St Bernard Nursing & Rehab

Based on observations and interview, the facility failed to maintain a functional environment by failing to ensure a water facet was functional in1 (Room B) of 1 (Room B) rooms observed for a functional environment. Findings: Observation on 06/08/2025 at 10:14AM revealed the hot water was not functional on the bathroom faucet in Room B Observation on 06/09/2025 at 12:35PM revealed the hot water was not functional on the bathroom faucet in Room B. In an interview on 06/09/2025 at 12:35PM, S1Administrator confirmed the hot water faucet should have been functional in Room B.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A resident's indwelling catheter tubing and bag were changed monthly as ordered (Resident #3); and, 2. Indwelling urinary catheter tubing and collection bags were not on the floor (Resident #3, Resident #R4). This deficient practice was identified for 2 (Resident #3, Resident #R4) of 2 (Resident #3, Resident #R4) sampled residents investigated for urinary catheter care and Urinary Tract Infections (UTI). Findings: Review of the facility's Urinary Catheterization policy and procedure dated 03/2023 revealed, in part, indwelling urinary catheters and drainage bags will be changed out as ordered. Resident #3 Review of Resident #3's February 2025 physician's orders revealed, in part, an order dated 12/19/2024 for a size 18 French Foley catheter for a neurogenic bladder. Further review revealed an order for the bedside unit, bag, and tubing to be changed monthly and as needed. Review of Resident #3's January 2025 electronic Treatment Administration Record (eTAR) revealed, in part, no documented…

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

Based on interviews and record reviews, the facility failed to ensure controlled drugs were accurately reconciled for 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's undated Licensed Practical Nurse job description, revealed, in part, Licensed Practical Nurses (LPNs) assume responsibility to assure narcotics were accounted for properly in accordance with professional standards. Review of the facility's February 2025 Medication Cart a Nurse's Narcotic Check List revealed, in part, the following shifts had an incomplete reconciliation of controlled drugs: - 02/01/2025 on the 7:00AM to 3:00PM shift (on-coming nurse [on]); - 02/01/2025 on the 11:00PM to 7:00AM shift (off-going nurse [off]); - 02/03/2025 on the 7:00AM to 3:00PM shift (off); - 02/03/2025 on the 3:00PM to 11:00PM shift (on); - 02/03/2025 on the 11:00PM to 7:00AM shift (off); - 02/11/2025 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 observations and interviews, the facility failed to ensure eight opened insulin (a medication that lowers blood glucose) multi-dose vials were dated when opened and/or discarded as required for 3 (Medication Cart a, Medication Cart b, Medication Cart c) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d) medication carts observed. Findings: Observation on 02/25/2025 at 9:10AM of Medication Cart a revealed: Resident #R8's open insulin Lispro multi-dose vial did not have an opened date documented; Resident #R9's open insulin Lantus multi-dose vial did not have an opened date documented; Resident #R9's open insulin Humalog 72-25 mixed multi-dose vial did not have an opened date documented; and, Resident #R10's open insulin Novolog multi-dose vial did not have an opened date documented. In an interview on 02/25/2025 at 9:15AM, S4Licensed Practical Nurse (LPN) confirmed the above mentioned multi-dose vials of insulin were opened and should have been labeled with an opened date. S4LPN further confirmed the above mentioned multi-dose vials of insulin…

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, observations and interviews, the facility failed to: 1. ensure a resident's water, used for jejunostomy tube (J-tube is a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine. The tube delivers food and medicine) flushes, was labeled properly; and, 2. ensure a resident's feeding syringe was labeled, dated and clean. This deficient practice was identified for 1 (Resident #72) of 3 (Resident #57, Resident #64, and Resident 72) sampled residents investigated for enteral feeding. Findings: Review of Resident #72's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 revealed, in part, a Brief Interview for Mental Status exam score of 13. A score of 13 which indicated Resident #72 was cognitively intact. Further review of Section K revealed Resident #72 had a feeding tube. Observation on 06/03/2024 at 9:45 a.m. revealed Resident #72's feeding syringe was not labeled and was not dated and the feeding syringe had a pink liquid in the tip. Observation on 06/03/2024 at 9:45 a.m. revealed 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.

Based on record reviews and interviews, the facility failed to ensure a resident received specialized psychological service recommendations for 1 (Resident #65) of 1 (Resident #65) sampled residents reviewed for PASRR (Preadmission Screening and Resident Review). Findings: Review of Resident #65's Electronic Medical Record (EMR) revealed, in part, Resident #65's was admitted to the facility 03/01/2024, and had medical diagnosis of Bipolar, and Major Depressive Disorder upon admission. Further review revealed no documented evidence that a Level II PASSR recommendations was completed for Resident #65. Review of Resident #65's Social Services' Note dated 06/05/2024 at 11:29 a.m., revealed, in part, S2Social Services received Resident #65's Level II PASSR recommendations on 06/05/24 from the Louisiana Office of Behavioral Health. Review of Resident #65's EMR revealed Resident #65's approved for admission by Level II Authority for a temporary period effective 09/10/2023 through 09/08/2024. Review of Resident #65's Level II PASSR Recommendations and Determination Notice dated 9/11/2023…

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

Based on record reviews, interviews and observations, the facility failed to ensure a resident's oxygen equipment was dated and stored in a sanitary manner when not in use for 1 (Resident #92) of 1 (Resident #92) sampled residents reviewed for respiratory care. Findings: Review of Resident #92's Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 05/01/2024 revealed, in part, Resident #92 received oxygen therapy. Further review revealed, Resident #92 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #92 was mildly cognitively impaired. Review of Resident #92's June 2024 Physician's Orders, revealed, in part, an order for oxygen at 2 liters (L) via nasal cannula (NC) to maintain oxygen saturation above 92 % every shift and as needed. In an interview on 06/03/2024 at 09:30 a.m., Resident #92 indicated he was short of breath and used his oxygen as needed. Observation on 06/03/2024 at 9:30 a.m., revealed Resident #92's nasal cannula tubing for his oxygen was uncovered and lying on the floor. Further observation revealed the…

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

Based on record reviews and interviews, the facility failed to ensure a physician was notified of a pharmacist recommendation for 2 (Resident #8 and Resident #94) of 5 (Resident #8, Resident #19, Resident #74, Resident #89, and Resident #94) sampled residents reviewed for unnecessary medications. Findings: Resident #8 Review of the facility's Psychotropic & Sedative/Hypnotic Utilization by Resident form updated in 2017 revealed, in part, Resident #8's last Gradual Dose Reduction (GDR) was completed on 03/10/2024. In a telephone interview on 06/05/2024 at 3:43 p.m., the Pharmacy Consultant for the facility indicated a GDR was recommended for Resident #8 on 03/10/2024 for Seroquel 50mg 1 tablet by mouth at bedtime. In an interview on 06/05/2024 at 3:15 p.m., S1Director of Nursing (DON) indicated the facility did not have documentation to show Resident #8's GDR was reviewed by a physician. Resident #94 Review of Resident #94's GDR revealed, in part, a pharmacist made a recommendation for a dose reduction of Resident #94's Risperdal (a medication used to treat mental disorders) 4.5 mg…

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 have accurate documentation for the route of medication administration for 2 (Resident #64 and Resident #72) of 3 (Resident #57, Resident #64, and Resident 72) sampled residents investigated for enteral feeding. Findings: Resident #64 Review of Resident #64's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/2024 revealed, in part, Resident #64 had a Brief Interview for Mental Status (BIMS) score of 9. A Score of 9 indicated moderate cognitive impairment. Further review of Resident #64's MDS revealed she had a feeding tube. Review of Resident #64's Care Plan, revised on 04/29/2024, revealed Resident #64 received medications through a feeding tube. Review of Resident #64's June 2024 Physician Orders revealed, in part, the following: 1. Zinc 50 milligram (mg) tablet give 1 tablet orally one time a day to aid in wound healing and prevention; 2. Vitamin d3 50 microgram (mcg) tablet give 1 tablet orally one time a day; 3. Vitamin C 500mg 1 tablet by mouth once a day; 4. Multivitamin take 1 tablet by…

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

Based on observation, interview, and record review the facility failed to ensure a functional call bell was available for 1 (Resident #77) of the 4 (Resident #23, Resident #47, Resident #72, and Resident #77) investigated for environmental issues. Findings: Review of Resident #77's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024 revealed, in part, resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact, and Resident #77 required substantial/maximal assistance with personal hygiene. In an interview on 06/04/2024 at 10:00 a.m., Resident #77 indicated his call bell was broken. Resident #77 further indicated because his call bell does not work, he had to go out into the hall to get assistance. Resident #77 further indicated he would use his call bell if it was functioning. A test of Resident #77's call bell was conducted on 06/04/2024 at 10:00 a.m., which revealed Resident #77's call bell was not functioning, and the indicator light did not illuminate on wall of Resident #77's room or outside 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.

Based on record reviews and interviews, the facility failed to ensure a resident that required two plus person assistance with transfers was transferred with at least two persons and the facility failed to prevent a resident fall for 1(Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for accidents hazards. Findings: Review of the facility's Quality of Care: Accident/Hazards/Supervision/Device Policy with a date of 03/2023 revealed the following, in part, Purpose: To provide an environment that is free from controllable accident hazards and provision of supervision and assistance devices to residents to avoid preventable accidents. Policy: The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents. Guidelines: The facility will develop a culture of safety and commit to implemented systems that address resident risk and environment hazards to minimize the likelihood of accidents. Efforts to minimize risk to residents will…

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

Based on interviews and record review, the facility failed to report and investigate an allegation of physical abuse to the State agency for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents investigated for abuse. Findings: Review of Resident #3's electronic medical record (EMR) revealed, in part, a nurse's note dated 03/11/2024 at 7:15 p.m. which documented Resident #3's refusal of dialysis and medications due to an allegation of physical abuse. Further documented was notification of the allegation to the nurse supervisor, the S3Director of Nursing (DON), and the doctor. Review of the facility incident reports revealed, in part, no documented evidence and the facility did not present any evidence Resident #3's allegation of physical abuse was reported to the State Agency. In a telephone interview on 04/02/2024 at 2:50 p.m., S1Licensed Practical Nurse (LPN) stated she reported Resident #3's allegation of physical abuse to S2Treatment Nurse. S1LPN further stated S2Treatment Nurse called S3DON and reported the allegation of…

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

Based on interview and record review, the facility failed to ensure staff implemented their Policy & Procedure for abuse for 1(Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse, Neglect, and Exploitation policy with a revision date of 08/14/2023 revealed, in part, the following: Section VII. Reporting/Response: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2023 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated he was moderately cognitively impaired. Review of Statewide Incident Management System (SIMS) Report revealed, in part, Resident #3 had an allegation of staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the incident was discovered to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3 ) sampled residents reviewed for abuse. Findings: Review of Resident #1's medical record revealed, in part, he was admitted to the facility on [DATE] with diagnoses, of Blindness, Delusional Disorder, Insomnia, and Generalized Anxiety Disorder. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/2023 revealed a Brief Interview of Mental Status (BIMS) score of 9 which indicated Resident #1 was moderately cognitively impaired. Further review revealed, Resident #1 required extensive assistance from one person with bed mobility, transfers, and toileting. Review of Resident #1's nurse's note dated 11/25/2023 at 11:30 a.m., revealed, in part, S7Certified Nursing Assistant (S7CNA) reported to…

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

Based on record review, observation, and interview, the facility failed to ensure residents were provided with privacy during care for 3 (Resident #30, Resident #43 and Resident #313) of 22 (Resident #10, Resident #29, Resident #53, Resident #45, Resident #97, Resident #48, Resident #42, Resident #264, Resident #43, Resident #24, Resident #313, Resident #106, Resident #1, Resident #101, Resident #89, Resident #17, Resident #91, Resident #74, Resident #30, Resident #18, Resident #73, and Resident #49) sampled residents observed for privacy. Findings: Resident #30 Observation on 08/07/2023 at 2:40 p.m. revealed Resident #30 lying in bed with no privacy curtain available around her bed. In an interview on 08/07/2023 at 2:40 p.m., Resident #30's daughter expressed concerns about the missing privacy curtain around Resident #30's bed. Observation on 08/08/2023 at 12:10 p.m. revealed Resident #30 did not have a privacy curtain available around her bed. In an interview on 08/08/2023 at 1:15 p.m., S23Licensed Practical Nurse (LPN) confirmed there was no privacy curtains available for…

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

Based on observation, record review, and interview, the facility failed to: 1. Ensure dining room tables were in good repair for 7 of 27 tables present in the dining room; 2. Ensure the residents' bathrooms had soap present in the soap dispensers for 4 (Resident #1, Resident #18, Resident #30, and Resident #101) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; 3. Ensure the residents' bathrooms had paper towels in the dispensers for 2 (Resident #18 and Resident #30) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; 4. Ensure the residents' furniture and window shades were clean and in good repair for 4 (Resident #1, Resident #17, Resident #18, and Resident #30) of 7 (Resident #1, Resident #17, Resident #18, Resident #24, Resident #30, Resident #101, and Resident #313) sampled resident rooms observed for environmental concerns; and, 5. Ensure a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure allegations of physical abuse were reported within 2 hours of the allegation being made for 3 (Resident # 45, Resident #49, and Resident #263) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure revealed, in part, it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Review revealed Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical,…

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: 1. Thoroughly investigate a resident's allegations of abuse and/or neglect for 3 (Resident # 45, Resident #49, and Resident #263) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse; and, 2. Protect residents from the potential of further abuse during the investigation process for 2 (Resident # 45 and Resident #49) of 5 (Resident #10, Resident # 45, Resident #49, Resident #101 and Resident #263) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy and Procedure revealed, in part, Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Review revealed an immediate investigation was warranted when suspicion 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 record review and interview, the facility failed to review and revise the residents' care plan after completion of quarterly review assessment for 2 (Resident #18 and Resident #91) of 24 sampled residents. Findings: Resident #18 Review of Resident #18's medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Coronary Artery Disease, Hypertension, Atrial Fibrillation, Anemia, Colostomy, Nephrostomy Tubes, Foley Catheter, Debility, and Persistent Nausea. Review of Resident #18's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/31/2023 revealed the MDS was completed on 06/14/2023. Review of Resident #18's comprehensive care plan revealed Resident #18's comprehensive care plan was initiated on 02/28/2023, with no updated review dates and the goal dates of 05/28/2023 were past due. Further review of Resident #18's care plan revealed the care plan was not updated with completion of Quarterly MDS with ARD of 05/31/2023. In an interview 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 record review, observation, and interview, the facility failed to accurately assess and document the presence of pain for 2 (Resident #17 and Resident #101) of 2 (Resident #17 and Resident #101) residents reviewed for pain. Findings: Resident #17 Review of Resident #17's medical record revealed Resident #17 was admitted [DATE] with diagnoses, in part, of arthritis, neuropathy (nerve pain), chronic right hip pain, myopathy (disorder which causes muscle pain), and osteoarthritis (disorder which causes joint pain). Review of Resident #17's August 2023 Physician orders revealed, in part, Hydrocodone/Acetaminophen (medication used to treat pain) 5-325 milligram (mg) tablet every 12 hours as needed for pain, and monitor Resident #17 for indication of pain. Review of Resident #17's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/14/2023 revealed, in part, Resident #17 was on a scheduled pain medication regimen and received as needed pain medication. Further review revealed 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.

Based on record review and interview, the facility failed to ensure communication with a resident's dialysis facility for 1 (Resident #48) of 1 (Resident #48) sampled residents reviewed for dialysis. Findings: Review of the facility's Hemodialysis policy revealed, in part, the facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice which included the ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Review of Resident #48's May, June, July, and August 2023 physician's orders revealed, in part, Resident #48 had a diagnosis of dialysis associated renal failure and orders for outpatient dialysis every Tuesday, Thursday, and Saturday. In an interview on 08/10/2023 at 5:32 p.m., S11Licensed Practical Nurse stated the facility communicated with Resident #48's dialysis facility via the dialysis communication sheet. Review of Resident #48's Dialysis Communication Binder from 05/01/2023 through 08/05/2023 revealed, in part, no documented…

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 Certified Nursing Assistants (CNA's) had completed annual competencies as required for 5 (S4CNA, S31CNA, S33CNA, S37CNA, and S38CNA)of 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) CNAs reviewed for annual competencies. Review of S4CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S31CNA's personnel file revealed, in part, the last annual competency documented was 07/26/2022. Review of S33CNA Supervisor's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S37CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. Review of S38CNA's personnel file revealed, in part, the last annual competency documented was 07/28/2022. In an interview on 08/10/2023 at 1:00 p.m., S8Human Resources (HR) stated the last annual competencies completed were completed in July of 2022. S8HR further stated competencies had not been completed annually. In an interview on 08/10/2023 at 1:30 p.m.,…

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

Based on record review and interview, the facility failed to complete annual performance evaluations for certified nursing assistants (CNA) for 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) of 6 (S4CNA, S13CNA, S31CNA, S33CNA, S37CNA, and S38CNA) CNA personnel files reviewed. Findings: Review of S4CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S31CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S33CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S37CNA's personnel file revealed, in part, no documented evidence of an annual performance evaluation and the facility was unable to provide any documented evidence. Review of S38CNA's personnel file revealed, in part, no documented evidence of an annual performance…

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 the required nurse staffing information on a daily basis. Findings: Observation on 08/08/2023 at 12:26 p.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 08/08/2023 03:18 p.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 08/09/2023 at 09:53 a.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. Observation on 08/10/2023 at 10:02 a.m. revealed the resident census and the total number of actual hours worked for licensed and unlicensed staff responsible for resident care was not posted in the facility. In an interview on 08/10/2023 at 10:30 a.m., S3Director of Nursing (DON) stated the certified nursing assistants' assignment sheet was…

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

Based on record review and interview, the facility failed to implement the facility's policy for the prevention of Legionella Disease. Findings: Review of the facility's Legionella policy with a revision date of 05/23/2023 revealed, in part, the facility should implement primary prevention strategies which include maintenance of cooling towers and potable water systems, store and distribute cold water below 68 degrees Fahrenheit (°F), store hot water above 140°F, and circulate water at a minimum return temperature of 124°F. The facility failed to present documentation of their assessment of where opportunistic pathogens may grow, measures they put into place to prevent the growth of legionella, and/or how they monitor for legionella. In an interview on 08/14/2023 at 10:28 a.m., S28Maintenance Director stated he was unable to present any documented evidence of water temperature checks which were to be completed weekly. In an interview on 08/14/2023 at 10:31 a.m., S1Administrator stated he did not have any documented evidence of the water temperature checks having been completed. In…

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

Based on record review, observations, and interviews, the facility failed to implement their abuse policies and procedures to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to ensure unlicensed staff who worked in the facility had a completed criminal background on file prior to providing care to residents for 2 (S6Agency Certified Nursing Assistant and S7Agency Certified Nursing Assistant) of 2 unlicensed contract staff personnel files reviewed. Findings: Review of the facility's Abuse, Neglect, and Exploitation policy with an implementation date of 12/01/2021 revealed, in part, potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Further review revealed criminal background, reference, and credentials' checks shall be conducted on contracted temporary staff. Review of the agency's generated time sheets for 08/11/2023 revealed S6Agency CNA worked in the facility from 10:23 a.m. until 4:27 p.m. and S7Agency CNA worked from 11:27 a.m. until 2:41 p.m. Observation 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 record review, observation, and interview, the facility failed to ensure a new interventions were implemented following a resident's fall to prevent future falls for 1 (Resident #42) of 4 (Resident #42, Resident #106, Resident #264, and Resident #313) sampled residents reviewed for accident hazards. Findings: Review of Resident #42's Minimum Data Set with an Assessment Reference Date of 07/03/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status score of 9, which indicated Resident #42 had moderate cognitive impairment. Further review revealed Resident #42 required limited one person assistance for transfers. Review also revealed Resident #42's balance was unsteady with walking and transferring, and Resident #42 had impaired range of motion to both lower extremities. Review of Resident #42's Quarterly Fall Risk Assessment completed on 06/27/2023 revealed, in part, Resident #42 required fall precautions due to a history of falls, cognitive deficits, impaired judgement, 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 review, observation, and interview, the facility failed to ensure a resident's indwelling urinary catheter was secured for 1 (Resident #313) of 1 sampled residents reviewed for urinary catheter or urinary tract infection. Findings: Review of the Centers for Disease Controls Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) revealed, in part, properly secure indwelling catheters after insertion was recommended to prevent movement and urethral traction. Review of Resident #313's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/24/2023 revealed, in part, Resident #313 was admitted to the facility on [DATE] and had an indwelling catheter. Review of Resident #313's Care Plan for catheter revealed, in part, Resident #313 required an indwelling catheter related to urinary retention and the staff should check for proper position of Resident #313's catheter every shift. Observation on 08/09/2023 at 2:47 p.m. revealed S10LPN (Licensed Practical…

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 administer intravenous (medication administered directly into the vein) medications per professional standards and physician's orders for 1 (Resident #264) of 1 (Resident #264) sampled residents investigated for intravenous medication administration. Findings: Review of the facility's Intravenous (IV) Therapy Policy revealed, in part, prior to medication infusion, the practitioner's order must be reviewed and verified for infusion solution or medication, dose, frequency, and route of administration. Further review revealed hand hygiene must be completed prior to putting on gloves. Review also revealed the medication/solution label must be compared against the practitioner's order for accuracy. The policy also revealed the connector must be disinfected with an antiseptic agent before tubing is connected to the injection port. Review of Resident #264's record revealed, in part, an admit date of 07/28/2023 with diagnoses including bacteremia (the presence of bacteria in the bloodstream), septic joint (infection…

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, observations, and interviews, the facility failed to ensure medications were locked and not available for use at a resident's bedside for 1 (Resident #264) of 22 (Resident #10, Resident #29, Resident #53, Resident #45, Resident #97, Resident #48, Resident #42, Resident #264, Resident #43, Resident #24, Resident #313, Resident #106, Resident #1, Resident #101, Resident #89, Resident #17, Resident #91, Resident #74, Resident #30, Resident #18, Resident #73, and Resident #49) sampled residents observed for medications left at the bedside. Findings: Review of the facility's Resident Self-Administration of Medication Policy revealed, in part, a resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. Further review revealed bedside medication storage was permitted only when it did not present a risk to confused residents and the manner of storage prevented access by other residents. Review of Resident #264's Minimum Data Set with an Assessment Reference Date 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 observations and interviews the facility failed to: 1. Failed to discard expired milk in 1 of 1 nourishment refrigerators. 2. Failed to ensure Orange and cranberry juice were stored at a proper temperature to prevent food borne illness. Findings: Observation of the nurse's station's nourishment room on 08/08/2023 at 9:06 a.m. revealed 4 16 ounce cartons of whole milk in the refrigerator with an expiration date of 8/1/2023 and 1 16 ounce carton of whole mile with an expiration date of 08/03/2023 and 3 16 ounce cartons of low-fat milk in the refrigerator with an expiration date of 08/07/2023. Further observation of the nourishment room revealed a tray of 20 8 ounce cartons of cranberry juice cartons and 10 8 ounce containers of orange juice sitting on top of the refrigerator, cool to touch with condensation on outside of containers. Observation of the nurse's station's nourishment room on 08/08/2023 at 12:01 p.m. revealed the same tray of 20 cartons of cranberry juice and 10 containers of orange juice was sitting on top of the refrigerator without ice and warm to touch.…

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 Quality Assurance and Performance Improvement (QAPI) committee meetings were held quarterly. Findings: Review of the facility's QAPI Committee Meeting Minutes revealed the last documented meeting was completed on 04/30/2023. There was no documented evidence and the facility did not present any documented evidence a QAPI committee meeting was held for the second quarter of 2023. In an interview on 08/14/2023 at 12:04 p.m., S15Regional Clinical Director stated the facility was supposed to have a QAPI committee meeting at the end of July 2023 but did not. S15Regional Clinical Director further stated the last QAPI committee meeting was held on 04/30/2023.