Beaumont Rehabilitation And Healthcare Center

A. Based on record review and interview, the facility failed to notify the State Ombudsman of resident transfers to the hospital for 3 of 5 residents reviewed for hospitalization. (Resident 83, Resident 120, and Resident 44) B. Based on record review and interview, the facility failed to provide the transfer/discharge notification and bed hold policy to the resident/representative when the resident was discharged for 2 of 5 residents reviewed for hospitalization. (Resident 18 and Resident 44) Findings include: A1. Resident 83's clinical record was reviewed on 9/18/25 at 12:42 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD) with acute exacerbation and acute and chronic respiratory failure with hypoxia. A 7/18/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 2/16/25, progress note indicated Resident 83 was sent out to the hospital due to shortness of breath. All necessary parties were made aware. A 2/17/25, progress note indicated the resident was admitted to the hospital for pneumonia. A 2/19/25, progress noted…

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

Based on record review and interview, the facility failed to ensure timely completion of a required Level I Preadmission Screening and Resident Review (PASARR) assessment for 1 of 2 residents reviewed for PASARR. (Resident 6) Findings include:Resident 6's clinical record was reviewed on 9/17/25 at 10:20 a.m. Diagnoses included hypokalemia, stage 3 chronic kidney disease, and acute kidney failure. His admission date was 8/6/25. His discharge date was 9/15/25. Review of a Level of Care Screen Outcome, dated 7/31/25, indicated short term approval for intermediate nursing care for the duration of 30 days. The end date was 8/30/25. Review of a Level I PASARR Screen Outcome, dated 7/31/25 indicated the exempted hospital discharge allowed for a 30 day duration without further PASRR evaluation. If more time was required, the nursing facility must submit a new Level 1 screen. This must be completed by or before the 30th day after admission to the nursing facility. During an interview, on 9/18/25 at 3:30 p.m., the Social Service Assistant (SSA) indicated Resident 6's current Level 1 had 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 ensure Enhanced Barrier Precautions (EBP) were followed during a dressing change for 1 of 2 residents reviewed for EBP. (Resident 19)Finding includes:On 9/15/25 at 10:47 a.m. Resident 19 was seated in a wheelchair watching television while the housekeeper mopped the floor of her room. No EBP signage or personal protective equipment (PPE) cart was observed. Resident 19's record was reviewed on 9/18/25 at 1:38 p.m. Medical diagnoses included major depressive disorder, acquired deformity of left and right lower leg, and polyneuropathy (complex nerve pain). Current physician orders included, surgical site right lower extremity cleanse with normal saline or wound wash, and apply silver alginate. Apply skin protectant film to peri wound then cover with dressing and secure daily. A nurse practitioner's note, dated 9/4/25 at 9:38 a.m., indicated the resident had a wound to her right shin with slough (moist, soft, non-viable tissue) on the surface easily penetrated to the underlying bone with a Q-tip.During a 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.

Based on record review and interview, the facility failed to provide COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for immunizations. (Resident 44)Findings includes: Resident 44's clinical record was reviewed on 9/17/25 at 1:53 p.m. Diagnoses included essential hypertension, epilepsy, and anxiety disorder. A 1/22/25, physician's order indicated Resident 44 may have all age appropriate and pertinent vaccinations. A 6/13/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident 44 was cognitively intact. Review of the resident's vaccinations included the following: The resident had no historical administration of the Pneumococcal vaccine. A 2/25/25, Vaccine Consent Form, indicated Resident 44 was educated and consented to the appropriate pneumococcal vaccination. The clinical record lacked further documentation of the pneumococcal vaccination. During an interview, on 9/19/25 at 11:50 a.m., LPN 18 indicated she was just recently asked to oversee the vaccination records. She was unable to locate any documentation…

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

Based on record review and interview, the facility failed to provide COVID-19 vaccines per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for immunizations. (Resident 44)Findings includes: Resident 44's clinical record was reviewed on 9/17/25 at 1:53 p.m. Diagnoses included essential hypertension, epilepsy, and anxiety disorder. A 1/22/25, physician's order indicated Resident 44 may have all age appropriate and pertinent vaccinations. A 6/13/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident 44 was cognitively intact. Review of the resident's vaccinations included the following: The resident had a historical administration of the COVID-19 vaccination on 1/26/21 and 2/23/21. A 2/25/25, Vaccine Consent Form, indicated Resident 44 was educated and consented to the appropriate COVID-19 vaccination. The clinical record lacked further documentation of the COVID-19 vaccination. During an interview, on 9/19/25 at 11:50 a.m., LPN 18 indicated she was just recently asked to oversee the vaccination records. She indicated she was unable to…

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 provide current education on influenza vaccines and to obtain current influenza vaccination consents for 4 of 6 residents reviewed for immunizations. (Resident D, E, G, and H) Findings include: 1. Resident D's clinical record was reviewed on 4/2/25 at 11:53 a.m. Diagnoses included type 2 diabetes, hypertension, history of traumatic brain injury, depression, cerebral infarction, obstructive and reflux uropathy, anemia, chronic kidney disease, anxiety, and dementia. A review of the resident's immunization record indicated the influenza vaccination consent form was signed and dated on 10/10/23 and was administered on 10/1/24. Education related to the risk and benefits of the influenza vaccine was dated 8/6/21. The consent for the pneumococcal vaccine was signed and dated 10/10/23. The pneumococcal vaccine was administered on 6/26/23. The consent for the COVID -19 vaccine was signed and dated 10/10/23. The COVID-19 booster was administered on 10/28/24. 2. Resident E's clinical record was reviewed on 4/3/25 at 11:00 a.m.…

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

Based on record review and interview, the facility failed to ensure shift to shift narcotic reconciliation was completed for 6 of 6 carts reviewed for medication storage of 11 total medication and treatment carts. (Rehab cart, Intermediate back cart, 400 hall cart, 500 hall cart, 200 hall cart and 300 hall cart) Findings include: 1. During a medication storage observation of the 400 hall cart, accompanied by LPN 33, on 6/26/24 at 9:23 a.m., the Controlled Substances Check Form record was reviewed and the following dates lacked shift to shift reconciliation of controlled substances: In June 2024- 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, and 6/8 on all three shifts, 6/10 on evening and night shifts, 6/11 on day and evening shifts, 6/12 from 6:00 p.m.- 10:00 p.m. and night shift, 6/13 on day shift and 2:00 p.m. - 6:00 p.m., and night shift 6/17 on day shift and 2:00 p.m.- 6:00 p.m., 6/18 on evening and night shift, 6/19 on day shift, 6/21 on day shift and night shift, 6/22 on all three shifts, 6/24 on night shift, 6/25 on all three shifts. 2. During a medication storage observation of the…

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

Based on record review and interview, the facility failed to develop and implement approaches to correct identified deficient practices and audits to measure success of Performance Improvement Plans (PIP) as part of the Quality Assurance and Performance Improvement (QAPI) program. Findings include: During an interview, on 6/26/24 at 10:14 a.m., the DON indicated she had started Performance Improvement Plan (PIP) for an identified concern at the facility, such the failure of nurses to sign in and out to acknowledge reconciliation of the narcotic medication at the change of shift. She indicated the completion date for her PIP was 9/13/24. A current facility PIP guide, provided by the DON on 6/26/24 at 10:14 a.m., indicated the start date as 6/13/24 for nurses not signing in and out on the record of accepting narcotic responsibilities. The plan or tasks to be completed included a review of sign in/sign out sheets, a staff in-service, and Clean Fridays audits were to be initiated. The staff in-service was held on 6/13/24. The facility nursing staff was verbally re-educated on 6/26/24.…

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 resolve and respond to resident grievances in a timely manner for 3 of 3 residents reviewed for choices. (Residents 30, 33, and 81) Findings include: 1. During an interview on 6/26/24 at 3:31 p.m., Resident 30 indicated he went to dialysis at 5:30 a.m. on Mondays, Wednesdays, and Fridays each week. Sometimes dietary staff was not there before he left with transportation for his appointment. He was not served breakfast, nor packed a breakfast, to take with him to dialysis. Due to his lack of breakfast, he had spoken to a [NAME] and the current Dietary Manager (DM) week after week until approximately a month ago when he finally gave up because no one resolved his concerns. He even suggested some simple solutions such as fresh fruit like grapes and bananas. As a result, he went to dialysis without breakfast. Approximately two months ago, he spoke with the Administrator yet it was not resolved. Resident 30's clinical record was reviewed on 6/26/24 at 4:10…

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 report an allegation of resident abuse to the Indiana State Department of Health (IDOH) for 1 of 4 residents reviewed for allegations of abuse. (Resident C) Finding includes: Resident C's clinical record was reviewed on 6/26/24 at 9:06 a.m. Current diagnosis included anxiety, depression, and dementia. A 4/24/24, significant change, Minimum Data Set Assessment (MDS) indicated the resident was severely cognitively impaired, wandered daily during the assessment period, and did not reject care during the assessment period. A 6/6/24 Nursing Note, signed by RN 22, indicated on 6/6/24 at 5:35 a.m.,Resident C had experienced a confusing night. The resident had been observed walking down the hall with no clothes on. RN 22 got the resident dressed Resident C was standing in their room attempting to to walk through the wall. The resident was hard to redirect, but the writer was able to get them to the side of the bed. The writer had to pull the back of the resident's pants to guide her to the bed to sit down before falling. 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 develop and implement a safety plan (regarding 15 minute monitoring checks) to prevent resident to resident abuse for a resident with a diagnosis of dementia and a history of intrusive wandering. This deficient practice resulted in the resident being hit in the face, choked, and relocated to a new dementia unit. (Resident E) Finding includes: Review of a 6/14/24 facility reported incident indicated the following: During an resident to resident event on 6/14/24, Resident E wandered into Resident F's room and was going through Resident F's belongings. Resident F popped Resident E in the mouth several times, resulting in Resident E having a red chin and a little cut on his lip. Both resident's had dementia and resided on a secured dementia unit. On 6/14/24, following the event, the facility implemented the preventative measures of separating the residents, Social Services spoke with Resident F about not hitting, and Resident E was placed on 15- minute checks. Review of a 6/15/24 facility reported incident…

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

Based on record review and interview, the facility failed to ensure timely completion of Quarterly Minimum Data Set (MDS) assessments every three months for 4 of 4 reviewed for timely assessment. (Residents 22, 35, 60, 73) Findings include: 1. Resident 22's clinical record was reviewed on 6/26/24 at 1:05 p.m. Current diagnosis included left sided hemiplegia following a cerebral infarction, major depressive disorder, and repeated falls. The resident had a Quarterly MDS assessment, with the Assessment Reference Date (ARD) of 11/11/23 which was completed on 11/29/23. The assessment was completed 4 days late. The resident had a Quarterly MDS assessment, with the ARD of 5/10/24 which was completed on 5/27/24. The assessment was completed 3 days late. 2. Resident 35's clinical record was reviewed on 6/28/24 at 10:05 a.m. Current diagnosis included hypertension, chronic obstructive pulmonary disease, and bipolar disorder. The resident had a Quarterly MDS assessment, with the ARD of 5/15/24 which was completed on 6/10/24. The assessment was completed 11 days late. 3. Resident 60's clinical…

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

Based on record review and interview, the facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for 1 of 1 resident reviewed for assessment submission. (Resident 104) Findings include: Resident 104's closed clinical record was reviewed on 6/26/24 at 10:43 a.m. Clinical diagnosis included sepsis, congestive heart failure, and diabetes mellitus. The clinical record indicated the resident discharged from the facility on 4/4/24. The resident had a Discharge MDS assessment with the Assessment Reference Date (ARD) of 4/4/24, which was completed on 4/18/24. This assessment was completed on time, but electronically transmitted for submission on 6/24/24. The assessment was transmitted 68 days late. During an interview, on 6/27/24 at 2:53 p.m., the MDS Coordinator indicated the assessment transmission task was split between herself and her offsite corporate consultant. This discharge assessment was missed in error during the transmission process. Once this error was discovered, the assessment was transmitted electronically immediately. She utilized the online…

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 schedule, hold, and invite resident representatives to care plan meetings, held in conjunction with the assessment process for 3 of 4 residents reviewed for the provision of care plan meetings. (Residents E, F, & 92) Findings include: During a confidential interview with a resident representative, the representative indicated they were the party who was responsible for decision making and direction of the resident's care. The resident did not make independent decisions. The facility had not held a care plan meeting thus far in 2024. Their resident resided on one of the two secured dementia units. 1. Resident F's clinical record was reviewed on 6/26/24 at 9:34 a.m. Current diagnoses included dementia, anxiety, and psychotic mood disturbance. The resident resided on a secured dementia unit. The resident had an annual Minimum Date Set (MDS) assessment completed on 5/23/24. The resident also had a quarterly MDS assessment completed on 3/22/24. The resident additionally had a quarterly MDS assessment completed on 12/21/23. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the completion of physician ordered wound care treatments to promote healing of an abrasion for 1 of 2 residents reviewed for skin conditions. (Resident 83) Finding includes: Resident 83's clinical record was reviewed on 6/27/24 at 10:22 a.m. Diagnoses included an abrasion of the left foot, subsequent encounter, weakness, and unsteadiness on feet. A physician's order, dated 6/5/25, indicated to clean with Dakins (wound cleanser), apply collagen (wound treatment) to open area, and cover with foam and secure with elastic bandage to left outer foot topically every evening shift for wound healing. This order was discontinued on 6/12/24. A current physician order, dated 6/25/24, indicated to cleanse the left outer foot with Dakins (wound cleanser), apply collagen (wound treatment) to the open area and skin preparation to the tissue surrounding the wound, secure with bordered dressing every night shift on Tuesdays, Thursdays, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide wound care treatment and care as ordered to promote healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 70) Finding includes: Resident 70's clinical record was reviewed on 6/26/24 at 4:20 p.m. Diagnoses included unspecified atrial fibrillation, weakness, chronic pain, and other abnormalities of gait and mobility. A physician order, dated 4/11/24, indicated to clean buttock with normal saline, apply Santyl (wound treatment for debridement) to open area, skin prep surrounding the wound area, and cover with a bordered dressing every evening shift for wound healing. This order was discontinued on 6/4/24. A current physician order, dated 6/4/24, indicated to clean buttock with normal saline apply santyl to the open area, skin prep the surrounding wound area and cover with bordered dressing every shift for wound healing. Review of the treatment administration record for May and June 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.

Based on observation, record review, and interview the facility failed to follow physician orders related to oxygen administration for 2 of 4 residents reviewed for respiratory care. (Residents 60 and 73) Findings include: 1. During an observation on 6/24/24 at 11:23 a.m., Resident 60 was seated upright in bed with a nasal cannula in place. The oxygen concentrator was set to 4 liters per minute. On 6/24/24 at 2:17 p.m., Resident 60 was observed slumped down in her bed with her nasal cannula in place. The oxygen concentrator was set to 4 liters per minute. On 6/25/24 at 10:25 a.m., Resident 60 was observed lying in bed with her nasal cannula in place. The oxygen concentrator was set to 4 liters per minute. On 6/26/24 at 11: 11 a.m., Resident 60 was lying in bed, with her head elevated and her nasal cannula in place. The oxygen concentrator was set to 4 liters per minute. On 6/26/24 at 3:22 p.m., Resident 60 was slumped down in her bed with her nasal cannula in place. The oxygen concentrator was set to 3.5 liters per minute. Resident 60's clinical record was reviewed on 6/26/24 at…

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 and interview, the facility failed to ensure insulin (a medication to treat diabetes mellitus) vials were dated when opened and disposed of when expired for 2 of 6 carts reviewed for medication storage. (Rehab hall cart and 400 hall cart) Findings include: During a medication storage observation of the 400 hall cart, accompanied by LPN 33 on [DATE] at 9:23 a.m., the following was observed: One open vial of Lispro (rapid-acting) insulin, dated [DATE]; the vial was approximately half full. One open vial of Glargine (long-acting) insulin, dated [DATE]; the vial was approximately half full. One open vial of Lispro (rapid-acting) insulin, dated [DATE]; the vial was approximately half full. During an interview at the time of the observation, LPN 33 indicated she thought insulin was good for 30 days, but if a nurse was unsure how long medication was good for, she should ask the unit manager or another staff member. The insulins dated [DATE], [DATE], and [DATE] were expired and should no longer be…

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

Based on observation, interview, and record review, the facility failed to follow infection prevention and control procedures during wound care related to Enhanced Barrier Precautions (EBPs) for 2 of 5 resident reviewed for skin impairments. (Residents 70 and 83) Findings include: During an observation on 6/24/24 at 11:02 a.m., Resident 70's door was closed with an Enhanced Barrier Precaution sign noted on the left side of the door. A personal protective equipment (PPE) canister was to the left of the door just outside the resident door. The sign was readily visible and indicated to use hand hygiene, a gown, and gloves for all high contact resident care to include wound care. During a wound observation and interview on 6/27/24 at 2:38 p.m., LPN 12 and CNA 13 entered Resident 70's Enhanced Barrier Precaution room with the sign visible to the left side of the door along with the personal protective equipment canister. They both performed hand washing, donned gloves, then LPN 12 set everything up for wound care. LPN 12 used gloved hands and removed the moderately soiled dressing from…

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 report an allegation of misappropriation of property within required timeframe to the Indiana Department of Health for 1 of 3 residents reviewed for misappropriation. (Resident C) Finding includes: Resident C's clinical record was reviewed on 4/4/24 at 1:12 p.m. Diagnoses included displaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing, alcohol abuse, difficulty in walking, and weakness. An admission Minimum Data Set (MDS) assessment, dated 2/11/24, indicated the resident was cognitively intact. A Nurse's Note, dated 3/4/24 at 6:55 p.m., indicated the resident was transferred to the hospital emergency room for lethargy. The clinical record lacked information on any personal items sent to the hospital with the resident. A Nurse's Note, dated 3/4/24 at 11:22 p.m., indicated the resident was admitted to the hospital. During an interview on 4/4/24 at 4:40 p.m., Resident C's representative…

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 thoroughly investigate an allegation of misappropriation of resident property for 1 of 3 residents reviewed for misappropriation. (Resident C) Finding includes: During an interview on 4/4/24 at 10:42 a.m., the Administrator was requested to provide the complete investigation files for any abuse/misappropriation investigations held in the last 30 days. Resident C's clinical record was reviewed on 4/4/24 at 1:12 p.m. Diagnoses included displaced intertrochanteric fracture of the left femur, subsequent encounter for closed fracture with routine healing, alcohol abuse, difficulty in walking, and weakness. An admission Minimum Data Set (MDS) assessment, dated 2/11/24, indicated the resident was cognitively intact. He required moderate assistance for transfers, toileting, and dressing. A Nurse's Note, dated 3/4/24 at 6:55 p.m., indicated the resident was transferred to the hospital emergency room for lethargy. The clinical record lacked information on any…

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 document and monitor behaviors and develop and implement a plan of care with targeted behavioral interventions for a cognitively impaired resident for 1 of 3 residents reviewed for behaviors. (Resident C) Findings include: The clinical record for Resident C was reviewed on 11/13/23 at 7:14 a.m. Diagnoses included Alzheimer's disease, anxiety disorder, depressive disorder, and Parkinson's disease. The resident was admitted on [DATE]. A 9/25/23, admission, Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired. Review of a facility self-reportable, dated 10/30/23, indicated during morning care, Resident C bit CNA 1 on the hand, breaking the skin and causing the hand to bleed. Review of the clinical record indicated lack of documentation and/or monitoring for known behaviors. During an interview on 11/13/23 at 8:08 a.m., LPN 2 indicated the resident reported to her that he was hit by a big black man. LPN 2 immediately reported…

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 dietary staff were competent to perform kitchen essential duties. This deficient practice had the potential to impact 118 of 119 residents. Findings include: During an interview on 4/23/23 at 9:23 a.m., [NAME] 16 indicated the Dietary Manager quit a week prior. The Administrator managed the kitchen due to the vacancy. During an observation on 4/25/23 at 11:33 a.m., the Maintenance Director indicated he had filled in as the Dietary Supervisor for the last three days. The kitchen was not kept in a sanitary manner. Staff should have completed a cleaning log check-off each day to ensure the kitchen cleaning was done each day, but it had not been done. He was unable to provide the kitchen cleaning logs. A bottom shelf on the table to the left of the sink remained with significant various food debris, where clean food trays were stored up on their edge. The bottom panel off of the range remained in the floor with brown thick baked on debris. The steam table remained with dried food spatters on the sides 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 observation, interview, and record review, the facility failed to ensure food was prepared, stored, and distributed in a safe and sanitary manner. This deficient practice had the potential to impact 118 of 119 residents who recieved meals from the facility kitchen. Findings include: During an interview on 4/23/23 at 9:23 a.m., [NAME] 16 indicated the Dietary Manager quit a week prior. The Administrator managed the kitchen due to the vacancy. During a kitchen observation on 4/23/23 at 9:23 a.m., the following was observed: a. Dried food was noted baked on the sides of the steam tables and around the temperature adjustment knobs on the side of the steam table with a brown appearance. b. Inside the free standing refrigerator, a package of unidentified lunch meat was opened and wrapped in plastic wrap on the second shelf. It lacked an opened date. c. Inside the microwave, dried food was splattered on the top, bottom, and sides. d. A shelf under the food preparation table, to the left of the sink, had moderate scattered food debris where clean food trays were stored on their…

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 showers according to the resident's preferences for 1 of 3 residents reviewed for choices. (Resident 26) Finding includes: During an interview on 4/23/22 at 11:27 a.m., Resident 26 was resting in her bed with her eyes closed. Her hair was disheveled. She indicated she required staff assistance with her activities of daily living due to numbness in her bilateral hands and the need for a mechanical lift to get out of bed. Staff had provided bed baths, but she felt trapped in her bed and she wanted to get a shower rather than a bed bath. She was unaware of which days of the week she was scheduled to get a shower because she had not been offered a shower. She spoke with a CNA about getting a shower on the shower bed, about two to three weeks ago. When she asked other CNAs about using the shower bed, they were unaware of what she referred to. The resident's family had also contacted the facility about the condition of her hair. Resident 26's clinical record was reviewed on 4/25/23 at 4:17 p.m. 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.

Based on observation, interview, and record review, the facility failed to ensure pressure relieving boots were in place as ordered for 1 or 1 residents reviewed for pressure ulcers. (Resident 85) Findings include: During an observation, on 4/24/23 at 9:10 a.m., Resident 85 was awake, lying in bed without socks or pressure relieving boots. His heels were not floated in the bed. On 4/25/23 at 10:22 a.m., the resident was lying on his back in bed, without pressure relieving boots applied or his heels floated. On 4/26/23 at 9:32 a.m., the resident was observed lying in bed on his right side, facing the window. He was without pressure relieving boots and his heels were not floated. Resident 85's clinical record was reviewed on 4/24/23 at 3:03 p.m. Diagnoses included, Alzheimer's disease, lumbar fracture, muscle wasting, and diabetes mellitus type 2. A significant change (MDS) minimum data set assessment, dated 2/25/23, indicated the resident was cognitively intact, required extensive assistance with bed mobility, dressing, eating, and toileting, and was at risk for impaired skin…

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 there was timely communication maintained between the facility and the hospice provider for 1 of 1 residents reviewed for hospice services. (Resident 85) Findings include: Resident 85's clinical record was reviewed on 4/21/23 at 3:03 p.m. Diagnoses included Alzheimer's disease, muscle wasting, and chronic pain. The resident was admitted to hospice services on 2/23/23. A current care plan, initiated 2/23/23, indicated the resident received hospice services. Interventions included, hospice staff to collaborate with the facility to provide comfort care for the resident through the next review period. During a review of the hospice documentation on 4/26/23, the binder lacked any communication log notes from the nursing staff since 3/29/23. The last documentation of a nursing visit was dated 4/3/23. During an interview, on 4/26/23 at 11:00 a.m., LPN 3 indicated communication between facility staff and hospice staff occurred through the hospice binder. She indicated the binder was not up-to-date, and she 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.

Based on observation and interview, the facility failed to ensure staff completed hand hygiene during medication administration for 1 of 3 staff observed during medication administration. (QMA 5) Findings include: During a medication administration observation on 4/26/23 at 8:53 a.m., QMA 5 was observed preparing medications for Resident 60. She failed to sanitize her hands prior to pulling the residents medications from the medication cart and while handling the medication cup. She placed her right index finger inside the cup when setting it on top of the medication cart. She did not sanitize her hands prior to, or after, administering the medications to the resident. At 9:07 a.m., QMA 5 began to prepare medications for Resident 83. She obtained a medication cup using her index finger and thumb to hold the cup, with her index finger inside the cup. Following preparation of the medication, she placed her right hand, with her palm resting on the top of the medication cup, to move them to the resident's room and administered the medication. QMA 5 went to the back up medication supply…

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.