Reginald P White Nursing Facility

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from neglect when two (2) staff members completed a resident transfer with a mechanical lift without using the required four (4) staff members for resident safety, which resulted in the resident falling backward for one (1) of three (3) sampled residents. Resident #1. Findings include: A review of the facility's policy Suspicion of Abuse, Neglect, Exploitation, Injuries of Unknown Origin, And/or Misappropriation of Funds/Property To Individuals Receiving Services/Residents, revised January 2024, revealed, .It is the policy.to affirm that all Individuals Receiving Services (IRS)/Residents have a right to be free from.neglect.Definitions.Neglect: The failure to supply an IRS with food, shelter, clothing, or other services necessary to maintain physical and mental health. A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/31/23 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with…

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

Based on interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan interventions related to transferring a resident with a Hoyer (type of mechanical lift) for one (1) of three (3) residents reviewed for care plan implementation. (Resident #1)Findings include:A review of the facility's policy Interdisciplinary Care Plan Team, dated August 2024, revealed, .The purpose of the team is to define and coordinate the treatment for each resident. A record review of the Face Sheet revealed the facility admitted Resident #1 on 7/31/23 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/25/25 revealed Resident#1 had a Brief Interview for Mental Status (BIMS) summary score of 09, which indicated her cognition was moderately impaired. A record review of the Physician Order Report revealed Resident #1 had an order, dated 7/3/25 for Transfer using Hoyer lift with 4 (four) person asst (assistance) to include nurse and 3 CNA's.A record review of the…

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

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain infection control practices during an annual recertification survey on 1/11/2024 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of three (3) deficiencies cited. (F880) Findings Include: A review of the facility's Quality Assurance document (undated) revealed, .The Outcome Services Division will .Periodically assess information based on established indicators, taking action to solve problems and pursue opportunities to improve quality . Record review of the Provider History Profile revealed the facility received a citation for F880-Infection Prevention & Control for the survey date of 1/11/2024. Record review of the CMS-2567 (a record that identifies 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 observation, interview, record review, and facility policy review, the facility failed to ensure staff followed appropriate infection prevention and control practices for two (2) of 18 sampled residents, Resident #13 and Resident #45. Specifically, the facility failed to ensure Registered Nurse (RN) #2 performed hand hygiene and donned appropriate personal protective equipment (PPE) while administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube for Resident #13 who required enhanced barrier precautions (EBP) and failed to ensure Licensed Practical Nurse (LPN) # 1 followed EBP and glove-changing protocols during wound care for Resident #45. The scope/severity for F880 was increased to E due to previous citation on the annual recertification survey on 1/11/24. Findings included: A review of the facility's Enhanced Barrier Precautions Protocol (undated), revealed, 1. Enhanced Barrier Precautions (EBP) are required for certain resident categories .3. For residents for whom EBP is indicated, EBP is employed when performing the following high-contact…

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, staff interview, record review, and policy review, the facility failed to ensure nursing services were provided in accordance with professional standards of practice by not verifying Percutaneous Endoscopic Gastrostomy (PEG) placement prior to administering medications for one (1) of four (4) residents observed for medication administration. Resident #13. Findings included: A review of the facility's policy titled Tube Enteral Nutrition, revised 10/24, revealed, The purpose of this protocol is to establish general guidelines for the use of tube enteral feedings for residents/Individuals Receiving Services (IRS) with a functioning Gastrointestinal Tract . On 5/29/25 at 9:23 AM, during an observation of medication administration via PEG tube, Registered Nurse (RN) #2 administered MiraLAX, potassium chloride, and ibuprofen to Resident #13 without verifying PEG tube placement prior to administration. On 5/29/25 at 10:40 AM, during an interview, RN #2 confirmed she had not verified PEG tube placement before administering medications. RN #2 acknowledged that…

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, staff interview, record review, and facility policy review, the facility failed to record daily temperatures for refrigerators and a freezer for the last six (6) days prior to survey entrance on 01/08/24 and failed to date and label stored food in the facility refrigerator for one (1) of two (2) kitchen observations. The deficient practice had the potential to affect 50 of 59 residents in the facility. Findings include: A review of the facility's policy, Food and Nutrition Services, dated January 2023, revealed, .The purpose of this policy is to provide guidelines for the creation and maintenance of an environment that is physically and bacteriologically safe for the storage, preparation, serving, and disposal of food .Procedure . (1) Food is stored in the original packaging and is properly labeled .B. Food Handling and Storage (1) Food will be held at the appropriate temperature to maintain quality and prevent the growth of harmful bacteria. (a) Immediately upon receipt, cold foods will be…

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, record review, and facility policy review, the facility failed to ensure a resident had a dignified dining experience for (1) one of seven (7) resident dining observations. (Resident #160) Findings include: Review of the facility's policy, Rights and Responsibilities of Residents, revised October 2023, revealed, .It is the policy of (Proper Name) to protect and support the fundamental human, civil, and constitutional rights of each resident .Procedure . (10) Treated with respect and full recognition of their dignity and individuality . During an interview and observation on 1/8/24 at 12:05 PM, Resident #160 was in her room and had not received her meal tray. She stated that her roommate had received her meal tray and had already finished eating lunch. Resident #160 said that for the last week, her tray has been served about an hour later than her roommate, and she was unsure as to why this has occurred. She expressed that she did not believe it was right that she had to watch…

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, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by staff failing to correctly wear a face mask on one (1) of four (4) days of survey and failed to perform hand hygiene during wound care for one (1) of five (5) wounds observed. (Resident # 57) Findings include: A review of the facility's policy Pandemic Influenza/Coronavirus Disease 2019- Infection Control Practices, revised September 2023, revealed .It is the policy of (Proper Name) to control and prevent pandemic influenza/coronavirus disease 2019 (COVID-19) in Individuals Receiving Services (IRS)/residents, employees, and visitors by providing guidelines for infection control practices.Procedure: A.) The primary strategies for preventing COVID-19 are: (2) Use of infection control measures to prevent transmission . An interview with the Director of Nursing (DON) upon entrance to the facility on 1/08/24 at 11:05 AM, she revealed the facility was in an active COVID-19 outbreak with one positive resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to ensure residents had readily available and reasonable access to their personal funds, seven (7) days a week, for four (4) of 15 residents sampled. Resident #8, Resident #10, Resident #34, and Resident #45 Findings Included: A review of the facility's Money Policy for Individuals Receiving Services/Residents, revised March 2020, revealed, . F. Money Call is the time established by the Division Director or Fiscal Services Director, during which, an IRS (Individual Receiving Service)/resident is distributed money from his/her RFMS (Resident Fund Management Service) account, held by their designated money custodian .G. Money day is one of the scheduled days when Patient Accounts issues cash and checks from the (Proper Name of Facility) Resident Trustee Account to the money custodians . Resident #8 On 10/17/22 at 12:53 PM, during an interview with Resident #8, he stated that they can only get their personal money on Tuesdays…

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, record review, and facility policy review, the facility failed to accurately code the admission Minimum Data Set (MDS) related to a resident's reentry into the facility from an acute care hospital for one (1) of 17 residents reviewed for MDS accuracy. Resident #46. Findings Included: A review of the facility's Minimum Data Set (MDS) policy, revised August 2022, revealed, .2. Purpose: The purpose of this policy is to .establish the framework for organizing an individual plan of care . A record review of the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, revealed, .A1800: Entered From .Item Rational .Understanding the setting that the individual was in immediately prior to facility .reentry informs care planning and may also inform discharge planning and discussions . A record review of the Face Sheet revealed the facility admitted Resident #46 on 9/29/21 with diagnoses including Type 2 Diabetes Mellitus and Unspecified Convulsions. A record review of the facility's document, Notice…

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.