Crown Point Health Campus

Based on record review and interview, the facility failed to ensure a resident's family/Responsible Party was notified for a new medication order, for 1 of 3 residents reviewed for family/Responsible Party notification. (Resident O)Finding includes:Resident O's record was reviewed on 8/18/25 at 1:06 p.m The diagnoses included, but were not limited to, osteomyelitis and schizophrenia.A Nurse Practitioner's Progress Note, dated 8/12/25 at 12:29 p.m., indicated the resident voiced she was not able to fall asleep at night and when she does fall asleep, she has difficulty staying asleep. A Nurse Practitioner's Order, dated 8/12/25, indicated melatonin three milligrams was to be administered every night for insomnia.There was no documentation that indicated the resident's Responsible Party/family had been notified of the change in medication.During an interview on 8/19/25 at 3:10 p.m., the Regional Nurse Consultant indicated the Responsible Party/family had not been notified of the medication order.This citation relates to Intake 2590825.3.1-5(a)(3)

Based on observation, record review and interview, the facility failed to ensure residents received necessary care and services, related to, treatments to surgical sites were not completed, glucometer monitoring (blood sugar checks) were not completed and orders not clarified for the glucometer monitoring, a thorough admission assessment was not completed, a elopement risk assessment was not completed accurately, insulin was not administered as ordered, and bruising un unknown cause was not investigated and monitored, for 4 of 12 residents reviewed for quality of care. (Residents D, E, F, and M)Findings include:1. During an observation on 7/23/25 at 2:42 p.m., the Wound Nurse indicated Resident D had two surgical wounds located on the left ischium and on the sacral area. There was a dressing on each of the areas with the date of 7/21/25. Both areas were washed and patted dried, covered with calcium alginate (wound treatment) and covered with foam dressings. She indicated the wounds were improving. Resident D’s record was reviewed on 7/24/25 at 10:13 a.m. The diagnoses included, but…

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 develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act related to an allegation of physical and sexual abuse for 1 of 1 resident reviewed for abuse. (Resident E) Finding includes:Resident E's closed record was reviewed on 7/22/25 at 9:09 a.m. The diagnoses included, but were not limited to dementia, bipolar with current manic episodes with psychotic features, and unsteadiness on her feet. The admission date was 6/20/25. A Nurse's Progress Note, dated 6/20/25 at 11:30 p.m., indicated the resident voiced an allegation that she had been both physically and sexually assaulted the day earlier.During an interview on 7/22/25 at 11:35 a.m., the Administrator indicated the allegation had not been investigated or reported immediately to the Administrator, Indiana Department of Health (IDOH), the resident's previous facility, physician, responsible party, or local law enforcement.A Reported IDOH Incident, dated 7/22/25, indicated 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 observations, record review, and interview, the facility failed to ensure a resident's tube feeding was infusing at the correct flow rate for 1 of 3 residents reviewed for feeding tube usage. (Resident H)Finding includes:During an observation on 7/22/25 at 3:03 p.m., the liquid tube feeding for Resident H was not infusing.During an observation on 7/23/25 at 11:51 a.m., the liquid tube feeding of Jevity 1.5 was infusing at 60 cc/hr (cubic centimeters per hour).Resident H's record was reviewed on 7/23/25 at 1:56 p.m. The diagnoses included, but were not limited to, gastrostomy tube and dysphagia.A Care Plan, dated 5/26/25, indicated a feeding tube was present. The interventions indicated the tube feeding and water flushes were to be administered as ordered by the Physician.An admission Minimum Data Set assessment, dated 5/28/25, indicated a severely impaired cognitive status and had a feeding tube and it provided 51% or more of daily nutrition and 502 milliliters or more of fluids daily. A Physician's Order, dated 7/17/25, indicated a liquid feeding of Jevity 1.5 at 60 cc/hr…

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 PICC (peripherally inserted central catheter) line had physician's orders for the care and monitoring and the dressing was changed once weekly for 1 of 1 resident reviewed for PICC line care. (Resident D)Finding includes:During an observation on 7/23/25 at 2:42 p.m., a PICC line was observed in the resident's left upper arm. The date on the dressing covering the PICC line was 7/13/25. The Wound Nurse indicated the dressing was to be changed weekly.Resident D's record was reviewed on 7/24/25 at 10:13 a.m. The diagnoses included, but were not limited to, osteomyelitis, stroke, and post-surgical closure and debridement of stage four (full thickness) pressure ulcers. The admission date was 6/20/25.A Skin/Wound Note, dated 6/20/25 at 4:30 p.m., indicated an intravenous (IV) line was observed on the left upper arm.A Physician's Order, dated 6/21/25, indicated ceftriaxone (antibiotic) 2 grams was to be administered daily for osteomyelitis until 7/17/25.There were no physician's orders for the flushes,…

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 medications were stored properly for 2 of 2 medication carts observed. (B wing medication cart and C wing medication cart)Findings include:1. On 7/23/25 at 8:04 a.m., LPN 1 was observed in Resident C's room. The C Wing medication cart was in the hallway and the following medications were sitting on top of the cart unsupervised and accessible to anyone in the hallway:a. 1 bottle of amoxicillin labeled for Resident T.b. 2 Nystatin bottles labeled for Resident U and Resident V.c. 1 tube of wound paste and 1 tube of cooling gel labeled for Resident W.During an interview on 7/23/25 at 8:36 a.m., LPN 1 indicated the medications on top of her cart belonged in the treatment cart and not in the medication cart. LPN 1 indicated the treatment cart was at the end of the hallway and those medications did not belong in her cart. 2. On 7/23/25 at 8:38 a.m., the B wing medication cart was observed with LPN 3 during a medication administration pass for Resident Y. LPN 3 was out of a medication and left her cart to check for it. 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 record review and interview, the facility failed to ensure medical records were complete and accurately documented related to an elopement incident and antibiotic administration for 2 of 24 residents reviewed for medical record documentation. (Residents E and D)Findings include: 1. During an interview on 7/22/25 at 5:24 a.m., LPN 2 indicated she had been the nurse assigned to Resident E on 6/23-6/24/25 night shift. On 6/24/25 in the early morning, the resident was in the Dining Room/Lounge, across from the Nurses’ Station, and requested coffee. She drank the coffee and said she was going back to her room. The resident was brought back to the facility through the [NAME] Unit Doors by a community person a little while later. LPN 2 indicated one of the staff members from the [NAME] Unit called the DON and the DON called the Grace Unit and directed her to go to the [NAME] Unit to assist the resident back up to the Grace Unit. There were no injuries observed. The resident was missing from the building for…

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 practices were in place related to hand hygiene during medication pass for 3 random medication pass observations. (LPN 1 and LPN 3, Residents Z, X and Y)Findings include:1. On 7/23/25 at 8:18 a.m., LPN 1 was observed leaving Resident C's room after administering medication. She then began a medication pass for Resident Z. She popped out all the medication required into a medicine cup and then donned a gown and gloves prior to entering resident Z's room. The residents' blood pressure was checked and pills were administered. She did not wash her hands or use hand sanitizer upon leaving resident C's room prior to preparing resident Z's medication or before donning the gloves upon entering Resident Z's room.2. On 7/23/25 at 8:29 a.m., LPN 1 was observed preparing a medication pass for Resident X. LPN 1 entered the resident's room and checked the blood pressure. She exited the room and prepared the resident's medication. She then re-entered Resident X's room and administered 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.

Based on observation, record review, and interview, the facility failed to notify the physician and the resident that a medication was unavailable for 1 of 3 residents reviewed for medications. (Resident E) Finding includes: During an interview on 4/8/25 at 11:09 a.m., Resident E indicated she had not received her long-acting insulin this past Saturday and Sunday evening. She had told the nurse where to look for it but apparently she couldn't find it. She was not sure why the nurse had not found it and was not given any further explanation. Record review for Resident E was completed on 4/7/25 at 3:09 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, and multiple sclerosis. The Quarterly Minimum Data Set (MDS) assessment, dated 3/13/25, indicated the resident was cognitively intact. The Physician's Order Summary, dated 4/2025, indicated Lantus (insulin glargine, long-acting insulin) 25 units subcutaneous at bedtime. The Medication Administration Record (MAR), dated 4/2025, indicated the Lantus administrations for 4/5/25 at 8:00 p.m. 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 document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 4 residents who were reviewed for ADLs. (Resident B) Finding includes: Resident B's record was reviewed on 4/7/25 at 10:20 a.m. Diagnoses included, but were not limited to, dementia, hemiplegia and hemiparesis (weakness and paralysis) following a cerebral infarction (stroke). The Discharge Minimum Data Set (MDS) assessment, dated 3/12/25, indicated the resident was severely cognitively impaired. She was totally dependent on staff for assistance with toileting and transfers. She was frequently incontinent of bladder and always incontinent of bowel. The current Care Plans indicated the resident had episodes of incontinence and was at risk for complications. Interventions included, but were not limited to, encourage fluids, provide incontinence care, and toilet at regular intervals or scheduled voiding. The CNA Task: Incontinence Care was reviewed from 3/17/25 to 4/7/25. The documentation frequency was every…

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

Based on record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice related to a medication not administered as ordered by the physician for 1 of 3 residents reviewed for quality of care. (Resident F) Finding includes: Resident F's record was reviewed on 4/9/25 at 2:04 p.m. The diagnoses included, but were not limited to neuropathy and arthritis. A Physician's Order, dated 3/29/25, indicated guaifenesin (cough syrup) extended release (ER) 600 mg, one tablet was to be administered every 12 hours for seven days for a cough. (14 doses) The Medication Administration Record (MAR), dated 3/2025, indicated the guaifenesin had not been administered on 3/29/25 at 9:00 p.m., 3/30/25 at 9:00 a.m. and 9:00 p.m., and 3/31/25 at 9:00 p.m. The guaifenesin was documented as given on 3/31/25 at 9:00 a.m. The MAR, dated 4/2025, indicated the guaifenesin had been administered on April 1-4, 2025 at 9:00 a.m. and 9:00 p.m., and April 5, 2025 at 9:00 a.m. The resident had not received the medication for seven…

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 provide supplements as ordered and document nutritional intake for meals for residents with weight loss for 2 of 3 residents reviewed for nutrition. (Residents D and H) Findings include: 1. On 4/8/25 at 11:24 a.m., CNA 3 was observed taking a lunch tray to Resident D. She received a cheeseburger, tater tots, pickles, and a can of soda. There was no Mighty Shake on the tray at the time. During an observation and interview on 4/8/25 at 11:45 a.m., CNA 3 brought out Resident D's tray to return to the tray cart. The resident had picked at the food. There was no Mighty Shake present on the tray. Both CNA 3 and LPN 1 confirmed the resident had not received the Mighty Shake and dietary was responsible for putting those on the trays. Resident D's record was reviewed on 4/7/25 at 11:16 a.m. Diagnoses included, but were not limited to, dementia, protein-calorie malnutrition, and cognitive communication deficit. The resident weighed 100.5 pounds on…

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

Based on record review and interview, the facility failed to ensure a resident was provided with routine medications in a timely manner by the contracted pharmacy, related to medications not available to be administered as ordered by a physician for 1 of 3 residents reviewed for medications. (Resident F) Finding includes: Resident F's record was reviewed on 4/9/25 at 2:04 p.m. The diagnoses included, but were not limited to neuropathy and arthritis. An After Visit Summary from the hospital, dated 3/28/25, indicated the resident was being treated for a urinary tract infection. The discharge orders included cephalexin (antibiotic) 500 mg (milligrams), one capsule three times a day for seven days. A Nurse's Progress Note, dated 3/29/25 at 3:32 a.m., indicated the resident was readmitted to the facility and the Physician's Discharge Orders were verified with the physician. a) The Physician's Orders, dated 3/29/25 and discontinued on 3/31/25, indicated cephalexin 500 mg, one tablet was to be given three times a day for infection for seven days. The medication was to be started on 3/29/25…

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

Based on record review and interview, the facility failed to ensure the residents' medical records included documentation the resident or resident representative was provided education on the benefits and potential risk associated with the COVID-19 vaccination and documentation why the vaccine was not administered for 4 of 5 residents reviewed for COVID-19 vaccinations. (Residents 53, B, 201, and 300) Findings include: 1. Resident 53's record was reviewed on 2/21/25 at 9:55 a.m. The COVID-19 vaccination had not been documented as offered or administered since 9/22/22. There was no documentation education on the benefits and potential risk of the the COVID-19 vaccine had been provided to the resident or the resident's representative. 2. Resident B's record was reviewed on 2/21/25 at 10:10 a.m. The resident received the first COVID-19 vaccination on 2/26/22. The COVID-19 vaccination had not been documented as offered or administered since 2/26/22. There was no documentation education on the benefits and potential risk of the the COVID-19 vaccine had been provided to the resident or…

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 were assessed to self-administer medication and had a physician's order to self-administer medication for 2 of 2 residents observed self-administering medications. (Residents 41 and 201) Findings include: 1. During a random observation on 2/17/25 at 9:09 a.m., Resident 41 was observed seated in her wheelchair in her room. There was a medicine cup with several pills on her overbed table in front of her. Several minutes later, the pills were again observed on the resident's table. The resident asked if she had to take all of them. RN 1 entered the room and then assisted the resident with taking the medications. During an interview on 2/17/25 at 9:13 a.m., the nurse indicated she had left them with the resident because she was taking her time, and she should not have left the medications with the resident. The resident's record was reviewed on 2/17/25 at 9:20 a.m. There was no self-medication administration assessment and no Physician's order to self-administer medications. 2. On 2/17/25 at 9:35…

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 comprehensive care plan was developed and in place for residents with significant weight loss for 2 of 24 care plans reviewed. (Residents 75 and 85) Findings include: 1. Resident 75's record was reviewed on 2/18/25 at 10:55 a.m. Diagnoses included, but were not limited to, heart failure, spinal stenosis, iron deficiency anemia and atrial fibrillation. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact and was dependent on staff assist for toileting and bed mobility. He had a weight loss of 5% or more in a month or 10% or more in 6 months and was not on a physician-prescribed weight loss regimen. The resident's admission weight on 8/8/24 was 324.4 pounds. The resident's weight on 11/5/24 was 293.6 pounds and on 2/5/25, was 246.5 pounds. This was a weight loss of 30.8 pounds, a 24% change, in six months. A Dietary Note, dated 2/13/25, indicated the resident had a significant weight loss.…

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 plans were updated for 1 of 24 resident care plans reviewed. (Resident 7) Finding includes: On 2/17/25 at 2:46 p.m., Resident 7 was observed in a wheelchair. Her left hand appeared to be contracted (a condition where the fingers or palm of the hand are involuntarily bent or curled in). The resident was unable to communicate if she was able to open her hand or if she wore any splinting devices. The record for Resident 7 was reviewed on 2/20/25 at 10:25 a.m. Diagnoses included, but were not limited to, cerebral palsy, mild intellectual disabilities, and hemiplegia and hemiparesis (paralysis and weakness) following a stroke affecting the left side. The Quarterly Minimum Data Set (MDS) assessment, dated 11/19/24, indicated the resident was moderately cognitively impaired, had a functional limitation in range of motion on one side of the upper extremities, and required assistance from staff with toileting, showering, and transfers. The February 2025 Physician Order Summary indicated the resident may…

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 document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 7 residents who were reviewed for ADLs. (Resident C) Finding includes: During an interview on 2/18/25 at 9:14 a.m., Resident C's Power of Attorney (POA) indicated she had come to the facility on multiple occasions and found the resident in a soaking wet brief. The resident was fully dependent on the staff for all activities of daily living (ADLs) including, but not limited to, toileting, eating, and drinking. The record was reviewed on 2/20/25 at 11:20 a.m. Diagnoses included, but were not limited to, Alzheimer's disease and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 12/8/24, indicated the resident was severely cognitively impaired and was dependent on staff for all ADLs including eating, toileting, personal hygiene, and transfers. She was always incontinent of bowel and bladder and received hospice care. The current Care Plans indicated the resident needed assistance with ADLs due to…

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

Based on observation, record review, and interview, the facility failed to ensure physician's orders were followed for non-pressure skin condition treatments and non-pressure skin areas were assessed and monitored for 2 of 5 residents reviewed for skin conditions, non-pressure related. (Residents 1 and 16). Findings include: 1. During an interview and observation on 2/17/25 at 9:42 a.m., Resident 1 indicated she had a sore area on her right upper chest. She had it for the last couple of weeks and told the staff about it the night before. The area was observed to be a large scab with the surrounding skin red in color. On 2/20/25 at 11:09 a.m., Resident 1 had a 4 by 4 padded gauze covering the area on her right upper chest. The resident indicated the staff put a cream on it the night before and was keeping it covered so her top would not rub the area. Resident 1's record was reviewed on 2/19/25 at 11:10 a.m. Diagnoses included, but were not limited to, hereditary motor and sensory neuropathy (affecting the peripheral nerves) and diabetes mellitus. The Quarterly Minimum Data Set (MDS)…

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 with pressure ulcers received the necessary treatment and services to promote healing related to weekly wound assessments not completed and a physician's treatment order not updated for 2 of 2 residents reviewed for pressure ulcers. (Residents D and 4) Findings include: 1. On 2/19/25 at 10:42 a.m., the Wound Nurse was observed providing care for a pressure ulcer on Resident D's left heel. There was a round, dime-sized scabbed area on the left heel. The nurse indicated it was a healing stage 4 pressure ulcer. The resident's record was reviewed on 2/18/25 at 3:05 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, depression and chronic respiratory failure. The Quarterly Minimum Data Set assessment, dated 12/24/24, indicated the resident had severe cognitive impairment, was dependent for toileting, eating, bed mobility and transfers and had a stage 4 pressure ulcer. The Pressure Injury Care Plan, dated 5/29/24, indicated the resident had a history of pressure ulcers and 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 an order for a palmar guard and a resting hand splint device was followed and in place for a resident with a right hand contracture for 1 of 1 resident reviewed for range of motion. (Resident 42) Finding includes: During random observations on 2/17/24 at 2:17 p.m., on 2/19/25 at 9:26 a.m., and on 2/20/25 at 10:35 a.m., Resident 42 was observed lying in bed. At those times, the resident was observed with her right hand clenched against her chest. On 2/19/25 at 2:01 p.m., CNA 1 indicated the resident could not open her right hand without forcing her hand open or using a hot water towel to open the resident's hand. She had never used a palm protector and did not know if the resident was supposed to have a palm protector applied to her right hand. The record for Resident 42 was reviewed on 2/17/25 at 2:17 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, generalized muscle weakness, and stiffness. The Quarterly Minimum Data Set (MDS) assessment, dated 1/29/25, indicated…

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

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 5 residents reviewed for accidents. (Resident 34) Finding includes: On 2/19/25 at 1: 49 p.m., Resident 34 was observed seated in his wheelchair in the unit dining room. There were no anti-rollback bars or anti-tippers noted to the wheelchair. On 2/19/25 at 2:50 p.m., Resident 34 was observed seated in his wheelchair propelling himself around the unit dining room. There were no anti-rollback bars or anti-tippers noted to the wheelchair. On 2/20/25 at 10:11 a.m., Resident 34 was observed seated in his wheelchair and was brought to the unit dining room by a CNA. There were no anti-rollback bars or anti-tippers noted to the wheelchair. The record for Resident 34 was reviewed on 2/19/25 at 2:56 p.m. Diagnoses included, but were not limited to, Alzheimer's Disease, hypertension, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 12/26/24, indicated the resident was cognitively impaired. He had two or more falls…

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 urinary output was recorded and the physician was notified for low urinary output as ordered for 1 of 1 resident reviewed for urinary catheters. (Resident 37) Finding includes: The record for Resident 37 was reviewed on 2/20/25 at 10:38 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, history of urinary tract infections (UTIs), urethral stricture (narrowing of the urethra), and obstructive and reflux uropathy (disorders of the bladder causing problems with urine flow). The Quarterly Minimum Data Set (MDS) assessment, dated 12/22/24, indicated the resident was severely cognitively impaired and had an indwelling urinary catheter. The current February 2025 Care Plans indicated the resident had an indwelling urinary catheter. An intervention indicated to monitor and document intake and output. The current February 2025 Physician Order Summary indicated monitor Foley catheter output every shift. If output was less than 300 milliliters (ml), notify the physician. The Medication Administration Record…

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 monitor weekly weights and document nutritional intake for fluids, meals, and supplements as ordered for residents with significant weight loss for 3 of 3 residents reviewed for nutrition. (Residents 75, 85 and C) Findings include: 1. Resident 75's record was reviewed on 2/18/25 at 10:55 a.m. Diagnoses included, but were not limited to, heart failure, spinal stenosis, iron deficiency anemia and atrial fibrillation. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact and was dependent on staff assist for toileting and bed mobility. He had a weight loss of 5% or more in a month or 10% or more in 6 months and was not on a physician-prescribed weight loss regimen. The resident's admission weight on 8/8/24 was 324.4 pounds. The resident's weight on 11/5/24 was 293.6 pounds and on 2/5/25, was 246.5 pounds. This was a weight loss of 30.8 pounds, a 24% change, in six months. A Physician's Order, dated…

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

Based on record review and interview, the facility failed to provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to a lack of documentation of tube feeding administration for a resident with a history of weight loss for 1 of 2 residents reviewed for tube feeding. (Resident 47) Finding includes: Resident 47's record was reviewed on 2/20/25 at 8:32 a.m. Diagnoses included, but were not limited to, vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 1/7/25, indicated the resident was severely cognitively impaired. She had a feeding tube and was receiving hospice care. The current Care Plans indicated the resident was as risk for dehydration related to the g-tube use. Interventions included, but were not limited to, administer all tube feedings and fluids via g-tube per order. The resident had a g-tube related to dysphagia after a stroke. Interventions included, but were not limited to, registered dietician (RD) to evaluate quarterly and as needed and tube feedings per order. The resident had a potential nutritional…

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 residents received the necessary care and treatment related to incorrect oxygen flow rates and not monitoring an oxygen level for 2 of 3 residents reviewed for respiratory care. (Residents 75 and 74) Findings include: 1. On 2/17/25 at 11:12 a.m. and 2/18/25 at 2:58 p.m., Resident 75 was observed lying in his bed with his nasal cannula in place and oxygen flowing at a rate of 3 liters per minute (lpm). Resident 75's record was reviewed on 2/18/25 at 10:55 a.m. Diagnoses included, but were not limited to, heart failure, spinal stenosis, iron deficiency anemia and atrial fibrillation. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact and was dependent on staff assist for toileting and bed mobility. A Physician's Order, dated 11/5/24, indicated to administer oxygen at 2 lpm continuously. On 2/19/25 at 10:05 a.m., the resident was observed with LPN 2. The nurse indicated 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 routine and emergency drugs were received in a timely manner and procedures for accurate dispensing were provided for 2 of 2 residents reviewed for pharmacy services. (Residents 32 and 77) Findings include: 1. On 2/17/25 at 2:00 p.m., Resident 32 was observed seated in her recliner in her room. She indicated she had an itching rash on both arms and her left leg for about a week. She had requested to see the Nurse Practitioner. The resident's record was reviewed on 2/20/25 at 1:30 p.m. Diagnoses included, but were not limited to, diabetes mellitus, asthma and colostomy. The Quarterly Minimum Data Set assessment, dated 1/25/25, indicated the resident was cognitively intact and was independent for toileting, transfers, bed mobility and eating. A Physician's Progress Note, dated 2/18/25, indicated the resident was seen that day for a complaint of itching. She had about five red patches to her upper arms and left leg. An order was given for triamcinolone cream twice daily for 14 days to the affected areas. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to giving narcotic pain medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 75) Finding includes: Resident 75's record was reviewed on 2/18/25 at 10:55 a.m. Diagnoses included, but were not limited to, heart failure, spinal stenosis, iron deficiency anemia and atrial fibrillation. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact and was dependent on staff assist for toileting and bed mobility. The resident had pain that occurred almost constantly, did not receive prn (as needed) pain medication or non-medication interventions for pain. A Pain Care Plan, dated 8/8/24, indicated the resident had chronic pain due to spinal stenosis. Interventions included, but were not limited to, encourage resident to try different pain-relieving methods such as positioning, relaxation therapy, progressive relaxation,…

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 improper personal protective equipment (PPE) worn in an isolation room and lack of signage in place for a room on contact isolation. (Residents D and B) Findings include: 1. On 2/19/25 at 3:34 p.m., LPN 1 was observed giving medications by g-tube to Resident D. She donned a pair of gloves, assessed the g-tube for placement and checked residual. She then administered the medication dissolved in water into the g-tube. There was a sign on the resident's door that indicated Enhanced Barrier Precautions should be used. Everyone that entered the room should wash hands before entering and when leaving. Staff must also: Wear gloves and a gown for the following high-contact resident care activities. Activities included, but were not limited to, device care or use: central line, urinary catheter, feeding tube, tracheostomy. During an interview on 2/19/25, immediately after the observation, the LPN indicated the resident wasn't on isolation any…

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

Based on observation and interview, the facility failed to ensure a controlled substance was double locked at all times for 1 of 2 medication rooms observed (Grace Point). This had the potential to affect the residents on Grace Point who had the ability to access the storage room. Finding includes: On 12/18/24 at 10:45 a.m., the Grace Point Medication Room was observed with LPN 1. Inside the unlocked refrigerator was a clear tackle box. The box was not locked. Inside the box was 2 medication cards of Dronabinol (Marinol) pills. Interview with LPN 1 at that time, indicated the clear box key was lost and the box should be locked. During an interview on 12/18/24 at 10:48 a.m., LPN 1 indicated the box should be locked and they lost they keys to the box. During an interview on 12/18/24 at 11:45 a.m., the Assistant Director of Nursing indicated the box should be lock at all times and she would locate the key to ensure the narcotic box was locked and stored correctly. A current facility policy, titled, Medication, Ordering, Receiving, and Storage, indicated, .4. Controlled substances will…

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 notify a resident's physician and responsible party in a timely manner related to abnormal laboratory results for 1 of 3 residents reviewed for change in condition (Resident F). Finding includes: Resident F's record was reviewed on 12/17/24 at at 9:42 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, colostomy status, iron deficiency anemia, and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 9/12/24, indicated the resident was severely cognitively impaired for daily decision making. He was dependent on staff for all activities of daily living including, but not limited to, hygiene, toileting, and transfers. The resident had an ostomy and required oxygen therapy. A Nurses' Note, dated 8/30/24 at 9:23 a.m., indicated the resident had audible crackles in the lungs with no improvement after nebulizer treatments were administered per orders. A Nurses' Note, dated 8/30/24 at 3:43 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, record review, and interview, the facility failed to ensure a resident received the necessary care and services related to a lack of orders or monitoring in place for a neck collar, a delay in treatment after notification of critical laboratory results, medications not administered as ordered by the Physician, lack of assessment or monitoring of a new skin condition, and labs not completed as ordered by the Physician for 2 of 3 residents reviewed for change of condition. (Residents M and F) Findings include: 1. On 12/18/24 at 12:05 p.m., Resident M was observed lying in bed in her room. She had a soft neck collar in place around her neck. During an interview with the resident's family at that time, they indicated the resident recently had neck surgery which was why she was wearing the neck collar. On 12/19/24 at 11:13 a.m., Resident M was observed lying in bed in her room. She had a soft neck collar in place around her neck. Record review for Resident M was completed on 12/18/24 at 2:11 p.m. Diagnoses included, but were not limited to, fusion of the spine,…

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 an x-ray was completed as ordered by the Physician in a timely manner for 1 of 3 residents reviewed for change in condition. (Resident M) Finding includes: On 12/18/24 at 12:05 p.m., Resident M was observed lying in bed in her room. She had a soft neck collar in place around her neck. During an interview with the resident's family at that time, they indicated the resident recently had neck surgery which was why she was wearing the neck collar. She was supposed to have a neck x-ray done last week to compare with the previous x-ray, but it was not completed until this week and they were unsure why there was a delay. Record review for Resident M was completed on 12/18/24 at 2:11 p.m. Diagnoses included, but were not limited to, fusion of the spine, osteomyelitis of the vertebra, and neoplasm of the spinal cord. A Nursing Note, dated 12/10/24 at 8:51 p.m., indicated a new order was received from the resident's surgeon for an x-ray of the cervical spine. The Nurse Practitioner was made aware. The order…

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

Based on interview and record review, the facility failed to ensure a resident's privacy was respected, related to RN 2 using her private cell phone to take pictures of bruising on the left arm and left breast of a cognitively impaired resident (Resident B) without the approval of the resident's Responsible Party, for 1 of 1 resident reviewed for privacy. See F609 for additional information regarding Resident B. Finding includes: Resident B's record was reviewed on 9/5/24 at 9:47 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. A Quarterly Minimum Data Set assessment, dated 6/22/24, indicated a moderately impaired cognitive status. A Nurse's Progress Note, dated 8/24/24 at 5:46 a.m. and signed by RN 2, indicated a large bruised area was observed on the left breast and left upper arm and the left ankle was slightly swollen. The resident complained of pain with movement of the ankle and was unable to remember how she received the bruises. Cross reference F609. During an interview on 9/5/24 at 1:16 p.m., RN 1 indicated the bruising of the left arm and breast…

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 an injury of unknown source was immediately reported to the Administrator/Abuse Coordinator and the Indiana Department of Health (IDOH) and failed to ensure the injury was investigated/assessed thoroughly for 1 of 3 residents reviewed for injuries and abuse. (Resident B) Finding includes: During an observation on 9/5/24 at 1:50 p.m., CNA 1 lifted up Resident B's shirt and removed her left arm from the sleeve of the shirt. There was a fading purplish/red bruised area from the underarm to the elbow, approximately 20 centimeters (cm) by 13 cm. The entire side and underneath the left breast had a purple bruise. CNA 1 indicated she was unsure how the injury occurred. The resident was unable to recall how the bruise occurred. Resident B's record was reviewed on 9/5/24 at 9:47 a.m. The diagnoses included, but were not limited to, Alzheimer's disease. A Quarterly Minimum Data Set assessment, dated 6/22/24, indicated a moderately impaired cognitive status, no behaviors, no impaired movements of the upper 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 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 an observation on 9/5/24 at 9:38 a.m., LPN 8 responded to an activated call light activated by Resident F. Resident F indicated Resident E's oxygen concentrator was alarming and it was driving him crazy. LPN 8 indicated she needed to administer medications then she would take care of the concentrator, said she would be back, then left the room. During an observation on 9/5/24 at 9:42 a.m., Resident E was lying in bed with the head of the bed elevated. A nasal cannula for the oxygen was in place. The oxygen concentrator was alarming and a lit picture of a wrench was flashing on the concentrator. The concentrator was set at less than 0.5 liters per minute. During an interview on 9/5/24 at 9:59 a.m., Minimum Data Set (MDS) Nurse 9 indicated she was unsure what the wrench…

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 provide a safe and sanitary environment to help prevent the potential of transmission of communicable diseases and infections, related to glucometers (blood sugar monitor) used for multiple residents not sanitized before and after each resident use (RN 8) and failed to sanitize an oximeter (oxygen saturation monitor) used for multiple residents after it was used on a resident. (Resident B, LPN 4) This had the potential to affect the 26 residents in the facility who receive glucometer testing and the 25 residents who reside on [NAME] C Hall. The facility also failed to ensure staff were educated on Enhanced Barrier Precautions (EBP), ensure staff were aware of which residents were on EBP, and correct Personal Protective Equipment (PPE) was used by staff members (CNA 5, CNA 6, CNA 7). This had the potential to affect the 96 residents who reside in the facility. Findings include: 1. During an observation of the Gracepoint Unit on 8/13/24 at…

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

Based on observation, record review, and interview, the facility failed to notify a resident's physician and responsible party in a timely manner, related to a gastrostomy (g-tube, feeding tube) mechanical malfunction requiring hospital intervention, which resulted in medications and flushes not being given as ordered for 1 of 3 residents reviewed for physician and family notifications. (Resident B) See F693 for additional information on Resident B. Finding includes: During an observation on 8/13/24 at 5:24 a.m., the resident was lying in bed with the head of the bed elevated. A liquid tube feeding of Osmolyte 1.5 was infusing at 72 cc (cubic centimeters) per hour. During an observation on 8/13/24 at 11:45 a.m., the resident's tube feeding was turned off. Resident B's record was reviewed on 8/13/24 at 10:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, gastrostomy, and iron deficiency anemia. An Annual Minimum Data Set (MDS) assessment, dated 5/15/24, indicated a feeding tube was present, the resident received 51% or more calories from the feeding tube…

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 residents who were dependent on staff for activities of daily living (ADL's) received bathing/showers at least twice a week for 2 of 3 dependent residents who were reviewed for ADL's. (Residents B and H) Findings include: 1. Resident B's record was reviewed on 8/13/24 at 10:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, gastrostomy tube, and iron deficiency anemia. An Annual Minimum Data Set (MDS) assessment, dated 5/15/24, indicated and short and long term memory problem, had no behaviors, and was dependent for ADL's. Shower and bathing status was marked as not assessed. A Care Plan, dated 5/10/23, indicated a self-care performance deficit and all ADL needs would be met. The Shower Schedule, located in the Shower Sheets Binder, indicated the resident was to be bathed/showered on Mondays and Thursdays. The Shower Sheets in the binder indicated bathing had occurred on 7/22/24 and 7/29/24. During an interview on 8/13/24 1:33 p.m., CNA 2 indicated the bathing was documented either 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 a resident received the necessary care and services related to medications not administered as ordered by the Physician, for 2 of 15 residents reviewed for quality of care. (Residents B and D) Finding includes: 1. Resident B's record was reviewed on 8/13/24 at 10:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, gastrostomy, and iron deficiency anemia. A Care Plan, dated 6/9/23, indicated a diagnosis of anemia. The interventions included the medications would be administered as ordered and laboratory testing would be completed as ordered. The complete blood count laboratory results on 5/10/24 indicated red blood cells (RBC) level was 3.88 (normal 4.7-6.10) and hemoglobin (HGB) was 11.4 (normal 14-18). On 7/15/24, the RBC was 3.46 and HGB 10.5. On 7/31/24, the RBC was 3.24 and HGB 9.7, and on 8/5/24, the RBC was 3.14 and HGB 9.3. The Physician's Orders, dated 6/13/23, indicated five cc's (cubic centimeters) of a liquid multi-vitamin was to be administered daily and seven cc'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 provide proper feeding tube (gastrostomy tube) (g-tube) care as per professional standards, related to water flushes not completed as ordered, verification of the g-tube placement not completed prior to medication administration, failure to flush the g-tube after each medication was administered, a liquid feeding bag not labeled, dated or timed, and a piston syringe (used for water flushing and other care for the g-tube) not changed daily, for 2 of 3 residents reviewed for feeding tube care. (Residents B and J) See F580 for additional information on Resident B Findings include: 1. Resident B's record was reviewed on 8/13/24 at 10:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, gastrostomy, and iron deficiency anemia. An Annual Minimum Data Set (MDS) assessment, dated 5/15/24, indicated feeding tube was present, he received 51% or more calories from the feeding tube and 501 cc's (cubic centimeters) or more of fluids from the feeding tube. A Care Plan, dated 5/15/24, indicated 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 a resident who required nebulizer breathing treatments was assessed prior to, during, and/or after the treatment for effectiveness of the treatment, lung sounds, pulse, oxygen status, and blood pressure status for 1 of 1 resident reviewed for oxygen therapy. (Resident B) Finding includes; Resident B's record was reviewed on 8/13/24 at 10:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, gastrostomy, and iron deficiency anemia. An Annual Minimum Data Set (MDS) assessment, dated 5/15/24, indicated a short and long term memory problem, had no behaviors, was dependent for activities of daily living and oxygen was administered. A Care Plan, dated 5/13/24, indicated the resident required oxygen therapy. The interventions included, the medications would be administered as ordered. A Physician's Order, dated 7/5/24, indicated a nebulizer treatment of ipratropium-albuterol (breathing medication) inhalation solution 0.5-2.5 mg (milligrams) per 3 cc's (cubic centimeters) was to be…

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

Based on record review and interview, the facility failed to ensure dependent residents received the necessary ADL (activities of daily living) care, related to lack of documentation of incontinence care for 3 of 4 residents reviewed for ADL care. (Residents F, G, and H) Findings include: 1. Resident F's record was reviewed on 5/8/24 at 9:00 a.m. Diagnoses included, but were not limited to Alzheimer's disease, gastrostomy and colostomy status, and traumatic brain injury. The Quarterly Minimum Data Set (MDS) assessment, dated 3/9/24, indicated the resident was severely cognitively impaired for daily decision making. He was dependent on staff for ADL care including, but not limited to, oral hygiene, toileting hygiene, and personal hygiene. A Care Plan, dated 5/10/23, indicated the resident had an ADL self-care performance deficit. Interventions included, but were not limited to, the resident required total assistance for toileting and colostomy care. A Care Plan, dated 5/18/23, indicated the resident was incontinent of bladder. Interventions included, but were not limited to, check…

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 physician's orders were followed related to an incorrect amount of enteral feeding documented and incomplete meal consumption logs for residents with a history of weight loss for 3 of 4 residents reviewed for nutrition. (Residents F, G, and H) Findings include: 1. Resident F's record was reviewed on 5/8/24 at 9:00 a.m. Diagnoses included, but were not limited to Alzheimer's disease, gastrostomy and colostomy status, and traumatic brain injury. The Quarterly Minimum Data Set (MDS) assessment, dated 3/9/24, indicated the resident was severely cognitively impaired for daily decision making. He had a feeding tube. He received 51% or more of his total calories and 501 cc per day or more fluids through the feeding tube. A Care Plan, dated 6/7/23, indicated the resident required a tube feeding. Interventions included, but were not limited to, feed via tube feed pump per Physician's order. A Physician's Order, dated 8/9/23, indicated Osmolite 1.5 at 72 milliliter per hour for 20 hours, on at 1:00 p.m. and off at 9:00 a.m.…

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

Based on observation and interview, the facility failed to ensure food was stored under sanitary conditions, related to unlabeled and undated food and beverages, and a scoop stored in the dry food storage bin, for 2 of 4 refrigerators reviewed (Main Kitchen), as well as unlabeled and undated staff beverages in 1 of 2 unit refrigerators (Grace Point 2 Unit) observed. This had the potential to affect 103 residents who received food from the kitchen. Findings include: 1. During the initial tour of the kitchen, with Chef 1 on 3/18/24 at 9:12 a.m., the following observations were made: a. There was an unlabeled and undated beverage in the dessert refrigerator. b. There was an unlabeled and undated pan of rice in the cook's refrigerator. c. In the dry storage room, there was a scoop stored in the rice bin. During an interview, on 3/18/24 at 9:15 a.m., Chef 1 indicated food and drinks should be labeled and dated and there should not be scoops stored in the bins. 2. During an observation of the Grace Point 2 Unit refrigerator, with LPN 4 on 3/21/24 at 2:55 p.m., there were unlabeled 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 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 2 of 2 residents reviewed for self-administration of medication. (Residents 35 and 101) Findings include: 1. On 3/18/24 at 2:13 p.m., a Breo Ellipta inhaler (asthma treatment) and an albuterol inhaler (asthma treatment) were both observed on Resident 35's bedside table. The resident indicated she administered the Breo Ellipta inhaler every morning and the albuterol inhaler only when she needed it. On 3/19/24 at 10:30 a.m., a Breo Ellipta inhaler (asthma treatment) and an albuterol inhaler (asthma treatment) were both observed on Resident 35's bedside table. Resident 35's record was reviewed on 3/21/24 at 8:55 a.m. Diagnoses included, but were not limited to, asthma and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 1/23/24, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 2/17/24, indicated Breo Ellipta…

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, the facility failed to ensure a resident's right to privacy, related to facility staff opening a resident's personal mail, for 1 of 1 residents reviewed for residents' rights. (Resident 35). Finding includes: During an interview on 3/19/24 at 9:14 a.m., Resident 35 indicated within the last week, she had ordered a new debit card. She had received a notification on her cell phone that indicated her card was going to be delivered to the facility soon. She had gone to see the Business Office Manager (BOM) upstairs regarding another matter, and asked if she had received any mail addressed to her. The BOM indicated she had received a letter the day before, and gave the letter to the resident. The letter had already been opened by the BOM. Resident 35 indicated she had never received a call from the BOM indicating the letter had arrived the day before. In the meantime, Resident 35 had canceled the card because she was afraid it had been lost, and now had to wait for another card to be delivered. Resident 35's record was reviewed on 3/21/24 at 8:55 a.m. The Quarterly…

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 dependent residents received the necessary ADL (activities of daily living) care, related to unshaven facial hair, lack of incontinence care, and long fingernails, for 3 of 3 residents reviewed for ADL care. (Residents 17, B, and 27) Findings include: 1. On 3/18/24 at 10:13 a.m., Resident 17 was observed in bed. She had long facial hair on her chin. On 3/19/24 at 1:26 p.m., the resident was again observed in bed, with long facial hair on her chin. She indicated she did not like the facial hair and the staff would sometimes shave her. Resident 17's record was reviewed on 3/19/24 at 1:50 p.m. Diagnoses included, but were not limited to, atherosclerotic heart disease, lymphedema and low back pain. The Quarterly Minimum Data Set (MDS) assessment, dated 1/4/24, indicated the resident had moderate cognitive impairment and required extensive staff assistance for bed mobility and transfers. The current ADL Care Plan indicated the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents received the necessary care and treatment, related to compression stockings not in place as ordered, a non-pressure skin treatment not completed as ordered, and a fall assessment not completed, for 1 of 1 residents reviewed for edema, 1 of 2 residents reviewed for non-pressure skin conditions, and 1 of 1 resident reviewed for falls. (Residents 64, 52 & 27) Findings include: 1. On 3/18/24 at 1:14 p.m., Resident 64 was observed seated in her Broda chair near the Nurses' Station. She was fully dressed with regular socks and tennis shoes on her feet. There were no compression stockings on her legs. On 3/19/24 at 9:30 a.m., the resident was in her room seated. There were no compression stockings on her legs. A family member was present in the room and indicated she frequently did not have them on. Staff said she would take them off, but she wasn't able to do so herself. On 3/19/24 at 1:25 p.m., the resident was observed again…

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 pressure ulcer care was provided as ordered and a pressure ulcer was correctly assessed, for 2 of 4 residents reviewed for pressure ulcers. (Residents 49 and B) Findings include: 1. On 3/20/24 at 1:26 p.m., Resident 49's wound care was observed with LPN 4. The LPN removed a Flagyl (antibiotic) 500 milligram (mg) tablet from the cart, crushed it and poured it into a medicine cup. She gathered additional supplies, then indicated she had not seen the wound before and did not know if there were one or two areas. She removed another Flagyl 500 mg tablet, crushed it and poured it into the same medicine cup. The resident was positioned on her side. The old dressing was removed from her sacral area. There was a full thickness wound with reddened edges, approximately 10 centimeters (cm) wide by 10 cm long. The area was cleansed with normal saline and gauze. The nurse then sprinkled all the crushed Flagyl over the area, applied calcium alginate and covered with a dry dressing. Resident 49's record was reviewed…

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 complete meal consumption logs for a resident with a history of weight loss, for 1 of 1 resident reviewed for nutrition. (Resident 78) Finding includes: On 3/19/24 at 9:45 a.m., Resident 78 was observed in the dining area eating breakfast, but falling asleep during breakfast time. The resident ate about 40% of her breakfast. The resident picked up a small piece of food and put it in her mouth, then fell asleep. The resident's breakfast tray was removed from in front of the resident. On 03/21/24 at 9:21 a.m., Resident 78 was asleep in bed. The resident's breakfast tray was on the food cart in the hallway and was untouched by the resident. Breakfast service time was at 7:00 a.m. The record for Resident 78 was reviewed on 3/18/24 at 9:39 a.m. Diagnoses included, but were limited to, unspecific dementia, behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 1/25/24 State Optional Minimum Data Set (MDS) assessment indicated the resident required supervision and set up help for eating.…

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 practices and standards were maintained, related to staff touching pills during medication administration, for 2 of 5 residents observed during the medication administration observation, and lack of hand hygiene during wound care, for 1 of 4 residents reviewed for pressure ulcers. (Residents 67, 47, and 27) Finding includes: 1. On 3/19/24 at 9:57 a.m., LPN 1 was observed preparing Resident 67's medications. She opened the pre-packaged medication pouch and poured the pills in to her hand, then placed them in a medicine cup. She then administered the medications. During an interview with LPN 1 at that time, she indicated she wasn't aware she was touching the pills and was not aware she shouldn't touch the medications with her hands. During an interview, on 3/19/24 at 10:15 a.m., the Director of Nursing (DON) indicated the nurse should not have been putting the pills in her hand and then administering them. 2. On 3/20/24 at 8:59 a.m., QMA 1 was observed preparing Resident 47'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 and record review, the facility failed to ensure agency staff were provided adequate orientation to the facility and residents care needs, related to Agency CNA 1 delivering a meal tray to a resident who was NPO (nothing by mouth), for a random observation on the 200 C hall. This had the potential to affect 3 residents residing in the facility who were NPO. Finding includes: On 3/21/24 at 11:48 a.m., Agency CNA 1 was observed delivering Resident C's lunch tray. She placed Resident C's tray on Resident B's bedside table and exited the room. Resident B was observed sitting in his bed with his eyes open. On 3/21/24 at 11:51 a.m., CNA 1 entered Resident B's room, picked up Resident C's tray from Resident B's bedside table and proceeded to assist Resident C with his lunch. Resident B's record was reviewed on 3/21/24 at 10:32 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, pressure ulcer of left heel, colostomy status, and benign prostatic hyperplasia (an enlarged prostate). The Quarterly Minimum Data Set (MDS) assessment, dated 12/8/23,…

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 who required minimal assistance with showers received bathing at least twice a week, for 1 of 1 resident who required minimal assistance with bathing. (Resident BB) Finding includes: During an interview on 1/31/24 9:16 a.m., Resident BB indicated her showers were scheduled on Wednesdays and Saturday days. She had not had a shower in over a week and does not always receive her showers. Resident B's record was reviewed on 1/31/24 at 10:24 a.m. The diagnoses included, but were not limited to, diabetes mellitus. An Annual Minimum Data Set assessment, dated 10/24/23, indicated an intact cognitive status, no behaviors, independent for toileting, hygiene, mobility, and walking. Shower status was not assessed. A Care Plan, dated 9/8/21, indicated self performance for activities of daily living fluctuates. The interventions indicated she preferred her shower in the morning. The Shower Task Form indicated a shower was received on 1/20/24 and 1/27/24. A bed bath was received on 1/24/24. There was no documentation 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 ensure residents who required extensive to dependent assistance for activities of daily living (ADL's), received bathing/showers at least twice a week, for 2 of 2 residents who require extensive to dependent assistance for ADL's. (Residents DD and EE) Findings include: 1) Resident DD's record was reviewed on 1/31/24 at 11:32 a.m. the diagnoses included, but were not limited to stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 12/21/23, indicated a moderately impaired cognitive status, no behaviors, dependent for ADL's, bed mobility, and transfers. A Care Plan, dated 1/11/24, indicated assistance was required for ADL's. The interventions included she was totally dependent for bathing, preferred bed baths, and did not have a time preference for her bathing. The shower/bathing schedule indicated bathing was on Mondays and Thursdays on the evening shift. There was no documentation that indicated showers/bathing had been completed in January. The bathing was documented as completed on 11/2/23, 11/13/23, 12/21/23,…

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 residents received medical records within 48 hours of request for 2 of 3 residents reviewed for medical record requests. (Residents H and J) Findings include: Requests for medical records were reviewed on 10/26/23 at 1:57 p.m. 1. Resident H requested his medical records on 9/25/23. The request was stamped as received by medical records on 9/25/23. The medical records were made available and released to the resident on 10/19/23. 2. Resident J requested his medical records on 8/4/23. The request was stamped as received by medical records on 8/9/23. The medical records were made available and released to the resident on 8/17/23. The current policy, Medical Record Request, indicated, .It is our policy to fulfill requests for uses and disclosures of protected health information within 30 days of receipt of a valid Authorization of Release of Medical Information Form Interview with the Medical Records Director on 10/26/23, indicated she had been on vacation when Resident J's request had been made, that was why the delay…

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.