Legacy Nursing and Rehabilitation of Port Allen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#107) of 5 (#6, #38, #71, #93, and #107) residents reviewed for ADL's. The facility failed to trim and clean fingernails for Resident #107.Review of the facility's undated policy titled, Nail Care Policy and Procedure, revealed the following, in part:5. To promote cleanliness.Procedure: 1. Care of fingernails and toenails is part of the bath.2. Be certain nails are clean.4. Nails are to be clipped and filed smoothly. Review of the Medical Record for Resident #107 revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis Affecting Right Dominant Side and Neuroleptic Induced Parkinsonism. Review of the most recent MDS (Minimum Data Set) for Resident #107 with an ARD (Assessment Reference Date) of 07/16/2025 revealed Resident #107 had a BIMS…

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 review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing was properly labeled for 1 (#89) of 1 (#89) residents reviewed for oxygen therapy.Review of Resident #89's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Emphysema, and Chronic Diastolic (Congestive) Heart Failure. Review of Resident #89's current Physician's Orders revealed the following, in part:Start date: 05/27/2025: Administer oxygen at 2 Liters per minute via nasal cannula, every shift for Chronic Obstructive Pulmonary Disease, Emphysema, Congestive Heart Failure, and Shortness of Breath. On 08/25/2025 at 10:15 a.m., an observation was made of Resident #89's oxygen tubing, which was not labeled with the date. On 08/25/2025 at 10:20 a.m., an observation…

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 garbage and waste were properly contained in the outdoor trash dumpster.Findings: On 08/25/2025 at 9:00 a.m., an observation was made of the facility's two outdoor trash dumpsters with S4DM. One of the dumpsters was observed with the lid open, half full of bagged trash with flies swarming around the dumpster. On 08/25/2025 at 9:02 a.m., an interview was conducted with S4DM. She observed and confirmed the above mentioned observations of the dumpster area. She stated S6HSK was responsible for the dumpster area. She confirmed the dumpster lid was open and should not be.On 08/25/2025 at 9:05 a.m., an interview was conducted with S6HSK. He stated he was responsible for the dumpster area. He stated he had opened the dumpster lid this morning to take out the trash and would close the lid on the dumpster when he was done. He confirmed the dumpster lid should be closed when not in use.On 08/25/2025 at 9:20 a.m., an interview was conducted with S1ADM. She was notified of the observation of the dumpster lid being open. She…

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 MAR (Medication Administration Record) was accurately documented for 1 (#21) of 31 residents included in the final sample. Review of the facility's undated policy titled Documentation and Charting Guidelines, revealed the following, in part:Purpose: The purpose of Charting and Documentation is to provide the following: a complete account to the resident's care.Review of Resident #21's clinical record revealed she was admitted on [DATE] with diagnoses which included Dementia with other Behavioral Disturbance. Review of Resident #21's admission MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 08/19/2025 revealed BIMS of 13, which indicated she was cognitively intact. Review of Resident #21's current Physician's Orders revealed the following:-Contact Precautions - every shift for infection Start date: 08/17/2025-Vancomycin HCl Oral Capsule 125 MG - Give 1 capsule by mouth four times a day for C. Diff (Clostridium…

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 implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff:1. Performed hand hygiene during medication administration for 1 (#88) of 5 (#52, #62, #74, #88 and #130) residents observed during medication administration; and2. Donned the appropriate Personal Protective Equipment (PPE) during medication administration for 1 of 1 (#4) residents reviewed for feeding tube.Findings: Review of the facility's undated policy, titled, Hand Washing/Hand Hygiene Policy and Procedure revealed the following, in part: Policy: All personnel shall perform hand washing/hand hygiene when working with residents. Procedure: Use an alcohol-based hand rub. for the following situations: b. Before and after direct contact with residents; c. Before preparing or…

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 each resident received necessary respiratory care consistent with professional standards of practice for 3 of 3 (#1, #2, and #R2) residents reviewed for respiratory care. The facility failed to ensure: 1. A protocol was implemented for cleaning and/or replacing Resident #1's non-invasive ventilation tubing and mask; and 2. Oxygen tubing and humidification bottles were changed in a timely manner for 2 (#2 and #R2) of 3 (#1, #2, and #R2) residents reviewed for oxygen therapy. Findings: Review of the facility's undated policy titled, Nebulizer CPAP Machine Cleaning Policy and Procedure revealed the following, in part: Purpose: To keep nebulizer or CPAP machine and equipment clean. Policy: Resident's Nebulizer or CPAP will be kept clean when in resident room. Procedure: 3. Tubing, mouthpiece, and mask to be changed out weekly and as needed. Review of the Trilogy clinical manual revealed the following, in part: Cleaning the Patient…

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 correct installation, use, and maintenance of bed rails. The facility failed to ensure: 1. The risks and benefits were reviewed with the resident and/or resident representative, and informed consent was obtained prior to bed rail installation for 1 (#1) of 4 (#1, #3, #R1, and #R3) residents reviewed with bed rails; and 2. Each resident was assessed for risk for entrapment prior to bed rail installation for 4 of 4 (#1, #3, #R1, and #R3) residents reviewed with bed rails. Findings: 1. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Polyneuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Acute Pulmonary Edema, Chronic Congestive Heart Failure, Cardiomegaly, Essential Hypertension, and Sleep Apnea. Further review of the Clinical Record revealed no documentation pertaining to bed rails, including an entrapment risk assessment, the risks 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 observations, interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (#R2) of 3 (#1, #2, and #R2) sampled residents reviewed with oxygen therapy. The facility failed to ensure Physician Orders for oxygen therapy were obtained for Resident #R2 prior to administration. Findings: Review of the facility's undated policy titled, Oxygen Administration Policy and Procedure revealed the following, in part: Procedure: 1. Check Physician's Order for liter flow and method of administration. Review of Resident #R2's Clinical Record revealed she admitted to the facility on [DATE] with diagnoses, which included Acute Respiratory Failure with Hypoxia, Emphysema, and Unspecified Heart Failure. Review of Resident #R2's admission BIMS (Brief Interview for Mental Status) assessment dated [DATE] revealed a BIMS of 13, which indicated intact cognition. Review of Resident #R2's Physician Orders dated June 2025 revealed no orders for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure a resident's medical record was complete and accurate by failing to ensure baths were documented as provided for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for activities of daily living. Findings: Review of the facility's undated policy titled, Documentation and Charting Guidelines revealed the following, in part: Purpose: The purpose of charting and documentation is to provide the following: A complete account to the resident's care . Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Polyneuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Chronic Congestive Heart Failure, and Cardiomegaly. Review of Resident #1's Significant Change MDS with an ARD of 05/20/2025 revealed he was dependent on staff for bathing. Review of Resident #1's Day Shift CNA Assignments dated 05/05/2025, 05/14/2025, 05/19/2025, and 05/23/2025 revealed S13CNA was assigned to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure there was a functioning call system to allow residents to call for staff assistance for 1 (#R1) of 7 (#1, #2, #3, #4, #R1, #R2 and #R3) residents reviewed for environment. This deficient practice had the potential to affect any of the 122 residents residing in the facility. Findings: Review of the facility's undated policy titled, Call Light, Use of Policy and Procedure revealed the following, in part: Policy: 2. To assure call system is in proper working order. Procedure: 3. For bedside call lights, a light and a sound will appear and be heard over the door of the resident's room . 14. Notify the maintenance department and enter defective call light location(s) in the maintenance log. Review of Resident #R1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Paraplegia, Other Reduced Mobility, and Other Chronic Pain. Review of Resident #R1's admission MDS with an ARD of 04/15/2025…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure alleged violations involving verbal abuse were reported to the state agency within 2 hours after the allegations were made for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for abuse. Findings: Review of the facility's undated policy, Abuse Reporting and Investigation Policy and Procedure revealed, in part, the following: Policy: 1. All reports of resident abuse shall be promptly reported to the local, state, and federal agencies as defined by current regulations. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis, which included Cerebral Vascular Accident with Hemiplegia and Hemiparesis and Contracture of Muscle. Review of Resident #2's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/08/2024, indicated the resident had a BIMS of 12, which indicated the resident was moderately cognitively impaired. Review of the facility's Grievance Report dated 01/08/2025…

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 each resident was provided a safe, clean, and comfortable interior by failing to ensure necessary housekeeping and maintenance services were maintained for 2 (Room A and Room C) of 6 rooms reviewed for environment. Findings: Review of the facility's policy Titled, Safety and Supervision of Residents effective February 2020 revealed the following, in part: Purpose and/or Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment . Definitions and Interpretation: 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment Room A On 08/12/2024 at 10:34 a.m., an observation was made of Room A. The window unit cover was lying on the floor with the filter exposed. On 08/14/2024 at 9:04 a.m., and observation was made of Room A. The window unit cover was missing with the filter exposed. 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 interviews and record reviews, the facility failed to transmit MDS assessments in the required timeframe for 8 of 8 (#11, #12, #22, #24, #34, #45, #53, #110) residents reviewed for resident assessment. Findings: Resident #11 Review of Resident #11's Clinical Record revealed an admission date of 09/13/2023. On 08/13/2024 at 9:40 a.m., review of Resident #11's most recent Annual MDS revealed the assessment was opened on 07/09/2024 with a current status of In Progress. Resident #12 Review of Resident #12's Clinical Record revealed an admission date of 10/01/2021. On 08/13/2024 at 9:43 a.m., review of Resident #12's most recent Annual MDS revealed the assessment was opened on 07/09/2024 with a current status of In Progress. Resident #22 Review of Resident #22's Clinical Record revealed an admission date of 11/01/2021. On 08/13/2024 at 9:46 a.m., review of Resident #22's most recent Quarterly MDS revealed the assessment was opened on 07/09/2024 with a current status of In Progress. Resident #24 Review of Resident #24's Clinical Record revealed an admission date of 09/30/2009. 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 interviews and record reviews, the facility failed to ensure resident's MDS assessments accurately reflected the resident's Pre-admission Screening and Resident Review (PASARR) status for 2 (#22 and #108) of 8 (#13, #22, #24, #55, #61, #99, #108, and #111) residents reviewed for PASARR. Findings: Resident #22 Review of Resident #22's Clinical Record revealed an admission date of 11/01/2021 and diagnoses, which included Schizoaffective Disorder - Bipolar Type, Psychotic Disorder with Hallucinations, and Mild Intellectual Disabilities. Review of Resident #22's BHSF Form 142 revealed she was approved for admission by Level II PASARR effective 06/08/2023. Review of Resident #22's Annual MDS with an ARD of 10/31/2023 revealed question A1500, Resident evaluated for PASARR, was answered as no. An interview was conducted with S4MDSN on 08/13/2024 at 1:14 p.m. S4MDSN reviewed Resident #22's yearly MDS with an ARD of 10/31/2023, and confirmed it was coded Resident #22 did not have a Level II PASARR. She confirmed Resident #22 had a Level II PASARR at the time of the assessment, and…

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

Based on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASARR) Level II by failing to incorporate PASARR Level II determinations and recommendations into each resident's assessment and care plan for 4 (#13, #22, #24, and #108) of 8 (#13, #22, #24, #55, #61, #99, #108, #111) residents reviewed for PASARR. Findings: Review of the facility's policy, PASARR Policy and Procedure, approved 11/29/2022, revealed the following, in part: Policy: This facility shall coordinate assessments with the PASARR program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. Purpose: PASARR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that: 1. All applicants to Medicaid certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 3. Receive the services they need in those settings.…

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 each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#61) of 33 residents reviewed in the initial pool for dignity. The facility failed to ensure staff treated Resident #61 with respect and dignity. Findings: Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnosis, which included Left Sided Hemiplegia following Cerebral Vascular Accident (CVA). Review of the most recent MDS (Minimum Data Set) for Resident #61 with an ARD (Assessment Reference Date) of 06/25/2024 revealed Resident #61 had a BIMS (Brief Interview for Mental Status) of 14, which indicated the resident was cognitively intact. Further review revealed Resident #61 required substantial assistance for ADLs. Review of the most current Care Plan for Resident #61 revealed the following: Problem: I…

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 residents call lights were within reach for 2 of 2 (#1 and #16) residents reviewed for accommodation of needs. Findings: Review of the facility's undated policy titled, Use of Call Light, revealed, in part, the following: Procedure: 10. When providing care to residents be sure to position the call light conveniently for the resident to use. 11. Tell the resident where the call light is and show him/her how to use the call light. Resident #1 Review of Resident #1's Clinical Record revealed an admission date of 03/08/2011. Review of Resident #1's most recent MDS, with an ARD of 06/25/2024, revealed a BIMS of 3, which indicated resident was severely cognitively impaired. Further review revealed Resident #1 was highly visually impaired and required moderate to maximum physical assist for transfers, repositioning and ADLs. Review of Resident #1's current Care Plan revealed, in part, the following: Focus: Resident has impaired Visual…

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 promote and facilitate residents' self-determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (#61) of 33 residents in the initial pool. The facility failed to ensure Resident #61 had a choice of when to go to bed. Findings: Review of the facility's policy titled Resident Rights and Quality of Life Policy and Procedure, with no review date, revealed the following, in part; Policy: All residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. A resident has the right: 22. To be treated with .individuality . Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with diagnosis, which included Left Sided Hemiplegia following Cerebral Vascular Accident (CVA). Review of the most recent MDS (Minimum Data Set) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 1 (#61) of 2 (#61 and #99) residents reviewed for ADL's. The facility failed to trim and clean fingernails for Resident #61. Findings: Review of the facility's policy, Nail Care Policy and Procedure, with no review date, revealed the following, in part: Policy: To promote cleanliness Procedure: 1. Care of fingernails and toenails is part of the bath 2. Be certain nails are clean 4. Nails are to be clipped and filed smoothly Review of the Medical Record for Resident #64 revealed the resident was admitted to the facility on [DATE] with a diagnosis, which included Left Sided Hemiplegia following Cerebral Vascular Accident. Review of the most recent MDS (Minimum Data Set) for Resident #61 with an ARD (Assessment Reference Date) of 06/25/2024 revealed Resident #61 had a BIMS (Brief Interview for Mental Status)…

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 ensure a resident's environment remained as free of accident hazards as possible by failing to ensure a padded wall was properly secured for 1 (#26) of 3 (#26, #40, #109) residents reviewed for accidents. Findings: Review of Resident #26's Clinical Record revealed an admission date of 09/01/2021 and diagnoses, which included Unspecified Dementia, Dysphagia Following Cerebrovascular Disease, Aphasia Following Cerebrovascular Disease, Alzheimer's Disease, Functional Quadriplegia, Contracture of Muscle - Multiple Sites, Impulsiveness, Tremor, Unspecified Convulsions, Anoxic Brain Damage, and Epilepsy. Review of Resident #26's Quarterly MDS with an ARD of 04/16/2024 revealed he had a BIMS of 03, which indicated severe cognitive impairment. Review of Resident #26's current Care Plan revealed the following, in part: Problem: High Risk for falls and injury related to history of Cerebrovascular Accident, Transient. Ischemic Attack, Anoxic Brain Injury, and Epilepsy diagnoses. Interventions: Padding added to wall by…

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

Based on observations and interviews, the facility failed to ensure nurse staffing data, including resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted on a daily basis in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 118 residents residing in the facility. Findings: On 06/18/2024 at 8:00 a.m., an observation revealed there was no nurse staffing data posted. On 06/20/2024 at 8:10 a.m., an observation revealed there was no nurse staffing data posted. On 06/22/2024 at 10:15 a.m., an observation revealed the nurse staffing data posted was dated 06/21/2024. On 06/23/2024 at 8:45 a.m., an observation revealed the nurse staffing data posted was dated 06/21/2024. On 06/24/2024 at 10:30 a.m., an interview was conducted with S2DON. S2DON confirmed the daily nurse staffing sheet should be updated and posted daily. On 06/24/2024 at 10:41 a.m. an interview was conducted with S1ADM. S1ADM confirmed the staffing data should have been updated and posted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure a plan of care was developed and implemented for 5 (#3, #R1 #R2, #R3, and #R4) of 8 (#1, #2, #3, #R1 #R2, #R3, #R4, and #R5) residents who had intravenous fluids ordered for hydration purposes. Findings: Resident #3 Review of Resident #3's Clinical Record revealed Resident #3 was admitted to the facility on [DATE] with the following diagnoses, in part: Unspecified Dementia, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Metabolic Encephalopathy, and Sepsis. Review of Resident #3's Physician's Orders revealed an order dated 05/30/2024 for Normal Saline 500 cc IV one time only for 1 day for Dehydration. Review of Resident #3's Comprehensive Plan of Care failed to reveal a problem or approach related to Resident #3's diagnosis of Dehydration. Resident #R1 Review of Resident Clinical Record revealed Resident #R1 was admitted to the facility on [DATE] with the following diagnoses, in part: Type 2 Diabetes Mellitus with Diabetic…

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 completed care was documented correctly in resident's records for 3 (#3, #R1, and #R2) of 8 (#1, #2, #3, #R1, #R2, #R3, #R4, and #R5) sampled residents. Findings: Resident #3 Review of Resident #3's Medical Record revealed, in part, Resident #3 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia, Schizophrenia, Benign Prostatic Hyperplasia, Metabolic Encephalopathy, Sepsis, and Acute Embolism and Thrombosis of Left peroneal vein. Review of Resident #3's MDS with an ARD of 05/07/2024 revealed, in part, Resident #3 was dependent with toileting hygiene. Review of Resident #3's Late Loss ADL document dated 04/30/2024 through 05/31/2024 revealed, in part, only one shift documented toileting on 04/30/2024, 05/03/2024, 05/04/2024, 05/05/2024, 05/08/2024, 05/11/2024, 05/15/2024, 05/16/2024, 05/17/2024, 05/18/2024, 05/21/2024, 05/23/2024, 05/24/2024, 05/26/2024, 05/27/2024, and 05/29/2024. Resident #R1 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 interviews and record review, the facility failed to ensure a resident's physician and responsible party were notified after a fall for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for falls. Findings: Review of the facility's Policy titled, Incident and Accident Policy and Procedure revealed the following, in part: Policy: Incident and accidents are to be reported, investigated and followed up in a timely manner. b. Notify family/ responsible party c. Notify MD Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia Without Behavioral Disturbance. Review of Resident #1's nurse's notes dated November 2023 revealed the following, in part: 11/12/2023 at 4:25 p.m. by S3RN: Resident #1 noted on the floor beside bed. Review of Incident Report dated 11/12/2023 at 4:25 p.m., and filed by S3RN revealed neither the physician or representative were notified of fall. Review of Resident #1's NP progress note dated 11/13/2023…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an allegation of sexual abuse was reported to the administrator, and to the State Agency, within two hours for 1 (#3) of 5 (#1, #2, #3, #4, and #5) residents investigated for sexual abuse. Findings: Review of the facility's policy titled, Abuse Reporting and Investigation Policy and Procedure revealed the following, in part: Policy: 1. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Role of the Administrator 1. If an incident or suspected incident of resident abuse, mistreatment, neglect , or injury of unknown source is reported the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the person in charge 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 observation, interviews, and record review, the facility failed to ensure each resident was treated with dignity and respect and in an environment which promoted maintenance and enhancement of his/her quality of life for 1(#32) of 32 residents reviewed in the initial pool. The facility failed to ensure Resident #32 was not left lying in bed unclothed with no bed linen on his mattress and the door and privacy curtain opened for others to see him when passing by his room. Findings: Review of the facility's policy titled Quality of Life-Dignity Policy and Procedure revealed: Purpose: To ensure each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Procedure: 1. Residents shall be always treated with dignity and respect. Review of the clinical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included, Unspecified Dementia without Behavioral Disturbance, Unspecified Alzheimer's Disease, Functional…

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: 1. CNA staff notified the nurse of a resident's change in condition for 1 (#114) of 26 residents investigated; and 2. Nursing staff notified the practitioner of a significant decline in 1 (#114) of 26 residents investigated. Findings: Review of the facility's policy titled, Change of Condition Policy and Procedure revealed the following, in part: Purpose: To ensure that person's involved in the residents care are made of aware of any changes to the resident. Policy: Physician's . shall be notified as soon as possible of any changes in the resident's condition. Procedure: 1. The Charge Nurse shall be responsible for notifying the attending physician when a change occurs in the resident's condition. 2. These changes shall include significant changes in physical, mental, or psychosocial status . Review of the Clinical Record for Resident #114 revealed he was admitted to the facility on [DATE]. The resident had diagnoses that included Unspecified…

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 maintain a safe, functional, and sanitary environment for 13 (#8, #15, #17, #28, #32, #34, #35, #62, #66, #75, #82, #104, and #516) of 32 residents included in the initial pool, as evidenced by: 1. a loose toilet and missing baseboard behind the toilet in the bathroom adjoining Rooms b and d for Residents #35 and #82; and 2. a stained mattress and stained wall in Room l for Resident #32; and 3. a loose sink, a loose baseboard, a cracked sink faucet, a cracked non-functioning hot water knob, 1 non-functioning light bulb, and no paper towels in the bathroom adjoining Rooms m and o for Residents #15, #62, #66, and #75; and 4. a soiled privacy curtain in Room k for Resident #516; and 5. a soiled privacy curtain in Room l for Resident #32; and 6. a soiled privacy curtain in Room n for Resident #8, and 7. a missing paper towel dispenser, a missing soap dispenser, a missing mirror, a missing handrail/grab bar, and a missing light fixture cover…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to develop comprehensive care plan and furnish services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to implement physicians orders for 1(#56) of 3 (#51, #56, and #95) residents reviewed for contractures/range of motion. Findings: A review of the facility's policy titled Policy: Care Planning and Procedure revealed, in part: Purpose: To provide a comprehensive plan of care addressing resident's needs. Policy: Each resident's care plan will remain current. A review of Resident #56's Medical Records revealed, in part: Resident was admitted to the facility on [DATE], with diagnosis of Right Hand Contracture, Right Knee Contracture, and Left Knee Contracture. A review of Resident #56's Quarterly MDS, with an ARD of 03/27/2023 revealed a BIMS score of 9 which indicated he was mildly cognitively impaired. A review of Resident #56's current Care Plan revealed there was 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 observations, interviews and record review, the facility failed to ensure 3 (#20, #27, and #35) of 3 (#20, #27, and #35) residents reviewed for activities of daily living received the necessary services to maintain personal hygiene for nail care. Findings: Review of the Nail Care Policy and Procedure policy revealed: Policy: 1. To prevent infection 5. To promote cleanliness Procedure: 2. Be certain nails are clean Resident #20 Review of the clinical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included, Paranoid Schizophrenia, Parkinson's disease, Major Depressive Disorder, and Pain. Review of the quarterly MDS with an ARD of 03/07/2023 revealed Resident #20 had a BIMS of 3, which indicated the resident was severely cognitively impaired. Further review revealed Resident #20 required supervision and set up only help with personal hygiene. Review of Resident #20's current care plan revealed the resident had an ADL self care performance deficit related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure 1 (#51) of 3 (#51, #56, and #95) residents reviewed for range of motion received services and assistance to maintain or improve mobility. Findings: Review of the facility's Range of Motion Exercises Policy and Procedure revealed the following, in part: Purpose: To move the resident's joints through as full a range of motion as possible. To improve or maintain joint mobility and muscles strength. To prevent pain. To prevent complications of immobility. Resident #51 was admitted to the facility on [DATE] with diagnosis which included, Cerebral Infarction, Hemiplegia and Hemiparesis Affecting Left Non-Dominant Side. Review of the Quarterly MDS with an ARD of 05/16/2023 revealed Resident #51 had a BIMS of 5, which indicated the resident was severely cognitively impaired. Further review revealed, in part, the resident had limited range of motion in the upper extremity on one side. Review of Resident #51's active physician's orders…

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 ensure the resident environment remained as free of accident hazards as possible for 11 (#22, #24, #35, #40, #41, #52, #60, #73, #82, #89, #102) of 27 ( #8, #15, #17, #21, #22, #24, #28, #32, #34, #35, #37, #40, #41, #44, #52, #59, #60, #66, #73, #75, #82, #89, #102, #104, #107, #113, #516 ) residents reviewed for accident hazards as evidenced by failing to ensure the water temperature in resident sinks remained under 120 degrees Fahrenheit. Findings: Review of the facility policy titled, Water Temperature, Safety of Policy and Procedure revealed the following, in part: Policy: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Resident #22 Review of Resident #22's Face Sheet revealed an admission date of 10/01/2010. Review of Resident #22's Annual MDS with an ARD of 03/28/2023 revealed a BIMS of 8, which indicated moderate cognitive impairment. Resident #22 resided in Room f. Resident #24 Review of Resident #24's Face Sheet revealed an admission date of…

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

Based on observations, interview, and record review, the facility failed to store and prepare food under sanitary conditions by failing to ensure: 1. Food was properly stored in the walk-in cooler and walk-in freezer; 2. Food was properly stored in the dry food storage room; 3. A ceiling vent was clean and free from debris; 4. Two wall vents were clean and free from debris; 5. Exposed pipes were clean and free from debris; and 6. A hanging pot rack was clean and free from debris. Findings: Review of the facility's policy titled, Food Safety and Sanitation Policy and Procedure revealed the following, in part: Procedure: Food Storage 5. Foods are protected from contamination (dust). 9. All time and temperature control for safety (TCS) leftovers are labeled, covered, and dated when stored. a. They are used within 72 hours (or discarded). Review of the facility's policy titled, Cleaning and Sanitation of Dining and Food Service Areas Policy and Procedure revealed the following, in part: Policy: The food service staff will maintain the cleanliness and sanitation of the dining and food…

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 an allegation of physical abuse was reported to the administrator, and to the State Agency within two hours for 1 (#113) of 32 residents reviewed for abuse in the initial pool process. Findings: Review of the facility's policy titled Abuse Prevention and Prohibition revealed in part: III. Abuse Prohibition Practice 7. Reporting/Response The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or director of nurses. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury. Review of Resident #113's Medical Records revealed Resident #113 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.