Heritage House at Paris Rehab & Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 2 residents (Resident #2) reviewed for activities. The facility failed to ensure Resident #2's Activities Evaluation was accurately completed on 09/09/2024. The facility failed to ensure Resident #2 was provided in-room activities in August 2024, September 2024, and October 2024. 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: Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part 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, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 81 residents residents (Residents #68, #79, #3, #11, #62, #48, #45, and #13) and 1 of 3 meals (lunch meal) reviewed for palatability, attractiveness, and appetizing. The dietary staff failed to provide food that was palatable and appetizing temperature for lunch meal observed on 11/5/24. Resident's #68, #79, #3, #11, #62, #48, #45, and #13 complained that food tasted bad, was not cooked properly and was served cold. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: Record Review of the menu indicated the lunch meal items on 11/5/24 included (A) fried chicken, mash potatoes, spinach, dinner roll and ice cream; (B) steak, egg noodles, green peas, dinner roll and ice cream. During an interview on 11/04/24 9:17 a.m., Resident #68 stated the food was bad every day. During an interview on 11/4/24 at 9:53a.m., Resident #79 stated the food 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.

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, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #2, Resident #53, and Resident #72) reviewed for infection control. 1. The facility failed to ensure LVN E and CNA F provided proper incontinent care to Resident #2. 2. The facility failed to ensure Resident #53's bagged, dirty briefs were taken out of her bathroom. 3. The facility failed to ensure CNA H provided proper catheter care to Resident #72, and the facility failed to ensure CNA H followed enhanced barrier precautions when she failed to wear gloves as she repositioned and touched Resident #72's sheets. These failures could place residents and staff at risk for cross-contamination and the spread of infection. Findings included: 1. Record review of a face sheet dated 11/06/2024 indicated…

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, record review, and interviews, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 23 residents (Resident #76) reviewed for accommodation of needs. The facility treatment nurse failed to ensure Resident #76's lunch meal was fully accessible for her to eat on 11/04/2024 at the lunch meal, when the Treatment Nurse served Resident #76 her lunch meal and did not remove it off the tray and kept her plate on the warmer and covered with a lid. This failure could have placed resident at risk of having nutritional needs gone unmet. Findings included: Record review of Resident #76's face sheet dated 11/06/2024 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses vascular dementia(disease in which it causes memory loss in older adults), glaucoma of left eye severe stage(eye condition that causes blindness), high blood pressure,…

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 prompt efforts were made to resolve grievances for 1 of 2 residents (Resident #40) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #40 was appropriately apprised of progress toward resolution when Resident #40's pink pants were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #40 was a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included sequelae of unspecified cerebrovascular disease (medical conditions that affect the blood vessels of the brain and circulation of blood to the brain). Record review of the MDS assessment indicated Resident #40 was understood by others and was able to understand others. The MDS assessment indicated Resident #40 had a BIMS score of 15, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 23 residents (Resident #63) reviewed for ADL (activities of daily living) care. The facility failed to provide nail care by removing black material from under fingernails for dependent female Resident #63 on 11/04/2024,11/05/2024, and 11/06/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of the face sheet, dated 11/06/2024, revealed Resident #63 was a [AGE] year old female with diagnoses which included malignant neoplasm of unspecified part of the right bronchus or lung (cancer that forms in tissues of the lungs, usually in the cell lining air passages), chronic respiratory failure with hypoxia (chronic respiratory failure with hypoxia), hemiplegia and hemiparesis following…

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 who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 1 of 2 residents (Resident #72) reviewed for urinary catheters. The facility failed to ensure CNA H provided proper catheter care to Resident #72 on 11/06/2024. This failure could place residents at risk of injury, urinary tract infections, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #72 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and urinary retention. Record review of a Comprehensive MDS assessment dated [DATE] indicated…

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 2 residents (Residents #2) reviewed for respiratory care. The facility failed to ensure Resident #2 had an order for oxygen. This failure could place residents requiring respiratory care at risk for respiratory complications. Findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #2 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain causes problems with reasoning, planning, judgment, and memory) and shortness of breath. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 was sometimes understood by others and understood others. The MDS assessment indicated Resident #2 had a short-term…

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 that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 2 residents (Resident #15 and Resident #46) reviewed for trauma-informed care 1. The facility did not ensure Resident #46 had an accurate trauma screen that identified possible triggers when Resident #46 had a history of trauma. 2. The facility did not ensure Resident #15's trauma screening was completed with triggers upon admission to the facility. These failures could place residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: 1. Record review of a face sheet dated 11/06/2024 indicated Resident #46 was a [AGE] year-old female originally admitted to the facility on [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 interview and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 23 residents reviewed for pharmacy services. (Resident # 15 and Resident # 68) The facility failed to ensure Resident #15's Metoprolol and Hydralazine (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters (systolic blood pressure less than 100 and diastolic blood pressure less than 60) on 10/06/2024. The facility failed to ensure Resident #68's Hydralazine (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters on 10/24/2024. These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #15's face sheet dated 11/05/2024, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder current…

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 store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 4 medication carts. LVN M failed to ensure the 100 Hall medication cart was locked when it was left unattended while she went to the restroom. This failure could place residents at risk of injury. Findings included: During an observation on 11/05/24 at 04:42 PM the hall 100 medication cart was unlocked, unattended, and parked beside the centralized nursing station. During an observation on 11/05/24 at 04:45 PM ADON N walked up to the hall 100 medication cart and locked it. She said the charge nurses were responsible for ensuring their medication carts were locked prior to walking away from them. She said there were all types of risks associated with the cart being left unlocked and unattended. ADON N said some of the risks associated with leaving the medication cart unlocked and unattended included theft of medications, poisoning for residents, and overdose. During an…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The Dietary staff failed to label and date all food items. 2) The Dietary staff failed to dispose of expired foods items located in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations on 11/04/24 at 9:11 a.m., the following observations were made in the kitchen walk in freezer (1 of 1) (1) zip lock bag of frozen catfish had an open date of 10/26/24 and an expiration date of 11/2/24. (expired) (1) 1/2-quart container of celery had a preparation date of 10/21/24 and an expiration date of 10/27/24. (expired) During observations on 11/04/24 at 9:17 a.m., the following observations were made in the kitchen walk in Refrigerator (1 of 1) (1) container of tomato juice was not…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 4 residents (Resident #8) reviewed for antibiotic use. The facility failed to ensure Resident #8 had documented signs and symptoms to support the use of prescribed antibiotics. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: Record review of a face sheet dated 11/06/2024 indicated Resident #8 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking…

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 residents had the right to be free from abuse, neglect, misappropriation or resident property, and exploitation for 1 of 17 residents (Resident #1) reviewed for abuse. The facility failed to keep Resident #1 free from abuse when CNA A roughly provided incontinent care to him on 06/07/2024. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation and a decreased quality of life. Findings include: Record review of a Grievance/Complaint Report dated 06/07/2024, received by ADON B reflected Resident #1's family member requested gentle movements of his legs during care. Documented facility follow-up action was to in-service staff members with 1:1 education and physical therapy in-service regarding transfer of resident out of bed. Record review of Resident #1's face sheet, dated 10/17/2024, reflected a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses…

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 all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 17 residents (Resident #1) reviewed for abuse and neglect. The facility failed to report to Health and Human Services Commission Resident #1's family member's allegation that CNA A roughly provided incontinent care to the resident on 06/07/2024. This failure could place residents at risk for abuse, humiliation, intimidation, fear,…

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 1 of 2 residents (Resident #1) reviewed for infection control practices. 1. CNA A failed to change her gloves and perform hand hygiene after removing Resident #1's soiled brief on 06/07/2024. 2. CNA A failed to dispose of Resident #1's soiled brief properly after removing it during incontinent care on 06/07/2024. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings include: Record review of Resident #1's face sheet dated 10/17/2024, indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses which include dementia (a group of thinking and social symptoms that interferes with daily functioning),…

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 store, prepare, distribute and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to store (1) dented can in a separate area. 4) Dietary Staff failed to effectively reseal, label and date frozen food items. 5) Dietary Staff failed to label and date beverage items in the dining room for resident use. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During observations on 09/25/23 beginning at 9:26 am, the following observations were made in the kitchen walk-in freezer (1 of 1): -(1) pack of Pork Ribs had a prep date of 9/20/23 was missing the use by date. -(1) container of chicken breast had a prep date of 9/21/23 was missing the use by date. -(1) bag 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 develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 20 residents reviewed for care plans. (Resident #25, #34, and #60) 1. The facility failed to care plan Resident #25's refusal of showers. 2. The facility failed to care plan that Resident #34 was PASRR (Preadmission Sceening and Resdient Review) positive. 3. The facility failed to care plan Resident #60's cracked teeth. These failures could place residents at risk for inaccurate care plans and decreased quality of care. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behavioral disturbance (group of symptoms that affects memory, thinking and interferes with daily life), essential (primary) hypertension (high…

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 meals served met the nutritional needs of residents for 1 of 1 meals (the lunch meal) reviewed for nutritional adequacy, as evidenced by: The facility served the residents on a pureed food consistency diet the wrong scoop size servings on the buttered broccoli florets for the noon time (lunch) meal on 9/26/23. This failure had the potential to affect all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of the facility diet and nourishment roster on 09/25/2023 indicated there were 8 residents in the facility on pureed food consistency diet. Record Review of the week 1 menu dated on 9/20/23, indicated the lunch meal (A) items included Fried Cod, Lemon Wedge, French Fries, [NAME] Slaw, Dinner roll, Margarine, Chocolate Brownie, whole milk, hot coffee or hot tea, tartar sauce lunch…

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 food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meal observed on 9/26/23 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an interview on 09/25/23 at 9:45 AM, Resident #42 stated the food was usually cold and They act like they don't know how to cook. Resident #42 stated the Meat was bad, and sometimes she could not even cut it. During an interview on 09/25/23 at 9:59 AM, Resident #54 stated the food did not have any seasoning at all and that it was bland. During an interview on 09/25/23 at 10:16 AM, Resident #57 stated the food was not cold, but it was not warm enough. During an interview on 09/25/23 at 11:10 AM, Resident #60 stated the food was always…

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 collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 resident (Residents #31,#44 and #51) reviewed for hospice services. The facility did not ensure Resident #31, #44 and #51's hospice records were a part of their records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of Resident #31's face sheet, dated 09/27/2023, indicated Resident #31 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included cancer of right breast. Record…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 4 of 4 residents and reviewed antibiotic use. (Resident #21, Resident #46, Resident #48, Resident #64) The facility failed to ensure Resident #21, Resident #46, Resident #48, and Resident #64 had documented signs and symptoms, appropriate lab work, and diagnoses to support the use of prescribed antibiotics. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #21 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic kidney disease (condition characterized by 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 develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 12 of 20 employees (RN D, Dietician, Occupational Therapist F, Physical Therapist G, Dietary Manager, Social Worker, CNA H, CNA K, CNA L, CNA M, Maintenance Director, Housekeeping Supervisor) reviewed for required trainings. The facility failed to ensure the Maintenance Director, the Housekeeping Supervisor, Occupational Therapist F, Physical Therapist G, CNA H, CNA K, CNA L, and CNA M received HIV and restraint training upon hire. The facility failed to ensure RN D, the Dietary Manager, the Social Worker, received annual HIV and restraint training. The facility failed to ensure the Dietician received annual restraint training. This failure could place residents at risk for inappropriate restraints and exposure to HIV. Findings included: Record review of the employee files revealed there was no HIV or restraint training completed upon hire for the following staff: Maintenance Director hire…

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 20 (Resident #33) residents reviewed for resident rights. The facility failed to ensure RN D fed Resident #33 while sitting down. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: During a dining observation on 09/25/2023 at 11:57 a.m., RN D was standing up while feeding Resident #33 green peas and a piece of cod fish. During an interview on 09/25/2023 at 2:29 p.m., Resident #33 was non-interviewable as evidenced by confused conversation. During a telephone interview on 09/27/2023 at 3:13 p.m., RN D stated she knew she had to sit at eye level while feeding Resident #33, but she was the nurse for the dining room and had to oversee all residents. RN D further stated Resident #33 was blind and had to be assisted with his meals. RN D stated it was important to treat residents…

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 have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents reviewed for the right to be informed. (Resident #2 and Resident #33) 1. The facility failed to ensure Resident #2 had a signed psychotropic consent form for alprazolam (antianxiety medication), Belsomra (sedative-hypnotic medication), and Remeron (antidepressant medication). 2. The facility did not ensure Resident #33 had a signed informed consent based on information of the need, benefits, and risk prior to administering Ativan (a medication used to treat anxiety). These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #2 was an…

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 the residents' rights to formulate an advance directive for 2 of 18 residents reviewed for advanced directives. (Resident #10 and Resident # 73) The facility failed to ensure Resident #10 and Resident # 73's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored. Findings included: Record review of Resident #10's face sheet dated 9/26/23, revealed Resident #10 was a [AGE] year-old female with a diagnose of vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs)…

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 consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 20 (Residents #46 and #135) residents reviewed for notification of change of condition. 1. The facility did not ensure RN D notified the physician when Resident #46 fell on [DATE]. 2. The facility failed to notify and consult with the physician about the changes in Resident #135's fall. This failure could place residents at risk of a delay in treatment, and a worsening of their condition. Findings included: 1. Record review of Resident #46's face sheet, dated 09/27/2023, indicated Resident #46 was a [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included fracture of right femur (the bone of the thigh) and essential hypertension (high blood pressure). Record…

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 review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 3 of 20 staff members (Physical Therapist, House Keeping and Food Service Supervisor) reviewed for develop and implement abuse policies. The facility failed to ensure the Human Resource (HR) Coordinator implemented the facility's abuse/neglect policy and procedure when she failed to complete an Employee Misconduct Registry (EMR) check for CNA G upon hire and annually for the Maintenance Supervisor, Activity Director, and Food Service Supervisor. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included: Record review of the facility's Abuse, Neglect and Exploitation policy revised on 10/24/2022, indicated . It is the police of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation…

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 assessments accurately reflected the resident status for 2 of 20 residents (Resident #34 and Resident #42) reviewed for MDS assessment accuracy. The facility did not ensure Resident #34's and Resident #42's MDS assessments were accurately coded to reflect their level II PASRR (Preadmission Screening and Resident Review) status for mental illness. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of a face sheet dated 09/27/2023, indicated Resident #34 was an [AGE] year-old female initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks with hallucinations or delusions), recurrent, severe with psychotic symptoms, anxiety disorder, 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 ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 5 residents (Resident #17, #69) reviewed for respiratory care. 1. The facility failed to ensure Resident #17's oxygen was set at 3 LPM as ordered by the physician. 2. The facility failed to ensure Resident #69 oxygen concentrator filters were cleaned. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #17 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs) and shortness of breath. Record review of the MDS assessment, dated 09/27/2023, revealed Resident #17 had clear speech and was understood by staff.…

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 all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 2 nurses' carts (Nurse Cart Hall 1&4, and Nurse Cart Hall 2&3) reviewed for drugs and biologicals and storage of medications. The facility failed to ensure Nurse Cart Hall 1&4, and Nurse Cart Hall 2&3 were secured and unable to be accessed by unauthorized personnel. The facility failed to ensure 1 insulin pen (device used to administer insulin to residents with high blood sugars) on the Nurse Cart Hall 2&3 was dated when opened. These failures could place residents at risk of misuse of medications, drug diversions, and not receiving the therapeutic benefit of medications Findings included: During an observation and interview on [DATE] at 7:06 AM, LVN X left nurse cart unlocked while in resident room performing blood sugar check. LVN X stated the cart should be locked. LVN X stated she just forgot to lock…

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 assist residents in obtaining routine dental services to meet the needs of 1 of 20 (Resident #60) residents reviewed for dental services. The facility failed to ensure Resident #60 obtained prompt dental services when he had cracked teeth and a tooth infection. These failures could place residents at risk of not receiving needed dental care and a decreased quality of life. Findings included: Record review of a face sheet dated 09/27/2023 indicated Resident #60 was a [AGE] year-old male initially admitted to the facility on [DATE], readmitted on [DATE], with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness of the left side of the body caused by decreased circulation to the brain), heart failure, unspecified (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and 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 ensure food was prepared in a form designed to meet individual needs for 2 of 9 residents (Resident #2 and Resident #25). 1. The facility failed to ensure Resident #2 received her health shake with her lunch meal as ordered by the physician. 2. The facility failed to ensure Resident #25 received a mechanical soft diet during the lunch meal as ordered by the physician. These failures could place residents with a therapeutic diet at risk for poor intake, weight loss, not meeting their nutritional needs and choking. The findings included: 1. Record review of the face sheet, dated 09/27/2023, revealed Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of recurrent depressive disorders (episodes of depression after periods of time without symptoms), anxiety disorder (characterized by significant and uncontrollable feelings of anxiety and fear), and unspecified atrial fibrillation (disease of the heart…

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 reviews, the facility failed to ensure each resident received and the facility provided food that accommodates resident preferences 1 of 78 residents (Resident #29) reviewed for resident food preferences. The facility failed to ensure Resident #29 received her preferred meal choice. This failure placed residents at risk for not having their nutritional needs met and a decreased quality of life. Findings included: Record review of Resident #29 face sheet dated 9/26/2023 revealed resident was a [AGE] year-old female admitted to facility on 10/11/2021 had diagnosis of muscle weakness generalized (lack of muscle strength), dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), iron deficiency anemia (a condition in which blood lacks adequate…

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.