Waters Of Batesville, The

Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for 2 of 3 residents reviewed for abuse. (Residents D and F)Findings include:1.During an interview, on 01/29/2026 at 9:22 A.M., Resident D indicated Certified Nurse Aide (CNA) 6 was mean and said bad words to him. He would not specify what the bad words were exactly.The clinical record for Resident D was reviewed on 01/30/2026 at 1:25 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cerebral palsy (neurological disorders appearing in infancy that permanently affect body movement), diabetes, and renal insufficiency. The resident was frequently incontinent of urine and bowel.In a CONFIDENTIAL WITNESS STATEMENT, dated 01/11/2026, Resident D indicated CNA 6 had said a bad word to him. Resident D had informed CNA 6 he needed to use the bathroom. The resident reported the aide responded, I will come back later; I've got other people to worry about. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to update a care plan related to suicidal ideation for 1 of 5 residents reviewed for care plans. (Resident B)Findings include:The clinical record for Resident B was reviewed on 01/29/2026 at 9:51 A.M. An admission minimum data set (MDS) assessment, dated 12/30/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, traumatic brain dysfunction (neurological and physical impairments of physical, cognitive, and emotional brain function) , anoxic brain damage (the brain was completely deprived of oxygen, causing widespread brain cell death within minutes), anxiety, and depression. The resident had little interest or pleasure in doing things nearly every day, the resident was feeling down/depressed/hopeless half or more of the days, the resident was feeling tired or having little energy nearly every day, and the resident was feeling bad about self.The resident was admitted to the facility on [DATE].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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility failed to ensure residents received adequate supervision to prevent them from exiting the building and provide One to One supervision for 2 of 3 residents reviewed for accidents. (Residents C and B) Findings include:1.The clinical record of Resident C was reviewed on 01/29/2026 at 10:54 A.M. The resident's diagnosis included, but was not limited to, non-Alzheimer's dementia (a decline in mental abilities) and arthritis. A physician's order dated 11/11/2025 at 6:00 A.M, indicated Resident C had a wander guard on his ankle for risk of elopement from the facility that needed checked for placement and function daily. A Social Services Progress Note, dated 01/16/2026 at 5:31 P.M., indicated Resident C had attempted to follow a visitor out of the facility. The resident's wander guard activated alerting staff. The resident did not exit the facility and was redirected away from the door. 15-minute monitoring of the resident was initiated for 48 hours. 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.

2. The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A current, open-ended physician's order, with a start date of 12/28/24, indicated the resident was to receive Metoprolol (a blood pressure medication) 25 mg, once a day. The staff were to hold the medication if the resident's heart rate was less than 60 or the blood pressure was less than 110/60. The December 2024, January and February 2025 EMAR indicated the resident received the medication when the vital signs were not documented for the following dates and times: - 12/28/24 through 12/31/24, no vital signs were documented, - 01/02/25 through 01/17/24, no vital signs were documented, and - 02/01/25 through 02/10/25, no vital signs were documented. The residents clinical record lacked any vital signs for the above dates. 3. The clinical record for Resident 22 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 interview and record review, the facility failed to provide the required RN coverage on duty for eight hours a day for 16 of the 21 days reviewed. Findings include: The as worked nursing schedule indicated there had not been an RN on duty for eight consecutive hours on the following dates: - Saturday 07/13/24, - Sunday 07/14/24, - Saturday 07/20/24, - Sunday 07/21/24, - Saturday 08/10/24, - Sunday 08/11/24, - Saturday 08/24/24, - Sunday 08/25/24, - Saturday 09/07/24, - Sunday 09/08/24, - Saturday 09/21/24, - Sunday 09/22/24, - Saturday 12/14/24, - Sunday 12/15/24, - Saturday 02/08/25, and - Sunday 02/09/25. During an interview on 02/10/25 at 09:52 A.M., The Director of Nursing (DON) indicated they did have issues with staffing in the previous months. The current, undated facility policy, titled Registered Nurse Coverage was provided by the DON on 02/10/25 at 9:19 A.M. The policy indicated, .It is the policy of the facility to provide the services of an RN for at least 8 consecutive hours per 24 hour day, 7days weekly . 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to store medications appropriately for 3 of 3 medication carts reviewed and 1 of 1 medication rooms reviewed. (39 Back Medication Cart, Front Medication Cart, Rehab Medication Cart, and the 39 Hall Medication Room) Findings include: 1. During a medication administration observation on 02/06/25 at 10:54 A.M., Licensed Practical Nurse (LPN) 4 removed a Fiasp insulin pen from the 39 Back Medication Cart. The pen was laying loosely in the drawer of the medication cart and not in a plastic bag. The pen was labeled with an opened date of 2/1. The pen was not labeled with a resident's name or anything that would identify who the pen belonged to. LPN 4 indicated the pen had been opened and was for Resident 37 because they were the only resident who used that type of insulin. The LPN proceeded to write the resident's name on the pen and administer the insulin to Resident 37. 2. The Front Medication Cart was observed on 02/10/25 at 9:37 A.M., with LPN 3 and contained the following loose pills: - one small oval peach…

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 notify the physician when a resident's blood glucose levels were out of range for 1 of 21 residents reviewed for notification of change. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS (Minimum Data Set) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident's current MD orders included an open-ended order, with a start date of 04/25/24, to administer 3 units of Humalog insulin, three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The resident also had an additional open-ended order, with a start date of 04/25/24, to check the blood glucose and administer an additional dose of Humalog based on a sliding scale (the amount of insulin administered would depend on the resident's blood glucose level) three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. 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 maintain resident records in a private manner related to personal information posted in a public setting for 1 of 54 residents who resided in the building. (Resident 59) Findings include: Resident 59's room was observed on 02/04/25 at 1:17 P.M. Signage on the resident's door indicated he was in contact isolation and enhanced barrier precautions. Posted on the wall next to the door directly above the resident's name and room number was a document titled, Guidelines for addressing Candida auris. The resident's room was observed on 02/05/25 at 9:20 A.M., The signage remained, including the Guidelines for addressing Candida auris documents posted on the wall above the resident's name and room number. During an interview on 02/05/25 at 9:22 A.M., Licensed Practical Nurse 5 indicated resident information, including resident profile information, medication lists, and diagnoses information was private and confidential, and should not be out for public viewing. During an interview on 02/05/25 at 9:30 A.M., 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 follow a acquired a resident's weight related to daily weights for 1 of 4 residents reviewed for nutrition. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual Minimum Data Set (MDS) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. A current, open-ended physician's order, with a start date of 12/28/24, indicated the resident was to be weighed daily. The physician was to be notified if the resident had a weight gain greater than 3 pounds in a day or greater than 5 pounds in a week. The clinical record lacked daily weights on the following dates: - 12/30/24 through 01/02/25, - 01/04/25, - 01/06/25 through 01/07/25, - 01/09/25 through 01/11/25, - 01/13/25 through 01/15/25, - 01/17/25, - 01/20/25, - 01/21/25, - 01/23/25 through 02/02/25, and - 02/04/25. During an interview 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 record review and interview, the facility failed to provide Parenteral/IV (Intravenous) site maintenance for 2 of 3 residents reviewed for vascular access sites. (Residents 4 and 38) Findings include: 1. The clinical record for Resident 4 was reviewed on 02/05/25 at 2:36 P.M. An admission Minimum Data Set (MDS) assessment, dated 01/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, acute osteomyelitis (infection in the bone or bone marrow) of the right ankle and foot. During an interview on 02/10/25 at 8:38 A.M., the Director of Nursing (DON) indicated the resident was admitted to the facility from the hospital and had an infected heel wound with osteomyelitis. The resident had been on IV antibiotics for his wound infection since he was admitted to the facility. During an interview on 02/10/25 at 2:25 P.M., Licensed Practical Nurse (LPN) LPN 2 indicated the resident had a Midline vascular access site in his right arm. He came from the hospital with an access site but then had to have it replaced because it would…

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 completed assessments before and following a resident's dialysis treatments for 1 of 2 residents reviewed for dialysis. (Resident 24) Findings include: During an interview on 02/04/25 at 11:25 A.M., Resident 24 indicated she left the facility for dialysis treatments on Monday, Wednesday, and Friday. During an interview while at the Resident Council Meeting, on 02/06/25 at 2:15 P.M., the resident indicated sometimes when she got back from dialysis, she had to sit in her wheelchair with her coat on for a half an hour before staff helped her. The clinical record for Resident 24 was reviewed on 02/06/25 at 2:41 P.M. A Quarterly Minimum Data Set assessment, dated 12/15/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, renal insufficiency, and diabetes. The resident received dialysis treatments. During an interview on 02/06/25 at 3:20 P.M., the Director of Nursing (DON) indicated the facility staff were supposed to complete an assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide IV (Intravenous) antibiotics in a timely manner for 2 of 3 residents reviewed for IV antibiotics. (Residents 4 and 29) Findings include: 1. The clinical record for Resident 4 was reviewed on 02/05/25 at 2:36 P.M. An admission Minimum Data Set (MDS) assessment, dated 01/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, acute osteomyelitis (infection in the bone or bone marrow) of the right ankle and foot. The resident was admitted to the facility on [DATE]. During an interview on 02/10/25 at 8:38 A.M., the Director of Nursing (DON) indicated the resident was admitted to the facility from the hospital and had an infected heel wound with osteomyelitis. From admission he was on IV antibiotics. The facility had run out of IV tubing. They were out of tubing for two days. The resident was on two different IV antibiotics and missed several doses, 6 doses altogether. The pharmacy 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.

Based on interview and record review, the facility failed to obtain blood tests for 1 of 5 residents reviewed for laboratory services. (Resident 27) Findings include: Resident 27's clinical record was reviewed on 02/06/25 at 11:00 A.M. A Quarterly Minimum Data Set assessment, dated 01/13/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, anxiety, and hypertension. The resident's current MD orders included, but were not limited to, an open-ended order, with a start date of 06/07/23, to check the resident's A1C (a blood test that measures the average blood glucose level over the past 2 to 3 months) every 3 month(s). Based on the physician's orders, the A1C blood tests should have been obtained in March, June, September, and December of 2024. The resident's A1C lab (laboratory) results for 2024 were provided by the Director of Nursing (DON). The resident's A1C was checked in March and December of 2024. During an interview on 02/07/25 at 2:24 P.M., the DON indicated the copies of the A1C labs she provided…

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 maintain a kitchen exterior door in good working order related to food safety for 3 of 3 kitchen observations. This deficient practice had the potential to affect 52 of 54 resident who received food from the kitchen. Findings include: During an initial kitchen observation on 02/04/25 at 10:30 A.M., an exterior kitchen door was cracked open about 1/2 to 1 inch that the outside was visible. The Dietary Manager closed the door. The bottom of the door contained a door draft stopper that was broken on the right side where the door opened to the outside. The part that was broken left an approximately 2-inch gap at the bottom of the door. During an observation on 02/04/25 at 11:01 A.M., an exterior kitchen door was cracked open about 1/2 to 1 inch that the outside was visible. The bottom of the door contained a door draft stopper that was broken on the right side where the door opens to the outside. The part that was broken left an approximately 2-inch gap at the bottom of the door. During an observation and interview on 02/10/25…

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 notify the physician when a resident's blood glucose levels were out of range for 1 of 21 residents reviewed for notification of change. (Resident 29) Findings include: The clinical record for Resident 29 was reviewed on 02/05/25 at 10:44 A.M. An Annual MDS (Minimum Data Set) assessment, dated 01/16/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, anemia, coronary artery disease, heart failure, hypertension, anxiety, and depression. The resident's current MD orders included an open-ended order, with a start date of 04/25/24, to administer 3 units of Humalog insulin, three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. The resident also had an additional open-ended order, with a start date of 04/25/24, to check the blood glucose and administer an additional dose of Humalog based on a sliding scale (the amount of insulin administered would depend on the resident's blood glucose level) three times a day at 7:00 A.M., 12:00 P.M., and 5:00 P.M. 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 interview and record review, the facility failed to update a resident's plan of care related to behaviors for 1 of 5 residents reviewed for care plans. (Resident E) Findings include: A Facility Reported Incident, dated 10/23/24, indicated Resident E reported that him and another resident engaged in sexual touching in the common area. The clinical record for Resident E was reviewed on 11/12/24 at 10:55 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 08/13/24, indicated the resident was cognitively intact. The resident's diagnoses include, but were not limited to, multiple sclerosis and depression. A current care plan, with the start date of 08/06/24 and revised date of 08/22/24, indicated the resident may exhibit inappropriate behavior symptoms related to: sexually oriented, and profane or subjective remarks. The interventions included but were not limited to: dated 08/06/24, encourage resident to verbalize feelings; may refer resident to mental health services including consultations with Psychologist and psychotherapy services; validate resident's feelings 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 record review and interview, the facility failed to follow the physician's orders for obtaining laboratory services for 1 of 3 resident's reviewed for laboratory testing. (Resident B) Findings include: The clinical record for Resident B was reviewed on 09/30/2024 at 9:23 A.M. An admission MDS (Minimum Data Set) assessment, dated 09/11/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, Gastroesophageal reflux disease (GERD), and End Stage Renal Disease (ESRD). A physician's order, dated 09/11/24, indicated the staff were to obtain a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), and a BNP (B-type Natriuretic Peptide). During an interview with Resident B, on 09/30/24 at 3:27 P.M., she indicated a QMA (Qualified Medical Assistant) came into get her blood and was unsuccessful. She was told another nurse would come back and try, but nobody ever came back. During an interview with the Administrator, on 09/30/24 at 2:32 P.M., she indicated that she was unable to find a laboratory (lab) report…

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 medication administration records accurately reflected the administration of narcotic pain medication for 4 of 6 residents reviewed for medication administration. (Residents B, D, G, and H). Findings include: 1. The clinical record for Resident B was reviewed on 4/25/24 at 11:01 A.M. An admission MDS (Minimum Data Set) assessment, dated 03/20/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, arthritis, spinal stenosis, and intervertebral disc displacement. The resident's physician's orders included, but were not limited to, an open ended order, with a start date of 03/11/24, for Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every eight hours as needed for pain. The Controlled Drug Receipt/Record/Disposition Form for the Hydrocodone-Acetaminophen 5-325 mg medication indicated the medication was signed out as given on the following dates and times: - 03/16/24 at 6:00 A.M., - 03/16/24 at 2:00 P.M., - 03/17/24 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.

Based on interview, observation, and record review, the facility failed to ensure a resident did not sustain a skin injury during therapy for 1 of 2 residents reviewed for skin wounds. (Resident B) Findings include: During an interview on 04/24/24 at 9:37 A.M., Resident B indicated he was in the facility related to issues with his back. He participated in physical therapy. A few weeks ago, he was in therapy and his back was burned while he was using the TENS (Transcutaneous Electrical Nerve Stimulation) machine (a device that used low-voltage electrical current to help with pain). The therapist wasn't sure what happened and said the machine malfunctioned. They took the patch off his back, and it had burned the first layer of his skin. The Wound NP (Nurse Practitioner) came in every week to assess and treat the wound. The burn was pretty painful. The wound treatment used to be daily, but now they only have to change it every three days. During an interview on 04/24/24 at 9:50 A.M., the DON (Director of Nursing) indicated the therapist was following the directions on the TENS unit.…

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 the required RN coverage on duty for eight hours a day for 5 of the 16 days reviewed. Findings include: The as worked nursing schedule indicated there had not been an RN on duty for eight consecutive hours on the following dates: - Saturday 11/04/23, - Sunday 11/05/23, - Saturday 11/25/23, - Saturday 12/09/23, and - Sunday 12/10/23. During an interview on 12/14/23 at 2:51 P.M., the Administrator indicated the facility did not have an RN on duty for eight consecutive hours for the days reviewed and they did not have any nurse waivers. The facility did not have a policy for RN coverage, they followed State and Federal regulations. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to notify the appropriate physician of laboratory results for 1 of 20 residents reviewed for notification of change. (Resident 24) Findings include: During an observation and interview on 12/06/23 at 1:40 P.M., Resident 24 indicated she currently had a bad UTI. She was on IV (Intravenous) antibiotics. The IV antibiotic was running at the time. The clinical record for Resident 24 was reviewed on 12/12/23 at 9:38 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. An Infectious Disease Physician's Progress Note, dated 08/01/23 at 6:21 P.M., indicated the resident had cloudy urine and was not on antibiotics. A recommendation was made for staff were to obtain urine for a U/A (Urinalysis) C&S (Culture and Sensitivity) and to please email or call with the results. A UA result, dated 08/03/23, indicated the resident 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.

Based on observation, interview, and record review, the facility failed to follow infection control guidelines and follow physician orders for 2 of 8 residents reviewed for pressure ulcers. (Residents 14 and 18) Findings include: 1. During an observation on 12/06/23 at 12:24 P.M., LPN (Licensed Practical Nurse) 5 retrieved Resident 14's treatment supplies from a treatment cart and stopped outside the resident's room. She placed the supplies on top of cart outside the room. She donned a gown, gloves, and a face mask. She picked up the supplies and went into the resident's room. She placed a paper towel on an over bed table and placed the supplies on top. She removed the resident's sheet, and the resident lifted his right stump. She removed an undated dressing and placed it in a garbage can. The dressing had heavy drainage. She removed a gauze from a package, sprayed it would wound cleanser, and cleansed the wound. She removed a collagen sheet and placed it over the wound with both hands, covered the wound with an abdominal pad. She misplaced her tape and found some on a bedside table…

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 treat a UTI (Urinary Tract Infection) appropriately for 1 of 2 residents reviewed for UTI. (Resident 24) Findings include: During an observation and interview on 12/06/23 at 1:40 P.M., Resident 24 indicated she currently had a bad UTI. She was on IV (Intravenous) antibiotics. The IV antibiotic was running at the time. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. A UA (Urinalysis) result, dated 09/27/23, indicated the resident's urine was positive for nitrates, had 2+ leukocytes, increased white blood cell count, 3+ bacteria, and increased red blood cells, which were all abnormal. A Physician Progress Note, dated 09/28/23 at 12:19 P.M., indicated the resident was seen due to UA that was positive for a UTI. The resident reported fatigue and malaise over the past couple days. The resident had a history of an indwelling…

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 follow a physician's order related to daily weights for 1 of 3 residents reviewed for nutrition. (Resident 48) Findings included: A Quarterly MDS (Minimum Data Set) assessment, indicated Resident 48 was cognitively intact. The diagnoses included, but were not limited to, anemia, heart failure, hypertension, and depression. An open-ended physician order, with a start date of 10/11/23, indicated the resident was to be weighed daily and to notify the MD or NP (Nurse Practitioner) of weight gain of greater than 5 pounds in 3 days. A Physician Note, dated 10/12/23 at 3:56 P.M., indicated the resident was seen. The plan was to continue daily weights and notify provider if greater than 3 pounds in 24 hours or 5 pounds in 1 week. The clinical record lacked that the order was changed to reflect the MD notification of weight gain greater than 3 pounds in 24 hours of 5 pounds in 1 week. The resident had the following weight gains or no weight was provided with no indication that the physician was notified: - On 10/14/23 the weight…

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 coordinate care related to the physician's dialysis form to decrease a resident's medication for 1 of 2 residents reviewed for dialysis. (Resident 42) Findings include: A Quarterly MDS (Minimum Data Set) assessment, dated 11/10/23, indicated Resident 42's cognition was moderately impaired. The resident's diagnoses included, but were not limited to, renal insufficiency and diabetes. The resident received dialysis treatments while a resident. The Dialysis Communication binder was reviewed on 12/12/23 at 9:09 A.M. A Physicians Order Sheet with a note, dated 11/22/23, indicating the resident's Nifedipine medication was to be decreased from 90 mg (milligrams) to 60 mg daily per the Dialysis NP (Nurse Practitioner) 2. The EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) for November and December 2023, was provided by the Interim DON (Director of Nursing) on 12/12/23 at 12:09 P.M. The record indicated the resident had a current order, with a start date of 10/12/23, for Nifedipine…

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 follow physician orders related to medication hold parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 24) Findings include: The clinical record for Resident 24 was reviewed on 12/12/23 at 9:38 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. An open-ended physician's order, with a start date of 04/05/23, indicated the staff were to administer Metoprolol Tartrate (a blood pressure medication) 12.5 mg (milligrams), twice a day, for hypertension. The medication was to be held if the resident's systolic blood pressure (top number) was less than 110. The medication was not held the following dated and times when the resident's systolic blood pressure was less than 110: - 09/16/23 at 8:00 A.M., when the resident's blood pressure was 103/60, - 09/17/23 at 8:00 P.M., when the resident's blood…

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 a resident received the prescribed significant medications upon admission for 1 of 20 residents reviewed. (Resident 53) Findings include: An admission MDS (Minimum Data Set) assessment, dated 09/14/23, indicated the Resident 53 was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, septicemia, anxiety, and respiratory failure. A Progress Note, dated 09/08/23 at 4:27 P.M., indicated the resident arrived to the facility via EMT (Emergency Medical Technician). A Progress Note, dated 09/21/23 at 2:28 P.M., indicated the nurse found four prescriptions from the admitting hospital infectious disease doctor that were written on 09/06/23 for antibiotics and labs. The resident had not received them. She would follow up with the MD tomorrow. The hospital discharge scripts, dated 09/06/23 indicated the resident was to receive the following: - IV (Intravenous) Penicillin (an antibiotic) 3 million units, six times daily, until 09/15/23 for possible…

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 demonstrate that ongoing corrective actions were in place to address unresolved quality deficiencies related to pressure ulcers, that were previously cited on the last annual survey, for 1 of 13 care areas reviewed. (Pressure Ulcers) Findings include: During the Annual Recertification and complaint survey, from 12/06/23 to 12/14/23, one deficiency was a repeated citation from the last annual survey, F686. The facility's Quality Assurance Committee did not implement on-going appropriate measures to correct identified issues or prevent deficiencies as follows: 1. Pressure Ulcers: 2 residents did not received appropriate infection control measures and physician orders followed. During an interview on 12/14/23 at 12:33 P.M., the Administrator indicated the QAPI involved their entire IDT (Interdisplinary Team). They invite Certified Nurse Aides and Nurses because the want the entire building involved to help things flow. They meet monthly. They usually always review wounds, infections, medications, discharges, turnover,…

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 appropriately track and monitor a resident's urinary track infections for 1 of 2 residents reviewed for UTI's. (Resident 24) Findings include: 1. A Quarterly MDS (Minimum Data Set) assessment, dated 11/11/23, indicated Resident 24 was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, hypertension, neurogenic bladder, seizure disorder, and depression. A UA (Urinalysis) result, dated 09/27/23, indicated the resident's urine was positive for nitrates, had 2+ leukocytes, increased white blood cell count, 3+ bacteria, and increased red blood cells, which were all abnormal. A Physician's Progress Note, dated 09/28/23 at 12:19 P.M., indicated the resident was seen due to UA that was positive for a UTI. The resident reported fatigue and malaise over the past couple days. The resident had a history of indwelling catheter and had a strong urine odor. The residents preliminary culture results were positive for proteus mirabilis and they would start the resident on IV Cefazolin (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 record review and interview, the facility failed to provide COVID-19 booster immunizations in a timely manner for 2 of 6 residents reviewed for immunizations. (Residents 10 and 53) Findings include: 1. The clinical record for Resident 10 was reviewed on [DATE] at 10:14 A.M. The resident was admitted on [DATE]. A Quarterly MDS (Minimum Data Set) assessment, dated [DATE], indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes and chronic obstructive pulmonary disease. The Informed Consent - Vaccination - COVID-19 record, signed by the resident and the resident's representative on [DATE], indicated the resident had received a copy of the most current COVID-19 Fact Sheet as published by the CDC (Centers for Disease Control), the resident understood the benefits and risks associated with the vaccine and consented to receive the vaccination as determined by current CDC guidelines. The resident had received the following COVID-19…

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 complete wound treatments as ordered by the physician for 1 of 5 residents reviewed for quality of care. (Residents D) Findings include: 1. The clinical record for Resident D was reviewed on 11/13/23 at 11:00 A.M. An admission MDS (Minimum Data Set) assessment, dated 08/31/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, hip and knee replacement, hypertension, renal insufficiency, diabetes, anxiety, and depression. a. A physician's order, dated 09/01/23 through 09/27/23, indicated the staff were to cleanse the resident's right third toe with wound cleanser, apply bacitracin (an antibiotic ointment), and cover with a Band-Aid every day shift. The September 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident's right third toe treatment was not completed on 09/15/23, 09/16/23, 09/24/23, 09/26/23, and 09/27/23. b. A physician's order, dated 09/08/23 through 10/02/23, indicated the staff were to cleanse…

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 hospice medications were administered as ordered by the physician for 1 of 4 residents reviewed for medication administration. (Resident M) Findings include: The clinical record for Resident M was reviewed on 11/14/23 at 10:15 A.M. The resident's diagnoses included, but were not limited to, secondary malignant neoplasm of retroperitoneum and peritoneum, dehydration, weakness, and malignant neoplasm of hypopharynx. A Progress Note, dated 11/08/23 at 8:35 P.M., indicated the hospice nurse came to the facility with morphine (a pain medication) and Ativan (an antianxiety medication) for the resident. New orders were received. The hospice nurse indicated the resident was in the end stages of life. The November 2023 EMAR/ETAR indicated the resident had the following physician orders with no documentation the medications were administered on the following dates and times: - A physician's order, with a start date of 11/09/23 at midnight, indicated the resident was to receive Lorazepam (an antianxiety medication) 0.25 ml…

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 appropriate infection control guidelines for residents who were under isolation precautions for Covid-19. (Residents L and H) Findings include: 1. During an observation on 11/13/23 at 2:28 P.M., CNA (Certified Nurse Aide) 2 went to answer a call light for Resident L's room. The CNA donned an N-95 mask from an isolation cart sitting in the hallway and entered Resident L's room. The CNA failed to don a gown, gloves, or clean his hands. He wore his own glasses. The sign posted on the outside of the room door indicated the resident was in Droplet/Contact Isolation and prior to entering the room staff were to clean their hands, don a gown, gloves, mask, and eye protection. The resident was sitting near the door to the room watching a television that sat on a small dresser. During an interview on 11/13/23 at 2:30 P.M., CNA 2 indicated if they were going into an isolation room, just to shut off the call light or bring in ice water and not providing patient care, he wore a mask and gloves. If he was providing…

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 clarify the physician's order and administer wound treatments for 1 of 3 residents reviewed for skin impairments. (Resident J) Findings include: The clinical record for Resident J was reviewed on 09/14/23 at 2:00 P.M. An admission MDS (Minimum Data Set) assessment, dated 08/18/23, indicated the resident was admitted to the facility from an acute hospital on [DATE]. The resident was cognitively intact. The diagnoses included, but were not limited to, diabetes and peripheral vascular disease. The resident had a recent amputation of their right leg above the knee. The physician's order for the resident's treatment of the surgical wound from the discharging hospital indicated the wound dressing was to be changed daily. The wound was to be cleansed with saline and gauze. Saline soaked gauze was to be packed into the wound. Alginate (a type of wound dressing), an absorbent pad, and gauze wrap were to be applied to the wound. If the wound was too wet, 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 obtain a urinalysis in a timely manner for a resident with signs and symptoms of a urinary tract infection for 1 of 3 residents reviewed for urinary tract infections. (Resident E) Findings include: A Nursing Progress Note, dated 02/12/23 at 6:10 A.M., indicated the resident's blood sugar was elevated and the resident had not eaten or drank anything on the 10:00 P.M. to 6:00 A.M. shift. The resident's urine is like light brown sludge. Will pass information on to day shift. A Nursing Progress Note, dated 02/13/23 at 9:54 A.M., indicated the MD was updated on the resident's urine and sediment. A new order was given, and the responsible party was updated. A Nursing Progress Note, dated 02/17/23 at 1:03 P.M., indicated the resident's urine was obtained as ordered for a UA (urinalysis) and was sent to the local hospital lab by courier. A Nursing Progress Note, dated 02/18/23 at 2:15 A.M., indicated there were no results from the hospital on the resident's UA at that time. A Nursing Progress Note, dated 02/21/23 at 6:38 P.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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were available for administration and follow physician's orders for 1 of 4 residents reviewed for medications. (Resident C) Findings include: An admission MDS (Minimum Data Set) assessment, dated 07/12/23, indicated the resident was admitted to the facility from a hospital on [DATE]. The resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, bipolar disorder, and enterocolitis due to Clostridium difficle (C.diff, a bacteria). The resident's July 2023 EMAR (Electronic Medication Administration Record) was reviewed on 09/12/23 at 2:00 P.M. The EMAR indicated the resident had a physician's order, with a start date of 07/07/23, for vancomycin (an antibiotic) oral solution, 25 mg/ml (milligrams per milliliter). Give 5 ml by mouth four times a day for infection for 7 days. The first dose of the medication was scheduled to be administered on 07/07/23 at 8:00 P.M., with subsequent doses scheduled at 8:00…

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.