficient practice was identified for 1 (Resident #2) of 2 (Resident #2 and Resident #3) sampled residents reviewed for dialysis. Findings: Review of Resident #2's October 2023 Physician's Orders revealed, in part, Resident #2 was to receive dialysis every Tuesday, Thursday, and Saturday due to end stage renal disease. Review of Resident #2's August 2023 through October 03, 2023 Medication Administration Record (MAR) revealed, in part, the following medications were not administered at 9:00 a.m. because Resident #2 was unavailable and/or at dialysis on the following dates: 1) Allopurinol (a medication used to treat pain and inflammatory disease) 100 milligram (mg) 1 tablet once a day on: 08/03/2023, 08/07/2023, 08/19/2023, 08/26/2023, 09/02/2023, 09/09/2023, 09/16/2023, 09/23/2023, and 10/03/2023; 2) Aspirin (a medication used to prevent heart attacks and…

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

Based on record review and interviews, the facility failed to: 1) Ensure a resident received a therapeutic diet as ordered for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss; 2) Ensure a resident's meal intake was documented for each meal for 2 (Resident #1 and Resident #2) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss; 3) Ensure a resident's dietary recommendation was implemented for 1 (Resident #2) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss; and, 4) Ensure a resident's weight was monitored weekly per physician orders for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for weight loss. Findings: Resident #1 Review of the facility's Weight and Height Measurement policy revealed, in part, staff are to obtain an accurate weight of each resident to assess nutritional and hydration status and to identify a significant change in condition. Further review revealed residents are to be weighed on admission and monthly unless otherwise ordered by 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.