Panola County Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities and to ensure the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in response to the pharmacist report for 1 of 5 residents (Resident #35) reviewed for (MRR) Medication Regimen Review. The facility failed to ensure Resident #35's Medication Regimen Review dated 4/30/25, had a specific duration for the extended duration beyond 14 days of PRN Ativan (Lorazepam). This failure could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy. Findings included: Record review of Resident #35's face sheet dated 8/12/25 indicated Resident #35 was an [AGE] year-old male admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #8) of 16 residents reviewed for infection control. The facility failed to ensure LVN C did not place Resident #8 feeding tubing, in his bed during g-tube medication administration on 8/12/25. This failure could place a resident at risk for an infection. Findings included:Record review of Resident #8's face sheet dated 8/12/25 indicated Resident #8 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 had diagnoses including cerebral palsy (is a group of conditions that affect movement and posture), paraplegia (is paralysis that affects your legs, but not your arms), abnormal posture, contractures (is a type of scarring in your soft tissues that causes them to tighten and stiffen),…

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, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 17 residents reviewed for environment. (Residents #9, #35, #36, #16, and #7) The facility failed to ensure Resident #35 and Resident #36 had a clean room free from dust and dead roaches. The facility failed to repair Resident #9 ceiling tiles in room with water spots, due to water damage. The facility failed to ensure Resident #16's room was free of roaches. The facility failed to ensure Resident #7's room was free of water bugs. The facility failed to repair the ceiling in hall by the dining area. The facility had a trash can catching rainwater. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of Resident #35's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 17 residents reviewed for care plans. (Resident #28, Resident #47, Resident #50) 1. The facility failed to provide Resident #28 with scheduled smoke breaks. Resident #28's care plan indicated he wished to smoke. 2. The facility failed to develop a care plan for Resident #47's ADL dependence, dietary needs, vision impairment, bowel/bladder status, and diagnoses of anemia (is when you have low levels of healthy red blood cells to carry oxygen throughout your body), constipation, insomnia, and gastroesophageal reflux disease (is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus). 3. The facility failed to ensure Resident #50's contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues 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.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit reviewed for activities. The facility failed to provide meaningful activities for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) residents on the memory care unit. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: During an observation on 06/03/24 at 9:32 a.m., the AD had a large television playing music in the dining area of the memory care unit. Approximately 8 residents were in the dining area. During an observation on 06/03/24 at 10:21 a.m.-12:00 p.m., the dining and sitting area nor hallways had any memory care/dementia focused activities. Television on in dining area but residents did not show interest. During…

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, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 3 of 16 residents (Resident #30, Resident #31, Resident #50) and 3 of 5 staff (CNA A, CNA H, DON) reviewed for transfer and supervision. The facility failed to ensure CNA A did not leave the secure unit unsupervised on 06/04/24 which resulted in Resident #30 ambulating without her wheelchair and with no supervision. The facility failed to ensure CNA H performed a safe 1 person transfer which resulted in Resident #31 obtaining a skin tear to his forearm on 05/28/24. The facility failed to ensure CNA H did not transfer Resident #50 without another staff assistance on 04/07/24. During one person transfer, Resident #50 obtained a skin tear during transfer. The facility failed to ensure the DON did not provide incontinent care without another staff assistance on 05/08/24. The DON left Resident #50…

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 have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 3 (Resident #50,#32, and #31) of 16 residents residing on the secured unit. The facility failed to have sufficient staff available to provide resident care and supervision to prevent falls with injury on the secured unit for 3 of 3 months reviewed for staffing (March 2024-May2024). This failure could put residents at risk of not receiving necessary care and supervision to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: 1. Record review of an undated face sheet revealed Resident #50 was a [AGE] year-old female admitted [DATE]…

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, interview, and record review, the facility failed to establish 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 for 4 of 14 residents (#35, #36, #3 and #6) reviewed for infection control practices. 1.The Facility failed to ensure Resident #35 and #36 had wash basins stored properly with names and in bags. 2. The facility failed to ensure wipes with feces were properly discarded and were left on Resident #3 and #6's bedroom floor. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #35's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis included: unspecified dementia (dementia without a specific diagnosis), restlessness and agitation (agitation is 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.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols for 6 of 6 months (January 2024 through June 2024) reviewed for Infection Control Tracking and Trending. -The facility did not implement the antibiotic orders protocol in their Antibiotic Stewardship policy. -The facility had missing information on the Tracking and Trending Logs as to the outcome of the antibiotic use (if the infections were resolved or not). -The facility did not implement the 72-hour Antibiotic Time Out protocol in their Antibiotic Stewardship program. These failures could place residents with infections at risk for unnecessary antibiotic use and increased infections that are resistant to antibiotics. Findings included: Record review of the Antibiotic Stewardship Policy revised 02/2022 indicated Goals: Prescribers will document a dose, duration, and indication for all antibiotic usage. Policy: Antibiotic Stewardship Program (ASP) Core Elements: 5. Tracking: The Facility monitors at least one process measure of antibiotic…

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, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 2 of 17 residents reviewed for dignity. (Resident #31, Resident #49) The facility to ensure CNA H did not push Resident #31 backwards in his wheelchair from his room to the dining room. The facility failed to ensure LVN D did not stand up while assisting Resident #49 with his lunch meal. These failures placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of a face sheet printed 06/03/24 indicated Resident #31 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including metabolic encephalopathy (as an alteration in consciousness caused due to brain dysfunction (due to impaired cerebral metabolism)) and Parkinson's disease (is a progressive disorder that affects the nervous…

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, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 16 residents reviewed for restraint use (Resident #30). The facility failed to ensure Resident #30 was free from physical restraints in the form of CNA A locking her wheelchair which did not allow her to move freely around the secured unit. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. Findings included: Record review of a face sheet printed on 06/05/24 indicated Resident #30 was a [AGE] year-old, female and was admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (is a general term for loss of memory, language, problem-solving and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for 2 of 7 residents reviewed for new admissions. (Resident #110 and Resident #111) The facility failed to develop a baseline care plan within 48 hours of admission for Residents #110 and #111. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of an undated face sheet revealed Resident #110 was an [AGE] year-old male admitted [DATE] with the diagnoses of cellulitis to lower extremities (skin infection to legs), diabetes mellitus (disease that affects blood sugar levels), and hypertension (high blood pressure). Record review of an incomplete admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 17 residents (Residents #50), reviewed for care plans. The facility failed to revise and update Resident #50's comprehensive care plan to reflect change in diet order from regular to pureed. The facility failed to revise and update Resident #50's comprehensive care plan to reflect swallowing disorder of coughing or choking during meals or when swallowing medications. The facility failed to ensure Resident #50's care plan for ADL dependence was updated to reflect a change from substantial-maximal assist to dependent assist with transfer per the MDS. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings included: Record review of a face sheet printed 06/03/24 indicated Resident #50 was [AGE] year-old, male and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care. (Resident #39) The facility failed to ensure Resident #39's nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. The facility failed to ensure Resident #39's nebulizer mask was labeled and dated. These failures could place residents at risk of respiratory infections. Findings included: Record review of a face sheet printed 06/05/24 indicated Resident #39 was a [AGE] year-old, male and admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and emphysema (is a lung disease that results from damage to the walls of the alveoli in your lungs). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #39 was usually understood and usually…

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 failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for 3 of 3 days reviewed, in a place readily accessible to residents and visitors, in that: The facility failed to update and post the daily nurse staffing information (current date, resident census, and numbers of staff actual hours worked) on 06/03/2024,06/04/2024, and 06/05/2024. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and facility census. The findings included: An observation on 06/03/2024 at 9:30 a.m. revealed the daily staffing pattern (number of nurses and CNAs working with each resident each shift) posted was from 05/30/2024. An observation on 06/04/2024 at 10:45 a.m. revealed the daily nurse staffing pattern posted was from 06/03/2024. An observation on 06/05/2024 at 2:00 p.m. revealed the daily 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 1 (Resident # 47) of 5 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #47 had an appropriate diagnosis for his prescribed Seroquel (Quetiapine; is an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration)) 2.The facility failed to ensure Resident #47 had behavior monitoring (monitor activities and mood) for his prescribed Seroquel. 3.The facility failed to ensure Resident #47 had side effects monitoring (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 (Resident #19) of 3 residents reviewed for special eating equipment and assistance when consuming meals, in that: The failed to assess and provide Resident #19 with an assistive device to helps prevent food from accidently being pushed off the plate while eating during meal service to minimize food spillage. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. The findings included: Record review of a face sheet dated 06/03/24 indicated Resident #19 was an [AGE] year-old, male and admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to 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 observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #26). The facility failed to ensure the refrigerator for Resident #26 did not contain a decomposing banana, watermelon, and expired meat. This failure could place resident at risk for food borne illnesses. Findings included: Record review of a face sheet dated 12/3/2023 indicated Resident #26 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors), Hypomagnesemia (happens when you have a lower-than-normal level of magnesium in your blood), Dysphagia (a medical term for difficulty swallowing). Record review of a quarterly MDS dated [DATE] indicated Resident #26 usually understood others and usually made himself understood. The MDS indicated Resident #26…

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 residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 4 of 14 residents (Resident #29, Resident #28, Resident #33, and Resident #4) reviewed for a homelike environment. 1. The facility failed to ensure water damaged ceiling tiles above Resident #29's bed were replaced. 2. The facility failed to keep Resident #28 and Resident #33's Geri chairs (are large, padded chairs with wheeled bases, and are designed to assist seniors with limited mobility) clean. 3. The facility failed to keep Resident #4's feeding pump and pole clean. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: 1. Record review of an undated face sheet revealed Resident #29 was a [AGE] year-old female admitted on [DATE] with diagnoses including schizoaffective…

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 accurate MDS assessment was completed for 4 of 14 residents reviewed for MDS accuracy. (Resident #13, Resident #16, Resident #7, and Resident #204) 1. The facility failed to accurately document Resident #13's and Resident #16's antidepressant usage. 2. The facility failed to accurately document Resident # 7's PASRR status. 3. The facility failed to accurately document Resident #204's fall history on the MDS. These failures could place residents at risk for not receiving needed care and services. Findings included: 1. Record review of an undated face sheet revealed Resident #13 was a 76- year-old-female, admitted on [DATE] with the diagnoses of anemia (a condition in which the body does not have enough healthy red blood cells), depression (a group of conditions associated with the elevation or lowering of a person's mood), and COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). Record review of a MDS dated [DATE] for Resident #13…

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, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 6 residents (Resident #4, Resident #19, Resident #33, Resident #42) reviewed for comprehensive person-centered care plans related to limited range of motion or contractures. The facility failed to care plan Resident #19's and Resident #33's limited range of motion. The facility failed to develop interventions for Resident #4 to address contractures and limited range of motion. The facility failed to implement an intervention to document meal consumption for Resident #19 and Resident #42. These failures could place residents at risk of not having their individualized needs met and a decline in their quality of care and life. Findings included:…

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, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 6 residents (Resident #4, Resident #19, Resident #33) reviewed for range of motion and mobility, in that: Resident #4 who had functional limitation in range of motion (interfered with daily functions or placed residents at risk for injury) to unilateral upper extremity and bilateral lower extremities was not provided treatment and services to prevent further decrease in range of motion. Resident #19 who had functional limitation in range of motion to bilateral upper extremities was not provided treatment and services to prevent further decrease in range of motion. Resident #33 who had functional limitation in range of motion to unilateral upper extremity and bilateral was not provided treatment and services to prevent further decrease in range of motion. These…

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, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for residents who are unable to carry out activities of daily living receives the for 2 of 16 residents reviewed for ADLs (Residents #10, Resident #33). The facility did not clean or trim Resident #10's fingernails. The facility failed to ensure Resident #33 did not have facial hair and received schedule shower/bed baths. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings included: 1. Review of Resident #10's electronic face sheet dated 04/29/2022 revealed he was admitted to the facility on [DATE] with diagnoses of paralytic syndrome (symmetric, ascending weakness), muscle wasting and atrophy (Muscle atrophy is the wasting or thinning of muscle mass), dysphagia…

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, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #204) reviewed for psychotropic medications. The facility failed to ensure Resident #204 had an appropriate diagnosis for usage of Olanzapine (antipsychotic). This failure could place residents at risk of being over-medicated or experience undesirable side effects. Findings included: Record review of a face sheet dated 04/18/23 revealed Resident #240 was [AGE] year-old female admitted on [DATE] with diagnoses including major depressive disorder (a mood disorder that interferes with daily life), anxiety (persistent and excessive worry that interferes with daily activities), hallucinations (a false perception of objects or events involving your senses: sight, sound, smell,…

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.