Legacy Nursing And Rehabilitation Of Plaquemine

Based on interviews and record review it was determined that the facility failed to communicate appropriate resident information to a receiving facility for 1 (Resident #1) of 1 (Resident #1) sampled residents reviewed for transfer requirements. Findings: Review of the facility's document titled Checklist for 6P-6A Shift revealed, in part, th nurse was supposed to call report to the hospital Resident #1 was being transferred to. Review of Resident #1's record revealed, in part, Resident #1 was discharged to the emergency department on 11/16/2024. Review of Resident #1's record revealed no documented evidence and the facility did not provide documented evidence that the receiving facility was provided with all Resident #1's required information for the 11/16/2024 transfer. In an interview on 12/10/2024 at 4:44 PM, S3License Practical Nurse (LPN) indicated she was assigned to work Resident #1's hall on 11/15/2024 for the 6:00 PM to 6:00 AM shift. S3LPN further indicated at 12:00 AM on 11/16/2024, Resident #1 was transferred to the emergency department. S3LPN further indicated she did…

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 test a resident with signs and symptoms of COVID-19 in a timely manner for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for infection control. Findings: Review of the facility's undated policy titled, COVID-19 testing Policy and Procedure, revealed, in part, any resident who had signs or symptoms of COVID-19 should be tested as soon as possible. Review of Resident #2's August 2024's physician's orders revealed, in part, an order dated 07/26/2022 for a rapid antigen (a marker that tells the immune system whether something in a body is harmful or not) test (a test that can quickly detect the presence or absence of an antigen) to be performed if resident displayed signs and symptoms of COVID-19. Review of Resident #2's nursing note dated 08/22/2024 at 11:20 a.m. reveled, in part, a late entry of Resident #2 requested his temperature be taken. Further review revealed Resident #2's temperature was 101.2, Resident #2 was given Tylenol ( a medication used to treat fever), and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure an allegation of resident to resident abuse was reported to the State Survey Agency within 5 working days for 2 (Resident #4 and Resident #5) of 4 (Resident #1, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for abuse and neglect. Findings: Resident #4 Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder. Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses of, in part, non-traumatic brain dysfunction, and paranoid schizophrenia. Review of Resident #4's undated Care Plan revealed Resident #4 had potential to be verbally aggressive due to mental and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a resident had a crisis intervention plan developed per the resident's pre-admission screening and resident review (PASRR) for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for care and services. Findings: Review of Resident #4's record revealed he was admitted to the facility on [DATE] with diagnoses, in part, delusional disorder, anxiety disorder, and paranoid personality disorder. Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/13/2024 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13-15 indicated the resident was cognitively intact). Further review revealed Resident #4 had diagnoses, in part, non-traumatic brain dysfunction, and paranoid schizophrenia. Review of Resident #4's Office of Behavioral Health PASRR Level II Evaluation Summary and Determination Notice for period 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 observation, record review, and interview, the facility failed to address signs of pain in a nonverbal resident for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 ) reviewed for pain. Findings: Review of Resident #1's care plan revealed the problem of left should fracture which was initiated on 04/02/2024. Further review revealed a goal for Resident #1 was to have minimal to no discomfort. Further review revealed interventions included for Resident #1 to have medications as prescribed by the physician and report any pain not relieved by pain medication to the physician. Review of Resident #1's March 2024 and April 2024 Electronic Medication Administration Record (EMAR) revealed the following , in part: pain level of 4 on the am shift on 03/29/2024, pain level of 8 on the am shift on 03/30/2024, pain level of 7 on the pm shift on 03/30/2024, pain level of 8 on the am shift on 03/31/2024, a pain level of 8 on the am shift on 04/03/2024 (for the pain scale 0 indicated no pain and 10 indicated the worst pain). Further 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 interviews and record reviews, the facility failed to protect the residents' right to be free from resident-to-resident physical abuse for 6 (Resident #3, Resident #51, Resident #102, Resident #104, Resident #205, and Resident #355) of 11 (Resident #3, Resident #25, Resident #50, Resident #51, Resident #52, Resident #83, Resident #87, Resident #102, Resident #104, Resident #205, and Resident #355) sampled residents investigated for abuse. Findings: Resident #3 Review of Resident #50's progress noted dated 12/16/2023, revealed, in part, Resident #3 approached Resident #50, and Resident #50 put hands around Resident #3's neck and called him racial slurs. In an interview on 02/09/2024 at 2:28 p.m., S13Licensed Practical Nurse (LPN) confirmed that she saw Resident #50 put his hands around Resident #3's neck. In an interview on 02/09/2024 at 2:51 p.m., S1Administrator confirmed the above physical abuse happened between Resident #3 and Resident #50 with her own investigation, and would consider this resident to resident abuse. Resident #51 Review of Resident #83's progress note…

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 report an allegation of abuse and the results of the investigation as required for 4 (Resident #3, Resident #102, Resident #205, and Resident #355) of 11 (Resident #3, Resident #25, Resident #50, Resident #51, Resident #52, Resident #83, Resident #87, Resident #102, Resident #104, Resident #205, and Resident #355) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Reporting and Investigation Policy and Procedure revealed, in part, all alleged violations involving abuse, neglect, exploitation or mistreatment would be reported to the facility Administrator, or his/her designee, and in turn they would notify the following persons or agencies, as applicable. Further review revealed alleged violations of abuse would be reported immediately, but no later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury or 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Further review revealed, in part, 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 observations, interviews, and record reviews, the facility failed to provide nail care to dependent residents. This deficient practice was identified for 2 (Resident #7 and Resident #89) of 4 (Resident #7, Resident #63, Resident #89, and Resident #97) sampled residents investigated for activities of daily living (ADLs). Findings: Review of the facility's nail care policy and procedure revealed, in part, the care of fingernails and toenails were part of the bath, nails were to be clipped and filed smoothly, and nails were to be kept clean. Resident #7 Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/2023 revealed, in part, Resident #7's cognition was unable to be conducted due to resident rarely or never being understood. Further review revealed Resident #7 had impairment of her upper and lower extremities. Review of Resident #7's care plan revealed, in part, Resident #7 was totally dependent on staff for nail care. Observation on 02/06/2024 at 10:00 a.m. revealed Resident #7 had jagged fingernails about ¼ inch in length with 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 residents received behavioral health care services for 2 (Resident #42 and Resident #61) of 2 (Resident #42 and Resident #61) sampled residents investigated for behavioral health care services. Findings: Resident #42 Review of Resident #42's medical records revealed, in part, Resident #42 was admitted to the facility on [DATE] on hospice care. Further review revealed Resident #42 was discharged from hospice care on 10/13/2023 after she was no longer considered terminally ill. Review of Resident #42's February 2023 Physician's Orders and February 2023 electronic Medication Administration Record revealed, in part, Resident #42 had orders and received anti-psychotic medication, anti-depressant medication, and anti-anxiety medication. Review of Resident #42's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2023 revealed, in part, Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12 which…

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: 1. Failed to ensure serve food that was free from contamination; and, 2. Failed to ensure a bottle of sanitizer was not placed on the food preparation area. Findings: 1. Observation on 02/06/2024 at 11:30 a.m. revealed S17Dietary Manager dropped an unopened alcohol prep wipe in the broccoli on the steam table. Further observation revealed S17Dietary Manager removed the unopened alcohol prep wipe from the broccoli, but did not remove any of broccoli. Observation on 02/06/2024 at 12:00 p.m. revealed kitchen staff served the broccoli in which the alcohol prep wipe fell into. In an interview on 02/07/2024 1:20 p.m. S17Dietary Manager confirmed it was unsanitary to serve the broccoli in which the alcohol prep wipe fell in. 2. Observation on 02/06/2024 at 12:00 p.m. revealed S29Dietary Aide placed a bottle of sanitizer on the food prep table. In an interview on 02/06/2024 at 12:08 p.m., S17Dietary Manager stated the bottle of sanitizer should not have been placed on the food prep table. In an interview on 02/08/2024 at 2:49 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 1 (Resident #21) of 27 (Resident #5, Resident #7, Resident #10, Resident #14, Resident #19, Resident #20, Resident #21, Resident #22, Resident #25, Resident #29, Resident #36, Resident #39, Resident #42, Resident #45, Resident #48, Resident #52, Resident #61, Resident #62, Resident #63, Resident #73, Resident #80, Resident #87, Resident #88, Resident #89, Resident #90, Resident #97, and Resident #456) sampled residents reviewed for environment. Findings: Review of the facility's Self-Administration of Medications policy revealed, in part, residents who request to self-administer medications would be assessed by the interdisciplinary team using the Self-Administration Safety Screen UDA (user defined assessment). Further review revealed the resident must know the reason for the medication, frequency, route, and the medication must be stored in a locked area away from other…

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 provide maintenance services by failing to ensure a resident's wall was repaired. This deficient practice was identified for 1 (Resident #48) of 27 (Resident #5, Resident #7, Resident #10, Resident #14, Resident #19, Resident #20, Resident #21, Resident #22, Resident #25, Resident #29, Resident #36, Resident #39, Resident #42, Resident #45, Resident #48, Resident #52, Resident #61, Resident #62, Resident #63, Resident #73, Resident #80, Resident #87, Resident #88, Resident #89, Resident #90, Resident #97, and Resident #456) residents investigated for environment. Findings: Review of Resident #48's Minimum Data Set with an Assessment Reference Date of 11/01/2023 revealed Resident #48 had a Brief Interview for Mental Status score of 15 which indicated Resident #48 was cognitively intact. Observation on 02/05/2024 at 11:34 a.m. revealed the wall next to Resident #48's bed had paint and the top layer of the wall missing which was approximately 6 inches long and 10 inches high. Observation on 02/06/2024 at…

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 conduct a thorough investigation following an allegation of abuse for 1 (Resident #104) of 11 (Resident #3, Resident #25, Resident #50, Resident #51, Resident #52, Resident #83, Resident #87, Resident #102, Resident #104, Resident #205, and Resident #355) sampled residents investigated for abuse. Findings: Review of Resident #104's progress note dated 10/14/2023 revealed, in part, a resident in Resident #104's room was observed hitting him on the shoulder and screaming, I am going to beat your a. Review of the facility's incident report log from October 2023 to present revealed no documentation of an incident regarding the above mentioned allegation of abuse. There was no documented evidence and the provider did not present any documented evidence that the allegation of abuse noted in Resident #104's progress note on 10/14/2023 was investigated. In an interview on 02/09/2024 at 2:54 p.m., S1Administrator stated she would have to look for documentation to see if an investigation was completed regarding the above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with diagnoses of Bipolar Disorder and Schizophrenia was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #63) of 2 (Resident #42 and Resident #63) sampled residents reviewed for PASARR. Findings: Review of Resident #63's Electronic Medical Record (EMR) revealed, in part, Resident #63 was admitted on [DATE] with diagnoses which included, in part, Bipolar Disorder and Schizophrenia. Further review of Resident #63's EMR revealed, in part, no evidence that a Level II evaluation was completed. There was no documented evidence and the facility did not present any documented evidence of completing a Level II PASARR evaluation as required for Resident #63. In an interview on 02/08/2024 at 10:40 a.m., S1Administrator confirmed the facility did not have documentation that a Level II evaluation was completed for Resident #63, and S15Social Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interview, the facility failed to notify the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation for a resident after a significant change in physical condition for 1 (Resident #42) of 2 (Resident #42 and Resident #63) sampled residents reviewed for PASARR. Findings: Review of the facility's Preadmission Screening, PASARR Resident Review policy and procedure revealed, in part, a resident review for level II evaluation should be considered for residents who have changes to their physical health, which negatively affect their behavioral, psychiatric, or mood-related symptoms, or cognitive abilities impacting their daily living. Review of Resident #42's medical records revealed, in part, Resident #42 was admitted to the facility on [DATE] to receive hospice care for comfort measures. Further review revealed Resident #42 had diagnoses of bipolar disorder and unspecified psychosis upon admit. Review of Resident #42'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 record reviews, observations, and interviews, the facility failed to ensure an unsafe smoker's care plan was implemented for 1(Resident #90) of the 3 (Resident #29, Resident #61, Resident #90) sampled residents reviewed for smoking. Findings: Review of Resident #90's medical record revealed, in part, Resident #90 was admitted to the facility on [DATE] and was listed as an unsafe smoker. Review of Resident #90's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/2024 revealed, in part, Resident #90 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognition. Review of Resident #90's Comprehensive Care Plan, with an initiation date of 09/19/2023 revealed, in part, Resident #90 was identified as being an unsafe smoker and interventions included Resident #90 was to wear a smoking apron when smoking. Observation on 02/05/2024 at 9:50 a.m. revealed Resident #90 was not wearing a smoking apron while smoking. Observation on 02/05/2024 at…

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, interview, and observation the facility failed to perform catheter care per policy and procedures. This deficient practice was identified for 1 (Resident #20) of 3 (Resident #7, Resident #20, Resident #36) sampled resident(s) reviewed for catheter care. Findings: Review of Resident #20's February 2024 physician orders revealed, in part, an order for catheter care every shift and as needed. Review of facility's Catheter Care, Indwelling Catheter Policy and Procedure revealed, in part, catheter care should be performed by pouring warm water over perineal area, washing with soap and water, cleansing the catheter tubing at the insertion, rinse well with warm water and pat dry gently with a clean towel. Review of Quarterly Minimum Data Set (MDS) with an assessment reference date(ARD) date of 11/08/2023 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #20 was cognitively intact. In an interview on 02/07/2024 at 1:50 p.m. Resident #20 stated catheter care was not performed daily. Resident #20 further…

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

Based on observations, interviews, and record review, the facility failed to follow a speech therapist's therapeutic diet recommendation for 1 (Resident #97) of 3 (Resident #7, Resident #73, and Resident #97) sampled residents investigated for nutrition. Findings: In an interview on 02/06/2024 at 10:15 a.m., Resident #97's family member stated she did not understand why Resident #97 was not getting a meal tray. Review of Resident #97's Speech Therapy notes signed by S25Speech Language Pathologist (SLP) on 12/19/2023 revealed, in part, a discharge recommendation that Resident #97 receive a pureed consistency diet. Observation on 02/07/2024 at 12:10 p.m., revealed S22Certified Nursing Assistant (CNA) did not provide Resident #97 with a lunch tray. In an interview on 02/07/2024 at 12:10 p.m., S22CNA stated that Resident #97 did not get a meal tray. In an interview on 02/08/2024 at 12:13 p.m., S25SLP stated if Resident #97 had a recommendation for a pureed consistency diet, an order should have been placed for Resident #97 to receive a pureed consistency meal tray by a nurse.…

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 administer the Influenza vaccine and Pneumococcal vaccine for 1 (Resident #42) of 5 (Resident #5, Resident #7, Resident #20, Resident #24, and Resident #42) sampled residents reviewed for Influenza vaccines and Pneumococcal vaccines. Findings: Record review revealed, in part, Resident #42 signed a consent to receive the Influenza vaccine and the Pneumococcal vaccine on 10/17/2023. There was no documented evidence and the facility failed to present documented evidence the Influenza vaccine and the Pneumococcal vaccine were administered for Resident #42 as per the consent, signed on 10/27/2023, in which she requested to receive the vaccine. In an interview on 02/07/2024 at 9:30 a.m., S2Director of Nursing confirmed the consent for the Influenza vaccine and Pneumococcal vaccine was signed for Resident #42, but there was no documented evidence the facility had administered the vaccines.

Based on record review and interview the facility failed to ensure the COVID-19 vaccine was administered for 1 (Resident #42) of 5 (Resident #5, Resident #7, Resident #20, Resident #24, and Resident #42) sampled residents reviewed for COVID-19 vaccines. Findings: Record review revealed, in part, Resident #42 signed a consent to receive the COVID-19 vaccine on 10/17/2023. There was no documented evidence and the facility failed to present documented evidence the COVID-19 vaccine was administered to Resident #42 as per the consent, signed on 10/27/2023, in which she requested to receive the vaccine. In an interview on 02/07/2024 at 9:30 a.m., S2Director of Nursing confirmed the consent for the COVID-19 vaccine was signed for Resident #42, but there was no documented evidence the facility had administered the vaccine.

Based on record review and interview, the facility failed to ensure the certified nursing assistant (CNA) reported an allegation of neglect for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for neglect. Findings: Review of the facility's Policy and Procedure for Abuse Reporting and Investigation revealed, in part, all alleged violations involving neglect will be reported to the administrator immediately. In an interview on 12/28/2023 at 1:39 p.m., S3CNA stated about 2 weeks ago she was in the hallway and she heard Resident #1 yelling that she, S3CNA, had left stool and urine on him. S3CNA stated she had not told anyone about the accusations, but she should have because Resident #1 accused her of neglect. In an interview on 12/28/2023 at 1:53 p.m., S1Administrator stated any allegations or grievances of potential neglect should be reported to her immediately for investigation.

Based on record review, observation, and interview, the facility failed to ensure a resident's catheter was properly assessed for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter. Findings: Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/08/2023 revealed Section H Bladder and Bowel appliances was coded as none of the above (section where indwelling Foley catheter was listed). Further review revealed no documented evidence and the facility presented no documented evidence Resident #3 had been assessed as having a Foley catheter. Review of Resident #3's readmission Note dated 12/05/2023 revealed, in part, 16 french/10 cubic centimeters (cc) Foley catheter (artificial tube placed in bladder to drain urine) in place and draining yellow urine to genitourinary bag. Observation on 12/28/2023 at 11:06 a.m. revealed Resident #3 had a catheter draining clear yellow urine to the genitourinary bag. In an interview on 12/28/2023 at 1:14 p.m., S4Licensed Practical Nurse (LPN) stated she had worked at the facility with Resident #3…

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 a resident's catheter was care planned with interventions for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter use. Findings: Review of Resident #3's readmission Note dated 12/05/2023 revealed, in part, 16 french/10 cubic centimeters (cc) Foley catheter (artificial tube placed in bladder to drain urine) in place and draining yellow urine to genitourinary bag. Observation on 12/28/2023 at 11:06 a.m. revealed Resident #3 with a catheter draining clear yellow urine to the genitourinary bag. Review of Resident #3's Care Plan revealed no documented evidence and the facility presented no documented evidence of a care plan for Resident #3's Foley catheter use. In an interview on 12/28/2023 at 1:14 p.m., S4Licensed Practical Nurse (LPN) stated she had worked at the facility with Resident #3 for 3 weeks, and Resident #3 had been having the Foley catheter for the time she had been employed. S4LPN stated there were no interventions on the medication administration record or the electronic…

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 a resident with a catheter received appropriate catheter care for 1 (Resident #3) of 1 (Resident #3) sampled residents with a catheter. Findings: Review of Resident #3's readmission Note dated 12/05/2023 revealed, in part, 16 french/10 cubic centimeters (cc) Foley catheter (artificial tube placed in bladder to drain urine) in place and draining yellow urine to genitourinary bag. Observation on 12/28/2023 at 11:06 a.m. revealed Resident #3 with a catheter draining clear yellow urine to the genitourinary bag. Review of Resident #3's record revealed no documented evidence of orders or interventions for Resident #3's catheter, nor did Resident #3's record reveal any documented evidence any catheter care had been performed. In an interview on 12/28/2023 at 1:14 p.m., S4Licensed Practical Nurse (LPN) stated she had worked at the facility with Resident #3 for 3 weeks, and Resident #3 had been having the Foley catheter for the time she had been employed. S4LPN stated there were no interventions on 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 review and interview, the facility failed to: 1. Ensure routine drugs were available for resident usage for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for medication availability; and 2. Ensure an accurate system for account of controlled drugs for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for controlled substance reconciliation. Findings: 1. Resident #1 Review of Resident #1's December 2023 Physician Orders revealed in part, Oxycodone (narcotic medication used to treat pain) 10 milligrams (mg) one tablet by mouth every six hour as needed for pain. Review of the facility's communication to Resident #1's physician dated 12/14/2023 revealed Resident #1 needed a refill for Oxycodone 10 mg. Review of Resident #1's Progress Note dated 12/18/2023 revealed the nurse contacted Resident #1's pharmacy and was informed Resident #1 required a prescription to refill Oxycodone 10 mg. Review of Resident #1's Prescription Delivery Audit…

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 ensure restorative services were provided for 1 (Resident #1) of 2 (Resident #1 and Resident #3) residents reviewed for therapy services. Findings: Review of Resident #1's record revealed, in part, a therapy referral dated 10/18/2023 to the Restorative Nursing Program (RNP) (nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). Review of Resident #1's October, November and December 2023 Physician Order Summary Reports revealed, in part, no order for restorative services. In an interview on 12/05/2023 at 9:51 a.m., S3Restorative Certified Nursing Aide (Restorative CNA) stated Resident #1 was not on her work load for residents receiving restorative services. In an interview on 12/05/2023 at 9:52 a.m., S4Restorative CNA stated Resident #1 was not on her work load for restorative services. In an interview on 12/05/2023 at 10:10 a.m., S2Director of Rehabilitative Services stated a referral was given to administration for restorative care in morning…

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 accurate and complete records which documented the activities of daily living (ADL) documentation for a resident's bath and/or shower/bed bath for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for ADL care documentation. Findings: Resident #1 Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/13/2023 revealed, in part, Resident #1 was totally dependent on staff assistance for bathing. Review of Resident #1's Activities of Daily Living (ADL) documentation for October 2023 revealed Resident #1 was to receive a bath and/or shower on Tuesdays, Thursdays, and Saturdays. Review further revealed no documented evidence and the facility presented no documented evidence that Resident #1 received a bath and/or shower or the reason as to why Resident #1 did not receive a bath and/or shower on 10/05/2023. Resident #2 Review of Resident #2's MDS ARD dated 08/23/2023 revealed, in part, Resident #3 was totally…

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 ensure the wound care nurse performed hand hygiene when changing gloves for 1 (S3Licensed Practical Nurse (LPN)/Wound Care Nurse) of 2 (S3LPN/Wound Care Nurse and S4Certified Nursing Assistant) sampled staff observed during wound care observations. Findings: Review of the facility's policy and procedure on Hand Washing/Hand Hygiene revealed use of alcohol based hand rub containing at least 62% alcohol or soap and water used an alternative should be used after removing gloves. Observation on 10/30/2023 at 1:26 p.m. of wound care provided to Resident #2 by S3LPN/Wound Care Nurse revealed after cleaning Resident #2's right knee wound, S3LPN/Wound Care Nurse removed her gloves, and placed a new pair of gloves on her hands without having performed hand hygiene, and placed a dressing on Resident #2's right knee wound. Further observation during wound care to Resident #2's left posterior lower leg revealed S3LPN/Wound Care Nurse removed her gloves, and placed a new pair of gloves on her hands without having…

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

Based on record review, observation, and interview, the facility failed to: 1. Ensure residents rooms did not contain a dried dark tan sticky unknown substance on the floor for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident rooms; and 2. Ensure air conditioners in resident rooms were sealed to prevent any access to the outside for 2 (Resident #1 and Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents observed for environmental observations. Findings: Review of the facility's policy and procedure on Infection Prevention and Control Environmental Services revealed, in part, hard floor surfaces shall be wet cleaned daily, tile floors shall be wet mopped daily with an approved solution, and spills shall be attended to immediately. Resident #2 Observation on 10/30/2023 at 12:41 p.m. revealed a 12 inch by 11 inch area of dried sticky dark tan substance under Resident #2's tube feeding pole. Observation on 10/31/2023 at 9:29 a.m. revealed under Resident #2's tube feeding pole was a large area of dried sticky…

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 an allegation of the misappropriation of resident funds and the results of the investigation were reported as required for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents investigated for misappropriation of property. Findings: Review of the facility's Abuse Reporting and Investigation Policy and Procedure revealed, in part, all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of property would be reported to the facility Administrator, or his/her designee, and in turn they would notify the following persons or agencies, as applicable. Further review revealed alleged violations of misappropriation of resident property would be reported immediately, but no later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury or 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. Further review revealed, in part, the Administrator, or his/her designee,…

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.