Laughlin Health Care Center

Based on facility policy review, observations, and interviews, the facility failed to maintain sanitary kitchen equipment and failed to replace damaged kitchen equipment that had not been maintained in a good working condition, which had the potential to affect 27 of 27 residents. The findings include: Review of the facility's policy titled, Cleaning of Food and Nonfood Contact Surfaces, dated 1/2023, showed .The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil .Nonfood contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant .smooth and easily cleanable, and maintained in good condition. Nonfood contact surfaces of equipment, such as handles .gaskets .exterior .shall be cleaned .to keep the equipment free of accumulation of dust, dirt, food particles, and other debris . Observation of the kitchen with the Food Services Lead Aide (FSLA) on 10/2/2023 at 10:15 AM, showed the following: Convection ovens (top and bottom oven) had dark-brown, crusty debris on 4 of 4 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 facility policy review, observation, and interview, the facility failed to ensure staff performed proper hand hygiene while delivering meal trays and during meal assistance in dining room. The findings include: Review of the facility policy titled, Hand Hygiene, revised 12/3/2021, showed .To outline indications for hand hygiene and correct procedure for performing hand hygiene in order to assist in preventing healthcare associated infections .When to perform hand hygiene .Hands must be washed with soap and water or alcohol hand gel used .after having direct contact with patients or their surroundings .After contact with inanimate objects .in the vicinity of the patient . During an observation of dining on 10/2/2023 from 12:17 PM-12:23 PM, showed the Wound Care Nurse retrieved a meal tray from the meal cart, served the tray to Resident #4, walked into the dining room to a wooden cabinet, opened the drawer, and retrieved a packet of coffee creamer. Further observation showed the Wound Care Nurse walked back to the food cart, reached in, retrieved a coffee cup, poured a cup 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 review of the Resident Assessment Instrument Manual 3.0 (RAI), medical record review, and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 4 residents (Residents #5, #7, #15, and #17) of 12 residents reviewed for MDS assessments. The findings include: Review of the RAI Manual 3.0 dated 10/2019, showed .The MDS contains items that reflect the acuity level of the resident, including diagnoses, treatments, and an evaluation of the resident's functional status .The RAI process .require that .the assessment accurately reflects the resident's status .an accurate assessment requires collecting information from multiple sources .Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable . Resident #5 was admitted to the facility on [DATE] with diagnoses to include Dysphagia, Vascular Dementia, Hemiplegia 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 facility policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect during dining observation when 2 Certified Nursing Assistants (CNAs) assisted 4 residents (Residents #1, #7, #14, and #22) simultaneously (at the same time) of 7 residents observed for assistance with dining. The findings include: Review of the facility policy titled, Feeding The Resident, revised 5/2014, showed .Identify residents that need assist with eating or need encouragement .Feed residents who are unable to feed selves . Review of the facility policy titled, Resident Rights & [And] Responsibilities, revised 7/9/2021, showed .You [Resident] have the right to .be treated with dignity and respect . Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychotic Disturbance, Anxiety, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 was rarely/never understood and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's Resident Fund Statement, medical record review, and interview, the facility failed to ensure the trust fund accounts for 2 residents (Residents #14 and #24) of 7 residents with trust fund accounts reviewed did not exceed the $2000.00 Supplemental Security Income (SSI) resource limit. The findings include: Resident #14 was admitted to the facility on [DATE]. Review of the facility's Resident Fund Statement report dated 7/31/2023 - 9/30/2023 revealed Resident #14 had a current balance of $3,008.48. Resident #24 was admitted to the facility on [DATE]. Review of the facility's Resident Fund Statement report dated 7/31/2023 - 9/30/2023 revealed Resident #24 had a current balance of $6,220.60. During an interview on 10/05/23 at 11:34 AM, the Corporate Business Office Account Representative (CBOAR) confirmed the Resident Trust Funds are to be maintained with a balance of less than $2000.00 and Residents #14 and #24 exceeded the balance.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview the facility failed to follow the policy for restraints for 2 residents (Resident #7 and #17) of 5 residents reviewed for restraints. The findings include: The facility policy titled, Restraints, revised 8/5/2022, showed .Physical Restraint: is defined as any manual method, physical or mechanical device/equipment that .Cannot be removed easily by the resident .Restricts the resident's freedom or movement or normal access to his/her body .The assessment is documented and use of the device is added to the plan of care .Restraints are discontinued as early as possible based on an individualized resident assessment and re-evaluation. Consideration whether to implement a restraint should weigh the risks of using a restraint against the risks presented by the resident's behavior. Reduction of risks associated with restraint use will be accomplished through preventative strategies, innovative alternatives, process improvement, planning, education,…

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 facility policy review, record review, observation, and interviews, the facility failed to develop a comprehensive care plan to address restraint usage for 1 resident (Resident #7) out of 12 residents reviewed for comprehensive care plans. The findings include: Review of the facility's policy titled, Restraints, dated 5/5/2022, showed .defined as any manual method, physical or mechanical device .cannot be removed easily by the resident .restricts the resident's freedom of movement .use of the device is added to the plan of care . Review of the facility's policy titled, Care Plan/ Comprehensive Assessment, dated 11/4/2022, showed .Residents will have a comprehensive assessment that determines their functional status .comprehensive care plan will be developed that includes objectives, measurable goals and timetables to meet their medical, mental, and psychosocial needs that are identified in the comprehensive assessment . Resident #7 was admitted to the facility on [DATE] with diagnoses including Spastic…

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 medical record review, observation, and interview, the facility failed to provide services to prevent further decline in functional status for 1 resident (Resident #17) of 17 residents reviewed for Activities of Daily Living (ADL). The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Anxiety, and Muscle Weakness. Review of a quarterly Minimum Data (MDS) assessment dated [DATE], showed Resident #17 required extensive assistance of 1 person with bed mobility, locomotion, and personal hygiene; required extensive assistance of 2 persons with transfers, dressing, toileting, and bathing; and required supervision with eating. Resident #17 did not receive therapy services. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 was severely cognitively impaired for daily decision making, required total dependence of 2 persons with bed mobility, dressing, toileting, personal hygiene, and bathing; required extensive assistance of 2 persons…

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 medical record review and interview, the facility failed to provide an evaluation and rationale for the continued use of a PRN (as needed) antianxiety medication beyond 14 days for 1 resident (Resident #17) of 5 residents reviewed for unnecessary medications. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses including Anxiety and Muscle Weakness. Review of a pharmacy recommendation note dated 8/15/2023, showed .Phase 2 limits PRN psychotropic medications to 14 days, unless the prescriber believes it is appropriate to extend the order .must document the following required information .if the PRN psychotropic medication is continued .Why the medication is needed on a PRN basis .What is the benefit of the PRN medication .Duration of PRN continuation/ reevaluation of medication . Further review showed the Medical Director had disagreed with the recommendations with no rationale documented. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed…

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 medical record review and interview, the facility failed to ensure laboratory (lab) tests were obtained for 1 resident (Resident #20) of 5 residents reviewed for laboratory services. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Vitamin D Deficiency, and Hypothyroidism. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment and had an active diagnosis of Diabetes Mellitus. Review of the comprehensive care plan revised 10/4/2023, showed Resident #20 had problems of Hypothyroidism and Diabetes with interventions to monitor lab work as ordered. Review of a Physician's Order dated 9/8/2022, showed Resident #20 had lab orders for TSH (a lab test to measure thyroid function and medication levels), Hemoglobin (Hgb) A1C (a lab test to measure how well blood glucose levels had…

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 facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 2 of 3 dumpsters (dumpster #1 and #2) and in the grease trap receptacle. The findings include: Review of the facility's policy titled, Solid Waste Disposal, dated 1/2023, showed .Garbage containers are clean .covered at all times .Place trash and garbage directly into designated receptacles .Keep lids closed on all outside trash receptacles . During an observation on 10/2/2023 at 10:43 AM, with the Food Services Lead Aide (FSLA) showed the outside dumpster area had 3 dumpsters present. 2 dumpsters (dumpster #1 and #2) for waste disposal and 1 dumpster (dumpster #3) for cardboard disposal. The area around dumpsters #1 and #2 had plastic pieces, used disposable gloves, and trash debris on the ground surrounding the dumpster area. The grease trap was 1/3 full, had one glove with presence of brownish-black, greasy debris located on the top of the receptacle, and the grease trap lid was fully open to air and elements. During an interview on 10/2/2023…

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 facility policy review, medical record review and interview the facility failed to ensure pneumococcal vaccinations were administered to 2 residents (Resident #11 and #14) of 5 residents reviewed for vaccinations. The findings include: Review of the facility policy titled, Immunizations-Influenza and Pneumococcal, revised 11/4/22, showed .pneumococcal immunizations will be offered to all residents .unless medically contraindicated .provide immunization .Residents over the age of sixty-five .years or older are encouraged to receive the vaccine . Resident #11 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. Review of a Physician Services form undated, showed .I hereby grant permission for inoculation [immunize] with the pneumonia vaccine . Further review showed the form was signed by Resident #11's Power of Attorney (POA). Review of Resident #11's immunization record showed the pneumococcal vaccine had not been…

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 policy review, observation, and interview, the facility failed to ensure infection control practices were followed to prevent the potential spread of infection for 1 resident ( #11) of 4 residents observed during medication administration. The findings include: Review of the facility Oral Medication, undated, .place pills/capsules in the medication cup using aseptic (Asepsis is a condition in which no living disease-causing microorganisms are present. Asepsis covers all those procedures designed to reduce the risk of bacterial, fungal or viral contamination including the gloved 'no touch') technique . Observations on 1/7/20 at 9:08 AM, at the East Hall Medication Cart, revealed LPN #1 removed an Iron 325 mg (milligram) tablet from the medication cart for Resident #11, dropped the tablet onto the medication cart, picked up the tablet with her bare hands, placed the tablet into the resident's medication cup, entered the resident's room, and administered the medication to Resident #11. Interview with the Director of Nursing (DON) on 1/8/20 at 9:47 AM, in the DON's office,…

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 facility policy review, observation, and interview the facility failed to properly label and date foods available for resident consumption, and failed to ensure employee and resident foods were stored separately in 2 of 2 nourishment refrigerators. The findings include: Review of the facility policy, .PANTRY ORDERS ., dated April 2001, and revised March 2006, revealed .If no date, put date on the product .Nursing department is responsible for cleaning pantry refrigerators . Interview and observation of the East wing nourishment refrigerator with the Dietary Supervisor and Registered Nurse (RN) Unit Manager #1 on 12/19/18 at 9:47 AM, in the East wing nourishment room revealed, 1 - 8 ounce opened, undated, and unlabeled chocolate milk, and 2 frozen meals unlabeled. Further interview confirmed nourishment refrigerators are used for employee and resident use, and the above items were available for resident use. Interview and observation of the [NAME] wing nourishment refrigerator with the Dietary Supervisor and RN Unit Manager #2 on 12/19/18 at 9:57 AM, in the [NAME] wing…

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.