Ignite Medical Resort Chesterton

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to wound treatments for 1 of 3 residents reviewed for pressure ulcers. (Resident G and H)Finding includes:Resident G's record was reviewed on 12/9/25 at 3:55 p.m. The diagnoses included, but were not limited to, diabetes, fracture of left tibia, and spiral fracture of left fibula.The 11/3/25 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident was dependent with lower body dressing, putting on footwear, toileting, and showering. The resident had surgical wounds on admission.A Care Plan, dated 11/29/25, indicated the resident had obtained a pressure injury to the left heel. Interventions were to follow facility protocols for treatment of injury and to evaluate and treat per physician orders.The Treatment Administration Record (TAR) for the month of 12/2025 indicated wound care was not signed out on the following dates: 12/1/25 and 12/2/25.During an interview on 12/10/25…

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 observation and interview, the facility failed to ensure a resident's call light was in reach for a resident who was trying to be put back to bed for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident H)Finding includes:On 9/25/25 at 11:33 a.m., Resident H was observed sitting in a wheelchair in her room. The resident appeared fatigued and was visibly shaking in the wheelchair. The resident indicated she had been waiting to be put back to bed. Her husband had asked the staff to put her back to bed when he left for the day and he was told it would be a while because they had a lot of things to do. The resident indicated she tried to press her call light again because she really needed to go back to bed and could not locate it. At 11:35 a.m., RN 1 was notified that Resident H could not locate her call light and wanted to be put back to bed. RN 1 looked around the room and located the resident's call light in the back corner of the room out of reach and not in view of the resident. RN 1 notified the resident that she would find an aide to assist her…

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 residents received the necessary care and treatment related to medications not given as ordered for 1 of 3 residents reviewed for death, (Resident C) and 2 of 3 residents reviewed for infections. (Residents J and H)Findings include:1.Resident C's closed record was reviewed on 9/24/25 at 9:34 a.m. Diagnoses included, but were not limited to, congestive heart failure (CHF), diabetes mellitus and acute kidney failure. The resident was admitted on [DATE] and passed away in the facility on 2/16/25. The 5-day Minimum Data Set (MDS) assessment, dated 2/16/25, indicated the resident was cognitively intact and required partial to moderate assistance for bed mobility and transfers. A Physician's Order, dated 2/10/25, indicated to give furosemide (a diuretic) 20 milligrams (mg) every day for CHF. A Physician Progress Note, dated 2/15/25, indicated the resident had complained of shortness of breath. The note indicated the plan was to give one more dose 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 record review and interview, the facility failed to ensure residents received the necessary care and treatment for dialysis related to lack of pre and post dialysis assessments, an incorrectly scheduled medication and not providing medications to be given at dialysis for 2 of 3 residents reviewed for dialysis. (Residents D and K)Findings include:1.Resident D's record was reviewed on 9/24/25 at 12:40 p.m. Diagnoses included, but not limited to, diabetes mellitus, acute respiratory failure and end stage renal failure dependent on dialysis. The resident was hospitalized from 9/19-9/23/25. The admission Minimum Data Set assessment, dated 9/18/25, indicated the resident was cognitively intact, was dependent for bed mobility and transfers and received renal dialysis. A Physician's Order, dated 9/8/25, indicated the resident went to dialysis on Tuesday, Thursday and Saturday. The order was discontinued on 9/21/25 while hospitalized . A Physician's Order, dated 9/15/25, indicated to give levetiracetam (a…

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

Based on record review and interview, the facility failed to ensure a copy of the resident transfer or discharge form was provided to the Office of the State Long Term Care Ombudsman's office prior to transfers or discharges as required. This had the potential to affect all discharged residents since May 2024. Finding includes: During an e-mail correspondence on 6/3/25, the State Ombudsman indicated the they had not received any notifications of transfers or discharges from the facility since May 2024. During an interview on 6/4/25 at 12:58 a.m., the Administrator indicated she was not aware the State Ombudsman notifications of transfers and discharges were still a requirement. She indicated the facility had not been sending them out. The policy, Ombudsman Notification, updated 5/2024, indicated, 1. Transfers/discharges initiated by the facility require the Ombudsman be sent a copy of the notice before or as close possible to the actual time of the facility-initiated notification to the resident

Based on record review and interview, the facility failed to ensure cognitively impaired residents were provided with ongoing activities to meet their preferences for 3 of 3 residents reviewed for activities. (Residents E, J and B) Findings include: 1. Resident E's record was reviewed on 6/2/25 at 9:10 a.m. Diagnoses included, but were not limited to, metabolic encephalopathy, heart disease and fracture of the right pubis. The admission Minimum Data Set (MDS) assessment, dated 5/8/25, indicated the resident had severe cognitive impairment and required maximum assistance for toileting and moderate assistance for transfers. The admission Activity assessment, dated 5/2/25, indicated the resident enjoyed snacks between meals, Hallmark movies, game shows, going out with family, pet visits and to attend Catholic services. The Activity Director provided a list of residents who were scheduled to be seen for one-on-one visits on 5/6, 5/15, 5/28 and 5/29/25. On 5/15/25, Resident E was noted not to be in the room. There was no documentation if the one-on-one visits had occurred or what type of…

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

Based on record review and interview, the facility failed to initiate medication administration in a timely manner for 1 of 3 residents reviewed for pharmacy services. (Resident C) Finding includes: The record for Resident C was reviewed on 6/3/25 at 1:12 p.m. Diagnoses included, but were not limited to, congestive heart failure, COVID-19, and pneumonia. The 5/9/25 admission Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and required moderate assistance with activities of daily living and transfers. A Progress Note, dated 5/9/2025, indicated the resident tested positive for COVID-19. The May 2025 Medication Administration Record (MAR) indicated Paxlovid (an antiviral medication used to treat COVID-19 infection for those who are at a high risk of developing severe illness) was ordered for the resident on 5/9/2025. The medication was not initiated until 5/12/2025. During an interview on 6/4/25 at 11:30 a.m. the Director of Nursing indicated the Paxlovid was not started until 5/12/2025 because they were waiting for the medication to arrive…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was treated with respect and dignity related to a delay in assisting a resident to the bathroom upon request by the resident for 1 of 10 residents reviewed for respect and dignity. (Resident B) Finding includes: During an interview and observation on 4/23/25 at 4:42 p.m., Resident B's call light had been activated. She was sitting in her wheelchair in her room and two family members were also present. The resident indicated she needed to use the bathroom and began to propel her wheelchair to the bathroom. At 4:50 p.m., LPN 1 entered the room and the resident informed the nurse she really needed to use the bathroom. The LPN indicated she would be a second and left the room. At 4:54 p.m., the resident stated, I guess they forgot I needed to go, then stated, come on. At 4:55 p.m. the resident wanted to know where the staff was and indicated she was told they would be right back. CNA 2 and CNA 3 then entered the room and assisted the resident to the bathroom. The resident then voided on the…

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

Based on observation, record review, and interview, the facility failed to ensure bladder training and post void residuals (urine amount in the bladder after voiding) were completed and documented after a urinary catheter was discontinued. The facility also failed to ensure the amount of urinary output was recorded for 3 of 3 residents reviewed for urinary catheters. (Residents D, H, and L) Findings include: 1. During an observation and interview on 4/23/25 at 7:05 p.m., Resident D was sitting on the side of her bed. A urinary catheter was present with clear urine in the tubing. She indicated she voided constantly and has an appointment with a urologist. Resident D's record was reviewed on 4/24/25 at 2:25 p.m. The diagnoses included, but were not limited to, right femur fracture, stroke, and urinary tract infection. An admission Minimum Data Set (MDS) assessment, dated 4/10/25, indicated a moderately impaired cognitive status, no behaviors, required maximum assistance for toileting, moderate assistance for transfers, a urinary catheter was present, and no bladder training had been…

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 correct Personal Protective Equipment (PPE) was used by a staff members (CNA 2 and CNA 3) when providing care to a resident (Resident B) who was in Enhanced Barrier Precautions (EBP) for one random observation for infection control. Finding includes: During an interview and observation on 4/23/25 at 4:42 p.m., Resident B's call light had been activated. Upon entering the room, a magnetic sign was on the outside door frame that indicated EBP was required when providing care. At 4:55 p.m., CNA 2 and CNA 3 entered the room, donned gloves and began to assist the resident to the toilet. The CNA's were stopped and asked if the resident required EBP and both CNA's stated, no and continued to assist the resident to transfer to the toilet. The resident's incontinent brief was changed after incontinence care had been completed. She was then dressed in a clean pair of slacks and transferred back to the wheelchair. Resident B's record was reviewed on 4/24/25 at 9:24 a.m. The diagnoses included, but were not…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was treated with respect and dignity, related to a delay in assisting a resident out of bed upon request by the resident for 1 of 8 residents reviewed for respect and dignity. (Resident J) Finding includes: During an observation on 3/11/25 at 12:30 p.m., Resident J activated the call light. RN 1 responded to the call light and the resident indicated she wanted her meal tray removed and assistance to get out of bed. RN 1 informed the resident the staff were with another resident and when they were done, someone would assist her out of bed. During observations on 3/11/25 at 12:44 p.m., 1:21 p.m., 1:21 p.m., and 2:37 p.m., the resident remained in bed. During an interview on 3/11/25 at 2:37 p.m., the resident indicated she had been informed someone would be in to help her out of bed and no one had come to assist her. She indicated this happened often and she had things she had planned to do, but was unable to do them since she still remained in bed. During an interview on 3/11/25 at 2:39 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 record review and interview, the facility failed to ensure a resident's Power of Attorney (POA) was notified of falls for 1 of 3 residents reviewed for physician/responsible party notification. (Resident E) Finding includes: Resident E's record was reviewed on 3/11/25 at 3:11 p.m. The diagnoses included, but were not limited to, pneumonia, fracture of the right arm, infection of the right hand, and dementia. The record indicated the resident had a POA who was the first contact person in case of changes/emergency. An admission Minimum Data Set assessment, dated 1/23/25, indicated a severely impaired cognitive status. Fall Investigations, dated 2/1/25 at 4:09 p.m., 2/9/25 at 7:40 a.m., and 2/15/25 at 5:34 p.m., indicated the resident had fallen. The person listed as number two for contact had been notified and not the POA. There was no documentation in the record that indicated the POA had been notified or why the second person was the one notified of the falls. During an interview on 3/13/25 at 10:50 a.m., the Clinical [NAME] President and Director of Nursing were unsure why…

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

Based on observation, record review, and interview, the facility failed to ensure a resident who was dependent for care received incontinent care in a timely manner for 1 of 3 residents reviewed for incontinent care. (Resident F) Finding includes: During an observation on 3/11/25 at 10:50 a.m., Resident F's call light had been activated by a visitor in the room. RN 4 answered the call light and was informed by the visitor that the resident needed his incontinent brief changed. RN 4 and CNA 5 began the incontinence care. The resident's gown and top sheet were wet and the incontinent brief was saturated with urine. The incontinent pad under the resident was soaked with urine and under the pad were two large dried yellow/brownish rings from urine. The abdominal binder worn by the resident was also wet. RN 4 acknowledged the urine saturation and dried urine rings. The resident indicated he was last changed yesterday. During an interview on 3/11/25 at 11:16 a.m., CNA 2 indicated she was assigned to Resident F. She started work at 6 a.m. and had not yet checked on Resident F. She…

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

Based on observation, record review, and interview, the facility failed to ensure residents received necessary care and services, related to skin assessments not completed as ordered by the Physician for residents with a brace and a immobilizer for 2 of 8 residents reviewed for quality of care. (Residents E and H) Findings include: 1. During an observation on 3/11/25 at 11:24 a.m., resident E was sitting in the wheelchair. There was a brace on the right wrist/forearm. Resident E's record was reviewed on 3/11/25 at 3:11 p.m. The diagnoses included, but were not limited to, pneumonia, fracture of the right arm, infection of the right hand, and dementia An admission Minimum Data Set assessment, dated 1/23/25, indicated a severely impaired cognitive status and had a fall with a fracture prior to the admission into the facility. A Physician's Order, dated 1/17/25, indicated skin checks were to be completed weekly on day shift every Monday and Thursday and a Skin Evaluation must be completed when each assessment was completed. A Physician's Order, dated 1/18/25, indicated the staff 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.

Based on observation, record review and interview, the facility failed to ensure care plan interventions were in place to prevent falls for 1 of 3 residents reviewed for falls. (Resident E) Finding includes: During observations on 3/11/25 at 10:49 a.m., 2:44 p.m. and on 3/12/25 at 10:13 a.m., there was no stop sign in Resident E's room to remind the resident to call for assistance and no floor mat in the room. During an interview on 3/12/25 at 10:13 a.m., RN 3 indicated there was no stop sign or floor mat located in the room. Resident E's record was reviewed on 3/11/25 at 3:11 p.m. The diagnoses included, but were not limited to, pneumonia, fracture of the right arm, infection of the right hand, and dementia. An admission Fall Risk Assessment, dated 1/17/25, indicated a high risk for falls. An admission Minimum Data Set assessment, dated 1/23/25, indicated a severely impaired cognitive status, required maximum assistance with transfers, was dependent for toileting and wheelchair mobility, was occasionally incontinent of bladder and frequently incontinent of bowel, and had a fall…

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

Based on observation, record review, and interview, the facility failed to ensure a resident's feeding tube was infusing at the correct flow rate for 1 of 1 resident reviewed for feeding tube usage. (Resident F) Finding includes: Resident F was observed lying in bed with the head of the bed elevated on 3/11/25 at 10:50 a.m. and 3/12/25 at 2:56 p.m. The tube feeing of Jevity 1.5 was infusing at 55 cc/hr (cubic centimeters (cc) per hour). During an interview on 3/12/25 at 2:56 p.m., LPN 6 indicated the tube feeding was infusing at 55 cc/hr and the bottle of the feeding indicated the feeding should have been infusing at 20 cc/hr. Resident F's record was reviewed on 3/12/25 at 2:35 p.m. The diagnoses included, but were not limited to, blood stream infection due to central venous catheter and dementia. The resident was admitted into the facility on 3/7/25. A Care Plan, dated 3/7/25, indicated a gastrostomy tube was present and he required enteral nutrition. The interventions included the tube feeding would infuse per current physician orders. A Physician Order, dated 3/7/25 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 care for a midline catheter (inserted into a vein in the upper arm for intravenous [IV] treatments) in accordance with professional standards of practice related to lack of measurements of the catheter length, dressing changes to the site, assessments of the site and flushes of the catheter for 1 of 1 resident reviewed with a midline catheter. (Resident E) Finding includes: Resident E's record was reviewed on 3/11/25 at 3:11 p.m. The diagnoses included, but were not limited to, pneumonia, fracture of the right arm, infection of the right hand, and dementia. An admission Minimum Data Set assessment, dated 1/23/25, indicated a severely impaired cognitive status. A Physician's Order, dated 3/6/25, indicated a midline catheter was to be inserted for IV antibiotic administration. A Physician's Order, dated 3/6/25, indicated Unasyn (antibiotic) 1.5 grams was to be given every 12 hours for seven days for a hand infection. The treatment was to start on 3/7/25 at 6:00 a.m. A Care Plan, dated 3/7/25, indicated IV antibiotics 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.

Based on observation, record review, and interview, the facility failed to ensure a resident who required respiratory care received care consistent with profession standards and was administered oxygen as ordered by the physician for 1 of 1 resident reviewed for respiratory care. (Resident E) Finding includes: During observations on 3/11/25 at 11:24 a.m., 12:24 p.m., and 12:27 p.m., Resident E was sitting in the wheelchair at a table in the lounge by the Nurses' Station. There was a nasal cannula present and in place. The portable oxygen unit was turned off. During the observation on 3/11/25 at 12:27 p.m., the Assistant Director of Nursing turned the portable oxygen unit on. She indicated the oxygen was just turned on at two liters per minute. Resident E's record was reviewed on 3/11/25 at 3:11 p.m. The diagnoses included, but were not limited to, pneumonia, fracture of the right arm, infection of the right hand, and dementia. A Physician's Order, dated 3/8/25, indicated oxygen was to be administered at two liters per minute every shift. A Care Plan, dated 3/9/25, indicated oxygen…

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 correct Personal Protective Equipment (PPE) was used by a staff member (CNA 2) when providing care to a resident (Resident E) who was in Enhanced Barrier Precautions (EBP) for two random observation for infection control. Finding includes: During an observation on 3/11/25 at 2:44 p.m., CNA 2 applied gloves and placed Resident E in bed. The resident had been incontinent of a moderate amount of urine and a small bowel movement. Incontinent care was completed by CNA 2. There was no sign on the door that indicated the resident was on EBP. During an observation on 3/12/25 at 10:13 a.m., there was a sign on the door that indicated the resident was on EBP and a container for the PPE was located on the door of the room. CNA 2 was in the bathroom with the resident and had assisted her into the wheelchair from the toilet. CNA 2 wore gloves and indicated care had just been completed due to diarrhea. CNA 2 had not donned a protective gown for the care and stated she was unaware the resident was on EBP. CNA 2…

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

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to food debris on food preparation equipment, dirty convection ovens, food not labeled and dated, and the proper test strips not available to check the sanitation buckets for 1 of 1 kitchen. (The Main Kitchen) and 1 of 2 resident refrigerators. (The D Wing refrigerator) This had the potential to affect 67 of 67 residents who resided in the facility and received food from the kitchen. Findings include: 1. During the Initial Kitchen Sanitation Tour on 10/27/24 at 9:47 a.m. with [NAME] 1, the following was observed: a. There was food debris underneath and behind the stainless steel lid for the salad bar. b. There was a sticky residue on the lid of the storage bins for the flour and sugar. c. An accumulation of dust and debris was observed on top of the convection oven and the bottom shelf of the stand that housed the convection oven. d. A bag of cocoa was opened on a shelf in the dry storage room. e. The reach in freezer contained a bag of onion rings that 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.

Based on observation and interview, the facility failed to keep kitchen areas clean related to debris on the floor, an accumulation of a dried substance on the garbage disposal, and an accumulation of dust and dead insects inside the plastic light covers for 1 of 1 kitchen observed. (The Main Kitchen) Findings include: 1. During the Initial Kitchen Sanitation Tour on 10/27/24 at 9:47 a.m. with [NAME] 1, the following was observed: a. There was an accumulation of food debris on the floor of the walk in freezer and underneath the shelf. b. The garbage disposal, located next to the dishwasher, had a thick accumulation of an orange substance on the outside. 2. During the Kitchen Sanitation Tour on 10/31/24 at 12:10 p.m. with the Executive Chef, five plastic light covers located above the steam table and food preparation area had an accumulation of dust and dead insects on the inside. During an interview on 11/1/24 at 9:50 a.m., the Executive Chef indicated all of the above had either been cleaned or were in need of cleaning. 3.1-19(f)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 8 of 8 residents reviewed for self-administration of medication. (Residents C, E, F, G, B, H, D, and J) Findings include: 1. During random observations on 10/27/24 at 10:39 a.m., and 1:14 p.m., Resident C was observed sitting in a chair in her room. At those times, there was a plastic medication cup of a white powder substance in the window sill. During an interview on 10/27/24 at 1:14 p.m., the resident indicated she had a rash on her upper left shoulder and asked a nurse for something for it and she came back with the white powder. During an observation on 10/29/24 at 10:25 a.m., the resident was in her room sitting in the wheelchair. There was a facility labeled bottle of Ammonium Lactate on the over bed table. The resident indicated the nurse had brought it into her room so she could apply the lotion to her foot. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure oxygen orders were complete, oxygen concentrators were set at the correct flow rate, and oxygen was signed out as being in use for 4 of 4 residents reviewed for oxygen therapy. (Residents 130, C, F and 127) Findings include: 1. On 10/27/24 at 1:20 p.m., Resident 130 was observed in his room in bed. The resident was wearing oxygen by the way of a nasal cannula at 3 liters. On 10/28/24 at 9:37 a.m., 12:06 p.m., and 4:32 p.m., the resident had oxygen in place via a nasal cannula at 3 liters. The record for Resident 130 was reviewed on 10/29/24 at 9:43 a.m. Diagnoses included, but were not limited to, congestive heart failure (CHF), type 2 diabetes, and sleep apnea. The admission Minimum Data Set (MDS) assessment, dated 10/30/24, indicated the resident was cognitively intact. A Care Plan, dated 10/25/24, indicated the resident required oxygen therapy. Interventions included, but were not limited to, administer oxygen per physician's…

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

Based on observation, record review and interview, the facility failed to ensure medications were not prepared in advance and treatment carts were locked for 1 of 2 units. (The C Wing) This had the potential to affect all residents receiving medications from LPN 6 and wound treatments. Findings include: 1. On 10/27/24 at 9:14 a.m., LPN 6 was seated in a chair at the C Wing nurse's station. The LPN was seated next to the medication cart and five plastic medication cups were observed on top of the medication cart. The medication cups had room numbers written on them. During an interview at that time, the LPN indicated that she always pre-poured her medications, then she quickly changed her answer and indicated that she didn't always do that, but today was a bad day. During an interview, on 11/1/24 at 10:55 a.m., the [NAME] President of Clinical Operations indicated the facility did not have a policy but the LPN should not have pre-poured the medications and education was going to be provided. 2. During a random observation on 10/27/24 at 9:16 a.m., Wound Nurse 1 was observed in a…

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

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to handling of medications with bare hands for 3 of 6 residents observed during medication administration and one random observation, enhanced barrier precautions (EBP) not in use for a resident with a peripherally inserted central catheter (PICC), and incorrect disinfecting of the glucometer for 1 of 1 glucometer observed. (Residents K, 21, G, L and 170) Findings include: 1. On 10/27/24 at 9:14 a.m., LPN 6 was seated in a chair at the C Wing nurse's station. The LPN was seated next to the medication cart and five plastic medication cups were observed on top of the medication cart. The medication cups had room numbers written on them. The LPN continued to prepare medications at that time. She punched the pills from the medication card into her bare hand and then placed them into the medication cups. During an interview, on 11/1/24 at 10:55 a.m., the [NAME] President of Clinical Operations indicated the LPN should not have touched 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, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 1 resident reviewed for dignity. (Resident 30) Finding includes: On 10/27/24 at 11:32 a.m., Resident 30 was observed in his room in bed wearing a hospital gown. On 10/28/24 at 9:52 a.m., 12:09 p.m., and 4:35 p.m., the resident was again observed in his room in bed wearing a hospital gown. On 10/29/24 at 9:25 a.m., 11:28 a.m., and 2:20 p.m., the resident was observed in his room in bed wearing a hospital gown. On 10/30/24 at 9:26 a.m., 10:36 a.m. and 3:30 p.m., the resident was observed in his room in bed wearing a hospital gown. At 1:25 p.m., the resident was seated in his broda chair by the nurses' station, he continued to wear a hospital gown. On 10/31/24 at 9:12 a.m., the resident was in his room in bed watching television. The resident was wearing a hospital gown at that time. The record for Resident 30 was reviewed on 10/30/24 at 10:52 a.m. Diagnoses included, but were not limited 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to dirty and long fingernails, greasy hair, and the removal of facial hair for 2 of 6 residents reviewed for ADLs. (Residents F and 170) Findings include: 1. During an interview on 10/27/24 at 10:14 a.m., Resident F indicated her hair had not been washed since she had been at the facility. At that time, her hair was greasy in appearance. The record for Resident F was reviewed on 10/29/24 at 9:30 a.m The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, heart failure, type 2 diabetes, peripheral vascular disease, anemia, high blood pressure, gout and migraines. The 10/23/24 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. It was very important for the resident to choose between a shower or a bed bath and the task of bathing was not attempted…

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, record review, and interview, the facility failed to ensure treatments were completed as ordered for dry flaky skin and signs of constipation were monitored for 2 of 4 residents reviewed for non pressure skin conditions and for 1 of 1 resident reviewed for constipation. (Residents 31, F and 170) Findings include: 1. During an interview on 10/27/24 at 1:36 p.m., Resident 31 indicated he had issues with constipation and would go longer than three days without having a bowel movement. The record for Resident 31 was reviewed on 10/29/24 at 9:00 a.m. Diagnoses included, but were not limited to, high blood pressure, anxiety disorder, panic disorder, post traumatic stress disorder, and COPD. The 9/4/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The Care Plan, revised on 9/8/23, indicated the resident was at risk for constipation related to the use of opioids. The approaches were to administer medications as ordered by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Foley (urinary) catheter orders were obtained timely and orders for catheter care were obtained for 1 of 1 resident reviewed for catheters. (Resident 131) Finding includes: On 10/27/24 at 1:30 p.m., Resident 131 was observed in her room in bed. Cloudy, yellow urine was observed draining from the resident's Foley catheter tubing. There was also a urine odor noted in the resident's room. On 10/28/24 at 9:30 a.m. and 4:30 p.m., the resident was observed in bed and her Foley catheter tubing was draining cloudy, yellow urine. The urine odor remained in the resident's room. On 10/29/24 at 9:22 a.m., the resident was observed in bed and her Foley catheter tubing was draining cloudy, yellow urine. The urine odor remained in the resident's room. The record for Resident 131 was reviewed on 10/29/24 at 10:41 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance and fracture of the the lower end of the right…

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 weekly weights for an underweight resident for 1 of 1 resident reviewed for nutrition. (Resident J) Finding includes: The record for Resident J was reviewed on 10/30/24 at 9:34 a.m. The diagnoses included, but were not limited to, heart failure, dementia, hypertension (high blood pressure), muscle weakness, need for assistance with personal care, and depression. The admission Minimum Data Set (MDS) assessment, dated 10/13/24, indicated the resident was severely impaired for daily decision making. The resident had no impairment of the upper and lower extremities and used a wheelchair. A Comprehensive Nutrition Assessment, dated 10/10/24 at 11:47 a.m., indicated the resident was underweight, not well nourished and at risk for malnutrition. Nutrition monitoring and evaluation included, monitor weight, appetite, skin, labs, and fluid status. A Physician's order, dated 10/13/24, indicated for weekly weights to be completed every Sunday. There were no weekly weights recorded after the 10/7/2024 admission weight. During…

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, record review, and interview, the facility failed to ensure a peripheral intravenous (IV) catheter was maintained, monitored and assessed for patency for 1 of 1 resident reviewed for hydration. (Resident 41) Finding includes: During random observations on 10/27/24 at 9:07 a.m. and 1:14 p.m., Resident 41 was observed with a peripheral IV in her right hand with a date of 10/23/24. On 10/28/24 at 9:30 a.m., the resident was observed with a bandaid on her right hand where the peripheral IV used to be. The IV was not visible at that time. The record for Resident 41 was reviewed on 10/28/24 at 3:55 p.m., The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, major depressive disorder with recurrent and severe psychotic symptoms, heart disease, history of breast cancer, anemia, anxiety, and high blood pressure. The 10/9/24 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and 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 record review and interview, the facility failed to ensure ongoing communication with the dialysis center was completed with each dialysis session for 1 of 1 resident reviewed for dialysis. (Resident 43) Finding includes: The record for Resident 43 was reviewed on 10/28/24 at 3:37 p.m. The diagnoses included, but were not limited to, diabetes with ketoacidosis, muscle weakness, dependence on renal dialysis, renal disease, anemia (low iron), insomnia (difficulty sleeping), heart failure, and hypertension (high blood pressure). The admission Minimum Data Set (MDS) assessment, dated 10/11/24, indicated the resident was cognitively intact for daily decision making. The resident had no impairment of the upper and lower extremities and was on dialysis. A Care Plan, dated 10/8/24, indicated the resident required dialysis related to end stage renal disease. Interventions were to check the permacath site daily and upon dialysis return, and monitor vital signs and labs. A Physician's Order, dated 10/9/24, indicated to obtain dialysis pre-weights and pre-vital signs in the morning…

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 each resident's medication regimen was managed and monitored related to not monitoring the resident's blood pressure as ordered for 2 of 5 residents reviewed for unnecessary medications. (Residents H and D) Findings include: 1. Record review for Resident H was completed on 10/29/24 at 3:56 p.m. Diagnoses included, but were not limited to, disruption of external operation (surgical) wound, muscle weakness, and chronic respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 10/1/24, indicated the resident was cognitively intact and required moderate to maximum assistance with activities of daily living and transfers. The October 2024 Physician's Order Summary indicated an order for Diltiazem HCl 60 mg one time daily for hypertension. A Care Plan, dated 9/25/24, indicated the resident's blood pressure, pulse, temperature, and respiratory rate were to be checked every shift (twice a day). The record lacked any documentation of blood pressure monitoring for 10/5/24, 10/7/24, 10/15/24, and 10/19/24. No…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents observed during medication pass. Two errors were observed during 34 opportunities for errors during medication administration. This resulted in a medication error rate of 5.88%. (Residents K and L) Findings include: 1. On 10/28/24 at 10:23 a.m., LPN 4 was observed preparing to administer an antibiotic to a resident via a PICC (peripherally inserted central catheter) line. The LPN applied gloves, then opened and attached new tubing to a medication bag with the antibiotic Unasyn. She finished setting up the machine and started the antibiotic on the resident at 10:30 a.m. She indicated the medication would take 30 minutes to administer. Record review for Resident K was completed on 10/28/24 at 10:35 a.m. The October 2024 Physician's Order Summary indicated an order for Unasyn 3000 mg (milligrams) intravenously three times a day for a left foot wound for 6 weeks. The administration times were to be at 12:00 a.m., 8:00 a.m., and 4:00 p.m. During…

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 maintain clinical records that were complete and accurately documented related to tube feeding administration for 1 of 1 resident reviewed for tube feeding. The facility also failed to document physician notification was completed related to blood sugar parameters and insulin documentation for 2 of 5 residents reviewed for unnecessary medications. (Residents 30, H, and 43) Findings include: 1. The record for Resident 30 was reviewed on 10/30/24 at 10:52 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, delusional disorder, anxiety, dysphagia (difficulty swallowing), and gastrostomy status (a tube inserted directly into the stomach for nutrition). The 9/13/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively impaired for daily decision making and he received a tube feeding while a resident of the facility. A Care Plan, dated 3/21/23 and reviewed on 9/6/24, indicated the resident required a tube feeding related to resisting eating, weight loss, failure…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a practitioner prescribing antibiotics for not true infections based on the McGeer Criteria for 1 of 5 residents reviewed unnecessary medications. (Resident 41) Finding includes: The record for Resident 41 was reviewed on 10/28/24 at 3:55 p.m., The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, major depressive disorder with recurrent and severe psychotic symptoms, heart disease, history of breast cancer, anemia, anxiety, and high blood pressure. The 10/9/24 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and was frequently incontinent of urine. The resident received an antipsychotic, antidepressant, antibiotic, and diuretic while at the facility. A 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 record review and interview, the facility failed to ensure correct parameters for a blood pressure medication were followed and medications were administered as ordered for 1 of 3 residents reviewed for unnecessary medications. (Resident B) Finding includes: Resident B's closed record was reviewed on 8/29/24 at 9:36 a.m. Diagnoses included, but were not limited to, pneumonia, sepsis (condition in which the body responds improperly to an infection), type 2 diabetes mellitus, end stage renal disease, hypotension (low blood pressure), heart failure, and dependence on renal dialysis. The Discharge Minimum Data Set (MDS) assessment, dated 7/23/24, indicated the resident was cognitively intact for daily decision making. He received scheduled pain, anti-anxiety, antidepressant, hypnotic, antibiotic, opioid, and antiplatelet medications. The July 2024 Physician's Order Summary indicated the resident received the following medications: - ascorbic acid tablet 500 milligrams (mg) once a day - aspirin 81 mg capsule once a day - chlorhexidine gluconate external pad 2% (antiseptic agent)…

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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to a resident receiving an anti-anxiety medication due to a transcription error for 1 of 3 residents reviewed for unnecessary medications. (Resident C) The deficient practice was corrected on 6/21/24, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed audits of new admission medication orders, required two nurses to verify admission medications, and completed an inservice for staff on confirmation of admission medications. Finding includes: Resident C's closed record was reviewed on 7/2/24 at 9:05 a.m. Diagnoses included, but were not limited to, hypertension, atrial fibrillation, and anxiety disorder. The resident was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment,…

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 a resident received the necessary care and treatment related to a wound treatment not provided as ordered for 1 of 3 residents reviewed for non-pressure wound care. (Resident B) Finding includes: Resident B's closed record was reviewed on 6/3/24 at 9:02 a.m. The resident was admitted to the facility on [DATE] and was discharged on 4/5/24. Diagnoses included, but were not limited to, infection and inflammatory reaction of right knee prosthesis, Diabetes Mellitus and hypertension. The admission Minimum Data Set assessment, dated 3/11/24, indicated the resident was cognitively intact, had a surgical wound, and received surgical wound care. A Physician's Order, dated 3/23/24, indicated to cleanse the right knee with 0.9% normal saline, apply xeroform gauze and apply a cover dressing daily and as needed for soilage or dislodgment. The March 2024 Treatment Administration Record lacked documentation the dressing change had been completed on 3/24, 3/26…

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 a resident was free of significant medication errors related to missed doses of an antibiotic for 1 of 3 residents reviewed for infections. (Resident C) Finding includes: Resident C's record was reviewed on 6/3/24 at 12:08 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, mechanical complication of other vascular grafts, localized infection of the skin and subcutaneous tissue and peripheral vascular disease. The admission Minimum Data Set assessment, dated 5/1/24, indicated the resident was cognitively intact, had a surgical wound, and received surgical wound care. A Physician's Order, dated 4/25/24, indicated to give meropenem (an antibiotic) 1 gram intravenously every 8 hours for a wound infection for 8 weeks. The May 2024 Medication Administration Record lacked documentation the antibiotic was given on 5/7 x 2 doses, 5/14, 5/22 and 5/28. The there was no documentation in the progress notes…

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

Based on observation, record review, and interview, the facility failed to ensure the intravenous (IV) antibiotic run time infused according to the physician's order for 1 of 1 IV medications observed. (Resident 6) Finding includes: On 10/5/23 at 1:15 p.m., LPN 2 entered Resident 6's room to administer his intravenous (IV) antibiotic. The LPN gathered her supplies, donned a gown and gloves, and began to set up the IV pump for the medication administration. The IV pump displayed a warning to reset the machine. Four separate attempts were made to reset the machine. The LPN retrieved a Dial-A-Flo IV tubing set (manual flow regulator or IV flow regulator). The LPN connected the Dial-A-Flo IV tubing to Resident 6's PICC line (Peripherally Inserted Central Catheter). The LPN began to administer the IV medication via the PICC line, using the Dial-A-Flo tubing. On 10/5/23 at 1:45 p.m., LPN 2 attempted to remove Resident 6's IV antibiotic. There was medication remaining in the IV bag so the LPN continued to let the medication infuse. On 10/5/23 at 3:07 p.m., LPN 2 informed the Director of…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents observed during medication pass. Two errors were observed during 31 opportunities for errors during medication administration. This resulted in a medication error rate of 6.45%. (Residents 5 and 6) Findings include: 1. During observation of medication administration on 10/5/23 at 4:30 p.m., RN 1 handed Resident 5 a Ventolin HFA inhaler. The resident administered his own inhaler with no instructions from RN 1 on how to properly administer the medication. The resident quickly pushed down on the inhaler twice for two puffs and immediately capped the inhaler and handed it to the RN. The RN put the inhaler in the cart and locked it. The record for Resident 5 was reviewed on 10/5/23 at 4:40 p.m. The October 2023 Physician's Order Summary (POS) indicated the resident was to receive his Ventolin HFA Inhaler, 2 puffs, 4 times per day. Interview with RN 1 on 10/5/23 at 4:45 p.m., indicated the resident initiated the puffs too quickly, and he 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 observation, record review, and interview, the facility failed to ensure medications were stored properly for 1 of 3 medication carts observed. (C hallway, Cart 2). Finding includes: On 10/6/23 at 9:37 a.m., LPN 3 was observed at the medication cart preparing to pass medications from Cart 2 on the C hallway. The cart was found to have 12 loose pills, varying in size, shape, and color. The pills were found in the bottom 3 drawers of the medication cart. The LPN removed the pills from the cart and disposed of them in the sharps container. Interview with LPN 3 on 10/6/23 at 9:37 a.m., indicated she always cleaned her med cart and she knew the loose pills should not have been in the cart. Interview with the Director of Nursing on 10/6/23 at 10:03 a.m., indicated the loose pills should not have been in the cart. A current facility policy, titled Medication Storage in the Facility: Storage of Medications, indicated . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . 3.1-25(m)