Meadowbrook Manor - Lagrange

Based on interview and record review, the facility failed to facilitate non-discriminatory discharge planning that meets the resident's preferences by allowing the resident to remain in the facility and paying privately for a bed.This applies to 1 resident (R5) reviewed for discharge planning in a sample of 30 residents.Findings include:On 7/22/25 at 11:53 AM, R5 and V31 (R5's Son-in Law) said they are concerned because they want R5 to be able to remain in the facility, but they were told R5 is going to be transferred to another facility on 7/29/25 when her Medicare days run out. V31 said they had a meeting with the facility staff and told the staff they want to remain in the facility after the 29th as private pay, but the staff said they will not have a room for R5 after 7/29/25.V1's (Administrator) progress note dated 7/10/25 at 9:12AM states V2 (DON/Director of Nursing) and V1 met with R5's POA (Power of Attorney) and son to discuss discharge planning. Progress note states R5's 100th day is on 7/29/25 and V1 explained to POA that at this time the facility does not have long 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.

Based on observation, interview, and record review, the facility failed to review and revise resident care plans to reflect significant incidents/changes in condition. This applies to 2 of 2 residents (R25 and R36) reviewed for care plans in a sample of 30. The findings include: 1. R25’s face sheet showed he was admitted to the facility with diagnoses including chronic kidney disease, diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, gout, dependence of renal dialysis, lymphedema, osteoarthritis, and hypertension. R25 had a fall incident on June 13, 2025 at 4:15 AM per V45’s (LPN/Licensed Practical Nurse) “Post Fall Observation” assessment form. V45’s progress noted dated June 13,2025, states she saw R25 “tipped back against the wall with her legs in the air and her head tilted to the right against the wall.” Per V45, “leaving her (R25) on the floor was not an option due to the Hoyer lift being stuck under the geri-chair.” V45’s “Post-Fall Observation” assessment form dated June 13, 2025, states that resident sustained a fall in her room and was sent 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.

Based on observation interview and record review the facility failed to provide incontinence care for a dependent resident.This applies to 1 of 9 residents (R11) reviewed for ADL (Activities of Daily Living) in a sample of 30 .Findings include:On 07/24/2025 at 12:29 PM, a head-to-toe skin check for R11 was conducted with V40 RN (Registered Nurse). V40 RN stated R11 sacral area was a little red due to frequent stooling related a chronic infection. V40 stated to minimize the irritation R11 is cleaned frequently, and barrier cream is applied. Before V40 started the skin assessment R11 requested butt cream be applied. When V40 RN pulled R11 blanket and top sheet back, her undergarment was saturated and soaked through to her bottom sheet. R11 had stool up through her vagina and her buttocks were reddened. No barrier cream was noted on R11.On 07/24/2025 at 12:44 PM, V41 CNA (Certified Nursing Assistant) assigned to R11 stated her work shift started at 06:00 AM. V41 stated the last time she provided incontinence care to R11 was between 08:00 and 08:30 AM. V41 stated she saw R11 at 10:00 AM…

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's equipment and environment were free from accident hazards, and failed to ensure a resident with known wandering habits was supervised to prevent a fall. This failure resulted in the emergent transfer to the hospital for 2 residents due to fall incidents. This applies to 2 of 2 residents (R25 and R36) reviewed for accidents and supervision in a sample of 30. The findings include: 1. R25’s face sheet showed he was admitted to the facility with diagnoses including chronic kidney disease, diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, gout, dependence of renal dialysis, lymphedema, osteoarthritis, and hypertension. R25’s MDS (Minimum Data Set) dated May 5, 2025, shows R25 is cognitively intact, non-ambulatory, and requires total assist with transfers with 2 staff members via Hoyer lift. R25’s latest fall risk assessment (prior to fall on June 13,2025) dated January 25, 2024, states R25 has 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 observation, interview, and record review, the facility failed to safely maintain and reconcile controlled medication counting logs for residents receiving narcotics.This applies to 2 out of 3 residents (R11 and R34) reviewed for narcotics in a sample of 30.Findings include:1. On 7/23/2025 at 10:40 AM, R11's Tramadol 50 mg (milligrams) medication punch card was observed with no tablets available. R11's Controlled Substances Proof of Use sheet for Tramadol showed R11 had 1 tablet remaining for use. R11's Pregabalin 75 mg medication punch cards were observed with 30 capsules available. R11's Controlled Substance Proof of Use sheet for Pregabalin showed R11 had 31 capsules remaining for use. The Pregabalin punch cards showed #5, #8, #14, and #16 medication punch slots were torn with loose capsules inside, not secured. V3 (Assistant Director of Nursing/ADON) was present during the observations and said she was not sure why the medication logs were inaccurate. V3 said controlled medications had to be logged when removed and if not properly secured they had to be reconciled and…

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

Based on interview and record review the facility failed to conduct quarterly Interdisciplinary Team meetings and invite residents and / or their POA (Power of Attorney) to participate in their care planning process. This applies to 6 of 6 residents (R1, R2, R3, R4, R5, and R6) reviewed for care plan meetings in a sample of 6. Findings include: On 6/6/25 at 7:55 AM, V3 (Family Member) stated she and R1 had not attended a care plan meeting in over a year. On 6/6/25 at 1:34 PM, R1 stated V3 is her POA would be the one to attend her care plan meetings. On 6/6/25 at 10:25 AM, R2 stated she had no knowledge of what a care plan meeting was. On 6/6/25 at 10:40 AM, R6 stated she has never had a care plan meeting. On 6/6/25 at 10:53 AM, R5 stated she has never had a care plan meeting. On 6/6/25 at 11:07 AM, R4 and V4 (Family Member) stated they had not been invited to a care plan meeting. On 6/6/25 at 11:25 AM, R3 stated she did not know the facility conducted care plan meetings. R3 stated she did not think her brother had been invited to a care plan meeting for her. On 6/6/25 at 12:24 PM,…

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 have physician-ordered medications available. This applies to 3 of 7 residents (R1, R2 and R3) reviewed for medication availability in a sample of 6. Findings include: 1.On 6/6/25 at 7:55 AM, V3 (Family Member) stated she refills R1's medications from an outside pharmacy. V3 stated most of the medications are on auto-refill, but there are times the facility runs out of medication and don't notify her that a refill is needed. On 6/6/25 at 12:24 PM, the medication cart was reviewed with V5 LPN Licensed Practical Nurse assigned to R1 and R2. R1's regularly scheduled medications Ammonium Lactate 12% cream that are to be applied to the bottom of both feet every evening, and propylene glycol-glycerin 1-0.3% that are scheduled one drop to both eyes two times per day were not available. R1 had orders for Albuterol Sulfate inhalation aerosol solution 108 (90 base) MCG (Micrograms) that is taken every four hours as needed for wheezing related to chronic obstructive pulmonary disease that was also unavailable. V5 LPN…

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 follow safe medication administration practice to avoid a significant medication error. This applies to 1 of 3 residents (R1) reviewed for significant medication error in a sample of 3. The findings include: On May 6, 2025 at 12:03 PM, R1 said a few weeks earlier, he was given three white pills which he was not supposed to take and were supposed to be for another resident. R1 said he went to the hospital to be evaluated for the reaction to the pills. On May 6, 2025 at 1:33 PM, V3 (RN/Registered Nurse) said she had floated onto a different unit than her normal and had received a phone call from the cardiologist. V3 said she had worked with R1 before but had misheard the cardiologist and did not realize there was another resident who had the same first name and same letter for the last name. V3 said she pulled the medication and went to R1's room and said the labs showed he needed his potassium replaced. V3 administered the potassium to R1 and after…

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 administer medications at ordered times. There were 31 opportunities with 8 errors resulting in a 25.8% medication error rate. This applies to 5 of 6 residents (R12, R13, R17, R18, R19) observed in the medication pass. 1) R12's electronic face sheet printed on 7/28/24 showed R12 has diagnoses including but not limited to dementia without behaviors, type 2 diabetes, diverticulitis, gastroesophageal reflux disease, major depressive disorder. R12's medication administration record for July 2024 showed R12 receives famotidine 10mg at 8:00AM and memantine 10mg at 8:00AM and 4:00PM. On 7/28/24 at 10:30AM, V3 (Licensed Practical Nurse) administered R12's memantine 10mg. (2 hours and 30 minutes past the scheduled administration time). V3 was unable to locate R12's famotidine 10mg that was due to be administered at 8:00AM and stated it was reordered from the pharmacy on 7/27/24. On 7/28/24 at 11:25AM, V3 stated she normally comes in at 7AM but…

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 assess a resident's wound, failed to initiate treatment as ordered by a physician for a resident (R1) that obtained a skin tear. This applies to 1 of 3 residents reviewed for wounds in the sample of 19. The findings include: R1's electronic face sheet printed on 7/28/24 showed R1 has diagnoses including but not limited to heart failure, pressure ulcer of sacral region stage 4, anxiety disorder, major depressive disorder, and dementia with behaviors. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and does not have non-pressure wounds. R1's nursing progress notes dated 7/1/24 showed, 7/1/24 Writer alerted by CNA (certified nursing assistant) that resident was being transferred into bed and now has a skin tear. Writer entered resident room and observed a long laceration noted to right leg. Writer assessed area of laceration .resident right leg dressed with pressure dressing physician ordered to send to hospital for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide treatment as ordered by a physician for a resident (R1) with a stage 4 pressure ulcer. This applies to 1 of 3 residents reviewed for wounds in the sample of 19. The findings include: R1's electronic face sheet printed on 7/28/24 showed R1 has diagnoses including but not limited to heart failure, pressure ulcer of sacral region stage 4, anxiety disorder, major depressive disorder, and dementia with behaviors. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and has 1 stage 4 pressure wound. R1's care plan dated 4/10/24 showed, (R1) has potential for further pressure ulcer development/impaired skin integrity related to decreased mobility and comorbidities. Currently has a stage 4 pressure injury on sacrum. Administer treatments as ordered and monitor for effectiveness. R1's wound physician note dated 4/25/24 showed, Stage 4 pressure injury to sacrum .recommend calcium alginate with dry dressing daily and as needed.…

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 ensure a resident (R13) was free from a significant medication error. This applies to 1 of 6 residents observed in the medication pass. The findings include: R13's electronic face sheet printed on 7/28/24 showed R13 has diagnoses including but not limited to pulmonary hypertension, anemia, chronic atrial fibrillation, anxiety disorder, and major depressive disorder. R13's medication administration record for July 2024 showed R12 receives apixaban 2.5mg at 8:00AM and 8:00PM. On 7/28/24 at 11:25AM, V3 was passing medications for R13 and stated she was unable to find any apixaban 2.5mg to administer to R13. V3 stated this would be considered a medication error due to R13 being unable to receive her ordered medication. V3 stated R13's apixaban was ordered on 7/27/24 and it must have been after the last dose was given. On 7/28/24 at 3:29PM, V2 (Director of Nursing) stated, We do not keep apixaban in our extra supply of medications. This would be considered a significant medication error to it being 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 ensure menus were followed. This applies to 1 of 3 residents (R4) reviewed for menus in the sample of 19. The findings include: R4's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include hemiplegia, vascular dementia with anxiety, vision loss, and protein calorie malnutrition. R4's care plan initiated 7/6/2023 showed, Nutrition: On Therapeutic diet . Obtain food preferences/dislikes . Provide some encouragement to increase oral intake as needed. Offer substitute on food dislikes . R4's Dietary Profile dated 7/12/24 showed, . Likes to eat/drink . coffee, juice, bacon, eggs, oatmeal with brown sugar . R4's Dietary Ticket for Sunday, July 28 showed, . choice of vitamin C juice, fresh fruit; choice of hot or cold cereal, Entree: Scrambled Egg; Sides: Crispy bacon strip . Likes/serve: Oatmeal (2 bowls), coffee, juice, Double Protein. Dislikes: Sausage . On 7/28/24 at 10:05 AM, V10 RN (Registered Nurse) went into…

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 ensure resident medications were available for administration for 2 of 3 residents (R3, R4) reviewed for medications in the sample of 4. The findings include: 1. R3's face sheet printed on 6/27/24 showed an admission date of 6/18/24. The same face sheet showed diagnoses including but not limited to surgical after care following respiratory system surgery, larynx and glottis cancer, tracheostomy, major depression, and anxiety disorder. R3's admission assessment showed no cognitive impairment. On 6/27/24 at 9:44 AM, R3 communicated via handwritten notes, she did not receive her anti-anxiety medication when she arrived at the facility. R3 said she has severe anxiety and missed several doses before anyone finally gave her the medication. R3's progress notes showed a facility arrival day of 6/18/24 at 5:00 PM. R3's June 2024 MAR (Medication Administration Record) showed an order start dated 6/18/24 at 5 PM for bupropion 75 milligrams two times a day for depression and 15 milligrams two times a day for anxiety. The MAR showed 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.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during provisions of incontinence carer and administration of medications. This applies to 4 of 31 residents (R79, R85, R94, R503) reviewed for infection control in the sample of 31. The findings include: 1. Face sheet shows that R503 is 70 years-old who has multiple medical diagnoses which include Extended Spectrum Beta Lactamase (ESBL) Resistance in the urine, and urinary tract infection. R503 was observed on isolation. On June 3, 2024, at 10:50 AM, V21 (Nurse) stated R503 was on isolation for ESBL in urine. On June 4, 2024, at 3:21 PM, V14 (Certified Nursing Assistant/CNA) and V15 (Wound Care CNA) rendered incontinence care to R503. V15 removed the soiled diaper which was heavily saturated with urine. V15 changed her gloves without hand hygiene. V15 wiped R503's buttocks then she took the clean incontinence pad and diaper and placed it underneath R503 while wearing same gloves. V14 continued to changed gloves multiple…

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 who requires assistance for activities of daily living (ADL) care were assisted for shaving and nail clipping. This applies to 2 of 3 residents (R84, R85) reviewed for ADL care in the sample of 31. The findings include: 1. According from face sheet, R85 is 80 years-old who has multiple medical diagnose which include dependence on hemodialysis. The Significant Change Minimum Data Set (MDS) dated [DATE], shows R85 is alert and oriented, and requires substantial to maximum assistance with hygiene and grooming. On June 4, 2024, at 1:54 PM, R85 was in bed resting. R85 displayed long dirty fingernails with black/brown substances underneath his fingernails. He had unkept, overgrown facial hair. R85 said that he would like his facial hair shaven, and his nails clipped, this would be more comfortable for him. On June 4, 2024, at 2:11 PM, V19 (Nurse) was prompted to assess R85's nails and said that she would clip it and clean…

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 ensure that a resident's medications were administered by the nurse and not left at the bedside for the resident to take on his own. This applies to 1 of 31 residents (R41) reviewed for medications at the bedside in the sample of 31. The findings include: R41 had multiple diagnoses including metabolic encephalopathy, altered mental status, alcohol dependence with alcohol-induced persisting dementia, cognitive communication deficit, bipolar disorder and hypocalcemia, based on the face sheet. R41's admission MDS (minimum data set) dated March 30, 2024 showed R41 was moderately impaired with cognition. The MDS showed R41 had functional limitation/impairment on both sides of his upper extremities. The same MDS showed R41 required maximum to total assistance from the staff with regards to most of his ADLs (activities of daily living). On June 3,2024 at 11:32 AM, R41 was in bed, alert and verbally responsive. R41 was observed attempting to take his medications from a medication cup and had spilled his pills on the…

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

Based on observation, interview, and record review, the facility failed to follow physician's order and treatment plan for a resident who has pressure ulcers. This applies to 1 of 6 residents (R503) reviewed for pressure ulcers in the sample of 31. The findings include: On June 4, 2024, at 3:00 PM, R503 was sitting at the edge of the bed. R503 was alert but forgetful. When R503 was asked if received wound treatment that day, R503 replied that she could not remember if wound care was done. R503 laid down in bed and showed her wounds. R503 had pressure ulcers to her left and right inner buttocks which extends down to the gluteal folds and posterior left and right thighs. The wounds were uncovered. There was no trace of any ointment or cream to her wounds. The wound bed looks tender and raw. The spot at the edge of the bed where R503 was sitting was heavily saturated with urine which shows brown ring formation at the edges of the wetness on the fitted sheet. R503 was unable to recall of when she was last changed or cleaned for incontinence care. On June 4, 2024, at 3:30 PM, V20 (Wound…

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 assess and provide splints and therapy services to residents, to prevent further reduction in ROM (range of motion). This applies to 2 of 4 residents (R34 and R40) reviewed for range of motion in the sample of 31. The findings include: 1. R34 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R34's annual MDS (minimum data set) dated April 19, 2024 showed R34 was moderately impaired with cognition. The MDS showed R34 had impairment in range of motion on one side of both upper and lower extremities. The same MDS showed that R34 required maximum to total assistance from the staff with her ADL's (activities of daily living). On June 3, 2024 at 10:56 AM, R34 was sitting in her wheelchair inside her room. R34 was alert, verbally responsive and was able to respond appropriately to questions. R34 had left arm and left hand weakness. R34 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely incontinence care and peri-care in a manner that would prevent urinary tract infection (UTI). This applies to 2 of 6 residents (R94, R503) reviewed for bowel and bladder care in the sample of 31. The findings include: 1. Face sheet shows that R503 is 70 years-old who has multiple medical diagnoses which include Extended Spectrum Beta Lactamase (ESBL) Resistance in the urine, and urinary tract infection. On June 4, 2024, at 03:00 PM, R503 was sitting at the edge of her bed. R503 was alert but forgetful. R503's incontinence brief was heavily saturated with urine which overflowed to the incontinence pad and fitted bedsheet. The urine flowed down the side of the mattress and was observed with brown ring formation at the edge of the wetness. R503 was unable to say the exact time of when she was last checked and change for incontinence. On June 4, 2024, at 3:21 PM, V14 (Certified Nursing Assistant/CNA) and V15 (Wound Care CNA)…

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 change a resident's Midline line dressing per facility policy and procedure. This applies to 1 of 3 resident's (R19) reviewed for IV (intravenous) catheter care in the sample of 31. The findings include: R19 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, based on the face sheet. R19's quarterly MDS (minimum data set) dated April 23, 2024 showed R19 was moderately impaired with cognition. On June 3, 2024 at 10:45 AM, R19 was in bed, alert, verbally responsive but with confusion. R19 had a single lumen Midline catheter (inserted into a vein) on her right inner upper arm. R19's Midline catheter site had a gauze dressing covered with a transparent tape and the dressing was dated 5/31/24. The transparent tape covering the gauze dressing was not intact. The tape was rolling and loose towards the antecubital fossa (depression located between the forearm and front of the arm). The transparent tape was not fully sealing the Midline catheter…

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 administer medication as prescribed by the physician and failed to ensure the medications being administered via gastrostomy tube were completely given to the resident. There were 6 errors observed out of the 25-medication opportunities resulting in a 24% medication error rate. This applies to 2 of 5 residents (R112, R129) reviewed during medication pass in the sample of 31. The findings include: 1. On June 4, 2024, at 4:45 PM, V11 (Nurse) checked R112's blood sugar level. R112's blood sugar showed 213 milligram (mg)/deciliter (dl). V11 administered Insulin Fiasp 5 units to R112. V11 confirmed to surveyor that it was the only dose prescribed by the physician for that hour. R112's Medication Administration Record (MAR) showed to give Insulin Fiasp (Insulin Aspart with Niacinamide)1000 units/ml. Inject 5 units subcutaneously three times a day for diabetes hold for blood sugar less than 140 mg/dl. The same MAR showed to give Fiasp Injection Solution 100 UNIT/ML (Insulin Aspart (with Niacinamide). Inject as per…

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 dietary staff failed to follow a resident's tray card and served the resident a food item she was known to be allergic to. This applies to 1 of 1 resident (R18) reviewed for food allergies in the sample of 31. The findings include: R18's EMR (Electronic Medical Record) showed R18 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, other sequelae following unspecified cerebral vascular disease, peripheral vascular disease, polyneuropathy, and unspecified dementia. R18's MDS (Minimum Data Set) dated May 21, 2024, showed R18 had moderate cognitive impairment, and required staff assistance with ADL's (Activities of daily Living) including dependent on staff for lower body dressing, and transfer and required substantial assistance with eating, bed mobility, bathing, toileting, and personal hygiene. R18's EMR physician order summary, showed R18's diet order, initiated on May 29, 2024, was regular texture,…

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 serve food to residents at a palatable temperature. This has the potential to affect all 155 residents consuming food from the kitchen. The Findings include: On 9/21/23 at 10:29 AM, V4 (Dietary Director) stated, We have 155 residents eating from the kitchen. R2 is a [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 9/20/23 at 9:05 AM, R2 stated, Eggs were cold for today's breakfast. The coffee was lukewarm. R3 is an [AGE] year-old female with moderate cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 9/20/23 at 9:10 AM, R3 stated, Food is always cold; It's terrible that the egg was cold in the morning, and I sent it back. I didn't eat it. Bacon was also cold. R4 is an [AGE] year-old male with mild cognitive impairment per Minimum Data Set (MDS) dated [DATE]. On 9/20/23 at 9:25 AM, R4 stated, Lots of time, food is cold. You are getting something not as warm as…

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 ensure residents were assisted with eating in a dignified manner for 2 of 26 residents (R91 and R105) reviewed for dignity in the sample of 26. The findings include: 1. On 5/22/23 during the noon meal, V10 (Social Service Designee) was standing up feeding R105 in the dining room. 2. On 5/22/23 during the noon meal, V11, Certified Nursing Assistant (CNA) was standing up feeding R91 in the dining room. On 5/23/23 1:40 PM, V18 (CNA) said that staff should always be sitting down and eye to eye with a resident when feeding them. V18 stated, They will eat better that way. The facility Assistance with Meals Policy revised July 2017 shows, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals

Based on observation, interview and record review the facility failed to ensure the call light was within reach for a resident who is dependent on staff for assistance for 1 of 1 resident (R57) reviewed for call lights in the sample of 26. The findings include: R57's Face sheet printed 5/23/23 showed diagnoses to include, but not limited to chronic congestive heart failure, type 2 diabetes mellitus, end stage renal disease, osteoporosis, adult failure to thrive, major depressive disorder, difficulty in walking, muscle weakness, pressure ulcer of sacral region stage 2. On 5/23/23 at 10:42 AM, R57 was sitting in his recliner chair in the middle of the room. The call light was lying on the bed out of R57's reach. At 10:43 AM, V17 License Practical Nurse (LPN) came into R57's room and said, Where is your call light. Let me find it? On 5/24/23 at 8:43 AM, V15 LPN said it (call light) is important for his safety and for him to get help when he needs it. They (residents) may fall because of trying to reach the call light if it is not where they can reach it. V15 said if in an emergency,…

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 dysphagia was fed safely and failed to ensure a gait belt was used to safely transfer a resident for 2 of 26 residents (R14 and R27) reviewed for safety in the sample of 26. The findings include: 1. R14's Speech Therapy Discharge summary dated [DATE] shows that she has a diagnosis of dementia, Parkinson's disease and dysphagia. R14's discharge recommendations shows, To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: general swallow techniques/precautions, bolus size modifications and alternation of liquid/solids along with the following maneuvers: head turn to unaffected side. On 5/22/23 during the noon meal, V8 (Resident Aide) was in the dining room feeding R14 a mechanically altered diet. On 5/24/23 at 9:50 AM, V2 (Director of Nursing) said that Resident Aides are not allowed to feed residents. The facility's Hospitality Aide Job Description does 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 observation, interview, and record review the facility failed to ensure a urinary drainage bag was secure and off the floor for a resident and failed to ensure incontinence care was thoroughly completed for a resident. This applies to 2 of 4 residents (R22 & R19) reviewed for catheters and urinary tract infections in the sample of 23. The findings include: 1. R22's face sheet shows he has diagnoses including: calculus of the kidney, presence of urogenital implants, chronic kidney disease, and encounter for artificial openings of urinary tract. R22's Order Summary Report shows he is on contact isolation for ESBL and VRE (bacterial infections) in the urine. R22's active care plan shows he has a nephrostomy tube (catheter inserted in the kidney to drain urine). R22's 5/20/23 2:01 PM, Progress Notes shows R22 is on an antibiotic for a Urinary Tract Infection (UTI). On 5/22/23 at 10:24 AM, R22 was sitting in the dining area doing an activity. A urinary drainage bag was seen under R22's wheelchair resting on…

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

Based on observation, interview and record review the facility failed to ensure a resident was observed during medication administration for 1 of 26 residents (R39) reviewed for pharmacy services in the sample of 26. The findings include: On 5/22/23 at 10:11 AM, R39 was in her room with her breakfast tray in front of her. On the tray was a plastic medicine cup with 2 yellow pills and 2 white pills. R39 said she was not sure when the pills were left, she must have fallen asleep. R39 was unable to indicate what pills were in the cup. On 5/22/23 at 10:17 AM, V5 (Registered Nurse/RN) said she was the nurse who left the medication in the room for R39 and it was 2 Tylenol and 2 baby aspirin. V5 said she was sorry and she should have stayed in the room and watched R39 take her medication. R39's Physician Order Summary Report shows she has orders for Acetaminophen 325 milligrams (mg.) give 2 tablets by mouth four times a day and an order for Aspirin 81 mg. give 2 tablets by mouth one time a day. R39's Physician Order Summary does not show an order for R39 to self-administer her medications.…

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 ensure PRN (as needed) anti-anxiety (psychotropic) medications had a duration/end date. This applies to 2 of 5 residents (R429, R48) reviewed for unnecessary medications in the sample of 26. The findings include: 1. On 5/23/2023, R429's Order Summary Report, dated 5/23/2023, shows an order for Lorazepam Oral Concentrate 2MG/ML - Give 0.5mg every 4 hours as needed for Anxiety/Agitation with a start date of 5/3/2023 and no specified end date. 2. On 5/23/2023, R48's Order Summary Report, dated 5/23/2023, shows an order for Lorazepam Concentrate 2MG/ML - Give 0.25 ml every 6 hours as needed for agitation and restlessness with a start date of 6/17/2022 and no specified end date. On 5/23/2023 at 1:22PM, V3 Assistant Director of Nursing (ADON) said PRN (as needed) psychotropic medications must indicate a stop date of 14 days. The facility's Antipsychotic Medication Use policy, revised December 2016, states the need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the…

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

Based on observation, interview and record review the facility staff failed to ensure the ordered dose of insulin was administered to a resident for 1 of 4 residents (R88) reviewed for significant medication errors in the sample of 26. The findings include: On 5/23/22 at 9:29 AM, V13 (Registered Nurse) brought a glucometer and R88's insulin pen into R88's room. V13 checked R88's blood sugar. R88's blood sugar was 165. Without exiting the room to verify the insulin dose needed, V13 attached the needle to the pen and primed the pen. V13 then turned the dial to 2 units and said that she would be giving 2 units. This surveyor verified that the pen was set to 2 units. V13 administered 2 units of insulin to R88 in his left upper arm. R88's Physician's Order Sheet printed on 5/24/23 shows an order for, Humalog Kwik Pen-Inject as per sliding scale: if 150-199 = give 1 unit: 200-249 = give 2 units . On 5/24/23 at 10:58 AM, V2 (Director of Nursing) said that if a resident gets sliding scale insulin, the blood sugar should be check and then the nurse should refer to the order to see how much…

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 ensure residents on a pureed diet were served protein at the noon meal. This applies to 2 of 15 residents (R6 & R14) reviewed for pureed diets in the sample of 26. The findings include: The facility menu for the noon meal on May 22, 2023 showed, Entrée: golden oven fried chicken, baked beans, chuckwagon corn, dinner roll or shrimp fettuccine alfredo, mixed green salad, choice of dressing, broccoli florets . On May 22, 2023 at 12:03 PM, V7 Dietary Aide was serving the noon meal to residents on the third floor. Residents receiving a puree diet were to get pureed chicken, pureed baked beans and pureed creamed corn. Mashed potatoes were also available. V7 Dietary Aide served R14 and R6 pureed baked beans, pureed creamed corn and mashed potatoes with gravy. R14 and R6 did not get any pureed chicken (protein) at the noon meal. On May 23, 2023 at 1:34 PM, V14 Dietary Manager stated, residents should get a meat, starch and veggie at every meal. The facility did not provide a policy on pureed diets.