Aperion Care Demotte

Based on record review and interview, the facility failed to ensure food consumption logs were complete for residents with a history of weight loss for 1 of 3 residents reviewed for nutrition. (Resident 20)Finding includes:The record for Resident 20 was reviewed on 9/3/25 at 3:49 p.m. Diagnoses included, but were not limited to, heart disease, pressure ulcer of buttock, and dementia.The 8/18/25 admission Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment, required maximal assistance with ADLs and transfers, and had a weight loss of 5% or more in the last month or 10% or more in last 6 months. The resident's record lacked documentation of 3 meal intakes per day on 8/13/25, 8/14/25, 8/16/25, 8/17/25, 8/18/25, 8/19/25, 8/20/25, 8/23/25, 8/25/25, 8/28/25, 8/29/25, 9/1/25, and 9/2/25.A care plan, revised 8/13/25, indicated the resident was at risk for fluctuations in weight. Interventions included monitoring and recording the resident's intake each shift.During an interview on 9/4/25 at 11:50 a.m., the MDS Coordinator indicated the resident had 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 medication error rate of less than 5% for 1 of 11 residents observed during medication pass. Two errors were observed during 26 opportunities for errors during medication administration. This resulted in a medication error rate of 7.69%. (Resident 17) Finding includes:On 9/5/25 at 3:11 p.m., RN 1 was observed preparing Resident 17's medications to be administered. The nurse popped out 1 Flomax 0.4 mg (milligrams) capsule (urinary medication) and 1 senna 8.6 mg (stimulant laxative) pill into a cup. She then proceeded to place the medications into a clear plastic bag and crushed the medications. She poured the crushed medications into a cup and put a spoonful of pudding on top of the medications and stirred. The capsule was not crushed and was flattened out but still intact. The nurse indicated she was finished and ready to administer the resident's medications. The nurse locked her medication cart and proceeded to go into the resident's room. The nurse was then asked to stop and not to administer 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 maintain clinical records that were complete and accurately documented related to duplicate medications on the Medication Administration Record (MAR) for 1 of 5 residents reviewed for unnecessary medications. (Resident 10)Findings include:The record for Resident 10 was reviewed on 9/8/25 at 10:23 a.m. Diagnoses included, but were not limited to, dementia and diabetes.The 8/5/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and required supervision or touching assistance with activities of daily living (ADLs) and transfers.The September 2025 MAR indicated, . Carboxymethylcellulose Sodium Ophthalmic Solution 0.5% [a lubricating eye drop] . Instill 1 drop in both eyes one time a day. and .Refresh Tears Solution (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes one time a day. Both entries were signed out as given each morning. During an interview on 9/8/25 at 11:03 a.m., LPN 1 indicated the resident received one drop to each eye every morning, and that 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 infection control practices were implemented related to a dirty bedside table used for wound care supplies and lack of hand hygiene with glove changes during wound care for 1 of 1 resident reviewed for pressure ulcers. (Resident 20)Finding includes:Wound care for Resident 20 was observed on 9/4/25 at 7:10 a.m. After removing the old dressing, the Wound Nurse took gauze that was placed directly on a bedside table, soaked it in Dakin's solution (a wound cleanser), and used it to cleanse the open wound on the resident's buttock. There was no barrier, and the table was visibly dirty. The Wound Care Physician assessed and measured the wound, removed his gloves, and put on gloves he got from his pocket. He debrided the wound, again removed his gloves and put on gloves from his pocket, and cleansed inside the open wound with gauze from the table. He did not perform hand hygiene after removing his gloves. During an interview on 9/4/25 at 7:40 a.m., the Wound Nurse indicated she told someone to clean 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 interview and record review, the facility failed to ensure residents were free from misappropriation of resident property related to drug diversions of residents' narcotic pain medications (hydrocodone and oxycodone) for 3 of 3 residents reviewed for misappropriation of resident property. (Residents B, F, and G) The deficient practice was corrected on 1/3/25, prior to the start of the survey, and was therefore past noncompliance. Finding includes: A Indiana Department of Health (IDOH) reported incident indicated on 12/27/24 at 10:01 a.m., it was reported to the Assistant Director of Nursing and the Administrator that the facility was unable to account for a Resident B's narcotic pain medication or oxycodone 15 mg (milligrams). A 5-Day Follow-up to the reported incident, dated 1/3/25, indicated a registered nurse had admitted to taking Resident B's oxycodone 15 mg. The investigation of the incident, undated and completed by the RN Nurse Consultant, indicated all residents' medications and count sheets were reviewed. There were discrepancies for the narcotic pain medications 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 record review and interview, the facility failed to ensure a 5-Day follow up to a reported incident of misappropriation to the Indiana Department of Health (IDOH) contained thorough and complete information from the facility's investigation of the incident, for 1 of 1 reported incident reviewed. Finding includes: A Indiana Department of Health (IDOH) reported incident indicated on 12/27/24 at 10:01 a.m., it was reported to the Assistant Director of Nursing and the Administrator, the facility was unable to account for a Resident B's narcotic pain medication or oxycodone 15 mg (milligrams). The Staff involved were RN 3 and RN 4. A 5-Day follow-up to the reported incident, dated 1/3/25, indicated the drug diversion was substantiated due to RN 4 admission of taking the oxycodone. Cross reference F602. The 5-day follow up lacked information from the investigation that indicated two other residents were found to have missing narcotic medication, how many narcotics were unaccounted for, and that RN 3 was not involved in the misappropriation of the medication. 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.

Based on observation, interview, and record review, the facility failed to ensure a resident received necessary care and services related to no investigation for the root cause for a resident's multiple skin tears for 1 of 2 residents reviewed for quality of care and skin tears. (Resident C) Finding includes: During an observation and interviews on 2/5/25 from 8:45 a.m. to 9:42 a.m., CNA 1 and CNA 2 entered Resident C's room to provide care. The resident was observed to have two dressings on the right arm and two dressings on the back of her right hand. CNA 1 indicated the resident had skin tears on her arms. Resident C's record was reviewed on 2/5/25 at 11:46 a.m. The diagnoses included, but were not limited to, vascular dementia and diabetes mellitus. The resident was receiving hospice care. A Significant Change Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident had short and long term memory problems, was dependent for all activities of daily living, had skin tears present, and received hospice care. The Wound Report indicated a skin tears were identified…

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 a resident's pressure ulcers were assessed thoroughly and timely, the Physician was notified timely of a decline in a pressure ulcer, and an intervention to prevent pressure ulcers was in place, for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: During an observation and interviews on 2/5/25 from 8:45 a.m. to 9:42 a.m., CNA 1 and CNA 2 entered Resident C's room to provide care. When the resident was turned to the right side, there was a large dressing on the left hip with copious amount of bloody drainage that was seeping under the dressing onto the pad underneath the resident and a foul odor was present from the dressing. There was a dressing also observed on the sacral area. At 9:24 a.m., the Assistant Director of Nursing (ADON) entered the room and indicated she was also the Wound Nurse. The ADON indicated she completed wound rounds with the Wound Nurse Practitioner (NP) weekly. Resident C was on hospice and the Wound NP did not see the resident weekly. The ADON…

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

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to a resident (Resident C) who was in Enhanced Barrier Precautions (EBP), for two random observations for infection control. Finding includes: During an observation on 2/5/25 at 8:45 a.m., CNA 1 and CNA 2 entered Resident C's room to provide care. There was a sign on the resident's door which indicated the resident required EBP and there was PPE stored in a container in the hallway. An indwelling urinary catheter was present and CNA 1 indicated the resident had skin tears and pressure ulcers. CNA 1 and CNA 2 wore gloves and no gowns. They were stopped prior to starting care. CNA 1 and CNA 2 indicated they should have a gown on while providing care. During an observation on 2/5/25 at 11:49 a.m., CNA 2 and LPN 5 were at Resident C's bedside and was repositioning the resident in bed. They wore gloves. They were not wearing a gown. LPN 5 indicated EBP PPE should have been worn during care. Cross…

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 2 of 4 medication carts observed. (ACU Cart, and [NAME] 1 Cart) Findings include: 1. On 9/20/24 at 2:33 p.m., the ACU Medication Cart was observed with Agency QMA 1. There were multiple pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The QMA indicated that was the first day she had worked on the cart. 2. On 9/20/24 at 2:47 p.m., the [NAME] 1 Medication Cart was observed with RN 2. There were multiple pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The RN indicated that nursing was responsible to clean the carts. During an interview on 9/20/24 at 2:45 p.m., the Assistant Director of Nursing indicated the Director of Nursing was usually responsible to make sure the carts were cleaned. 3.1-25(j) 3.1-25(o)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were assessed for self-administration of medications and had a Physician's Order to self-administer medications, for 2 of 2 residents reviewed for self-administration of medication. (Residents 9 and 32) Findings include: 1. During a medication pass observation on 9/19/24 at 11:12 a.m., LPN 1 was observed preparing Resident 9's medications. The nurse indicated the resident was to have a nebulizer breathing treatment. She poured a plastic vial of ipratropium-albuterol (medication to help control the symptoms of lung disease) 3 ml (milliliters) into a medicine cup attached to an oxygen mask. She then placed the oxygen mask over the resident's face, turned on the treatment machine, and told the resident to take a few deep breaths. She then told the resident she would be back in to remove the breathing treatment in about 10 minutes. The LPN then proceeded to leave the room and walked back to the medication cart to prepare 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 a resident involved in a physical altercation with another resident received psychosocial follow up care for 1 of 3 residents reviewed for abuse. (Resident 136) Finding includes: The closed record for Resident 136 was reviewed on 9/19/24 at 9:30 a.m. The resident was admitted to the facility on [DATE] and discharged to home on 9/8/24. Diagnoses included, but were not limited to, unspecified dementia, hypertension and depression. He resided on the locked memory care unit. The admission Minimum Data Set assessment, dated 8/29/24, indicated the resident had severe cognitive impairment. An IDOH (Indiana Department of Health) Facility Reported Incident, dated 9/5/24, indicated another resident had approached Resident 136 and struck him numerous times. The residents were immediately separated and assessed for injuries. The other resident was sent to the hospital for aggressive behaviors to be evaluated, and Resident 136 was to be monitored for signs…

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 and/or their Responsible Party were notified in writing related to a transfer to the hospital for 1 of 3 residents reviewed for hospitalization. (Resident 27) Finding includes: Resident 27's record was reviewed on 9/18/24 at 3:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and elevation of levels of liver transaminase levels (liver enzymes). The Quarterly Minimum Data Set (MDS) assessment, dated 7/23/24, indicated the resident was moderately impaired for daily decision making. A Nurses' Note, dated 7/12/24 at 6:47 p.m., indicated the Physician was in to see the resident and new orders to send the resident to the hospital were obtained due to elevated liver enzymes. The Responsible Party was notified and report was called to the hospital. The resident was sent with appropriate paperwork. A Physician Order Note, dated 7/12/24 at 6:48 p.m., indicated the resident was seen due to elevated liver enzymes. The resident indicated he had nausea and emesis, but he did not inform…

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 and/or their Responsible Party were sent the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital for 1 of 3 residents reviewed for hospitalization. (Resident 27) Finding includes: Resident 27's record was reviewed on 9/18/24 at 3:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and elevation of levels of liver transaminase levels (liver enzymes). The Quarterly Minimum Data Set (MDS) assessment, dated 7/23/24, indicated the resident was moderately impaired for daily decision making. A Nurses' Note, dated 7/12/24 at 6:47 p.m., indicated the Physician was in to see the resident and new orders to send the resident to the hospital were obtained due to elevated liver enzymes. The Responsible Party was notified and report was called to the hospital. The resident was sent with appropriate paperwork. A Physician Order Note, dated 7/12/24 at 6:48 p.m., indicated the resident was seen due to elevated liver enzymes. The resident indicated he had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident with abnormal lab results received timely intervention for 1 of 3 residents reviewed for hospitalization (Resident 68), medications were given as ordered for 2 of 5 residents reviewed for unnecessary medications (Residents 24 and 55), and skin discolorations were assessed and monitored for 1 of 2 residents reviewed for non-pressure skin conditions. (Resident 37) Findings include: 1. On 9/18/24 at 9:31 a.m., Resident 68 was observed lying in bed with his eyes closed. Normal Saline 0.9% intravenous fluids were infusing at 100 ml (milliliters) per hour to his left upper arm PICC (peripherally inserted central catheter, intravenous access) line. The record for Resident 68 was reviewed on 9/18/24 at 9:43 a.m. Diagnoses included, but were not limited to, cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 8/30/24, indicated the resident 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 a resident received ancillary services to maintain vision and hearing in a timely manner, for 1 of 1 residents reviewed for vision/hearing. (Resident 27) Finding includes: During an interview on 9/16/24 at 10:43 a.m., Resident 27 indicated he could not hear or see and required outside services, however, the facility had not done anything to help him with hearing or vision services at the time. Resident 27's record was reviewed on 9/18/24 at 3:01 p.m. Diagnoses included, but were not limited to, encephalopathy (brain disease), legal blindness, and hearing loss. The Quarterly Minimum Data Set (MDS) assessment, dated 7/23/24, indicated the resident was moderately impaired for daily decision making. He had moderate difficulty with the ability to hear and did not have hearing aids. He had highly impaired vision and did not have corrective lenses. A Care Plan, dated 3/25/24, indicated the resident had a behavior problem related to being hard of hearing and yelling out and speaking loudly. A Care Plan, 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, 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 7 residents reviewed for accidents. (Resident 21) Finding includes: On 9/16/24 at 10:23 a.m., Resident 21 was observed seated in her wheelchair near the front Nurse's Station. Observation of her room at that time, indicated there were no non-skid strips to the floor anywhere in her room or bathroom. On 9/18/24 at 9:27 a.m., Resident 21 was assisted by staff to her room and was seated in her wheelchair. There were no non-skid strips observed to the floor anywhere in her room or bathroom. The record for Resident 21 was reviewed on 9/19/24 at 11:05 a.m. Diagnoses included, but were not limited to, dementia with psychotic disturbance, chronic obstructive pulmonary disease, and anxiety disorder. The Quarterly MDS (Minimum Data Set) assessment, dated 8/15/24, indicated the resident was cognitively impaired. She had one fall with major injury and one fall with no injury since the prior assessment. A Care Plan, updated 10/23/23,…

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 observation, record review and interview, the facility failed to ensure a resident received the necessary care and treatment related to oxygen not administered as ordered or monitored for 1 of 1 residents reviewed for respiratory care. (Resident 7) Finding includes: On 9/17/24 at 9:44 a.m., Resident 7 was observed seated in her recliner. There was an oxygen concentrator next to her that was turned on. The oxygen tubing and nasal cannula were lying on the floor. The resident indicated she only used the oxygen at night. On 9/18/24 at 11:53 a.m. the resident was observed seated in her room. The oxygen concentrator was off and the oxygen tubing was in a plastic bag. The resident's record was reviewed on 9/18/24 at 10:25 a.m. Diagnoses included, but were not limited to, acute and chronic respiratory failure, diabetes mellitus, schizoaffective disorder and depression. The Quarterly Minimum Data Set assessment, dated 8/15/24, indicated the resident had moderate cognitive deficits, required substantial assistance for transfers and moderate assistance for bed mobility. A Physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide the necessary care and services for residents who received hemodialysis, related to not monitoring the dialysis access site, for 1 of 1 resident reviewed for dialysis. (Resident 231) Finding includes: On 9/16/24 at 10:19 a.m., Resident 231 was seated in his wheelchair near the front Nurse's Station. He had his dialysis bag on his lap and indicated he was waiting to leave for dialysis. He went to dialysis on Mondays, Wednesdays, and Fridays. He had a catheter to his right chest that was used for dialysis. The record for Resident 231 was reviewed on 9/19/24 at 11:05 a.m. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 7/10/24, indicated the resident was cognitively intact and received hemodialysis services. The resident was hospitalized on [DATE] and readmitted to the facility on [DATE]. The Physician's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure abnormal lab results were reported to the Physician for 1 of 3 residents reviewed for hospitalization (Resident 68). Finding includes: On 9/18/24 at 9:31 a.m., Resident 68 was observed lying in bed with his eyes closed. Normal Saline 0.9% intravenous fluids were infusing at 100 ml (milliliters) per hour to his left upper arm PICC (peripherally inserted central catheter, intravenous access) line. The record for Resident 68 was reviewed on 9/18/24 at 9:43 a.m. Diagnoses included, but were not limited to, cerebral infarction, chronic kidney disease, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 8/30/24, indicated the resident was cognitively impaired. The resident was hospitalized [DATE] and returned to the facility on 7/15/24. The resident was again hospitalized on [DATE] and returned to the facility on 8/24/24. A Care Plan, updated 3/4/24, indicated the resident was at risk for decreased…

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 multiple use equipment was disinfected after use on residents for 1 of 8 residents reviewed during a medication administration observation. (Resident 9 and LPN 1) Finding includes: During a medication pass observation on 9/19/24 at 11:12 a.m., LPN 1 was observed preparing Resident 9's medications. The nurse indicated she had to check the resident's blood pressure prior to giving him his medications. She removed a blood pressure wrist cuff from her medication cart and took it into the resident's room. She then proceeded to apply the blood pressure cuff to the resident's right wrist and turn on the machine. The blood pressure was completed and the LPN removed the blood pressure cuff and returned the blood pressure cuff to the medication cart. The LPN then proceeded to prepare and administer the residen'ts medication before moving onto the next residents. The LPN was not observed to clean the blood pressure cuff before or after applying it to the resident's wrist. During an interview after 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 cardiopulmonary resuscitation (CPR) (full code) was initiated as requested by the resident's Responsible Party/Health Care Representative, for a resident (Resident B) who was admitted into the facility on hospice, for 1 of 3 deceased residents who were reviewed for cardiopulmonary resuscitation status. Finding includes: Resident B's record was reviewed on [DATE] at 9:42 a.m. The diagnoses included, but were not limited to diabetes mellitus, dysphagia, urinary retention, prostate cancer, severe vascular dementia, acute and subacute stroke, coronary artery disease, and quadriplegia. A family member was listed as his Health Care Representative (HCR). A Hospital Physician's Note, dated [DATE] and signed by Hospital Physician 1, indicated the resident was to be discharged from the hospital on [DATE] with an order for hospice care. A Post Scope of Treatment form, dated [DATE] and signed by the HCR, indicated a request for CPR to be initiated if there…

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 the pneumococcal and influenza immunizations after the resident/Responsible Party had signed a consent for the immunizations, and failed to thoroughly investigate if prior immunizations had been completed, for 3 of 5 residents reviewed for immunizations. (Residents C, D, and J). The facility also administered the influenza and pneumococcal immunizations to a resident who had a declination signed by the Responsible Party for 1 of 5 residents reviewed for immunizations. (Resident E) Findings include: 1. During an interview on 3/12/24 at 11:54 a.m., Resident C indicated he was unable to remember if he had been questioned about his immunizations when he was first admitted to the facility. He indicated if he was due for any of the immunizations, he would like to receive them. Resident C's record was reviewed on 3/12/24 at 2:47 p.m. The diagnoses included, but were not limited to, heart failure. The resident's admission date was 1/29/24. The admission Minimum Data (MDS) assessment, dated 2/5/24,…

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

Based on observation, record review, and interview, the facility failed to ensure fall prevention interventions were in place, for 1 of 3 residents reviewed for falls. (Resident D) Finding includes: During an observation on 3/12/24 at 12:05 p.m., Resident D was lying in bed. The mattress he was lying on was a regular mattress without bolsters. The wheelchair was positioned next to his bed. There were no anti-tip bars on the wheelchair. During an observation on 3/12/24 at 5:05 p.m., the resident was lying on the bed. There were no anti-tip bars on the wheelchair next to the bed and no bolsters on the mattress. LPN 1 indicated there were no anti-tip bars on the wheelchair and no bolsters on the mattress. Resident D's record was reviewed on 3/12/24 at 4:24 p.m. The diagnoses included, but were not limited to, diabetes mellitus, and stroke. A Significant Change Minimum Data Set assessment, dated 2/20/24, indicated a severely impaired cognitive status, maximum assistance was required for bed mobility and transfers, and had one fall with a non-major injury. A Care Plan, dated 12/5/23,…

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 observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate, for 1 of 1 resident reviewed for oxygen usage. (Resident D) Finding includes: During an observation on 3/12/24 at 12:05 p.m. and 5:05 p.m., Resident D was lying in bed. Oxygen was being administered through a nasal cannula, and the oxygen flow rate was set at 3.5 liters per minute. LPN 1 was interviewed on 3/12/24 at 5:05 p.m., and indicated the oxygen was being administered between 3 and 3.5 liters per minute. She was unsure what the Physician's Order was for the oxygen administration flow rate. Resident D's record was reviewed on 3/12/24 at 4:24 p.m. The diagnoses included, but were not limited to, diabetes mellitus, and stroke. A Significant Change Minimum Data Set assessment, dated 2/20/24, indicated a severely impaired cognitive status, maximum assistance was required for bed mobility and transfers, and oxygen was administered. A Care Plan, dated 12/6/23, indicated oxygen therapy was required. Oxygen was to be administered per the Physician's Orders was 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.

Based on record review and interview, the facility failed to ensure the COVID-19 vaccination and boosters were administered to the residents who signed consents to receive them. They also failed to ensure accurate documentation of when and what COVID-19 immunizations had been given prior to admission into the facility, for 2 of 5 residents reviewed for COVID-19 immunizations. (Residents C and J) Findings include: 1. During an interview on 3/12/24 at 11:54 a.m., Resident C indicated he was unable to remember if he had been questioned about his immunizations when he was first admitted to the facility. He indicated if he was due for any of the immunizations he would like to receive them. Resident C's record was reviewed on 3/12/24 at 2:47 p.m. The diagnoses included, but were not limited to, heart failure. The resident's admission date was 1/29/24. The admission Minimum Data (MDS) assessment, dated 2/5/24, indicated an intact cognitive status. The Immunization Record indicated the COVID-19 booster immunization was refused. The admission Agreement, dated 1/30/24, indicated he received…

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 food was prepared in form to meet individual needs related to not following a recipe for pureed food or making pureed food the correct consistency. This had the potential to affect all 4 residents who received a pureed diet. Finding includes: On 11/1/23 at 11:10 a.m., [NAME] 1 was observed preparing pureed food. She indicated she was going to puree tacos. There was no recipe out for reference. She measured 5 scoops of taco meat and placed it in the blender and pureed. She then placed the meat in a prepared serving pan and put it on the steam table. The taco meat looked dry and chunky, not smooth. There were no additional ingredients added to the mixture. She indicated it was completed. The Dietary Manager (DM) observed the meat and indicated it was not smooth, it should be creamier. She also indicated it should not be just meat, but the whole taco that was pureed. At 11:40 a.m., the pureed taco mixture was observed. It was creamier and smoother. The [NAME] indicated she had just added liquid to 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 an inventory record of a resident's property was provided to a resident and/or the resident's representative on admission or discharge from the facility for 1 of 1 residents reviewed for personal property. (Resident B) Finding includes: Record review for Resident B was completed on 10/30/23 at 2:02 p.m. Diagnoses included, but were not limited to, hypertension, diabetes mellitus, and dementia. The resident admitted to the facility on [DATE] and discharged on 9/25/23. The admission Minimum Data Set (MDS) assessment, dated 8/28/23, indicated the resident was cognitively impaired. A Nurse's Note, dated 9/25/23 at 2:30 p.m., indicated the resident's son called and requested his dad be dressed and up in his chair around 4:00 p.m. and then hung up the phone. The last progress note in the resident's record was a Social Service Note, dated 9/26/23 at 10:00 a.m., that indicated she spoke with APS (Adult Protective Services) in regards to inappropriate…

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 care plan meetings were completed quarterly and/or included the family and IDT (interdisciplinary team) members as required for 2 of 19 residents reviewed for care planning. (Residents E and 5) Findings include: 1. Resident E's record was reviewed on 10/31/23 at 9:12 a.m. Diagnoses included, but were not limited to, Diabetes Mellitus and vascular dementia. The Quarterly Minimum Data Set assessment, dated 7/21/23, indicated the resident had severe cognitive impairment and required substantial/ maximum assistance for bed mobility and transfers. There was no documentation a quarterly care plan meeting had been completed since November 2022. Telephone interview on 11/1/23 at 9:46 a.m. with the resident's health care representative, indicated she had not been invited to or attended a care plan meeting in about a year. Prior to that, she had been invited regularly. A copy of the last invitation to the health care representative was provided by the Social Service Director (SSD) and was post marked 10/25/22. Interview with…

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 ADL (activities of daily living) assistance needed related to uncut, dirty fingernails for 2 of 3 residents reviewed for ADL care. (Residents D and E) Findings include: 1. On 10/30/23 at 11:29 a.m., Resident D was observed seated in his room. His fingernails were long and some were broken and jagged. On 10/31/23 at 10:28 a.m., the resident was observed seated in his room, his nails were still long and jagged. The resident's record was reviewed on 10/31/23 at 10:17 a.m. Diagnoses included, but were not limited to, osteoarthritis of the knee and frequent falls. The Quarterly Minimum Data Set assessment, dated 10/4/23, indicated the resident had significant cognitive impairment and required partial/ moderate assistance for eating, transfers and toileting. Interview with CNA 1 on 10/31/23 at 11:13 a.m., indicated staff did resident fingernail care on Sundays. She was unable to locate documentation the resident had nail care recently, but would complete it today. 2. 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, record review, and interview, the facility failed to ensure a resident received treatment of edema related to compression stockings not in place, a skin discoloration was assessed and monitored, and a Physician's Order was in place for a resident with a back brace for 1 of 2 residents reviewed for edema, 1 of 2 residents reviewed for non-pressure skin conditions and 1 of 2 residents reviewed for positioning and range of motion. (Residents D, 57 and 220) Findings include: 1. On 10/30/23 at 11:29 a.m. and 10/31/23 at 10:28 a.m., Resident D was observed seated in his room. He had on two pair of regular socks and shoes, there were no compression socks worn. The resident's record was reviewed on 10/31/23 at 10:17 a.m. Diagnoses included, but were not limited to, osteoarthritis of the knee and frequent falls. The Quarterly Minimum Data Set assessment, dated 10/4/23, indicated the resident had significant cognitive impairment and required partial/ moderate assistance for eating, transfers and toileting. The current Edema Care Plan indicated the resident had edema 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 fall interventions were in place for a resident with a history of falls for 1 of 4 residents reviewed for falls. (Resident C) Finding includes: On 10/30/23 at 10:00 a.m. and 10/31/23 at 10:29 a.m., Resident C's bed was observed. It was a standard mattress without bolsters. On 10/31/23 at 11:27 a.m., the resident was seated in the activity room. CNA 1 assisted the resident to a standing position from her wheelchair. There was a cushion in place, but there was not a Dycem (a non slip device for chairs) in place on the chair. The CNA indicated she thought the Dycem was in place, but it was not. The resident's record was reviewed on 10/30/23 at 2:35 p.m. Diagnoses included, but were not limited to, Parkinson's disease, difficulty walking, and repeated falls. A Progress Note, dated 10/24/23, indicated the resident had a witnessed fall in the bathroom attempting to self transfer. A Progress Note, dated 10/28/23, indicated the resident had an unwitnessed fall and was found lying on the floor next to her bed.…

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 Physician's Orders were in place for feeding tube maintenance and a feeding bag was changed daily for 1 of 1 residents reviewed for tube feeding. (Resident 119) Finding includes: On 10/29/23 at 9:47 a.m., Resident 119 was observed in bed. He was non-responsive, had a trachea with oxygen flowing and tube feeding connected and running. The bag with the feeding solution was noted to have dried, clumpy solution on the inside sides of the bag and the date had been covered with a black marker. The date underneath the black marker was visible and indicated 10/24/23. On 10/29/23 at 2:40 p.m., the tube feeding was observed with the Nurse Consultant, it was still hanging and running. The Nurse Consultant indicated she could see the date beneath the black marker and she would look into it. The resident's record was reviewed on 10/30/23 at 1:15 p.m. Diagnoses included, but were not limited to, acute respiratory failure with hypoxia, persistent…

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.