St Jude's Health & Wellness Center

Based on observation, interview, and record review, the facility failed to ensure a resident was served a diet that met the resident's special dietary needs for 1 (Resident #9) of 1 sampled residents reviewed for nutrition. Findings:Review of the facility's undated Nutrition policy and procedure revealed, in part, all physician ordered diets shall be implemented promptly upon receipt, and the dietary department shall prepare and serve meals which meet the ordered diet and nutritional requirements. Review of Resident #9's record revealed diagnosis of, in part, stage 4 Chronic Kidney Disease (condition in which the resident's kidneys were damaged and were unable to filter out toxins). Review of Resident #9's January 2026 Physician's Orders revealed, in part, Resident #9 was to be provided a renal diet. Review of Resident #9's Meal Ticket dated 01/21/2026 revealed Resident #9 was to receive a renal diet with no potatoes. Observation on 01/21/2026 at 1:05PM revealed Resident #9 was served cubed potatoes. In an interview on 01/21/2026 at 1:06PM, S16Licensed Practical Nurse indicated…

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 staff completed hand hygiene while performing incontinence care for 1 (Resident #63) of 1 sampled residents observed for incontinence care. Findings:Review of the facility's undated Standard Precautions policy and procedure revealed, in part, hand hygiene must be performed immediately after contact with any resident item that may be contaminated. Review of the Centers for Disease Control and Prevention (CDC)'s October 2022 Guidelines for Hand Hygiene in Health-Care Settings revealed, in part, staff should decontaminate their hands if moving from a contaminated body site to a clean body site during patient care. Observation on 01/21/2026 at 11:39AM revealed S17Certified Nursing Assistant (CNA) and S18CNA entered Resident #63's room to perform incontinence care. S17CNA and S18CNA removed Resident #63's soiled diaper and wiped Resident #63's buttocks and perineal area. S17CNA and S18CNA then placed a clean diaper on Resident #63, rolled Resident #63, placed a clean draw sheet under Resident #63,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure the pneumococcal (an infection caused by streptococcus pneumonia bacteria) and influenza (a respiratory infection caused by a virus) vaccines were administered for 1 (Resident #60) of 5 sampled residents investigated for immunizations. Findings:Review of the facility's undated Influenza and Pneumococcal Vaccine policy and procedure revealed, in part, residents should be vaccinated against the pneumococcal disease and influenza virus unless the vaccination was medically contraindicated or the resident and/or legal representative refused the vaccination. Review of Resident #60's Minimum Data Set with an Assessment Reference Date of 01/07/2026 revealed, in part, Resident #60 was admitted to the facility on [DATE]. Further review revealed a Brief Interview for Mental Status score of 10, which indicated Resident #60's cognition was moderately impaired. Review of Resident #60's Pneumonia Vaccine Consent Form revealed, in part, Resident #60's…

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

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents investigated for resident abuse. Findings:Review of the facility's undated Abuse Recognition, Reporting, and Investigation policy revealed, in part, the facility was to protect residents from any physical and mental mistreatment and to not permit residents to be subjected to abuse by anyone, including other residents. Further review revealed physical abuse was defined as hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Review of the facility's Statewide Incident Management System Report investigation entered on 09/17/2025 that occurred on 09/10/2025 at 9:35AM revealed, in part, Resident #2 walked into the day room and hit Resident #4 in the face. Further review revealed the altercation was witnessed by 2 Certified Nursing Assistants (CNAs) (S2CNA and S3CNA), and resident to resident abuse was substantiated.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews the facility failed to ensure a resident's Minimum Data Set (MDS) assessment reflected the resident's accurate cognitive status for 1 (Resident #1) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9) sampled residents investigated for accuracy of assessments. Findings:Review of Resident #1's quarterly MDS with an Assessment Reference Date (ARD) of 08/20/2025 revealed, in part, Resident #1 was comatose. Review of Resident #1's nurse progress note dated 8/20/2025 at 11:23AM revealed, in part, Resident #1 was alert and oriented to person, place and time and was able to make her needs known. Review of Resident #1's nurse progress note dated 8/20/2025 at 9:59PM revealed, in part, Resident #1 was able to express her needs and could self-feed. Further review revealed, Resident #1 was mobile via wheelchair and was able to swallow medications whole. Review of Resident #1's nurse progress note dated…

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 1.) maintenance services placed an outlet cover over a wall socket in a resident's room (Resident #1); and, 2.) housekeeping services cleaned an unknown brown substance off of a resident's floor (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents reviewed for environment. Findings: Observation of Resident #1's room on 03/10/2025 at 6:42AM revealed the outlet cover over a wall socket near the foot of Resident #1's bed did not have a wall covering. Observation further revealed an unknown brown substance about an inch long was seen on the side of Resident #1's bed on the floor. Observation on 03/12/2025 at 9:40AM of Resident #1's room revealed the outlet cover over a wall socket near the foot of Resident #1's bed did not have a wall covering. Observation further revealed an unknown brown substance about an inch long was seen on the side of Resident #1's bed on the floor. In an interview on 03/12/2025 at 11:50AM, S1Chief Operation…

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, interviews, and record reviews, the facility failed to provide incontinence care for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for activities of daily living (ADLs). Findings: Review of Resident #1's Minimum Data Set with an assessment reference date of 01/24/2025 revealed, in part, Resident #1 required substantial/maximal assistance for toileting and personal hygiene. Review of Resident #1's Care Plan revealed, in part, Resident #1 was incontinent of bowel and bladder. Further review revealed an intervention included to check Resident #1 every 2 hours as required for incontinence. Observation on 03/10/2025 at 6:32AM revealed S4Certified Nursing Assistant (CNA) and S5CNA pulled back the sheets to provide incontinence care to Resident #1. Resident #1 had a bowel movement leaking from the adult brief onto her abdomen, incontinent pad, and bed sheets. The bowel movement was wet in the center and dry around the edges. In an interview on 03/10/2025 at 6:40, S4CNA indicated the last time she checked on Resident #1…

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 staff utilized the correct personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP) for 1 (Resident #10) of 4 (Resident #1, Resident #2, Resident #3, Resident #10) residents observed during incontinence care. Findings: Review of the facility's undated Enhanced Barrier Precautions Policy and Procedure revealed, in part, gowns and gloves should be worn when emptying a urinary catheter. Observation on 03/10/2025 at 5:18AM revealed an EBP sign on the outside of Resident #10's door. Observation further revealed S5Certified Nursing Assistant (CNA) entered Resident #10's room without a gown and proceeded to empty Resident #10's urinary catheter into a graduated cylinder. In an interview on 03/10/2025 at 5:23AM, S5CNA indicated she did not use a gown when emptying urinary catheters and further indicated she did not know that she needed to. In an interview on 03/10/2025 at 10:25AM, S2Director of Nursing (DON) indicated gowns should be worn when emptying…

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 allow residents unrestricted visitation. Findings: Review of the facility's undated visitation policy and procedure, revealed, in part, residents and families are encouraged to have visitors between the hours of 8:00AM and 8:00PM. Further review revealed exceptions to these hours must be cleared by the Administrator and/or Director of Nursing. There was no documented evidence, and the facility was unable to present any documented evidence, the limitations placed on the residents' right to visitation was based on a clinical or safety concern. In an interview on 01/28/2025 at 10:10AM, Resident #37 indicated residents were not allowed to have visitors after 8:00PM. In an interview on 01/29/2025 at 11:00AM, S7Receptionist indicated the facility's visiting hours were from 8:00AM to 8:00PM. S7Receptionist further indicated residents are not allowed visitors before 8:00AM or after 8:00PM. In an interview on 01/29/2025 at 3:40PM, S8Certified Nursing Assistant (CNA)/Receptionist confirmed visitors were not allowed to enter 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 interview and record reviews, the facility failed to ensure: 1. A resident's dialysis access site was assessed and vital signs were obtained upon the resident's return from dialysis (Resident #32); and, 2. The facility communicated with a resident's dialysis center regarding the residents condition (Resident #32) This deficient practice was identified for 1 (Resident #32) of 1 (Resident #32) sampled residents reviewed for dialysis. Findings: Review of Resident #32's January 2025 physician's orders revealed, in part, an order dated 12/11/2024 for Resident #32 to attend dialysis every Tuesday, Thursday, and Saturday, and to obtain post dialysis vital signs of blood pressure, pulse, respirations, and temperature. Review of Resident #32's dialysis communication sheets revealed, in part: -No documented evidence the facility communicated with the dialysis center on 12/03/2024; -No documented evidence Resident #32's dialysis access site was assessed or Resident #32's vital signs were obtained after he returned from dialysis on 12/05/2024; -No documented evidence the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and observation, the facility failed to ensure: 1. Opened insulin pens were labeled with the date the pen was opened; and, 2. Expired insulin pens were not available for resident use. This deficient practice was identified for 1 (Medication Cart a) of 2 (Medication Cart a, Medication Cart b) medication carts reviewed for the storage of medications. Findings: Observation of Medication Cart a on [DATE] at 12:44PM revealed: -Resident #10's open Humulin R insulin pen (a medication used to lower blood sugar) had an opened date of [DATE]; -Resident #36's open Humulin R insulin pen had an opened date of [DATE]; -Resident #36's open Lantus insulin pen (a long acting medication used to lower blood sugar) had an opened date of [DATE]; -Resident #40's open Novolog insulin pen (a medication used to lower blood sugar) had an opened date of [DATE]; and, -Resident #40's open Humulin 70/30 vial (a medication used to lower blood sugar) was not dated with an opened date. In an interview on [DATE] at 12:46PM,…

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 maintain a resident's right to make choices regarding smoking for 1 (Resident #32) of 3 (Resident #26, Resident #32, Resident #45) sampled residents reviewed for smoking. Findings: Review of the facility's undated Resident Rights policy and procedure revealed, in part, residents should be encouraged to exercise their rights as a resident and citizen, and be treated courteously, fairly, and with the fullest measure of dignity. Further review revealed residents had the right to use tobacco in accordance with applicable policies, rules, and laws. Review of the facility's undated Smoking policy and procedure, revealed, in part, residents were allowed to smoke only in the designated smoking areas located outside the building. Further review revealed no documented evidence of a set time for smoking hours. There was no documented evidence, and the facility did not present any documented evidence the facility and residents had any agreed upon facility rules restricting a resident's right to smoke. 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 review and interviews, the facility failed to ensure a resident's code status documented in the resident's medical record was consistent with the resident's wishes for 1 (Resident #81) of 25 (Resident #1, Resident #3, Resident #4, Resident #8, Resident #11, Resident #12, Resident #15, Resident #24, Resident #26, Resident #31, Resident #32, Resident #33, Resident #38, Resident #45, Resident #51, Resident #55, Resident #56, Resident #59, Resident #61, Resident #70, Resident #73, Resident #75, Resident #76, Resident #78, Resident #81) sampled residents included in the initial pool. Findings: Review of Resident #81's chart/medical record revealed a notification signed and dated on [DATE] which indicated Resident #81's wished to be a Full Code (which indicated in the event she no pulse or no breath, medical interventions would take place). Review of Resident #81's Electronic Medical Record (EMR) revealed, in part, Resident #81's code status was Do Not Resuscitate ([DNR] code status that instructed 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 interviews and record reviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form Centers for Medicare and Medicaid Services (CMS)-10055 and/or the Notice of Medicare Non-Coverage (NOMNC) Form (CMS-10123) notices were given, explained, and/or signed by residents prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 3 (Resident #62, Resident #68, Resident #234) of 3 (Resident #62, Resident #68, Resident #234) sampled residents reviewed for termination of Medicare Part A services. Findings: Resident #62 Review of Resident #62's medical record revealed, in part, Resident #62 was admitted to the facility on [DATE]. Review of Resident #62's Skilled Nursing Facility Beneficiary Protection Notification Review, Form CMS-20052, completed by the facility, revealed, in part, Resident #62's last day of Medicare Part A Services was on 07/29/2024. Review of Resident #62's NOMNC Form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed to conduct an accurate comprehensive assessment for 2 (Resident #61, Resident #75) of 2 (Resident #61, Resident #75) sampled residents reviewed for comprehensive dental status assessment. Findings: Resident #61 Review of Resident #61's medical record revealed, in part, Resident #61 was admitted to the facility on [DATE]. Review of Resident #61's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed, in part, A Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Further review revealed Resident #61 was assessed to have no oral and dental issues identified. Observation on 01/27/2025 at 11:12AM revealed Resident #61 had several upper and lower teeth missing. In an interview on 01/27/2025 at 11:15AM, Resident #61 indicated he was missing teeth when he was admitted to the facility. In an interview on 01/30/2025 at 1:30PM, S1Administrator could offer no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide documentation of a resident's Level II Pre-admission Screening and Resident Review (PASARR) for 1 (Resident #8) of 3 (Resident #8, Resident #59, Resident #70) sampled residents reviewed for PASARR. Findings: Review of Resident #8's medical record revealed, in part, Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Schizophrenia, Bipolar Disorder and Unspecified Dementia on 02/15/2022. Review of Resident #8's Form 142 revealed Resident #8 was approved by the Office of Behavioral Health Level II Appointing Authority for admission for the time period of 11/08/2024 through 11/07/2025. There was no documented evidence and the facility was unable to present any documented evidence, that the facility had received, reviewed and/or maintained Resident #8's Level II PASARR which was completed by the Office of Behavioral Health. In an interview on 01/30/2025 at 1:45PM, S3SocialServices acknowledged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews, the facility failed to ensure safe smoking interventions were carried out for a resident identified by the facility as being an unsafe smoker for 1 (Resident #45) of 3 (Resident #26, Resident #32, Resident #45) sampled residents reviewed for safe smoking. Findings: Review of the facility's Unsafe Smoker List revealed, in part, Resident #45 was listed as being an unsafe smoker. Review of Resident #45's medical record revealed, in part, Resident #45 was admitted to the facility on [DATE] with diagnoses, in part, of vascular dementia, tremors, and epilepsy. Review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed, in part, Resident #45 had a Brief Interview for Mental Status (BIMS) score of 03 which revealed Resident #45 had severe cognitive impairment. Review of Resident #45's Care Plan with a start date of 12/04/2025 and a review date of 04/01/2025 revealed, in part, a care plan for unsafe smoking with…

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

Based on interview and record reviews, the facility failed to ensure a resident's psychotropic medication was not ordered on an as needed basis for greater than 14 days for 1 (Resident #55) of 5 (Resident #1, Resident #15, Resident #33, Resident #55, Resident #70) sampled residents reviewed for unnecessary medications. Findings: Review of Resident #55's January 2025 physician's orders revealed, in part, an order dated 09/28/2024 for Resident #55 to be administered 1 tablet of Lorazepam (a psychotropic medication used to treat anxiety) 0.5 milligrams (mg) every eight hours as needed. There was no documented evidence, and the provider did not present any documented evidence, Resident #55's physician gave a clinical rational for continuation, or provided a duration of Resident #55's order dated 09/28/2024 to administer Resident #55 1 tablet of Lorazepam 0.5 mg every eight hours as needed. In an interview on 01/30/2025 at 1:00PM, S2Director of Nursing indicated the facility should have clarified a duration and clarified the physician's rational for the continuation of Resident #55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure a physician was notified laboratory tests were not completed as ordered for 1 (Resident #55) of 1 (Resident #55) sampled resident reviewed for laboratory services. Findings: Review of Resident #55's pharmaceutical consultant report dated 12/10/2024 revealed, in part, a recommendation for a Complete Blood Count ([CBC] a commonly ordered blood test that measured several blood components to evaluate a person's overall health and detect a wide range of disorders) to be completed on Resident #55 every 6 months. Review of Resident #55's January 2025 physician's orders revealed, in part, an order dated 01/03/2025 to complete a CBC for Resident #55 every 6 months beginning 01/07/2025. Review of Resident #55's chart/medical record and Electronic Medical Record (EMR) revealed no documented evidence, and the facility did not present any documented evidence, a CBC was completed in January 2025 as ordered for Resident #55. Review of Resident #55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure residents received dental services for 2 (Resident #61, Resident #75) of 2 (Resident #61, Resident #75) sampled residents reviewed for dental services. Findings: Review of the facility's undated Dentist policy and procedure revealed, in part, the facility will ensure residents are seen by the dentist as needed. Further review revealed the facility will assure the dental needs of the resident were met. Resident #61 Observation on 01/27/2025 at 11:12AM revealed Resident #61 was missing several upper and lower teeth. In an interview on 01/27/2025 at 11:15AM, Resident #61 indicated he wanted to see the dentist. Resident #61 further indicated he did not have dentures, but wanted them. Review of Resident #61's medical record revealed, in part, Resident #61 was admitted to the facility on [DATE]. Further review revealed there was no documented evidence, and the provider could not provide any documented evidence, Resident #61 was…

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

Based on observations and interviews, the facility failed to ensure the facility's dumpster was maintained in a sanitary manner. Findings: Observation on 01/28/2025 at 10:35AM revealed the facility's dumpster was missing a lid and open to air. Further observation revealed loose trash was on the ground around the dumpster. Observation on 01/28/2025 at 12:40PM revealed the facility's dumpster was missing a lid and open to air. Further observation revealed loose trash was on the ground around the dumpster. In an interview on 01/28/2025 at 12:48PM, S4Dietary Manager indicated she was aware the dumpster's right side lid was missing, and it should not have been. In an interview on 01/30/2025 at 11:46AM, S1Administrator indicated the facility's dumpster's right side lid was missing, and the trash should have been contained. S1Administrator further indicated the facility's dumpster and the area around the dumpster was not maintained in a sanitary manner, and it should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the facility assessment included active involvement from direct care staff, residents, and residents' representatives in its development. Findings: Review of the facility's facility assessment dated [DATE] revealed, in part, there was no documented evidence direct care staff including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) were involved in the development of the facility's facility assessment. Further review revealed there was no documented evidence a resident and/or a resident representative was involved in the development of the facility's facility assessment. In an interview on 01/30/2025 at 1:00PM, S1Administrator confirmed the facility could not present any documented evidence direct care staff, residents, and residents' representatives were involved in the development of the facility's facility assessment dated [DATE].

Based on record review and interview, the facility failed to administer the pneumococcal (a bacterial infection caused by Streptococcus pneumonia bacterial) vaccine for 2 (Resident #43, Resident #81) of 5 (Resident #30, Resident #43, Resident #77, Resident #80, Resident #81) sampled residents investigated for pneumococcal vaccines. Findings: Resident #43 Review of Resident #43's vaccine consent form revealed Resident #43 signed a consent to receive the pneumococcal vaccine on 04/05/2024. There was no documented evidence and the facility did not present documented evidence the pneumococcal vaccine was medically contraindicated for Resident #43 or that the pneumococcal vaccine was administered to Resident #43 as per the consent signed on 04/05/2024. In an interview on 1/30/2025 at 9:16AM, S1Administrator confirmed the consent for the pneumococcal vaccine was signed for Resident #43, but there was no documented evidence the pneumococcal vaccine was medically contraindicated for Resident #43 or administered to Resident #43. Resident #81 Review of Resident #81's vaccine consent form…

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 the COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccine was administered for 1 (Resident #81) of 5 (Resident #30, Resident #43, Resident #70, Resident #80, Resident #81) sampled residents investigated for COVID-19 vaccines. Findings: Review of Resident #81's vaccine consent revealed Resident #81's responsible party signed a consent for Resident #81 to receive the COVID-19 vaccine on 10/11/2024. There was no documented evidence and the facility did not present documented evidence the COVID-19 vaccine was medically contraindicated for Resident #81 or that the COVID-19 vaccine was administered as per the consent signed on 10/11/2024. In an interview on 01/30/2025 at 9:15AM, S1Administrator confirmed the consent for the COVID-19 vaccine was signed by Resident #81's responsible party, but there was no documented evidence the COVID-19 vaccine was medically contraindicated or administered to Resident #81.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure new individualized fall prevention interventions were implemented and/or reviewed for effectiveness to prevent future falls for 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed for falls. Findings included: Review of the facility's undated Fall Prevention Program policy and procedure revealed, in part, the facility will protect residents from injury from falls. Further review revealed, the Minimum Data Set (MDS) coordinator will update interventions on the resident's fall care plan with any new occurrence of falls. Review of the facility's undated Post-Falls Protocol policy and procedure revealed, in part, the unit nurse will assess the resident from head to toe and document that assessment along with circumstances of the fall in the resident's chart. Further review revealed, one new fall intervention shall be implemented for the resident, 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 observations, interviews, and policy review the facility failed to maintain a sanitary environment for 2 (Resident #1 and Resident #2) of 3 residents reviewed for a sanitary environment. Findings included: Review of facility's Bathroom Policy with revision date of April 2006, revealed, in part, bathrooms should be cleaned daily and daily cleaning included cleaning walls, wash basins, commodes and floors Resident #1 Observation on 11/21/2023 at 12:36PM, revealed Resident #1's room had a brown smear noted on the wall above the trash can. Observation on 11/21/2024 at 4:20PM, revealed Resident #1's room had a brown smear noted on the wall above the trash can. In an interview on 11/21/2024 at 4:22PM, S1Administrator confirmed the brown substance on the wall above the trash can in Resident #1's room. S1Administrator further indicated the substance should not be on the wall above the trash can. Resident #2 Observation on 11/25/2024 at 8:40AM, revealed an isolation cart at Resident #2's room door. Further observation revealed the isolation cart was visibly dirty with a brown…

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 thorough investigation was completed for an allegation of neglect related to an injury of unknown origin for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse/neglect. Findings: Review of the facility's Abuse Prevention policy dated 2002 revealed, in part, a full investigation will include any other witness who was in the area, and written and signed statements will be obtained. Further review revealed all records of the investigation will be kept on file. Review of the facility's initiated incident report dated 07/09/2024 revealed, in part, Resident #1 had a dislocation of the left hip which was discovered on 07/09/2024 at 8:20 a.m. Further review revealed Resident #1 was unable to voice how the injury occurred, and no falls involving Resident #1 were reported. The above mentioned incident report also revealed on 07/08/2024, S7Certified Nursing Assistant (CNA) put resident #1 to bed at approximately 6:15 p.m. in a supine position with an abductor cushion (a…

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

Based on record reviews, and interviews the facility failed to ensure a resident's care plan: 1. Was revised to include a decline in a resident's activities of daily living [ADLs] (Resident #1); and, 2. Was revised after a resident sustained a fall(s) (Resident #1). This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of Resident #1's Significant Change Minimum Data Set (MDS) with an ARD of 06/11/2024 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3 which indicated severely impaired cognition. Further review revealed Resident #1 was dependent on staff for transfers and functional mobility, and had one fall which resulted in a major injury since his previous assessment. Review of Resident #1's Incident Report dated 05/29/2024 revealed Resident #1 had a witness fall from his wheelchair in the dining/day room resulting in a left hip fracture. Review of Resident #1's Incident Report dated 07/20/2024 revealed, in part, Resident #1 had an unwitnessed fall from…

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, observation, and interviews, the facility failed failed to ensure staff was available at all times to provide care and services to meet the resident's needs by failing to ensure staff was not sleeping while on duty. This deficient practice was identified for 1 staff member S6Certified Nursing Assistant (CNA) observed for 1 of 3 days during the survey. Findings: Review of facility's Employee Code of Conduct revealed, in part, sleeping while on duty was a violation that would constitute cause for immediate termination. Review of S6CNA's personnel record revealed, in part, S6CNA signed the Employee Code of Conduct on 07/08/2024 which indicated he understood and would abide by the rules of conduct while on or off duty on the facility premises. Review of facility's Daily Nursing Staff Schedule dated 07/29/2024 revealed, in part, S6CNA was assigned to provide services to residents on the day shift from 7:00 a.m. to 7:00 p.m. on floor x. Further review revealed S6CNA was assigned to provide care and services to 7 residents during this time frame. 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.

Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) resident assessments were transmitted and accepted by the Centers for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment being completed for 4 (Resident #12, Resident #52, Resident #62, and Resident #278) of 4 (Resident #12, Resident #52, Resident #62, and Resident #278) sampled residents reviewed for Resident Assessment. Findings: Resident #12 Review of Resident #12's Quarterly MDS with an ARD of 11/08/2023 revealed, in part, a completion date of 11/27/2023. Review of the facility's Final Validation Report for Resident #12's MDS with an ARD of 11/08/2023 revealed the MDS was rejected. There was no documented evidence and the facility presented no documented evidence the facility had transmitted an approvable MDS for Resident #12's ARD of 11/08/2023 from completion of the MDS on 11/27/2023 until the start of the survey on 02/05/2024. Resident #52 Review of Resident #52's Quarterly MDS with an ARD of 11/08/2023 revealed, in part, a completion date of 11/22/2023.…

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 observation and interview, the facility failed to ensure water accessible to residents did not exceed 120 degrees Fahrenheit for 9 (Bathroom A, Bathroom B, Bathroom D, Bathroom E, Bathroom F, Bathroom H, Bathroom I, Bathroom J, and Bathroom L) of 12 (Bathroom A, Bathroom B, Bathroom C, Bathroom D, Bathroom E, Bathroom F, Bathroom G, Bathroom H, Bathroom I, Bathroom J, Bathroom K, and Bathroom L) bathrooms observed for water temperature. Findings: Observations on 02/05/2024 between 10:10 a.m. and 10:30 a.m. of resident rooms on Hall W and Hall X revealed bathroom sink water temperatures were hot to touch, and surveyors were unable to maintain their hand in the flow of water for more than 5 seconds due to high temperature. In an interview on 02/05/2024 at 12:20 p.m., S6Facilities Manager stated he thought the maximum safe temperature was 120 degrees Fahrenheit, but was not sure. Observations on 02/05/2024 between 1:10 p.m. and 1:25 p.m. revealed S6Facilities Manager obtained water temperatures (in degrees Fahrenheit) as followed: 1:10 p.m. 123.3 degrees in Bathroom A; 1:11…

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 (CNAs) had completed annual competencies as required for 3 (S17CNA, S23CNA, S24CNA) of 5 (S9CNASuperviosr, S17CNA, S23CNA, S24CNA, and S27CNA) CNAs personnel records reviewed for competencies. Findings: Review of S17CNA's personnel file revealed, the last annual competency documented was 07/28/2022. Further review revealed no documented evidence and the facility presented no documented evidence of the facility had completed competencies on S17CNA since the CNA was re-hired on 12/19/2022. Review of S23CNA's personnel file revealed, in part, a hire date of 10/17/2019 with a re-hire date of 09/19/2023. Further review revealed, the last competency documented was 02/14/2022. Review of S24CNA's personnel file revealed, in part, a hire date of 06/11/2023 with a re-hire date of 12/15/2023. Review revealed, S24CNA's competency was without a completion date and an overall evaluation of S24CNA's competency of skills to be provided to residents. In an interview on 02/07/2023 at 1:00 p.m., S13Human…

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 complete an annual performance review for every certified nurse aide (CNA) at least once every 12 months for 1 (S17CNA) of 5 (S9CNASupervisor, S17CNA, S23CNA, S24CNA, and S27CNA) CNA personnel records reviewed. Findings: Review of S17CNA's personnel record revealed, in part, a hire date of 11/06/2020 with a re-hire date of 12/19/2022. Further review revealed no documented evidence and the facility presented no documented evidence the facility had completed an annual performance review for S17CNA since the CNA was re-hired on 12/19/2022. In an interview on 02/08/2024 at 3:26 p.m., S1Administrator confirmed S17CNA did not have an annual performance review completed in the last 12 months. There was no documented evidence and the facility did not present any documented evidence of an annual performance review being completed for S17CNA.

Based on record review, observation, and interview the facility failed to: 1. Ensure staff performed hand hygiene during dining observation for 3 (Hall W, Hall X, and Hall Z) of 4 (Hall W, Hall X, Hall Y, and Hall Z) sampled halls observed during dining observations; 2. Ensure the Certified Nursing Assistant (CNA) removed their gloves and completed hand hygiene during incontinence care for 1 (S9CNA Supervisor) of 1 staff observed during incontinence care; and, 3. Ensure a system of surveillance was in place for water management to prevent Legionella. Findings: Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene policy and most recently reviewed on 02/08/2024 revealed, in part, staff should perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, and before and after assisting a resident with meals. Review of the facility's policy and procedure title, Employee Education on Performing Hand Hygiene most recently reviewed on 02/08/2024 revealed, in part, hand…

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

Based on record review and interview the facility failed to develop policies and procedures to investigate injuries of unknown origin for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for abuse. Findings: Review of the facility's Resident Abuse, and Abuse Recognition, Reporting, and Investigation policies and procedures revealed no documented evidence and the facility presented no documented evidence of the facility having developed policies and procedures on how to identify, investigate, and reporting requirements for injuries of unknown origin. In an interview on 02/08/2024 at 2:29 p.m., S1Administrator stated the facility did not have a policy and procedure on how to identify, investigate, and reporting requirements for injuries of unknown origin.

Based on record review and interview, the facility failed to report a bruise with an unknown origin within 2 hours of the bruise having been identified for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for abuse. Findings: Review of Resident #42's Nurse's Notes dated 01/30/2024 revealed Resident #42 was noted to have a bruise under Resident #42's right breast. Further review revealed no documented assessment of the bruise nor any documented evidence of a potential cause for the bruise under Resident #42's right breast. Review of Resident #42's Wound Care Notes dated 01/30/2024 revealed no documented evidence of an assessment of the bruise under Resident #42's right breast or potential cause of the bruise. In an interview on 02/06/2024 at 1:54 p.m., S35Licensed Practical Nurse (LPN) stated on 01/30/2024 she noted a bruise under Resident #42's right breast which was approximately the size of a nickel and was purple in color. S35LPN further stated the staff prior to my shift had not reported any new skin conditions and/or bruising. S35LPN stated she reported 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 have evidence that injuries of unknown origin were thoroughly investigated for 1 (Resident #42) of 1 (Resident #42) sampled residents reviewed for abuse. Findings: Review of Resident #42's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status (BIMS) score of 0 (score of 0-7 indicated the resident had a severe cognitive impairment). Further review revealed Resident #42 had altered level of consciousness with behavioral fluctuations. Review of Resident #42's nurse's notes dated 01/30/2024 at 6:25 a.m. revealed Resident #42 was noted to have scratches to her chest, scratches to her abdomen, and a bruise underneath her right breast. Further review revealed the nurse asked the Certified Nursing Assistant (CNA) what happened, and the CNA replied Resident #42 was being combative. Review revealed the nurse then asked the CNA what happened to Resident #42's arm, chest, abdomen and right breast and the CNA stated the scratches to Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure: 1. Louisiana Physician Orders for Scope of Treatment (LaPost) was placed on residents records per the care plan for 2 (Resident #42 and Resident #63) of 2 (Resident #42 and Resident #63) sampled residents reviewed for Advanced Directives; and 2. A Resident with a significant weight loss was care planned for nutritional interventions for 1 (Resident #18) of 2 (Resident #18 and Resident #36) sampled residents reviewed for nutrition. Findings: 1. Resident #42 Review of Resident #42's record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses, in part, cerebral vascular accident (CVA). Further review revealed there was no documented evidence of advanced directives. Review of Resident #42's Physician Progress Notes dated [DATE] revealed, in part, Resident #42 was a full code (Cardio Pulmonary Resuscitation (CPR) was to be initiated if found without breathing or a pulse). Review of Resident #42's Care Plan with a goal 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 record review and interview, the facility failed to obtain the resident's most recent plan of care, certification of terminal illness, and documentation of services provided for 1 (Resident #26) of 1 (Resident #26) sampled residents reviewed for hospice. Findings: Review of the facility's contract with the local hospice agency revealed, in part, the hospice agency shall develop the plan of care specifying information pertinent to the resident's treatment. The plan will be reviewed by the hospice agency on a minimum of every two weeks and updated as necessary by the hospice agency. Review of Resident #26's hospice binder revealed Resident #26 was admitted to hospice on 01/19/2024. Further review of Resident #26's hospice binder revealed no documented evidence of Resident #26's certification of terminal illness, hospice plan of care, nor any documents for services provided. In an interview on 02/07/2024 at 4:00 p.m., S33Licensed Practical Nurse (LPN) stated she was aware Resident #26 was receiving hospice services, however S33LPN was not aware of all the hospice disciplines…

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.