Majestic Care Of Avon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident Council Grievance concerns related to call light wait and response times was addressed in a timely and effective manner to prevent ongoing concerns for 5 of 82 residents who attended the Resident Council Meeting and complained on behalf of all 82 residents who resided in the facility. Findings include: During an interview on 8/7/24 at 8:53 a.m., the Executive Director (ED) indicated, he could not find Resident Council Minutes from October 2023 through (-) February 2024. The ED indicated, since he and the new Activity Director (AD) started, they had been keeping track of and organized the minutes. At that time, the ED provided copies of the minutes from March 2024 - July 2024. Minutes from a meeting held on 3/26/24 at 2:30 p.m. indicated, .overnight staff call lights on for 1-2 hours- staff on phones all the time including during resident care Minutes from a meeting held on 4/29/24 at 1:30 p.m., indicated, .night shift,…

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 the facility's non-smoking policy was followed and allowed unassessed residents who smoked to smoke on the facility grounds and keep smoking materials in their rooms for 6 of 6 residents reviewed for smoking (Resident 6, 22, 26, 67, 77, and 79). Findings include: A list of smokers in the facility was requested from the Executive Director (ED) and Director of Nursing (DON) several times on 8/4 and 8/5/24. The facility provided the list on 8/6/24 at 1:52 p.m. 1. On 8/6/24 at 1:08 p.m., Resident 6 was observed smoking a cigarette. He was in his wheelchair, in the parking lot in front of the facility. On 8/6/24 at 10:14 a.m., Resident 6's record was reviewed. His diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis of left non-dominant side (partial paralysis), epilepsy (brain disorder with recurring seizures), diabetes mellitus (DM) (blood sugar disorder), and tobacco use. A smoking care plan, dated 4/23/24, indicated Resident 6 was 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 label and date medications when opened and remove expired medications from use for 3 of 5 medication carts and 1 of 2 refrigerators observed for medication storage. Findings include: 1.On 8/4/24 at 10:14 a.m., the 600 hall medication cart was observed for medication storage. a. Resident 26 had an albuterol AER 90 mg (milligram) inhaler (used to treat breathing conditions) with no date to indicate when it was opened. b. Resident 26 had trelegy ellipta (used to treat breathing conditions) 100/62.56/25 mcg (microgram) without a date to indicate when it was opened. c. Resident 22 had a bottle of fluticasone nasal spray (used for allergies) 50 mcg without a date to indicate when it was opened. 2.On 8/4/24 the 700 hall medication cart was observed for medication storage. a. Resident 32 had a Humalog insulin pen with a date opened of 5/24/24. It had expired on 6/23/24. b. Resident 2 had a Humalog insulin pen with a date opened of 5/29/24. It had expired on 6/27/24. c. Resident 2 had a glargine insulin pen with 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 ensure resident assessments were completed for 1 of 1 resident who self-administers medications (Resident 15). Findings include: On 8/4/24 at 12:01 p.m., Resident 15 was observed to have medications in her room and bathroom. On her over the bed table, she had fluticasone nasal spray (treats chronic rhinosinusitis) and carboxymethylcellulose eye drops (treats dry eyes), and on her bathroom counter she had metronidazole (treats facial rosacea). On 8/6/24 at 10:28 a.m., Resident 15's record was reviewed. Her physician orders included, but were not limited to: fluticasone nasal spray dated 1/3/24, may keep at bedside to self-administer; carboxymethylcellulose eye drops dated 1/3/24, may keep at beside and self-administer; and metronidazole lotion dated 5/17/24, unsupervised self-administration. A document titled, Medication Self-Administration Safety Screen, dated 1/3/24, indicated Resident 15 could keep at bedside and self-administer fluticasone nasal spray. It indicated eye drops and topical creams were 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.

Based on record review and interview the facility failed to accurately code falls on the MDS (Minimum Data Set) for 1 of 2 Residents reviewed for MDS accuracy (Resident 53). Findings include: On 8/6/24 at 2:18 p.m., Resident 53's medical record was reviewed. She was a long-term care resident who resided on the secured Memory Care (MC) unit with diagnoses which included, but were not limited to, Alzheimer's disease with late onset (Alzheimer's is a type of dementia, dementia is an irreversible degenerative brain disease which affects memory and cognitive function). A nursing progress note, dated 5/14/24 at 5:53 a.m., indicated, Resident 53, .was up in the hall several times in the night, and escorted back to bed. During a.m. bed check she was seen in a male patient's bed, while being escorted back to her room she fell on her right hip that had a brush in the pocket and c/o [complains of] pain at that hip . A hospital History & Physical, dated 5/15/24, indicated, Resident 53 sustained a fall and had suffered an acute, impacted, nondisplaced right subcapital femoral neck fracture.…

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 sufficient licensed nurse coverage was available on the weekends for 1 of 4 quarters of staffing reviewed which had the potential to effect 82 of 82 residents who resided in the facility. Findings include: On 8/6/24 at 9:30 a.m., the facilities CASPER report was reviewed and indicated, staffing concerns had been triggered in the second quarter of 2024 for low weekend staffing. On 8/8/24 at 8:36 a.m., the actual worked licensed nursing schedule was request for the month of May 2024. On 8/8/24 at 10:47 a.m., the above requested schedule was provided by the Executive Director (ED) and reviewed at that time. For the first week of the month, May 1 through (-) 7th, the licensed staff per-patient-per-day (licensed staff PPD- the number of hours a licensed nursing staff member is granted per patient, per day) averaged to 0.74. For the second week of the month, May 8th-14th, the licensed staff PPD averaged 0.62. For the third week of the month, May 15th-21st, the licensed staff PPD averaged 0.61. For the fourth week 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two cognitively impaired residents who wished to have a relationship and resided on the secured memory care unit had assessments for appropriateness, ongoing supervision, and person-centered goals and interventions for 2 of 3 residents reviewed for dementia services (Residents 53 and 55). Findings include: On 8/6/24 at 2:07 p.m., Resident 53 was unable to be located after looking in her room, her private bathroom, the secured memory care (MC) activity/dining room and in the therapy gym. During an interview on 8/6/24 at 2:08 p.m., the MC Facilitator (MCF) indicated, Resident 53 was probably visiting with her friend, Resident 55, and asked two passing Certified Nursing Aides (CNAs) to find Resident 53. CNA 17 and CNA 18 went to Resident 55's room. Resident 55 and Resident 53 were observed lying in bed together with Resident 55's arm wrapped around Resident 53's waist. The CNAs indicated Resident 53 visited Resident 55 all the time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure the secured memory care unit provided person-centered care, supervision, and engaging activities to prevent resident-to-resident altercations and/or accidents. These deficient practices had the potential to affect 30 of 30 residents who resided in the secured memory care unit (Residents L, B, EE, GG, X, M, N, W, FF, and HH). Findings include: During a confidential interview, a visiting family member indicated, there were a lot of residents that wandered on the locked memory care unit. When they came to visit their loved one, they would be interrupted several times by residents who would wander into the room while they visited. It had really bothered their loved one when they first moved in, but they have since gotten used to it. It could be problematic for some other residents and the visitor sometimes heard other residents yelling at their peers to get out. The family member indicated the unit was usually staffed with two aides…

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 non-verbal, cognitively impaired resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident B). Findings include: During the survey, the family provided the video from Resident B's web camera showing the abuse on 2/4/24. In the video Qualified Medication Aide (QMA) 11 was standing on the left side of the bed next to Resident B. The blankets were off of Resident B and QMA 11 was preparing to change the resident's incontinence brief. Certified Nurse Aide (CNA) 12 came to the right side of the bed from the bathroom. CNA 12 was smiling and talking with QMA 11. Resident B was calm and watching QMA 11 and CNA 12. Once CNA 12 was next to Resident B, CNA 12 reached over and grabbed Resident B's left arm and left hip to pull her toward her while QMA 11 pushed the resident's back and left shoulder to turn her onto her right side toward CNA 12. Resident B slid her legs down off the edge of the bed like she was getting out of bed. Resident B moved her hands toward CNA 12's lower arm and elbow…

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 staff immediately reported to the Administrator witnessed abuse by another staff member to a resident for 1 of 3 residents reviewed for abuse (Resident B). Findings include: During the survey, the family provided the video from Resident B's web camera showing the abuse on 2/4/24. In the video Qualified Medication Aide (QMA) 11 was standing on the left side of the bed next to Resident B. The blankets were off of Resident B and QMA 11 was preparing to change the resident's incontinence brief. Certified Nurse Aide (CNA) 12 came to the right side of the bed from the bathroom. CNA 12 was smiling and talking with QMA 11. Resident B was calm and watching QMA 11 and CNA 12. Once CNA 12 was next to Resident B, CNA 12 reached over and grabbed Resident B's left arm and left hip to pull her toward her while QMA 11 pushed the resident's back and left shoulder to turn her onto her right side toward CNA 12. Resident B slid her legs down off the edge of the bed like she was getting out of bed. Resident B moved her hands toward 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 ensure the kitchen foods were dated, all refrigeration units had working thermometers, the kitchen was clean, and staff facial hair was covered for 3 of 3 kitchen observations, and the facility failed to ensure staff used appropriate hand hygiene with making, delivering, and assisting to fed residents for 4 of 4 random observations (Residents 4, 59, 71, and 95). Findings include: 1. On 6/25/23 at 9:46 a.m., a trash can was observed uncovered. On 6/25/23 at 9:48 a.m., Dietary Aide (DA) 34 was observed wearing a surgical mask in the kitchen, the sides of his beard were exposed. On 6/25/23 at 9:49 a.m., the Kitchen Manager in Training (KMIT) provided a tour of the kitchen. She indicated the Kitchen Account Manager (KAM) 24 was her supervisor and was training her. On 6/25/23 at 9:53 a.m., DA 26 was observed in the kitchen with no hair net and no beard cover, only a surgical mask. During the initial kitchen tour, on 6/25/23 from 9:54 a.m. to 10:10 a.m., the following was observed. a. The double refrigerator had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Resident Council received responses and follow-up for their requests and grievances related for 6 of 6 months of resident council notes reviewed. This deficient practice had the potential to effect 92 of 92 residents who resided in the facility. Findings include: On 6/29/23 at 12:25 p.m., the Resident Council (RC) Meeting Minutes were reviewed. On 1/10/23 the RC met and requested the creation of a Dietary Council group. There was no response. Additionally, the RC indicated Housekeeping/Laundry department needs work. Although a grievance form was submitted late, on 1/19/23, it was not responded to until 2/16/23. On 2/14/23 the RC met and discussed new concerns related to the Nursing Department which included, staff use of cell phones, language barriers, and call light response times. There was no response. The RC discussed concerns related to the Dietary department which included, a request to have more consistent mealtimes, resident…

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 information for the Indiana Long-Term Care Ombudsman Program was easily available and accessible for Residents and/or their representatives to review for 5 of 6 days of the survey. This deficient practice had the potential 92 of 92 residents who resided in the facility. Findings include: Upon the survey entrance on 6/25/23 and on 6/26/23, 6/27/23, 6/28/23, and 6/29/23 information related to the Ombudsman program was not visibly posted in the facility. During an interview on 6/28/23 10:18 a.m., the Activity Assistant indicated she had worked since September and had never heard of the Ombudsman program and was unfamiliar with the term. She did not know if information about the program was available for Residents to review and would not know where it would be posted. On 6/29/23 at 2:30 p.m., a Resident Council meeting was conducted with 5 residents who regularly attended the monthly meetings and included the attendance of the Resident Council President. When asked if they knew who their Ombudsman 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.

A. Based on observation, interview, and record review, the facility failed to ensure randomly tested memory care (MC) resident rooms had water temperatures able to reach 100 degrees Fahrenheit (F) for 11 of 11 resident rooms tested for water temperature (Resident 8, 51, 52, 59, 67, 71, 75, 76, 77, 85 and 95). B. Based on observation, interview, and record review, the facility failed to ensure the resident rooms in the 800 hall and in MC were clean and a home-like environment for 22 of 22 residents' rooms observed on the 800 hallway and MC unit (Resident 4, 8, 9, 16, 21, 26, 43, 45, 46, 47, 52, 54, 57, 67, 76, 77, 81, 85, 95, 100, 113, and 252). Findings include: A. On 6/25/23 at 1:52 p.m., Certified Nursing Aide (CNA) 27 indicated the facility had issues with water not getting hot enough on the memory care (MC) unit on the 100 hallway and 300 hallways. The residents' showers were only lukewarm, and the MC residents complained of being cold during showers. On 6/25/23 at 1:55 p.m., the Administrator (Admin) brought a digital thermometer and provided the warmest water temperatures in…

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

Based on observation, interview, and record review, the facility failed to provide oxygen therapy and respiratory care according to physician orders and residents' plans of care for 4 of 4 residents reviewed for oxygen therapy (Residents 6, 48, 251, and 252). Findings include: 1. On 6/26/23 at 11:39 a.m., observed Resident 6, lying in bed. The oxygen was not being administered and the tubing and trach mask were draped over the easy air machine (EasyAir compressor is a high performance portable medical air compressor designed to supply compressed air 24 hours a day), and oxygen concentrator at the bedside. On 6/27/23 at 2:03 p.m., the resident was sitting on the bed. His hair was oily with white and yellow flakes in his hair. The resident was more receptive and communicated with a white board. He had a trach speaking device but chose not to use it. The Larrytube (a flexible silicone tube designed to maintain the stoma right after the laryngectomy surgery) was in a cup filled with water next to the bed. A tracheostomy (trach) inner cannula tube (an inner tube inserted within the main…

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 kitchen had enough staff to provide meals in a timely manner for 92 of 92 resident who received food from the kitchen. Findings include: 1a. On 6/25/23 at 11:46 a.m., 15 memory care (MC) resident were observed in chairs in the dining room. Awaiting lunch that was due to begin at 12:00 p.m. They had no drinks. On 6/25/23 at 12:49 p.m., 25 MC resident were observed in the dining area waiting for lunch. They had no drinks. Staff were trying to keep them engaged by redirecting them to stay in the dining room. The first tray out to the MC dining room was at 12:57 p.m. The KMIT indicated the trays were late coming out because there were only to dietary staff working in the kitchen. She indicated there were only 2 of us and we are doing the best we can do. 1b. On 6/25/23 at 12:10 p.m., no food had been provided in the main dining room. The Administrator came in and started proving drinks. On 6/25/23 at 1:00 p.m., the residents in 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 ensure the memory care (MC) did not have crawling insects in resident rooms and the kitchen for 2 or 2 observations (Resident 57). Findings include: 1. On 6/28/23 at 1:21 p.m., Resident 109, a MC resident, was observed in her bed. Her floor was sticky and three small, separate, gravel ant hills were observed on her outside wall. Her bed was about 3 feet away from the outside wall. The ants were observed crawling on the floor and through two of the ant hills. On 6/28/23 at 1:24 p.m., Qualified Medication Aide (QMA) 6 indicated she saw the ants and ant nests on the floor of Resident 57's room in the past and had reported it. She would let Environmental Services know about it and her expectation was for the housekeeping staff to keep the floors clean. On 6/28/23 at 1:28 p.m., Certified Nursing Assistant (CNA) 29 indicated she had reported the issues with the ant nests in Resident 57's room. The ants brought in that small gravel from outside. On 6/28/23 at 1:32 p.m., Resident 77 indicated sometimes she would see…

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 a resident with timely toileting assistance resulting in discomfort for the resident for 1 of 1 random observation (Resident 78). Findings include: During an observation, on 6/27/23 at 2:10 pm, Resident 78 was sitting in his doorway with his call light was on. At 2:14 p.m., an unidentified staff member walked by the resident and asked what he needed. He indicated he needed to use the bed pan and it was almost too late. He indicated he had been waiting 90 minutes. The 2 staff members then went into another room on the hall. At 2:16 p.m., CNA (Certified Nursing Assistant) 7 asked him what he needed, and he told her same information as above. She went into his room and turned off the call light, exited the room, and proceeded down the hall. The resident remained in the doorway. At 2:20 p.m., CNA 7 exited the other resident's room and walked by Resident 78 without assisting him. Resident 78 turned on his call light again. At 2:22 p.m., CNA 7 exited a resident's room, proceeded to the food cart, and moved…

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 A. Based on observation, interview, and record review, the facility failed to ensure a resident who had a history of falls with fractures, had fall interventions in place to prevent the potential for additional falls for 1 of 8 residents reviewed for accidents (Resident 7). B. Based on observation, interview, and record review, the facility failed to ensure a memory care (MC) resident's room was free of medications for 2 of 2 random observations (Resident 16) and failed to ensure a resident with medications in her room was accessed for safety to self-administrate medications (Resident 252) for 1 of 8 residents reviewed for accidents. Findings include: A. On 6/28/23 at 9:25 a.m., Resident 7 was observed. She was seated in a regular high back wheelchair (WC) and was assisted by Certified Nursing Aide (CNA) 19 back into her room to lay down. CNA 19 conducted a stand and pivot transfer without placing a gait belt around the resident, neutralizing/stabilizing the low air loss mattress (LAL) or locking the WC's…

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 a resident received care for constipation for 1 of 1 resident reviewed for bowel continence (Resident 14). Finding includes: On 6/25/23 at 11:18 a.m., Resident 14 indicated on 6/20/23 she was severely constipated. She had been trying to have a bowel movement for two hours and she could not go. She asked the nurse for an enema and was told the staff did not give enemas. The staff only gave laxatives. The resident then called 911 and asked them to take her to the hospital for an enema. The resident went to the hospital by ambulance and was given an enema at the hospital. After she returned to the facility, the staff asked the resident why she had called 911. The resident replied she called because she needed someone who would help her. The resident indicated prior to going to the hospital she was bloated and in severe pain. On 6/28/23 at 1:52 p.m., Licensed Practical Nurse (LPN) 10 indicated after three days of no bowel movement (BM), she would do a bowel assessment, then administer Miralax if the resident did 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.