Saint Anthony

Based on record review and interview, the facility failed to ensure residents on the Memory Care Unit were treated with respect and dignity, related to a staff member yelling and using foul language in the hallway where residents could hear the staff member. This had the potential to affect all the residents on the Memory Care Unit. (Terminated Employee 1 and Resident G). The deficient practice was corrected on 12/16/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A facility initiated staff to resident incident reported to the Indiana Department of Health (IDOH), dated 12/6/24, was reviewed on 1/15/25 at 1:03 p.m. The incident indicated an altercation between Terminated Employee 1 and Resident G. Review of the facility's finished investigation of the incident, dated 12/11/24, indicated staff to resident abuse had not occurred. Terminated Employee 1 was immediately placed on administrative leave and was instructed to leave the building. She admitted to using some profanity in front of the residents. A typed statement from the ED, 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 observation, interview, and record review, the facility failed to ensure care-planned interventions to prevent injuries due to a fall were in place, related to a non-slip pad not on the wheelchair pad when the resident was sitting in the wheelchair and a mat not placed on the floor next to the bed when the resident was lying in bed, for 1 of 3 residents reviewed for falls and fall interventions. (Resident D) Finding includes: Resident D was observed on 1/14/25 at 9 a.m., 10:05 a.m. and 11:31 a.m., sitting by herself in the wheelchair in her room. During an observation on 1/14/25 at 11:35 a.m., QMA 3 and CNA 4 assisted the resident from the wheelchair to the bed. The resident was assisted to stand from the wheelchair. A non-slip pad was not under the resident in the wheelchair. During an interview at the time of the observation, QMA 3 and CNA 4 indicated they were unsure if a non-slip pad was to be on the wheelchair pad and both indicated it was not on the wheelchair. The resident was assisted in a lying position on the bed and incontinence care was completed. She was…

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

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 10/8/24 at 2:05 p.m., Resident D's room was observed. There were no non-skid strips on her bathroom floor. The record for Resident D was reviewed on 10/8/24 at 11:15 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertensive chronic kidney disease, type 2 diabetes mellitus, osteoarthritis, dementia, and repeated falls The Quarterly Minimum Data Set (MDS) assessment, dated 8/29/24, indicated the resident was severely cognitively impaired and required substantial assistance with activities of daily living. A Care Plan, updated 10/23/23, indicated the resident was at risk for falls. An intervention, dated 9/23/24, indicated non-skid strips were to be placed on the bathroom floor, near the toilet. An Indiana Department of Health reportable incident, dated 9/9/24, indicated new bruising was found under the resident's eye and on both…

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 food consumption logs were completed for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents F and C) Findings include: 1. Record review for Resident F was completed on 10/8/24 at 2:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, [NAME] syndrome (body makes too much cortisol hormone), diabetes mellitus, and end stage renal disease. The admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact. The resident required partial assistance with eating. A Care Plan, dated 8/14/24, indicated the resident was at risk for complications and symptoms of hypoglycemia or hyperglycemia due to diabetes. An intervention included to document the resident's meal and snack intake. An IDT Risk Review, dated 10/3/24, indicated the resident's most recent weight on 10/3/24 was 203 pounds. The previous weight on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to 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 not monitoring the resident's pulse as ordered prior to administering a blood pressure medication for 1 of 3 residents reviewed for unnecessary medications. (Resident F) Finding includes: Record review for Resident F was completed on 10/8/24 at 2:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, [NAME] syndrome (body makes too much cortisol hormone), diabetes mellitus, and end stage renal disease. The admission Minimum Data Set (MDS) assessment, dated 8/20/24, indicated the resident was cognitively intact. The October 2024 Physician's Order Summary indicated an order for metoprolol succinate (treats high blood pressure) 100 mg (milligrams) one time a day. Hold the medication for heart rate less than 60. The September…

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 dependent residents received the activities of daily living (ADL) care needed related to showers not given as scheduled, facial hair unshaven, and soiled sheets on a resident's bed for 5 of 8 residents reviewed for ADL care. (Residents 76, 121, 52, C, and 45) Findings include: 1. On 5/13/24 at 2:53 p.m., Resident 76 was observed lying in his bed. His hair appeared greasy and there was visible white debris observed. His beard had visible food debris. On 5/14/24 at 9:11 a.m., the resident was observed lying in bed. His hair was greasy with white debris observed. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting. The current ADL…

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 properly stored for 4 of 5 medication carts observed. (1A Medication Cart, 2C Medication Cart, 2B Medication Cart, and 3D Medication Cart) Findings include: 1. On 5/20/24 at 9:13 a.m., the 1A Medication Cart was observed with RN 2. There were approximately 20 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 2. On 5/20/24 at 9:26 a.m., the 2C Medication Cart was observed with LPN 2. There were approximately 40 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The nurse indicated nursing was responsible for making sure the medication carts were cleaned. 3. On 5/20/24 at 9:33 a.m., the 2B Medication Cart was observed with RN 3. There were approximately 12 pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the…

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

Based on observation, record review, and interview, the facility failed to ensure residents had physician's orders for self-administration of medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 111) Finding includes: On 5/14/24 at 9:21 a.m., Resident 111 was observed in her room in bed. There was a medication cup noted with multiple pills in it on the table next to her. The resident indicated the nurses always had left her morning medications for her to take after she had eaten her breakfast. Resident 111's record was reviewed on 5/15/24 at 1:22 p.m. Diagnoses included, but were not limited to, dementia, heart disease, and anxiety disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 4/5/24, indicated the resident was cognitively intact for daily decision making. She had taken antidepressants, anticoagulants, diuretics, and opioid medications in the last 7 day look back period. An Interdisciplinary Team (IDT) note, dated 5/14/2024 at 9:18 a.m., indicated the IDT met to review the resident and determined the resident was able 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 record review and interview, the facility failed to notify the family/representative of a significant weight loss, a weight loss, and a new order for a nutritional supplement for 2 of 7 residents reviewed for nutrition. (Residents 59 and 143) Findings include: 1. Resident 59's record was reviewed on 5/14/24 at 2:42 p.m. Diagnoses included, but were not limited to, Lewy body dementia, psychotic disorder, depressive disorder and diabetes mellitus. The resident resided on the locked dementia unit. The Quarterly Minimum Data Set (MDS) assessment, dated 3/29/24, indicated the resident had severe cognitive impairment and required limited staff assistance for bed mobility and transfers, and could eat independently after set up. The Current Physician Orders indicated the resident was on a regular diet. There were no nutritional supplements or fortified food ordered. The resident's weights were as follows: 2/5/24: 232 pounds (lbs) 2/11/24: 230 lbs 2/18/24: 218 lbs 2/25/24: 217 lbs 3/6/24: 217 lbs This was a…

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

Based on observation and interview, the facility failed to ensure a clean and homelike environment related to stained and dirty bed linens for 1 of 35 residents reviewed for a homelike environment. (Resident B) Finding includes: On 5/14/24 at 10:03 a.m., Resident B was observed lying in bed with his eyes closed. There was a dark reddish-brown stain on the bottom sheet next to where his left forearm was resting. His pillowcase also had a large brown stain along the end of it. On 5/15/24 at 10:42 a.m., Resident B was observed lying in bed with his eyes closed. The stains remained to the bottom sheet and the pillowcase. On 5/15/24 at 10:58 a.m., a CNA exited the room after providing care to Resident B. Resident B was now sitting up in his wheelchair in his room. His bed had been made, however, the stains remained to the bottom sheet and the pillowcase. During an interview with the Administrator on 5/15/24 at 11:11 a.m., she indicated the linens were probably already stained when they were put on the bed. She then changed the linens. This citation relates to Complaint IN00431905.…

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 the necessary treatment and services related to the monitoring and assessment of skin discolorations for 3 of 7 residents reviewed for non-pressure related skin conditions. (Residents B, 66, and 10) Findings include: 1. On 5/14/24 at 10:03 a.m., Resident B was observed lying in bed with his eyes closed. He had 2 scabbed areas to his right forearm and multiple purple discolorations to his left forearm. On 5/15/24 at 10:42 a.m., Resident B was observed lying in bed with his eyes closed. The scabbed areas and discolorations remained to his arms. Record review for Resident B was completed on 5/15/24 at 3:50 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia with behavioral disturbance, and chronic kidney disease. The Significant Change Minimum Data Set (MDS) assessment, dated 3/5/24, indicated the resident was cognitively impaired and required substantial/maximal assist with upper body dressing. A current Care Plan, updated 3/11/24, 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 a resident received the assistive device needed to maintain vision related to broken glasses not addressed in a timely manner, for 1 of 2 residents reviewed for vision/hearing. (Resident 76) Finding includes: On 5/13/24 at 2:53 p.m., 5/14/24 at 9:11 a.m., and 5/15/24 at 1:20 p.m., Resident 76 was observed lying in his bed. There was a pair of glasses with one of the arms broken off sitting on the overbed table. The resident indicated he used them for reading. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus, and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting. There was no documentation in the record related to the broken glasses or optometry appointments. During an interview…

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 each resident received the necessary treatment and services to promote healing for pressure ulcers, related to ensuring a wound treatment and offloading boots were in place for 2 of 8 residents reviewed for pressure ulcers. (Residents D and E) Findings include: 1. The closed record for Resident D was reviewed on 5/16/24 at 2:52 p.m. Diagnoses included, but were not limited to, anemia, dementia with mood disturbance, and atrial fibrillation. The resident was admitted to the facility on [DATE] and discharged on 4/1/24. The admission Minimum Data Set (MDS) assessment, dated 2/13/24, indicated the resident was cognitively impaired, had no unhealed pressure ulcers, and was at risk for pressure ulcers. A Care Plan, dated 3/19/24, indicated the resident had a pressure ulcer to the left hip. An intervention included, wound treatments as ordered. The Skilled Care Nursing Documentation form, dated 3/18/24, indicated there were no current…

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 positioning was maintained related to hand splints not applied as ordered, for 3 of 4 residents reviewed for positioning/mobility. (Residents 76, 10 and 125) Findings include: 1. On 5/13/24 at 2:53 p.m., Resident 76 was observed lying in his bed. His left hand was contracted and there was no splint in place. On 5/15/24 at 1:20 p.m., the resident was observed lying in bed. His left hand was contracted and there was no splint in place. The resident indicated he used to wear a splint, but was told he didn't need to wear it anymore. He was unable to open his left hand. The resident's record was reviewed on 5/15/24 at 12:50 a.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular accident, diabetes mellitus and vascular dementia. The Annual Minimum Data Set assessment, dated 2/8/24, indicated the resident had moderate cognitive impairment and required extensive assistance for bed mobility and toileting.…

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 interventions were in place for 2 of 3 residents reviewed for accidents. (Residents B and 91) Findings include: 1. On 5/14/24 at 10:03 a.m., Resident B was observed lying in bed with his eyes closed. There were no floor mats in place at the bedside. Both mats were leaning up against the wall by the window. On 5/15/24 at 10:42 a.m., Resident B was observed lying in bed with his eyes closed. There were no floor mats in place at the bedside. Both mats were leaning up against the wall by the window. Record review for Resident B was completed on 5/15/24 at 3:50 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, dementia with behavioral disturbance, and chronic kidney disease. The Significant Change Minimum Data Set (MDS) assessment, dated 3/5/24, indicated the resident was cognitively impaired and required substantial/maximal assist with bed mobility and transfers. A current Care Plan, updated 3/11/24, indicated the resident was at risk for falls An intervention included, mat…

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 urinary output was recorded as per the plan of care for 1 of 1 residents reviewed for urinary catheters. (Resident 89) Finding includes: On 5/13/24 at 1:57 p.m., Resident 89 was observed lying in bed. The resident had a urinary catheter attached to the side of his bed. The bag was observed with a small amount of urine in the bag. The resident indicated staff did not empty his catheter bag and he would have to tell them multiple times a day to make sure they emptied it. Record review for Resident 89 was completed on 5/16/24 at 1:37 p.m. Diagnoses included, but were not limited to, obstructive uropathy, diabetes mellitus, and end stage renal disease. The Quarterly Minimum Data Set (MDS) assessment, dated 4/1/24, indicated the resident was cognitively intact. The resident was dependent for toileting and required substantial assistance with bed mobility. The resident had an indwelling urinary catheter. A Care Plan, dated 5/8/23 and revised 6/28/23, indicated the resident was at risk for infection 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure interventions were implemented for a resident with a significant weight loss, failed to ensure food consumption logs were completed and weekly weights were completed as ordered for 3 of 7 residents reviewed for nutrition. (Residents 59, 91 and 158) Findings include: 1. Resident 59's record was reviewed on 5/14/24 at 2:42 p.m. Diagnoses included, but were not limited to, Lewy body dementia, psychotic disorder, depressive disorder, and diabetes mellitus. The resident resided on the locked dementia unit and was admitted on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 3/29/24, indicated the resident had severe cognitive impairment and required limited staff assistance for bed mobility and transfers, and could eat independently after set up. The current May 2024 Physician Order Summary indicated the resident was on a regular diet. There were no nutritional supplements or fortified food ordered. The resident's weights were as…

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 with a gastronomy tube (g-tube) received appropriate treatment related to not completing water flushes before medication administration as ordered by the physician, for 1 of 7 residents reviewed during medication administration. (Resident 115 and RN 1) Finding includes: On 5/16/24 at 11:11 a.m., RN 1 was observed preparing Resident 115's medication to administer via a g-tube. The nurse crushed Tylenol 325 mg (milligrams) x 2 tablets and poured them into a medicine cup. She then proceeded to add 30 ml (milliliters) of water to the cup with the Tylenol. RN 1 checked placement of the g-tube, attached a syringe to the g-tube and poured the medicine cup into the syringe. After the diluted medication went through the tubing, she then proceeded to administer 30 ml of water into the tubing. Record review for Resident 115 was completed on 5/16/24 at 11:08 a.m. The May 2024 Physician's Order Summary indicated an order to administer 30 ml of water before and 30 ml of water after medication…

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 to deliver care and services and to address the needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD) related to not following care plan interventions or updating care plans for a PTSD diagnosis for 1 of 1 residents reviewed for behaviors. (Resident 134) Finding includes: On 5/13/24 at 9:54 a.m., Resident 134 was noted to be yelling out. On 5/16/24 at 10:10 a.m., Resident 134 was observed in a broda chair in a common area with other residents. He was observed making noises under his breath. On 5/17/24 at 10:23 a.m., Resident 134 was observed in his room in a broda chair loudly yelling out. Resident 134's record was reviewed on 5/15/24 at 1:57 p.m. Diagnosis included, but were not limited to, dementia, PTSD, psychosis, major depressive disorder, and generalized anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 3/3/24, indicated the resident was severely cognitively impaired for daily decision making. He displayed inattention, disorganized thinking, 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 ensure clinical records were complete and accurately documented related to medication administration, for 1 of 2 residents reviewed for antibiotic use. (Resident 74) Finding includes: During an interview with Resident 74 on 5/14/24 at 9:32 a.m., she indicated she had a urinary infection and was being treated with antibiotics. The record for Resident 74 was reviewed on 5/16/24 at 11:22 a.m. Diagnoses included, but were not limited to, anemia, congestive heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact and had septicemia and a urinary tract infection in the last 30 days. A Physician's Order, dated 5/6/24, indicated to give piperacillin-tazobactam (Zosyn, an antibiotic) 3.375 grams intravenously every 8 hours for 7 days for sepsis due to pseudomonas (bacteria). The Medication Administration Record (MAR), dated 5/2024, indicated the antibiotic medication had not been signed off as given on the following dates and times: 6 a.m. 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 observation, interview, and record review, the facility failed to ensure infection control guidelines were in place and implemented related to a lancet disposed of improperly for a random observation during a blood sugar check. (Resident 37 and RN 1) Finding includes: On 5/16/24 at 11:25 a.m., RN 1 was observed testing Resident 37's blood sugar level. The nurse washed her hands, donned gloves, cleaned the resident's finger, and then poked the resident's finger with a lancet to obtain the blood sample. The resident's blood sugar level was then assessed. The nurse then took off her gloves and disposed of them into the resident's garbage can along with the lancet. The nurse then proceeded to walk out of the resident's room into the hallway. During an interview after the observation, RN 1 indicated she disposed of the lancet into the resident's garbage can. She should have disposed of the lancet into the sharps container. A facility policy titled, Sharps Disposal and received as current from the Administrator indicated, .2. Contaminated sharps will be discarded into containers…

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 who required extensive and dependent care for activities of daily living (ADL's), received showers and/or bathing per their preferences and timely incontinent care for 5 of 6 residents reviewed for ADL assistance. (Residents F, J, N, B, and L) Findings include: 1) Resident F was interviewed on 12/13/23 at 10:18 a.m She indicated she has had one shower since being admitted into the facility and has bed baths the rest of the time when they bathed her. She has not received a bed bath twice a week. She also does not get incontinent care timely and has had to sit in urine and bowel movement for long periods of time because they turn her call light off and say they will be back but never come back. During the interview, the resident was observed wearing a purple gown/top. During an observation on 12/13/23 at 11:07 a.m., the call light was activated and answered by Employee 1. Employee 1 and Employee 2 entered the room to provide incontinent care. The incontinent brief was saturated with urine 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 provide residents' medical records to the family/Power of Attorney (POA) in a timely manner after a request was made for 2 of 3 residents reviewed for medical record requests. (Residents B and K) Findings include: 1. Resident B's closed record was reviewed on 12/13/23 at 3:40 p.m. The diagnoses included, but were not limited to, Parkinson's disease. The resident was discharged from the facility on 9/11/23. During an interview on 12/14/23, the Medical Records Clerk indicated the family requested the medical records on 10/9/23 and it was faxed to the Corporate Office on 10/10/23. She indicated the request for records has to be filled out and signed and brought to the facility. It is then faxed to the Corporate Office and the records are sent out from there. During an interview with Corporate Medical Records Employee 3 on 12/14/23 at 9:08 a.m., she indicated the resident's records were not sent to the family until 10/26/23. 2. Resident K's closed record was reviewed on 12/15/23 at 9:39 a.m. The diagnoses included, but 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 to prevent falls were in place, related to non-skid strips on the floor and dycem (non-slide material) on the wheelchair to prevent sliding for 1 of 3 residents reviewed for falls. (Resident M) Finding includes: During an observation on 12/15/23 at 10:02 a.m. with Employee 4, there were no non-skid strips on the resident's bathroom floor and no dycem on the wheelchair seat. Resident M's record was reviewed on 12/15/23 at 9:46 a.m. The diagnoses included, but were not limited to, vascular dementia. An Annual Minimum Data Set assessment, dated 12/2/23, indicated a severely impaired cognitive status, maximum assistance required for transfers, moderate assistance required for ambulation, and no falls. A Care Plan, dated 5/13/21, indicated a risk for falls. The interventions included, on 7/31/23 dycem was applied to the seat of the wheelchair and on 12/11/23, non-skid strips were applied to the bathroom floor. A Nurse's Progress Note, dated 7/29/23 at 11:05 a.m., 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 implement their written policies and procedures that protected residents after an allegation of abuse, related to a CNA continued to work the rest of the shift after an allegation of abuse was reported by a resident for 1 of 3 residents reviewed for abuse. (Resident B and CNA 2) Finding includes: During an interview on 8/11/23 at 4:37 a.m., Nurse 1 indicated an altercation had occurred between staff members and Resident B on 8/8/23. Resident B accused CNA 2 of throwing water on her. The Director of Nursing (DON) was notified and CNA 2 was removed from the resident's care. CNA 2 had not been sent home and worked the rest of her shift. Cross reference F609 The facility abuse policy, dated 3/2021 and received from the Director of Nursing as current, indicated employees who have been accused of resident abuse shall be suspended of duty immediately until the results of the investigation have been reviewed by the Administrator. This Federal tag relates to Complaint IN00414807. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Indiana Department of Health (IDOH) and other proper authorities for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: During an interview on 8/11/23 at 4:37 a.m., Nurse 1 indicated an altercation had occurred between staff members and Resident B on 8/8/23. Resident B had several outbursts of yelling at staff. CNA 2 was in the room and she was in the hallway. She heard something that sounded like an object sliding across the floor like it had been thrown. When she entered the resident's room, Resident B accused CNA 2 of throwing water on her and there was a bath basin on the floor. CNA 2 indicated the resident had thrown water on her. The Director of Nursing (DON) was notified and CNA 2 was removed from the resident's care. The resident was mad and would not let anyone complete care on her. During an observation on 8/11/23 at 4:55 a.m., Resident B was awake, sitting up in bed, the TV was on, and she was doing something on her cell phone. 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 record review and interview, the facility failed to accurately document behaviors, triggers for the behaviors, interventions, and the outcome of the interventions for the behaviors, for 1 of 3 residents reviewed for behaviors. (Resident B) Finding includes: Resident B's record was reviewed on 8/11/23 at 7:16 a.m. The diagnoses included, but were not limited to, depression. An admission Minimum Data Set assessment, dated 7/17/23, indicated an intact cognitive status, and physical behaviors, verbal behaviors, other behaviors, and rejection of care occurred one to three days. A Care Plan, dated 7/11/23 and revised on 8/9/23, indicated behaviors exhibited were refusals of care, medications/treatments, she dictated her care with the staff what she wants/doesn't want and what she will or won't do, demanding of staff when wants/needs could not be accommodated, threatened staff that she will just go home, has made multiple complaints about care, exhibited a rude/unpleasant demeanor, has been manipulative like making a request then refusing and then told others it was never offered,…

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 there was adequate nursing staff available to meet the residents' needs related to receiving scheduled showers for 1 of 9 units reviewed for staffing. (Unit 3A) Finding includes: On 6/14/23, the 3A unit was observed continuously from 10:15 to 11:40 a.m. The was one QMA and one CNA on the unit. There were 24 residents on the unit. There was no additional staff on the unit. The shower book indicated there were four residents scheduled to receive a shower that day on day shift. Interview with QMA 1 on 6/14/23 at 2:00 p.m., indicated there was only one CNA that day. There were sometimes two CNAs, or a split that would work two units. She indicated they would offer residents bed baths instead of showers when they were short staffed. Interview with CNA 1 on 5/14/23 at 2:25 p.m., indicated she was only able to give one of the four scheduled residents a shower that day. When working alone it was impossible to give all four showers during a shift. Interview with the Executive Director and the Administrator on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were labeled correctly related to eye drops, nasal sprays, and insulin with no labels and insulin in use that was expired for 3 of 5 medication carts observed. (3D, 2D, and 1A Medication Carts) Findings include: 1. On [DATE] at 10:26 a.m., the 3D Medication Cart was observed with QMA 3. Resident 149's insulin glargine 100 unit/milliter (mL) vial was labeled with an expiration date of [DATE]. QMA 3 indicated the resident was still receiving the medication nightly and the medication should have been disposed of on [DATE]. 2. On [DATE] at 2:05 p.m., the 2D Medication Cart was observed with LPN 1. The following medications were found in the cart: a. There was Aller-flo nasal spray, Refresh Tears, Combigan (eye drops), and a Novolog insulin vial opened on [DATE] in a drawer with no label. b. Resident 153's had two vials of Lantus insulin 100 unit/mL vial that were opened on [DATE] and [DATE]. She had a Humalog 100 unit/mL…

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

Based on observation and interview, the facility failed to follow proper sanitation and food handling practices related to the high temperature dish machine not reaching appropriate rinse temperature and use of expired sanitizer test strips for 1 of 1 kitchens. This had the potential to affect 170 residents who received food from the kitchen. (The Main Kitchen) Findings include: 1. On 6/14/23 at 9:40 a.m., the Dietary Food Manager (DFM) was observed wiping down a preparation counter with a sanitizer solution. At the time, a sanitizer test strip was used to test the solution. The test strips expired on 6/30/22. The strip did not have a readily discernable color change. The DFM brought another package of test strips to test the solution, which had expired on 3/1/22. The strip did not have a readily discernable color change. Interview with the DFM at the time indicated he would send someone out to purchase sanitizer test strips that were not expired. The Sanitation Bucket Log for the month of June 2023, received from the Executive Director on 6/15/23 at 3:51 p.m., indicated three…

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 self-medication administration assessment was completed for residents with medications at the bedside for 2 of 2 random observations. (Residents H and F) Findings include: 1. On 6/12/23 at 11:33 a.m., Resident H was observed lying in her bed. There was a Symbicort inhaler on her bedside table. On 6/12/23 at 2:56 p.m., the inhaler was observed still on her bedside table The record for Resident H was reviewed on 6/15/23 at 9:09 a.m. Diagnoses included, but were not limited to cellulitis, dementia and neoplasm of the brain. The admission Minimum Data Set (MDS) assessment, dated 5/26/23, indicated the resident had moderate cognitive deficits and required a total of 2 staff assistance for bed mobility and transfers. A Physician's Order, dated 5/20/23, indicated to give Symbicort Inhalation 2 puffs, twice daily. There was no self-medication administration assessment, care plan or Physician order to self administer medications. Interview with QMA 2 on 6/12/23 at 2:56 p.m., indicated she was not sure if the…

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

Based on record review, and interview, the facility failed to report, investigate the root cause, and resolve resident grievances for 2 of 2 residents reviewed for grievances. (Residents D and J) Findings include: 1. The record for Resident D was reviewed on 6/14/22 at 2:54 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, dementia with behavioral disturbance, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 4/21/23, indicated the resident was mildly cognitively impaired and required extensive assist x 1 for personal hygiene and bathing. A Grievance form, dated 5/2/23, indicated the resident had not received her shower on 5/1/23. The findings indicated the resident's family had her shower day mixed up and the resident was given a shower on 5/3/23. A Grievance form, dated 5/3/23, indicated the resident's showers were not given consistently per the resident's daughter. The findings indicted the resident had not received her shower on the scheduled day and the shower was provided on the following day shift. A Grievance form,…

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 showers were provided as scheduled for a dependent resident for 1 of 11 residents reviewed for activities of daily living (ADL) care. (Resident L) Finding includes: On 6/12/23 at 1:01 p.m., Resident L indicated he wasn't getting his scheduled showers, he hadn't been showered in over a week. The resident's record was reviewed on 6/14/23 at 12:14 p.m. Diagnoses included, but were not limited to, Muscular Sclerosis and Diabetes Mellitus. The Annual Minimum Data Set assessment, dated 5/4/23, indicated the resident was cognitively intact, and required extensive assistance of 2 for bed mobility and transfers. The shower schedule indicated the resident was to be showered on Wednesday and Saturday evenings. Shower sheets for the past 30 days indicated the resident had a bed bath on 5/6/23. The Point of Care charting (used by CNAs) indicated the resident got a shower on 5/25/23 and 6/7/23. There was no additional documentation. Interview with CNA 1 on 6/14/23 at 2:25 p.m., indicated she was the only CNA on the hall that day.…

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 skin discolorations were assessed and monitored, a treatment order for a bandage was in place, and a treatment was in place for dry and flaky legs for 3 of 7 residents reviewed for non-pressure skin conditions. (Residents H, 5 and D) Findings include: 1. On 6/12/23 at 11:33 a.m., Resident H was observed lying in her bed. There was a dark purplish discoloration on her left forearm and left thigh. The resident indicated she did not know what happened to the areas. On 6/13/23 at 10:09 a.m., the resident was again observed in bed and the discoloration to her left forearm and left thigh were visible. The record for Resident H was reviewed on 6/15/23 at 9:09 a.m. Diagnoses included, but were not limited to cellulitis, dementia and neoplasm of the brain. The admission Minimum Data Set (MDS) assessment, dated 5/26/23, indicated the resident had moderate cognitive deficits and required total 2 staff assistance for bed mobility and transfers. A Medication Care Plan indicated the resident was at increased risk 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 resident's positioning was maintained related to a hand splint not applied as ordered for 1 of 2 residents reviewed for positioning/ mobility. (Resident 74) Finding includes: On 6/12/23 at 10:12 a.m., Resident 74 was observed in bed, there was no hand splint on her right hand. She was again observed in her room on 6/12/23 at 11:16 a.m., 6/14/23 at 9:25 a.m., 6/15/23 at 8:50 a.m., and 11:12 a.m., 6/16/23 at 9:41 a.m. and 10:21 a.m., with no hand splint on her right hand. The resident's record was reviewed on 6/16/23 at 10:08 a.m. Diagnoses included, but were not limited to, chronic pain syndrome and hypertension. A Quarterly Minimum Data Set assessment, dated 4/4/23, indicated the resident was cognitively intact and required extensive assistance of two staff for bed mobility and transfers. A Physician's Order, dated 1/13/23, indicated to wear a splint to the right hand at all times, to be removed for skin checks each shift. The June 2023 Medication Administration Record indicated the right hand splint…

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 supervision and follow protocols related to random observations of residents transferred by a Hoyer lift (suspension lift to reposition and transfer into a chair or bed) for 2 of 2 Hoyer transfers observed. (Residents B and 151) Findings include: 1. During a random observation on 6/14/23 at 9:30 a.m., CNA 2 was observed in Resident's B's room to transfer him from his bed to his wheelchair via a Hoyer lift. CNA 2 was the only staff member in the room completing the transfer. On 6/14/23 at 9:42 a.m., CNA 2 left the resident's room and the resident was sitting in his wheelchair. Record review for Resident B was completed on 6/13/23 at 2:00 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia, end stage renal disease, and respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 4/17/23, indicated the resident was cognitively impaired. The resident required a total 2+ person assist for transfers. The resident had an impairment on one side of his upper and lower…

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 with a urinary tract infection (UTI) received the necessary treatment and services related to completing an ordered laboratory test timely for 1 of 2 residents reviewed for urinary tract infections. (Resident K) Finding includes: On 6/12/23 from 2:23 p.m. through 2:36 p.m., Resident K was observed lying in her bed. The resident was repetitively yelling out I need help. Where am I going to go? Somebody help me. Where will I go? The Unit Manager entered the room and spoke to the resident. Upon exiting the room, the resident again began repetitively yelling out. The record for Resident K was reviewed on 6/16/23 at 9:21 a.m. Diagnoses included, but were not limited to, Alzheimer's Disease, hypertension, and atrial fibrillation. A Psych Services Progress Note, dated 6/1/23, indicated the resident was experiencing worsening behaviors and anxiety. A medication change was made, and a urinalysis (UA, urine test) was ordered. A Progress Note, dated 6/2/23, indicated the urine sample was obtained 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 provide proper respiratory care and services related to not changing nebulizer (machine that turns liquid medications into a mist to be inhaled) masks timely and not completing nebulizer treatment assessments as ordered for 1 of 3 residents reviewed for oxygen. (Resident B) Finding includes: On 6/12/23 at 10:33 a.m., a nebulizer mask was observed in a bag laying on Resident B's bed. The mask was dated 5/27. On 6/13/23 at 10:24 a.m., Resident B was observed lying in bed. A nebulizer mask was in a bag on the resident's wheelchair. The mask was dated 5/27. Record review for Resident B was completed on 6/13/23 at 2:00 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia, end stage renal disease, and respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 4/17/23, indicated the resident was cognitively impaired. The resident had received oxygen therapy. A Care Plan, dated 4/21/23, indicated the resident was at risk for respiratory distress related to respiratory failure. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were free from unnecessary psychoactive medications related to administration of an anti-anxiety medication as ordered and antipsychotic medication use for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for behavior/ emotional care. (Residents D and K) Findings include: 1. The record for Resident D was reviewed on 6/14/22 at 2:54 p.m. Diagnoses included, but were not limited to, Parkinson's Disease, dementia with behavioral disturbance, and major depressive disorder. The resident was admitted to the facility on [DATE]. The Quarterly MDS (Minimum Data Set) assessment, dated 4/21/23, indicated the resident had not had any behaviors. She received antipsychotic and antidepressant medications. A Progress Note, dated 1/20/23, indicated the resident's family was requesting she be started on Abilify (aripiprazole, an antipsychotic medication) as she would have hallucinations without 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.