Ambassador Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was referred for home health nursing services upon discharge for 1 of 3 residents reviewed for discharge. (Resident B)Findings include:The clinical record for Resident B was reviewed on 7/17/25 at 11:10 a.m. His diagnoses included, but were not limited to, mechanical complication of internal left knee prothesis, infection and inflammatory reaction due to internal left knee prosthesis, hypertension, and type 2 diabetes mellitus. He was admitted to the facility on [DATE] and discharged on 6/18/25. The 6/7/25 admission MDS (Minimum Data Set) assessment indicated he was cognitively intact.An interview was conducted with Resident B on 7/18/25 at 3:03 p.m. He indicated he had an infection in his leg and was on IV (intravenous) antibiotics four times a day while at the facility. When he was discharged from the facility on 6/18/25, they should have ordered nursing services for him, not just therapy. He wasn't able to get the IV antibiotics…

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 implement fall interventions, as care planned; transfer a resident utilizing a gait belt, as required; ensure position change alarm use was monitored for efficacy on an on-going basis; and ensure position change alarm use was aimed at assisting staff to assess for patterns and routines of residents for 4 of 5 residents reviewed for accidents. (Residents 23, 31, 41, and 71) Findings include: 1. The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. She was admitted to the facility on [DATE]. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing,…

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 privacy during care for 2 of 2 random observations (Resident 50 and Resident 36). Findings include: 1. During a medication pass observation on 4/28/25 at 10:10 a.m., Registered Nurse (RN) 11 knocked on Resident 50's door and walked in without waiting for a response. Resident 50 was standing up in front of his wheelchair and Certified Nurse Aide (CNA) 10 was applying an incontinent brief on the resident. The resident had no clothes on, and the privacy curtain was not pulled. Resident 50 was visible to the hallway. Review of the clinical record of Resident 50, on 4/30/25 at 11:10 a.m., indicated the diagnoses included, but were not limited to, schizophrenia, diabetes, depression, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 3/3/25, indicated the resident was cognitively intact for daily decision making. The resident was frequently incontinent of bowel and bladder. 2. Review of the clinical record of Resident 36, on 4/28/25 at 10:35 a.m., indicated the diagnoses included,…

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 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. An observation and interview were conducted with Resident 71 in her room on 4/24/25 at 11:59 a.m. She was lying in bed with the covers over her. Her call light was clipped to her outer cover but was wedged between her left side enabler bar and mattress. Resident 71 attempted to reach for her call light but was unable to reach it. She indicated, I can't reach it. I need my call light. An observation and interview were conducted with Resident 71 in her room on 4/30/25 at 1:14 p.m. She was lying in bed with the covers over her. Her call light cord was wrapped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain comfortable sound levels for 1 of 5 residents reviewed for accidents. (Resident 71) The clinical record for Resident 71 was reviewed on 4/24/25 at 11:55 a.m. Her diagnoses included, but were not limited to, rheumatoid arthritis, diabetes mellitus, and stage four pressure ulcer of sacral region. She was admitted to the facility on [DATE]. The 1/14/25 Annual MDS (Minimum Data Set) assessment indicated she was cognitively intact. She was totally dependent for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. She required substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. The physician's orders indicated to check the function and placement of her bed and chair alarm every shift, effective 9/11/23. The 9/11/23 at risk for falls care plan indicated she would climb out of bed and onto the floor mat and unplug her bed alarm. Interventions were bed 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 nail care and oral care for 3 of 3 residents reviewed for activities of daily living (ADLs). (Resident 9, Resident 66 and Resident 23) Findings include: 1. During an observation on 4/23/25 at 1:05 p.m., Resident 9 had a dark substance underneath her fingernails on both hands. During an observation on 4/28/25 at 9:46 a.m., Resident 9 had a dark substance underneath her fingernails on both hands. During an observation and interview on 4/28/25 at 12:44 p.m., Resident 9 had a dark substance underneath her fingernails on both hands. Resident 9 indicated her fingernails were horrible. During an observation and interview on 4/29/25 at 10:08 a.m., Certified Nurse Aide (CNA) 12 verified Resident 9 had a black substance under her fingernails. CNA 12 indicated that the aides were supposed to clean her fingernails on bed bath days. Resident 9 received her bed bath on evening shift. CNA 12 indicated she was unsure if Resident 9 was a diabetic,…

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 timely provide optometry services and timely address a resident's missing glasses for 2 of 3 residents reviewed for vision services. (Residents 38 and 91) Findings include: 1. The clinical record for Resident 38 was reviewed on 4/24/25 at 12:10 p.m. Her diagnoses included, but were not limited to, cataracts, history of cerebral infarction, and dementia. The 3/26/25 Quarterly MDS (Minimum Data Set) assessment indicated she was cognitively intact. An interview and observation were conducted with Resident 38 in her room on 4/24/25 at 12:13 p.m. She indicated she had a hard time seeing, needed glasses, and hadn't seen the optometrist lately. She was not wearing glasses at that time. The physician's orders indicated she may be seen by the optometrist, effective 3/22/19. The 3/30/20 facility optometry provider's Request for Services Consultation indicated to please have the optometrist examine Resident 38. The 6/30/23 eye exam indicated new…

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 pressure wound interventions for a resident at high risk of developing pressure areas for 1 or 2 residents reviewed for pressure wounds. (Resident 67) Findings include: The clinical record for Resident 67 was reviewed on 4/28/2025 at 2:08 p.m. The medical diagnoses included anoxic brain injury and contractures. A Significant Change Minimum Data Set Assessment, dated 2/14/2025, indicated Resident 67 was able to participate in his cognition exam, was severely cognitively impaired, and at risk for developing pressure areas. A skin care plan, last revised 4/7/2025, indicated to provide Resident 67 with wound care as ordered. A physician order, dated 4/24/2025, indicated to apply a foam dressing to the top of Resident 67's right foot as a preventative measure. A wound practitioner note, dated 4/28/2025, indicated for Resident 67 to encourage the use of pressure reducing (prevalon) boots at all times. During an observation on 4/29/2025 at 12:01 p.m., Resident 67 was observed in bed. Resident 67's pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement and provide interventions for a resident with bilateral hand contractures for 1 of 2 residents revived for range of motion (ROM). (Resident 98) Findings include: Review of the clinical record of Resident 98, on [DATE] at 10:12 a.m., indicated the diagnoses included, but were not limited to, anoxic brain damage, anxiety, and respiratory arrest. The admission assessment for Resident 98, dated [DATE], indicated both arms were contracted at varying degrees. The admission Minimum Data Set (MDS) assessment for Resident 98, dated [DATE], indicated the resident was severely cognitively impaired for daily decision making. The resident had impairment on both sides of his upper extremities. The plan of care for Resident 98, revised date of [DATE], indicated the resident was at risk for skin breakdown due to bilateral upper extremity contractures. During an observation on [DATE] at 1:20 p.m., Resident 98 was lying in bed, 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 interview and record review, the facility failed to ensure 1 of 3 residents reviewed for pressure ulcers received the care and services required to treat the identified wound and documented the status of the wound routinely. (Resident B) Findings include: The clinical record of Resident B was reviewed on 2-10-25 at 11:02 a.m. His diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) with a dependency on supplemental oxygen, a history of TIA's (transient ischemic attacks or mini strokes), opioid abuse in remission, anxiety, polyneuropathy, hypertension, peripheral vascular disease and vascular dementia. His admission Minimum Data Set (MDS) assessment, dated 12-16-24, indicated Resident B was admitted to the facility with one unstageable pressure ulcer. In a telephone interview on 2-10-25 at 10:30 a.m., with a family member of Resident B, she indicated the skin issue to the coccyx area developed while he was at home, prior to going to an area hospital and then to the facility. A review of Resident B's nursing progress notes, dated 12-7-24,…

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.

Based on interview and record review, the facility failed to complete a thorough investigation of the root cause of a fall and failed to implement a fall intervention for 1 of 3 residents reviewed for accidents (Resident B). Findings include: Review of the clinical record for Resident B, on 1/7/25 at 1:30 p.m., indicated the diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic pain, hypertension, hypertensive heart disease, muscle weakness, need for assistance with personal care, dementia, abnormal gait, anxiety, and osteoarthritis. A progress note for Resident B, dated 12/2/24 at 1:57 a.m., indicated the resident pushed the call light and was found on the floor next to the bed. The resident stated she had a headache prior to the fall and when she got out of the bed, she slid to the floor. The resident denied hitting her heard. There were no injuries noted. The resident was assisted back to bed. The resident indicated she was going to get a clean shirt and was assisted with changing her shirt. The physician was notified. A progress note…

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 have complete and accurate documentation of a resident's fall for 1 of 3 residents reviewed for accidents (Resident B). Findings include: Review of the clinical record for Resident B, on 1/7/25 at 1:30 p.m., indicated the diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic pain, hypertension, hypertensive heart disease, muscle weakness, need for assistance with personal care, dementia, abnormal gait, anxiety, and osteoarthritis. A progress note for Resident B, dated 12/2/24 at 3:57 a.m., indicated the staff were checking on the resident often during the night. The resident was found sitting on the floor next to her bed. The resident indicated she was sitting on the side of the bed and slid off. There were no injuries noted. The resident was assisted back to bed. The resident's bed was in the lowest position and call light was in reach. The physician was notified. This progress note was struck out with lines through it, dated 12/2/24 at 8:04 a.m., with the strike out reason…

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 medication administration was conducted in a safe manner and did not include leaving medication at a resident's bedside unattended for 1 of 25 residents rooms observed for unattended medications. (Resident G) Findings include: During random observations of 25 resident rooms for unattended medications on 12/4/24, between 12:58 p.m. and 2:00 p.m., with the facility's Director of Nursing (DON), one resident room was observed with two medication cups of two similar-looking white oblong tablets and observed in close proximity to Resident G. Resident G was observed seated in his recliner with his rollator located adjacent to the recliner. On the rollator, one pill cup containing two large, white oblong tablets were observed, with a second pill cup containing two large, white oblong tablets were observed on his overbed table. All four tablets appeared to resemble each other. Resident G indicated he had asked the nurse who provided the medication to him to leave the meds for him to take later. During 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 residents remained free from physical abuse for 2 of 13 residents reviewed for abuse. (Resident K and Resident M) Findings include: 1. The clinical record for Resident K, reviewed on 9/4/24 at 1:37 p.m., indicated diagnoses that included, but were not limited to, unspecified dementia, cognitive communication deficit, cardiovascular disease, and hypertension. An admission Minimum Data Set (MDS) assessment, dated 7/1/24, indicated Resident K had severe cognitive impairment. Resident K exhibited other behavioral symptoms not directed towards others one to three days during the lookback period. A progress note written by Licensed Practical Nurse (LPN) 2, dated 8/31/24 at 7:57 p.m., indicated, [Resident K] observed pacing unit making attempts to grab at peers. He did make contact to the wrist of one female peer and immediately let go when staff intervened. [Resident K] then repeated the grabbing of another female peer twisting her wrist. [Resident K] was redirected and he did let go after nursing staff…

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

Based on interview and record review, the facility failed to thoroughly report an allegation of sexual abuse and report resident to resident physical altercations to the Indiana Department of Health (IDOH) for 4 of 13 residents reviewed for abuse (Resident N, Resident P, Resident K and Resident M). Findings include: 1. The incident report filed by the facility to IDOH, dated 9/2/24 at 2:35 a.m., indicated there was an alleged altercation between Resident N and Resident P. During an interview with the Administrator on 9/3/24 at 2:32 p.m., he indicated, on 9/2/24 during third shift, Qualified Medication Aide (QMA) 10 reported to Registered Nurse (RN) 11 that Resident N reported to QMA 10 he had entered Resident P's room and touched her genitalia. RN 11 reported the incident to the Administrator and called the police. RN 11 assessed Resident P and there were no findings. Resident N was placed on 1 to 1 with staff. This was an ongoing investigation. During an interview with the Police Chief on 9/3/24 at 2:38 p.m., they indicated the police had obtained a standard Deoxyribonucleic Acid…

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 complete initial assessments after a fall and follow-up assessments after residents had a fall with injury for 2 of 3 residents reviewed for accidents. (Resident D and Resident C) Findings include: 1. Review of the clinical record of Resident D, on 9/3/24 at 11:40 a.m., indicated the diagnoses included, but were not limited to, schizoaffective disorder, bipolar disorder, dementia, unsteadiness on feet, muscle weakness, abnormal gait and anxiety. The quarterly Minimum Data Set (MDS) assessment for Resident D, dated 6/8/24, indicated the resident was severely cognitively impaired. A progress note for Resident D, dated 8/23/24 at 9:01 a.m., indicated the Interdisciplinary Team (IDT) met to discuss the resident's fall on 8/22/24. Resident D went into another resident's room and the other resident was helping Resident D leave her room and Resident D fell to the ground. The resident sustained a skin tear to her right elbow and voiced complaints of pain to the elbow. Range of motion (ROM) was per usual. An order 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, interview, and record review, the facility failed to monitor and supervise a resident with dementia resulting in the potential for resident-to-resident interaction and failed to monitor and supervise residents on the memory care unit, assess residents, conduct follow-up, and notify family and the physician of inappropriate sexual contact between two residents for 4 of 13 residents reviewed for abuse. (Resident N, Resident P, Resident K and Resident L) Findings include: 1a. Review of the clinical record of Resident N, on 9/5/24 at 1:34 p.m., indicated the diagnoses included, but were not limited to, schizoaffective disorder, osteoarthritis, major depressive disorder and insomnia. The quarterly Minimum Data Set (MDS) assessment for Resident N, dated 6/14/24, indicated the resident was cognitively intact for daily decision making. 1b. Review of the clinical record of Resident P, on 9/5/24 at 1:55 p.m., indicated the diagnoses included, but were not limited to, dementia, weakness, need for personal care, unsteadiness on feet, chronic obstructive pulmonary disease,…

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 their policies and procedures related to abuse prohibition were implemented for the prohibition of staff to resident abuse, for reporting of an allegation of abuse within two hours of the facility learning of the abuse allegation to the Indiana Department of Health's Long Term Care Division and for ensuring all persons with any facts or observations who might have pertinent information related to the alleged abuse were included in the investigation for 3 of 3 residents reviewed for staff to resident abuse. (Residents B, C, D and CNA 3) Findings include: A. The facility filed a reportable incident on 3-20-24 with the Indiana Department of Health, Long Term Care Division, citing concerns related to CNA 3, touching two male residents inappropriately while providing personal care to them during the night shift of 3-19-24 into 3-20-24. The report indicated an investigation had begun and CNA 3 had been suspended, pending results of the investigation. In an interview with the Executive Director (ED) on 4-16-24 at 2:43…

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 staff to resident sexual abuse to the Indiana Department of Health's Long Term Care Division and other state agencies within two hours of the facility being made aware of the abuse. (Residents B, C, D and CNA 3) Findings include: The facility filed a reportable incident on 3-20-24 with the Indiana Department of Health, Long Term Care Division, citing concerns related to CNA 3, touching two male residents inappropriately while providing personal care to him during the night shift of 3-19-24 into 3-20-24. The report indicated an investigation had begun and CNA 3 had been suspended, pending results of the investigation. In an interview with the Executive Director (ED) on 4-16-24 at 2:43 p.m., he indicated on the morning of 3-20-24, he was informed by the Director of Nursing (DON) she had received a report of an allegation of sexual abuse regarding Resident C by CNA 3. On 4-16-24 at 4:55 p.m., the ED provided a copy of a timeline of events surrounding this incident. It indicated the DON received 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 beard restraints were utilized while working with food. This had the potential to affect 89 out of 94 residents who receive food from the kitchen. Findings include: A kitchen tour was conducted on 2/13/24 at 9:45 a.m., with the Dietary Manager (DM). [NAME] 22 was observed in the food preparation area with the DM and they both were observed with having facial hair and no beard restraint was utilized. Another kitchen tour was conducted on 2/13/24 at 10:47 a.m., with the DM and [NAME] 22. The food temperatures were obtained and both DM and [NAME] 22 were standing over the food without wearing a beard restraint. A kitchen observation was conducted on 2/16/24 at 10:43 a.m., with the DM and [NAME] 22 noted with facial hair and no utilization of a beard restraint. A kitchen observation and interview was conducted on 2/16/24 at 1:23 p.m., with the DM indicated [NAME] 22 has a clean cut to his facial hair and would not have to wear a beard restraint. The DM indicated [NAME] 24 and Dietary Staff 26, who were…

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 reviewed, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed timely, or at least every 92 days, for 3 of 4 residents reviewed for MDS timeliness. (Resident 36, 73, and 79) Findings include: 1 The clinical record for Resident 36 was reviewed on 2/19/2024 at 11:48 a.m. An admission record for Resident 36 indicated she was admitted on [DATE] with a diagnosis of muscle weakness. An admission MDS Assessment for Resident 36 had an Assessment Reference Date (ARD) of 8/24/2023. No follow up assessment was reflected on the record upon reviewed on 2/19/2024. A discharge assessment for Resident 36 was completed on 2/19/2024 and dated with an ARD date of 9/14/2023. 2. The clinical record for Resident 73 was reviewed on 2/19/2024 at 11:57 a.m. An admission record for Resident 73 indicated she was admitted on [DATE] with a diagnosis of dementia. A Quarterly MDS Assessment for Resident 73 had an ARD date of 9/29/2023. The next MDS assessment had an ARD date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to accurately code dental status for Resident 82, failed to accurately code Resident 79's urinary status, and failed to accurately code falls for Resident 93. This affected 3 of 34 residents reviewed. Findings include: 1. Resident 82 was observed, on 2/14/24 at 11:08 a.m., to have no teeth. Resident 82's record was reviewed on 2/15/24 at 10:53 a.m. The record indicated Resident 82 had diagnoses that included, but were not limited to, stroke, difficulty swallowing, and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment, dated 3/7/23, indicated no natural teeth or tooth fragment(s) (edentulous) was not marked, which indicated the resident did have teeth. On 2/19/24 at 2:00 p.m., the MDS coordinator, provided paperwork from her admission assessment where the family had said she had her own teeth, and this was documented on the baseline care plan. The MDS coordinator indicated the MDS should have been been marked for 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.

Based on observation, interview, and record review, the facility failed to update Resident 12's care plan after refusal to use a lap buddy, failed to update a care plan after Resident 2 had bruising, and failed to update Resident 93's care plan with fall interventions. This affected 3 of 34 residents reviewed for care plan revisions. Findings include: 1. During an observation, on 2/15/24 at 10:42 a.m., Resident 12 was observed sitting in her wheelchair in her room, watching TV. She did not have a lap buddy (a firm, flat, pillow like device to provide upper body support, help with posture, and reminds residents to ask for help before getting out of their chair) in place. On 2/15/24 at 2:40 p.m., Resident 12 was sitting in her wheelchair in her room, eyes closed, TV on, and had no lap buddy in place. On 2/16/24 at 9:00 a.m., Resident 12 was sitting in her wheelchair in her room, TV on, and had no lap buddy in place. On 2/19/24 at 10:20 a.m., Resident 12 was sitting in her doorway in her wheelchair and had no lap buddy in place. Resident 12's record was reviewed on 2/14/24 at 2:45 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.

Based on observation, interview, and record review, the facility failed to provide a dependent resident with nail care, and failed to ensure facial hair was to a resident's preference. This affected 2 of 7 residents reviewed for activities of daily living care. (Residents 82 and 93) Findings include: 1. During an observation, on 2/14/24, at 11:07 a.m., Resident 82's nails were observed to be long with a black substance on the nails of both hands. On 2/15/24, at 10:33 a.m., Resident 82 was observed to have a yellow substance under some of the nails on her right hand, and her left hand had a black substance under 2 of the nails that were observable due to the left hand contracture. On 2/15/24, at 2:38 p.m., Resident 82 sat near the nurse's desk, in a Broda (a specialty chair for comfort and mobility) chair, asleep. The fingernails on her right hand were soiled with a dark substance, her left hand was contracted and unable to view at that time. Resident 82's record was reviewed on 2/15/24, at 10:53 a.m., and indicated diagnoses that included, but were not limited to, stroke, left sided…

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 in room activities for 1 of 4 residents reviewed for activities (Resident 59). Finding include: During an observation on 2/13/24 at 11:18 a.m., Resident 59 was sitting in her room with no TV or radio on, no magazine, books or any self initiated activities available. The resident was sitting in her recliner staring at the wall. During an observation on 2/14/24 at 2:35 p.m., Resident 59 was sitting in her room with no TV or radio on, no magazine, books or any self initiated activities available. The resident was sitting in her recliner staring at the wall. During an observation on 2/15/24 at 1:48 p.m., Resident 59 was sitting in her room with no TV or radio on, no magazine, books any self initiated activities available. The resident was sitting in her recliner staring at the wall. Review of the record of Resident 59 on 2/19/24 at 1:20 p.m., indicated the resident's diagnoses included, but were not limited, schizoaffective disorder, dementia, vascular dementia, unsteadiness on feet, abnormal gait, bipolar…

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 date a gastrostomy tube (G-Tube) dressing and failed to date the piston irrigation syringe for 1 of 1 residents reviewed for G-Tube (Resident 49). Finding include: During an observation on 2/13/24 at 11:25 a.m., Resident 49's piston irrigation syringe was sitting on her bedside table with no date and the resident's G-tube dressing was not dated. During an observation on 2/14/24 at 2:40 p.m., Resident 49's piston irrigation syringe was sitting on her bedside table with no date and the resident's G-tube dressing was not dated During an observation on 2/15/24 at 1:49 p.m., Resident 49's piston irrigation syringe was sitting on her bedside table dated 2/15/24 and the resident's G-tube dressing was dated 2/15/24. Review of the record of Resident 49 on 2/15/24 at 10:10 a.m., indicated the resident's diagnoses included, but were not limited to, cerebral infarction, vascular dementia, muscle weakness, major depressive disorder, post traumatic stress disorder, apraxia, difficulty walking, unsteadiness on feet, anxiety,…

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 wound treatments were signed off as administered, conduct weekly would assessments on a pressure ulcer, and ensure there was not multiple treatments for the same pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: The clinical record for Resident B was reviewed on 2/16/24 at 2:23 p.m. The diagnoses included, but were not limited to, pressure ulcer of sacral region, peripheral vascular disease, acquired absence of left leg below knee, cerebrovascular disease, and chronic pain. An admission nursing assessment, dated 8/17/23, indicated shearing above coccyx and bilateral buttocks. A wound assessment, dated 8/29/23, indicated a stage 2 pressure ulcer was present to Resident B's coccyx. The coccyx wound was documented as resolved on 9/19/23. A Quarterly Minimum Data Set (MDS) assessment, dated 11/10/23, indicated a stage 4 pressure ulcer, diabetic foot ulcer, along with infection of the foot. A wound care…

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 Passive Range Of Motion (PROM) exercises for 1 of 4 residents reviewed for Range Of Motion (ROM) (Resident 49). Finding include: During an observation and interview on 2/13/24 at 11:27 a.m., Resident 49 had a left hand contracture with no splint in place. The resident indicated she did not want to wear a splint. During an observation and interview on 2/15/24 at 1:49 p.m., Resident 49 had a left hand contracture. The resident indicated the staff did not provide her with PROM exercises and she would like to participate in a PROM program. Review of the record of Resident 49 on 2/15/24 at 10:10 a.m., indicated the resident's diagnoses included, but were not limited to, cerebral infarction, vascular dementia, muscle weakness, major depressive disorder, post traumatic stress disorder, apraxia, difficulty walking, unsteadiness on feet, anxiety, hemiplegia/hemiparesis and cerebral infarction affecting left non-dominant side. The plan of care for Resident 49, dated 3/13/23, indicated the resident had left sided…

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 observation, interview and record review the facility failed to ensure fall interventions were implemented and failed to transfer a resident in a safe manner for 2 of 5 residents reviewed for accidents (Resident 87 and Resident 72). Finding include: 1.) During an interview with Resident 87 on 2/13/24 at 11:43 a.m., indicated she had a fall in the last six months, she was unsure what caused her to fall. During an observation on 2/14/24 at 2:50 p.m., Resident 87 was lying in bed, there was no fall mat beside her bed. During an observation on 2/15/24 at 1:56 p.m., Resident 87 was lying in bed, there was no fall mat beside her bed. Review of the record of Resident 87 on 2/19/24 at 2:10 p.m., indicated the resident's diagnoses included, but were not limited to, diabetes, dementia, muscle weakness, age related physical debility, hypertension, major depressive disorder and rheumatoid arthritis. The Quarterly Minimum Data (MDS) assessment for Resident 87, dated 12/9/23, indicated the resident was moderately impaired for daily decision making. The fall risk assessment for Resident 87,…

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 date oxygen tubing and storage bag, failed to store oxygen tubing in a sanitary manner when not in use and failed to have a physician order for oxygen therapy for 2 of 4 residents reviewed for respiratory therapy (Resident 72 and Resident 2). Findings include: 1.) During an observation 2/13/24 on 11:57 a.m., Resident 72 had a portable oxygen on her wheelchair, the resident was receiving oxygen via nasal cannula. The oxygen tubing and the storage bag was not dated. During an observation on 2/14/24 at 2:45 p.m , Resident 72 had a portable oxygen on her wheelchair, the oxygen tubing and nasal cannula was lying the seat of her wheelchair not stored in the storage bag. The oxygen tubing and the storage bag was not dated. During an observation on 2/15/24 at 1:58 p.m., Resident 72 had a portable oxygen on her wheelchair, the oxygen tubing and nasal cannula was lying the wheelchair wheel not stored in a storage bag. CNA 1 indicated hospice staff must not have put it in the storage bag when they assisted the resident 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.