Heritage Manor Of Opelousas

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center for Medicare And Medicaid Services) in a timely manner, after a resident was discharged for 1 (#82) of 1 (#82) resident investigated for Resident Assessment out of a final sample of 39 residents. The deficient practice had the potential to affect 107 residents. Findings: Review of Resident #82's medical record revealed an admission date of 08/03/2021, and a discharge date of 05/06/2024. Further review of Resident #82's medical record revealed no documented evidence that a discharge assessment was opened, completed and/or transmitted since he was discharged . On 08/28/2024 at 4:39 p.m., an interview was conducted with S18MDS (Minimal Data Set). who confirmed Resident #82 was discharged home on [DATE]. She also confirmed the discharge assessment had not been opened, completed, or transmitted in greater than 120 days and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#56) out of 39 sampled residents. Findings: Review of Resident #56's clinical medical record revealed she was admitted to the facility on [DATE]. Her current diagnoses include, but where no limited to, Cerebral Infarction, Hemiplegia affecting right dominant side, Chronic Obstructive Pulmonary Disease and Muscle Weakness. Review of Resident #56's Significant Change MDS dated [DATE] revealed under Section P-Restraints, the resident was coded for the use of restraints. Review of the resident's active physician order as of 08/01/2024 revealed no order for restraints. On 08/26/2024 at 8:30 a.m., an interview and review of the residents MDS dated [DATE] was conducted with S9LPN/MDS (Licensed Practice/Minimum Data Set. She confirmed that she incorrectly coded the use of the bed rails as a restraint on the resident's MDS.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews and observations, the facility failed to develop and/or implement a resident centered comprehensive plan of care for 3 (#36, #76 and #105) out of 39 sampled residents as evidenced by failing to: 1. implement Resident #36's plan of care to apply bilateral heel protectors while in bed; 2 develop a plan of care for Resident #76 that addressed his significant weight loss; and 3. develop a plan of care to address Resident #105's Urinary Catheter and her diagnosis of Urinary Tract Infection. Findings: 1. Resident #36 Review of Resident #36's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Pressure Ulcer of Sacral Region Stage 4, Rash and other Nonspecific Skin Eruption, Unspecified, and Severe Protein-Calorie Malnutrition. Review of Resident #36's care plan revealed a problem onset on 04/02/2021 which read in part .Resident is at risk for further skin breakdown due to decline in mobility. This…

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 facilitate the resident's and if applicable, the resident representatives' participation in the care planning process for 1 (#5) of 2 (#5, and #76) residents investigated for care planning out of a total sample of 39 residents. Findings: Review of Resident #5's medical records revealed he was admitted to the facility on [DATE] and he was his own representative. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively intact. Review of S16SS (Social Services) notes dated 11/02/2023 read in part .the residents daughter was having phone trouble, but left her P.O Box address so that she could also be contacted by the facility via mail. On 08/26/2024 at 12:35 p.m., an interview was conducted with Resident #5, in which he stated that he had not been invited to attend any care plan meetings. On 08/27/2024 at 4:15 p.m., an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility failed to provide oral care for 1 (#64) of 4 (#44, #56, #64, #91) residents reviewed for ADL's (Activities of Daily Living) from a sample of 39 Residents. Findings: Record review revealed Resident #64 was admitted to the facility on [DATE] and had a BIM (Brief Mental Exam) of 10. She had a diagnosis of Muscle weakness and required extensive assistance with all ADL's. Record review of Resident #64's Care Plan revealed the C.N.A.'s were to assist Resident #64 with maintaining good oral hygiene daily. On 08/26/24 at 12:48 p.m., an observation revealed Resident #64 had a white milky substance between her upper and lower teeth. At this time Resident #64 stated she has been in the facility going on 2 months and during this time the staff have not provided her with oral care in the morning. On 08/27/24 9:12 a.m., another observation revealed Resident #64 had a white milky substance between her upper and lower teeth. At this time Resident #64 stated no one…

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 provide respiratory care consistent with professional standards of practice for 2 ( Resident #31 and #54) of 3 (Resident #31, Resident #54 and Resident #359) investigated for respiratory care by failing to properly store: 1. Resident #31's nebulizer mask, and 2. Resident #54's BiPAP (Bilevel Positive Airway Pressure) mask Findings: 1. Resident #31 Review of Resident #31's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but not limited to, Chronic Obstructive Pulmonary Disease with Exacerbation, Chronic Systolic Heart Failure and Shortness of Breath. Review of Resident #31's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/30/2024 revealed a BIMS (Brief Interview for Mental Status) of 14, indicating he was cognitively intact. Review of Resident #31current physician's orders read in part, Pulmicort 0.5 mg/2ml (milligram/milliliter) respule - Give 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (#64) of 3 (#11, #64, and #69) residents sampled for pain. The facility failed to ensure Resident #64 who displayed verbal pain received the ordered interventions to alleviate pain. Findings: Record review revealed Resident #64 was admitted to the facility on [DATE]. She had diagnosis that included but were not limited to, Pain in Leg, Intervertebral Disc Degeneration in her Lumbar Region, Scoliosis, Angina Pectoris, Weakness, and Type 2 Diabetes Mellitus. Her BIMS (Brief Interview for Mental Status) was 10 (Moderate Cognitive Status). Record review of Resident #64's care plan read in part, Resident is at risk for pain. Administer meds as ordered. Notify MD (Medical Doctor) of any unrelieved pain. Record review of Resident #64's physician orders read in part, Tylenol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, the facility failed to ensure nursing staff demonstrated competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (# 61, #78) residents out of 39 sampled residents. The facility failed to ensure staff demonstrated competency for: 1. safe injection practices when S27LPN used Resident #61's used multi-dose insulin pen designed for single patient use to administer insulin to Resident #6; and 2. correct application of Resident #78's bed bolsters by CNAs (certified nursing assistants). The facility had a census of 107 residents. Findings: 1. On 08/28/2024, a review of the facility's policy titled Injections with a last reviewed date of 01/2024 read in part, Purpose: To administer medication via injection. Procedure: 2. Verify the physician's order, comparing the medication label to the order verify the following:…

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 reviews, and interviews, the facility failed to ensure that recipes were followed for residents who received pureed diets, by failing to follow a recipe for steamed rice. This deficiencies had the potential to effect 8 residents receiving a pureed diet. Findings: On 08/27/2024, a review of the facility's policy titled Preparation and service of pureed diets with a revision date of 05/18/2018, with no review date, read in part, Policy: Pureed diets are served when a modification in texture is needed because of lack teeth, chewing, and/or swallowing problems. Pureed foods are prepared in a consistency that is appropriate for each resident's ability to chew and shallow. 6. The pureed foods should be blended to the consistency that holds its shape such as mashed potatoes, unless otherwise specified in the diet order. Only the smallest amount of liquid possible should be used to puree the foods, since dilution will decrease the amount of calories, protein, vitamins and minerals the resident/patient will receive. A review the recipe for Steamed [NAME] puree…

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 coordinate care as evidenced by failing to obtain pertinent information from the contracted hospice agency for 1 (#99) out of 2 (#99, #46) residents investigated for hospice. Findings: A review of the facility's Assignment and Assumption Agreement with the contracted Hospice Agency dated [DATE] read in part: Preparation- Nursing Facility and Hospice each shall prepare and maintain complete, detailed clinical records for each patient receiving services under this Agreement in accordance with prudent record- keeping procedures, and as required by applicable federal and state laws and regulation on Medicare/Medicaid guidelines. Review of the Resident #99's electronic medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Dementia, Pain, and Unspecified protein- calorie malnutrition. Review of the Resident #99's clinical record revealed a Hospice Certification that expired on [DATE] and the last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the staff followed the policy and procedures to prevent accidents for 1 (#1) out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy titled Toileting Residents with the latest review date of 01/24 read in part .Purpose: Residents are toileted safely on a routine basis in a timely manner according to their individualized plan of care . Procedure: 5 . If the resident is high risk for falls, the nursing assistant/designee is to remain in the bathroom for resident safety. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Atherosclerotic Heart Disease, Urge Incontinence, Hypertension, and Bilateral Osteoarthritis of Knee. Review of the resident's quarterly MDS (Minimum Data Set) dated 05/21/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 14 for being cognitively intact. 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 interview, the facility failed to ensure that the nursing staff failed to immediately notify the Administrator of an injury of unknown origin for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents investigated. This deficient practice had the potential to effect a census of 109. Findings: On 05/06/2024, a review of the facility's policy titled, Incident Investigation and Reporting, (review date 04/11/2024) was conducted. This policy read in part, 3. In the event of any incident involving an allegation or suspicion of mistreatment, exploitation, neglect, abuse, misappropriation or other crime, as well as injuries of unknown origin, elopement, and/or adverse events, . each occurrence will be reported immediately to the Administrator of the facility. Review of Resident #1's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but not limited to, Cognitive Communication Deficit, Alzheimer's Disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan as evidenced by failing to administer pain medication to a resident who displayed nonverbal indicators of pain for 1 resident (#2) out of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #2's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses including but not limited to: Displaced fracture of base of neck of right femur, Age related osteoporosis with current pathological fracture, Unilateral primary osteoarthritis of left knee, and Vascular dementia. Review of Resident #2's March 2024 physician's orders revealed an order dated 02/05/2024 that read: Ibuprofen 200 mg (milligrams) - Give 2 tablets by mouth every 6 hours as needed for pain. Further review of Resident #2's March 2024 physician's orders revealed an order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care as ordered for 4 residents (#12, #33, #61 and #68) out of a final sample of 44 residents. This deficient practice was evidenced when: 1. S10LPN (Licensed Practical Nurse) failed to administer scheduled morning medications as ordered for Resident #12 2. S8TX (Treatment Nurse) failed to accurately document Resident #33's wound assessment and physician's ordered wound care to the right lower leg. 3. Nursing staff failed to discontinue Resident #61's order for pneumatic compression devices after the resident's family member removed the devices from the facility because the devices were painful for Resident #61. Nursing staff continued to document that the pneumatic compression devices were applied at night despite there being no device to apply. 4. Nursing staff failed to administer scheduled pain medication as ordered for Resident #68 for five shifts. Findings: 1. Resident #12…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's plan of care and clinical record reflected their advance directives for 2 (#52, #78) residents out of 2 (#52, #78) residents investigated for advance directives. Findings: Review of the facility's policy titled Advance Directives read in part: All staff providing care for the resident will: Review the Advance Directive and clarify any discrepancies between the Directive and current treatment plan. Resident #52 Resident #52 was admitted to the facility on [DATE] with diagnoses including but not limited to Rheumatoid Arthritis, Cognitive Communication Deficit, and Hypertension. Review of Resident #52's EHR (Electronic Health Record) revealed she was a full code and required CPR (Cardiopulmonary Resuscitation). Review of Resident #52's current Plan of Care revealed in part: Resident is a full code. Review of Resident #52's Progress Notes revealed a nurse's note dated [DATE] at 11:16 a.m. that read: Daughter (Power of Attorney) came…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to maintain a homelike environment by failing to ensure the air conditioner (AC) cover for the AC unit was intact for 1 (#2) of 7 (#2, #7, #64, #75, #77, #80 and #83) residents investigated for environment. Findings: Review of the facility's policy, Resident Environment revealed, in part, the following: Policy Statement: It is the policy of this facility to provide a safe, clean, comfortable and homelike environment . Review of Resident #2's record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to, Acquired Absence Of Unspecified Leg Below Knee, Anxiety Disorder, Muscle Weakness, and Difficulty In Walking. On 07/17/2023 at 10:42 a.m., an observation was made of Resident #2's room. The AC unit was underneath the window in the resident's room. Further observation revealed AC unit's cover was not attached to the unit and was on the floor. On 07/18/2023 at 12:40 p.m., a second observation 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 reviews and interviews, the facility to accurately code the Resident's Minimum Data Set(MDS) Assessments to reflect the status of a state Level II PASRR for 3 (#3,#64, #95) out of 4 (#3,#62, #64, #95) residents reviewed for PASARR (Preadmission Screening and Resident Review); and, Resident #101's discharge disposition status out of 44 sampled residents. Findings: Resident #3 admitted to the facility on [DATE] with diagnoses that included, in part: Schizoaffective Disorder and Vascular Dementia with other behavior disturbance. A review of Resident #3's record revealed his Notice of Medical Certification was Approved for admission by Level II Authority effective 12/22/2022. Further record review revealed the Level I Pre-admission Screening and Resident Review (PASRR) indicated Resident #3 had a mental illness diagnosis of Schizoaffective Disorder. A review of Resident #3's Minimum Data Set (MDS) Significant Change in Status 5 Day (SM5) assessment with an Assessment Reference Date (ARD) 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 interview and record review, the facility failed to incorporate the recommendations from the PASARR (Preadmission Screening and Resident Review) Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 (#62) of 4 (#3, #62, #64, #95 ) residents reviewed for PASARR out of a total of 44 sampled residents. Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses including but not limited to Major Depressive Disorder, Schizophrenia, and Anxiety Disorder. Review of Section O of Resident #62's quarterly MDS (Minimum Data Set) dated 06/06/2023 revealed the resident was not assessed for receiving psychological therapy. Review of Resident #62's Plan of Care revealed he had potential for altered mood state related to diagnosis of Schizophrenia. Review of Resident #62's clinical record revealed he was approved for admission by Level II Authority for a temporary period effective 10/18/2022 through 10/25/2023. Review 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 complete a baseline care plan within 48 hours of admission for 1 (#102) out of 44 sampled residents. Findings: Review of Resident #102's electronic clinical record revealed an admit date of 05/18/2023 with diagnoses that included: Congestive heart failure, Acute kidney failure, Acute respiratory failure, Atrial fibrillation, Aortic aneurysm, Anxiety, Endocarditis, Chronic pain syndrome, Chronic obstructive pulmonary disease, Depression, Hypertension, and Cardiomyopathy. Further review revealed admission orders beginning on 05/18/2023 for admission under hospice services, and do not resuscitate (DNR). Review of a Resident #102's Baseline Care Plan and Summary revealed a completion date of 05/24/2023. On 07/18/2023 at 9:25 a.m., an interview was conducted with S6NCM (Nurse Case Manager). She confirmed Resident #102 was admitted to the facility on [DATE]. She reviewed the Baseline Care plan and summary and verified it indicated that it was completed 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 and interview the facility failed to weigh a resident weekly as per plan of care for 1 (#64) of 4 (#38, #64, #65, #78) reviewed for nutrition. This deficient practice had the potential to affect a census of 98 residents. Findings: Review of the facility's policy titled Weight Evaluation read in part, weight shall be obtained weekly on people with the following problems: #4. Residents with a significant unplanned or unexplained weight loss (or gain) both prior to or during stay in the facility. Resident #64 was admitted to the facility on [DATE] with diagnoses that included Acute Kidney Failure, Hypertension, Edema, Major Depressive Disorder and Schizophrenia. Review of Resident #64's quarterly MDS (Minimum Data Set) dated 05/09/2023 revealed in part a BIMS (Brief Interview for Mental Status) of 14 which revealed she was cognitively intact. Review of Resident #64's comprehensive care plan revealed in part that resident had a weight loss that had an onset date of 02/06/2023. One 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 interviews and record reviews, the facility failed to ensure staff implemented interventions to prevent or reduce the risk of accidents for 1 resident ( #33) of 3 residents (#1, #12 and #33) investigated for accidents out of a final sample of 44 residents. Findings: Review of facility's policy and procedure titled Accident/Incident Report revealed in part, . 1. All accidents/incidents including residents, employees or visitors, will be reported to the Charge Nurse and to appropriate department head immediately upon knowledge of occurrence, so that it may be evaluated. Accident/Incident is defined as an unexpected happening which may or may not have cause loss of injury to a visitor, resident and/or staff person .2. All accidents/incidents reports will be electronically accessible by the DON (Director of Nursing) immediately after his/her notification of the accident/incident .5. If there is any accident/incident the nurse completes the Resident Incident Report in the clinical computer software and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure that a resident who required hemodialysis receive such services consistent with professional standards of practice by not assessing the dialysis resident's shunt site for bruit and thrill for 1(#78) out of 1(#78) sampled residents for dialysis. Findings: A review of the Policy Hemodialysis - Care of Resident revealed the following, in part: 2) Daily check shunt site for bruit or thrill, pain, swelling, redness, excessive warmth, serous or purulent drainage indicating infection. Resident #78 admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #78's Care Plan revealed the following, in part: Dialysis on Monday, Wednesday, and Friday. Dialysis fistula to left upper arm. Interventions included, in part: Check dialysis fistula site to left upper arm for bruit and thrill, check for pain, swelling, redness, heat, drainage, coolness. A review 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 interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 from 01/01/2023 - 03/31/2023 revealed triggers for the following: failed to submit accurate data for the quarter- One Star Staffing Rating, and Excessively Low Weekend Staffing. On 07/18/2023 at 02:08 PM, a PBJ review, and interview conducted with S5HR, and S1ADM. The facility had the correct number of staff and agency staff needed for the Quarter from January 2023 to March 31, 2023, however they confirmed contract workers were not being inputted correctly in the PBJ system, indicating data did not reflect the correct number of staff present for that shift.