Dyer Nursing And Rehabilitation Center

Based on record review, and interview, the facility failed to report Doppler ultrasound results to the physician in a timely manner resulting in delayed treatment for 1 of 3 residents reviewed for notification. (Resident D)Finding includes:Resident D's record was reviewed on 8/11/25 at 1:51 p.m. The diagnoses included, but were not limited to, stroke, aphasia (difficulty speaking), hemiparesis (paralysis on one side of the body, dysphagia (difficulty swallowing) and weakness.The Quarterly Minimum Data Set (MDS) assessment, dated 5/12/25, indicated the Resident was severely impaired for daily decision making. The resident required substantial/maximum assistance with shower/bathing, upper body dressing and personal hygiene. The resident required dependent care with lower body dressing and toileting. A Physician's Order, dated 7/29/25, indicated for a Doppler ultrasound (non-invasive imaging technique used to assess blood flow in various parts of the body) to be completed on the right lower extremity due to new onset edema with pain.A Nurse's Note, dated 7/29/25 at 10:35 a.m.,…

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

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to food spillage on the clothing and a shirt raised up exposing the resident's back for 1 of 3 residents reviewed for dignity. (Resident E) Finding includes: During a random observation on 6/18/25 at 9:42 a.m., Resident E was observed sitting in a wheelchair at a table. The resident's shirt was raised up exposing his abdomen, the incontinent brief, and his back and side. There was a wet red stain on the front of the shirt and scrambled eggs were observed on his shorts and lower abdomen. During a random observation on 6/18/25 at 1:15 p.m., the resident was observed sitting in his wheelchair in the main lobby after eating ice cream. There was a white towel over the front of the white shirt. The white shirt was the same one as above and it was still raised up in the back, exposing the resident's sides and back. The red stain was now dried. On 6/18/25 at 1:27 p.m., the resident was observed sitting in his wheelchair in the east unit dining room. The white towel…

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 activities of daily living (ADLs) were completed for dependent residents related to incontinence care for 1 of 3 residents reviewed for ADLs. (Resident E) Finding includes: During a random observation on 6/18/25 at 9:42 a.m., Resident E was observed sitting in a wheelchair at a table. The resident's shirt was raised up exposing his abdomen, the incontinent brief, and his back and side. There was a wet red stain on the front of the shirt and scrambled eggs were observed on his shorts and lower abdomen. On 6/18/25 at 1:45 p.m., CNA 1 pushed the resident back to his room and was going to lay him down and provide incontinence care. CNA 2 entered the room with the hoyer lift and assisted CNA 1 with the resident as they put him in the bed. CNA 1 indicated at that time, that she had given the resident a shower before breakfast that morning. She then proceeded to remove the resident's shorts and incontinent brief. The brief was heavily soiled with urine and bowel movement and had the remnants of dried scrambled eggs near…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to assistance with meals, shaving, oral care, and providing showers and nail care for 12 of 14 residents reviewed for ADLs. (Residents E, K, O, B, M, G, F, H, L, N, P, and J) Findings include: 1. On 2/5/25 at 8:05 a.m., Resident E received her breakfast tray. The resident was seated at a table with two other residents. At 8:11 a.m., the resident was asked by a staff member if she was going to eat. The resident picked up her milk and put it back down. At 8:18 a.m., no staff had offered to sit down and feed the resident or assist her with her meal. Staff were observed to be passing coffee and the trays. At 8:25 a.m., a CNA walked over to the resident and handed her a spoon and told her where her fork was. The resident then proceeded to start eating her oatmeal. On 2/6/25 at 11:59 a.m., Resident E was seated at a table in the unit dining room. She 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 insulin was signed out as ordered for 2 of 5 residents reviewed for unnecessary medications. The facility also failed to ensure treatments for skin excoriation, skin tears, and bruises were ordered and the areas were assessed and monitored for 2 of 6 residents reviewed for non-pressure related skin conditions, signs and symptoms of edema were addressed for 1 of 1 resident reviewed for edema, and no assessment of lung sounds were documented and new orders put into place for 1 of 1 resident reviewed for a change in condition. (Residents S, T, R, Q, and F) Findings include: 1. The record for Resident S was reviewed on 2/6/25 at 9:44 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance and type 2 diabetes. The Annual Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively impaired for daily decision making and she was receiving insulin injections. A Care Plan, reviewed…

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

Based on observation and interview, the facility failed to ensure residents in the memory care unit were supervised during meals and while eating for 4 of 4 residents reviewed for supervision. (Residents 81, R, L, and 6) Findings include: 1. During a random observation on 2/3/25 at 12:03 p.m., there were 4 residents observed in the memory care unit lounge at the end of the hall. All of them were observed with their lunch meal in front of them and eating by themselves with no staff in the room. Resident 81 and Resident R were observed seated at a table by themselves. Resident R was served pork, broccoli, and a baked potato. The baked potato was cut up, however the pork was still whole and not cut into smaller pieces. Resident 81 was observed sitting in a wheelchair next to Resident R. She was served pureed meat, pureed vegetable, pureed potatoes, and a pureed dessert in a separate bowl. She was also served a red beverage and a carton of lactose free milk. At 12:15 p.m., Resident R picked up the carton of lactose free milk, which was Resident 81's milk, and drank it. Again there 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to staff failing to disinfect multi-use equipment, perform hand hygiene after glove removal, medications touched with bare hands, hand hygiene not completed after direct resident contact, glucometers not disinfected after use for 1 of 1 glucometer observed, not donning personal protective equipment (PPE) for a resident in enhanced barrier precautions (EBP), not containing soiled linen, and the improper storage of personal care equipment during random infection control observations. (Residents 63, 25, 83, 72, and 10 ) Findings include: 1. On 2/4/25 at 9:13 a.m., CNA 4 and CNA 5 were observed in Resident 63's room preparing to transfer her via a Hoyer lift (a mechanical lift). At 9:25 a.m., the CNAs donned gloves without hand sanitizing and transferred the resident via the Hoyer lift. After transferring the resident, the CNAs removed their gloves and CNA 5 placed the…

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

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown while in bed during the day for 1 of 2 residents reviewed for dignity. (Resident 72) Finding includes: On 2/3/25 at 11:49 a.m. and 2:12 p.m., Resident 72 was observed in her room in bed. The resident was wearing a hospital gown at both times. On 2/4/25 at 10:23 a.m., the resident was again observed in her room in bed wearing a hospital gown. On 2/5/25 at 9:27 a.m., 10:54 a.m., and 1:49 p.m., the resident was observed in her room in bed wearing a hospital gown. On 2/6/25 at 9:25 a.m., 10:25 a.m., 11:40 a.m., and 3:27 p.m., the resident was again observed in her room in bed wearing a hospital gown. On 2/7/25 at 5:45 a.m., AM care was provided to the resident. The resident was dressed in a clean hospital gown. The record for Resident 72 was reviewed on 2/6/25 at 10:54 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, dysphagia (difficulty swallowing) and gastrostomy status (a tube surgically…

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

Based on observation, record review, and interview, the facility failed to ensure residents were assessed to self-administer medications and oxygen therapy and had physician's orders to self-administer for 3 of 3 residents reviewed for self-administration of medication. (Residents 91, 105 and 30) Findings include: 1. During a random observation on 2/3/25 at 2:15 p.m., there was an Albuterol hand held inhaler observed on Resident 91's over bed table. The resident was not in her room at that time. During random observations on 2/4/25 at 9:39 a.m. and 11:25 a.m., the resident was observed in bed. At those times, the Albuterol inhaler was observed on the over bed table. During an interview on 2/4/25 at 9:40 a.m., the resident indicated she brought the inhaler from home and used it almost every day. The record for Resident 91 was reviewed on 2/4/25 at 10:00 a.m. Diagnoses included, but were not limited to, heart failure, type 2 diabetes, and dyspnea (difficulty breathing) The 12/21/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily…

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 PASARR (preadmission screening and resident review) was completed when a new mental health diagnoses was added for 1 of 1 resident reviewed for PASARR. (Resident 124) Finding includes: The record for Resident 124 was reviewed on 2/7/25 at 10:32 a.m. Diagnoses included but were not limited to, metabolic encephalopathy, dementia, and unspecified psychosis not due to a substance or known physiological condition. A PASARR level I, dated 1/10/25, indicated further screening was not needed unless the resident had a serious mental illness or intellectual development disability. The diagnosis of unspecified psychosis not due to a substance or known physiological condition was added to the resident's record on 1/13/25. There was no PASARR level 2 performed. During an interview on 2/4/25 at 1:44 p.m., the Social Services Director indicated they did not do a level 2 PASARR, but she would re-do the level 1. She thought the resident had the diagnosis of psychosis since a prior hospitalization, but she was not sure. The PASARR…

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 develop a plan of care that was individualized to the needs of a bilateral amputee for 1 of 27 residents reviewed for care plans. (Resident P) Finding includes: During a random observation on 2/3/25 at 3:37 p.m., Resident P was observed to have bilateral below-the-knee amputations. The record for Resident P was reviewed on 2/7/25 at 8:44 a.m. Diagnoses included, but were not limited to, ESRD (end-stage renal disease), congestive heart failure, diabetes, and stroke. The 11/27/24 Quarterly Minimum Data Set (MDS), indicated the resident was cognitively intact for daily decision making and required maximum assistance with ADLs. A Care Plan, revised on 2/4/25, indicated the resident was at risk for complications related to diabetes. Approaches included inspecting the resident's feet for open areas, sores, pressure areas, blisters, edema, or redness and referring to a podiatrist to monitor and document foot care needs and cut long nails as needed. During an interview on 2/7/25 at 4:00 p.m., the Director of Nursing…

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 2. During an interview on 2/3/25 at 3:05 p.m., Resident 30 indicated he was trying to contact his sister to get his lab results because when the facility got the results, they gave them to his sister and not to him. The record for Resident 30 was reviewed on 2/5/25 at 10:09 a.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), dementia, schizophrenia, and sleep apnea. The 12/1/24 Annual Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had lab testing completed on 1/28/25, 1/31/25, and 2/3/25. There was no documentation the resident was informed of his lab results. During an interview on 2/7/25 at 1:40 p.m., Assistant Director of Nursing (ADON) 2 indicated she documented that she updated the family member because they were the POA (power of attorney), but that she would inform the resident of his results. 3.1-35(c)(1) Based on record review and interview, the facility failed to ensure residents…

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 limited range of motion had a physician-ordered splint in place for 1 of 1 resident reviewed for range of motion. (Resident O) Finding includes: During an observation on 2/3/25 at 2:52 p.m., Resident O was observed sitting in his wheelchair in his room. At that time, his left hand was flaccid and closed and he could not open his hand without assistance. There was no anti-contracture device in his left hand. During random observations on 2/4/25 at 11:02 a.m., 2/5/25 at 7:25 a.m. and 1:56 p.m., on 2/6/25 at 9:28 a.m. and 3:20 p.m., and on 2/7/25 at 11:05 a.m., the resident's left hand was observed flaccid and closed. There was no anti-contracture device in his left hand. The record for Resident O was reviewed on 2/5/25 at 3:06 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia affecting the left side. The 11/27/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had a functional range of motion…

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

Based on observation, record review and interview, the facility failed to ensure residents were assisted with meals and nutritional supplement consumption was recorded for residents with a history of weight loss for 2 of 4 residents reviewed for nutrition. (Residents R and 81) Findings include: 1. During a random observation on 2/3/25 at 12:03 p.m., Resident R was observed sitting in a wheelchair in the memory care lounge area at a table. The resident's lunch was in front of her. She was served pork, broccoli, and a baked potato. The baked potato was cut up, however the piece of pork was still whole and not cut into smaller pieces. There was no staff in the room to assist the resident and she just stared out of the window. At 12:15 p.m., the resident picked up a carton of lactose free milk, belonging to the resident who was sitting next to her, and drank it. Again, no staff were in the room to assist the resident. At 12:23 p.m., CNA 6 entered the lounge and offered to help the resident eat. The resident had not touched or ate any of her food before the CNA arrived. During a random…

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 gastrostomy tube (a tube surgically inserted into the stomach that allows for the delivery of food and medication) placement was checked prior to medication administration, water flushes and medications were instilled via gravity, and documentation of gastrostomy tube care was completed for 2 of 3 residents reviewed for tube feeding. (Residents 72 and K) Findings include: 1. On 2/7/25 at 6:40 a.m., RN 3 was observed preparing a medication for Resident 72. The resident received her medications by the way of a gastrostomy tube. Upon entering the room, the RN donned gloves and placed the cup containing the medication on the over bed table. The RN proceeded to place his stethoscope on the resident's abdomen and listen to her bowel sounds. After listening to the resident's bowel sounds, the RN proceed to flush the resident's gastrostomy tube, he pushed 30 milliliters (mls) of water in via the syringe plunger rather than instilling the water via gravity. He then proceeded to administer the resident'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 ensure oxygen was at the correct flow rate for 3 of 3 residents reviewed for oxygen. (Residents T, G, and 30) Findings include: 1. On 2/3/25 at 11:59 a.m., Resident T was observed in his room in bed. The resident had oxygen in use by the way of a nasal cannula. The oxygen concentrator, which was located in the resident's bathroom, was set at four liters. At 3:18 p.m., the oxygen remained in use at four liters. On 2/4/25 at 10:34 a.m., the resident's oxygen remained in use at four liters per nasal cannula. On 2/5/25 at 9:31 a.m., 11:10 a.m., and 1:53 p.m., the resident remained in his room in bed with oxygen per nasal cannula in use. The resident's oxygen concentrator was set at three liters. On 2/6/25 at 9:30 a.m., 11:58 a.m., and 3:03 p.m., the resident remained in his room in bed with oxygen per nasal cannula in use. The resident's oxygen concentrator was set at three liters. On 2/7/25 at 5:43 a.m., the resident was observed in his 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.

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 3 of 8 residents observed during medication pass. Four errors were observed during 34 opportunities for errors during medication administration. This resulted in a medication error rate of 11.7% (Residents 72, 9, and 114) Findings include: 1. On 2/7/25 at 6:58 a.m., RN 3 was observed preparing Resident 72's Lispro insulin. The RN administered 8 units of insulin by the way of an insulin pen for a blood sugar of 362. At 8:34 a.m., RN 2 was observed preparing the resident's Entrapenem (an antibiotic) for an intramuscular (IM) injection (a medical procedure where the medication was injected directly into the muscle). The RN diluted the medication with 3.2 milliliters (mls) of Lidocaine (a medication to numb the skin) and then proceeded to dilute the medication with 10 cc's (cubic centimeters) of normal saline. The RN administered the injection into the right upper arm. The record for Resident 72 was reviewed on 2/7/25 at 10:00 a.m. The resident's diagnoses…

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 controlled substance was double locked at all times for 1 of 2 medication rooms observed. (West Unit) Finding includes: On 2/10/25 at 10:11 a.m., the [NAME] Unit Medication Room was observed with Assistant Director of Nursing (ADON) 2. Inside the unlocked refrigerator, there was an unlocked white hospice box which contained Morphine Sulfate Roxanol 20 milligrams (mg), a Schedule II controlled substance. During an interview on 2/10/25 at 10:11 a.m., ADON 2 indicated the hospice box should be locked due to the narcotic contents inside. A facility policy, titled Receiving Controlled Substances, indicated, .G Medications listed in Schedules II, III, IV, and V were stored double lock . 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure a resident received routine dental services for 1 of 1 resident reviewed for dental services. (Resident J) Finding includes: During an interview on 2/4/25 at 9:18 a.m., Resident J indicated he wanted to see a dentist for routine dental treatment. The record for Resident J was reviewed on 2/5/25 at 1:54 p.m. Diagnoses included, but were not limited to, dysphasia (difficulty swallowing). The Quarterly Minimum Data Set (MDS) assessment, dated 12/9/24, indicated the resident was cognitively intact. A signed dental consent, dated 3/28/24, indicated the resident wanted to receive dental services offered by the facility. There was no documentation any dental appointments had been completed for the resident. Documentation provided by the Social Service Director on 2/6/25 at 12:40 p.m., indicated the facility switched to a different dental company in July of 2024. During an interview on 2/6/25 at 12:47 p.m., the Social Service Director indicated the resident did not sign a consent form for the new dental…

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

Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary care and services related to medications not administered as ordered by the Physician, for 2 of 15 residents reviewed for quality of care. (Residents F and G) Findings include: 1. During a random observation on 9/26/24 at 8:18 a.m., QMA 1 was preparing Resident F's morning medication. She indicated the Vitamin D was not in the medication cart and the medication had been ordered from the Pharmacy on 9/23/24. Resident F's record was reviewed on 9/26/24 at 1:09 p.m. The diagnoses included, but were not limited to, anemia and chronic kidney disease stage three. The admission Physician's Orders, dated 8/13/24, included Vitamin D2 (supplement), 10 micrograms (mcg) (400 Units) every morning and medications were to be initiated upon arrival from the pharmacy. The Medication Administration Record (MAR), dated 8/2024, indicated the Vitamin D2 10 mcg had been administered at 9:00 a.m. on 8/14/24 through 8/31/24. The MAR, dated 9/2024, indicated the Vitamin D2 10 mcg had been…

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

Based on record review and interview, the facility failed to ensure a resident with pain was monitored and assessed, medication effectiveness was evaluated and non-pharmacological interventions were attempted prior to giving pain medication for 1 of 2 residents reviewed for injury of unknown origin. (Resident D) Finding includes: An IDOH (Indiana Department of Health) Facility Reported Incident, dated 8/19/24, indicated Resident D was noted to have pain in the left knee. The nurse assessed the area and observed swelling and left thigh/knee pain. The MD was notified and orders received to obtain an X-ray. The X-ray results indicated a comminuted, displaced left femoral (upper leg) fracture. The resident's record was reviewed on 9/25/24 at 1:30 p.m. Diagnoses included, but were not limited to, cardiomegaly, osteoarthritis of both knees and repeated falls. A Significant Change Minimum Data Set assessment, dated 8/30/24, indicated the resident had significant cognitive impairment, and was dependent for toileting and transfer assistance. She received scheduled and prn (as needed) pain…

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

Based on record review and interview, the facility failed to ensure a resident's behavior plan of care was implemented related to a resident with dementia who was exhibiting challenging and aggressive behaviors, for 1 of 2 residents reviewed for abuse. (Resident E) Finding includes: An IDOH (Indiana Department of Health) Facility Reported Incident, dated 8/19/24, indicated a CNA had reported that while caring for Resident E during a combative episode, the nurse was rough with the resident. The resident was unable to describe any incident occurred. There was no apparent sign of abuse or deviation in psychosocial well being noted. The follow up report, dated 8/26/24, indicated there were two CNAs in the room during the incident. One had been bending over and unable to see exactly what happened. The other CNA stated that she thought LPN 1 shoved the resident at some point during the event and his hands swiped the resident's ears. The LPN denies being rough with the resident and was trying to assist with care, it was possible his hands bumped the resident's ear as he continued to swing…

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 medical records were thoroughly and accurately documented related to pain medication administration for 1 of 2 residents reviewed for injury of unknown origin. (Resident D) Finding includes: Resident D's record was reviewed on 9/25/24 at 1:30 p.m. Diagnoses included, but were not limited to, cardiomegaly, osteoarthritis of both knees and repeated falls. A Significant Change Minimum Data Set assessment, dated 8/30/24, indicated the resident has significant cognitive impairment, and was dependent for toileting and transfer assistance. She received scheduled and prn (as needed) pain medication and showed signs of pain during the assessment period. A Physician's Order, dated 7/17/24, indicated to give Norco (opioid pain medication) 5 milligram (mg)/325 mg every 6 hours as needed for pain. The Controlled Drug Receipt/Record/Disposition Form for August 2024 indicated the resident received prn Norco between 8/13 and 8/19 on the following dates and times: 8/13/24 2:30 am 8/14/24 12:00 a.m. 8/14/24 10:00 a.m. 8/15/24 2:39…

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

Based on record review and interview, the facility failed to ensure a Resident's record was completed in a timely manner, related to a change in condition assessment not charted at the time of the change and then had late entries entered 9 days after the event, for 1 of 10 residents reviewed for medical records. (Resident C) Finding includes: Resident C's record was reviewed on 4/3/24 at 11:48 a.m. The diagnoses included, but were not limited to, stroke, subarachnoid hemorrhage, non traumatic, respiratory failure, bipolar, aphasia, vascular implants and grafts, spina-bifida with shunts, and history of breast cancer (9/23/22). A Nurse's Progress Note, dated 3/27/24 at 3:54 p.m. for 3/18/24 at 4:01 p.m., written by LPN 1, indicated the resident was exiting the facility and being transferred to the emergency room by three Paramedics. The resident's Power of Attorney was made aware. The Nurse Practitioner was notified of the transfer. A Change of Condition assessment form, dated 3/27/24 at 3:54 p.m. for 3/18/24 at 3:30 p.m., written by LPN 1, indicated Resident C had abnormal vital…

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 determine self-administration of medications was appropriate for residents, related to medications left with the residents for self administration and no assessment to indicate the residents were appropriate for self administration of medications, for 2 of 2 residents observed with medications left in the room for administration. (Residents N and K) Findings include: 1) During an observation on 2/19/24 at 9:03 a.m., Resident N was in her room and in bed. with the head of the bed elevated. Located on the table next to the bed. were four stacked plastic medication cups with three to four pills in each one, one cup by itself with one pill, and one cup by itself with five pills in it, and a bottle of turmeric capsules (supplement). She indicated she takes the turmeric. She indicated the cup sitting by itself with the five pills contained the vitamins she takes and it was brought to her this morning, and the others were extras. She stated she did not need the Nurse to stand by her when she took the medications.…

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 requirements for a resident initiated discharge were completed, related to documentation of the intent to discharge, lack of a discharge planning Care Plan, lack of a discussion with the resident or Responsible Party about the discharge, and lack of a Discharge Summary, for 1 of 3 residents reviewed for discharges from the facility. (Resident J) Finding includes: Resident J's closed record was reviewed on 2/20/24 at 11:19 a.m. The diagnoses included, but were not limited to, stroke. The resident was discharged from the facility on 2/13/24. An admission Minimum Data Set assessment, dated 1/22/24, indicated an intact cognitive status, had no behaviors, required moderate assistance for toileting, dressing of the upper body, bed mobility, transfers and ambulation. She required maximum assistance with showers and dressing of the lower extremities and was dependent for wheelchair mobility. The current Care Plan, dated 1/15/24, indicated assistance was required for all activities of daily living. The Care Plan…

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 and care in accordance with professional standards, related to treatment, assessment, and documentation of a skin condition, for 1 of 3 residents reviewed for quality of care related to skin conditions. (Resident D) Finding includes: During an interview on 2/19/24 at 4 p.m., Resident D was in her room and in bed. She indicated she was given a shower today, she had a rash under her breasts and abdominal folds, and the staff only applied powder to the areas after they bathed her. The area under the left breast was observed and was pink, and had a superficial rash on the inner area of the upper abdomen under the breast. Resident D's record was reviewed on 2/19/24 at 1:51 p.m. The diagnoses included, but were not limited to, diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 1/9/24, indicated an intact cognitive status, no behaviors, was dependent for showers, hygiene, bed mobility, and transfers. Applications of ointments or medications were provided to areas…

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

Based on record review and interview, the facility failed to initiate Care Plans related to psychotropic medications for 1 of 26 residents whose Care Plans were reviewed. (Resident 80) Finding includes: The record for Resident 80 was reviewed on 12/15/23 at 10:55 a.m. Diagnoses included, but were not limited to, metabolic encephalopathy, cellulitis of the left lower limb, vascular dementia, dementia with behaviors, high blood pressure, non-psychotic mental disorder, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 10/3/23, indicated the resident was not cognitively intact and was receiving an antipsychotic, antianxiety, antidepressant, and diuretic medication. Physician's Orders, dated 5/25/23, indicated Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), 1 tablet by mouth two times a day. Physician's Orders, dated 9/28/23, indicated Sertraline (an antidepressant medication) 50 mg, give 1 tablet by mouth daily. There was no Care Plan for the Sertraline or the Lorazepam medications. During an interview on 12/19/23 at 12:30 p.m., Nurse Consultant…

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 resident, responsible party, and IDT (interdisciplinary team) members as required for 2 of 3 residents reviewed for care planning. (Residents 72 and 20) Findings include: 1. During an interview on 12/13/23 at 10:21 a.m., Resident 72 indicated he had not been invited or attended any care plan conferences for a while. Resident 72's record was reviewed on 12/15/23 at 10:27 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, chronic kidney disease, and heart failure. The Quarterly Minimum Data Set assessment, dated 9/3/23, indicated the resident was cognitively intact. There was a lack of documentation any care plan meetings had been completed. During an interview on 12/15/23 at 11:20 a.m., the Social Service Director indicated she was new to the facility and would see if she could find any care conference documentation. On 12/15/23 at 12:51 p.m., the Administrator provided a care conference report from the facility's previous…

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 assistance with activities of daily living (ADL's) related to nail care and the removal of facial hair for 3 of 9 residents reviewed for ADL's. (Residents 88, B, and 20) Findings include: 1. On 12/13/23 at 10:44 a.m., Resident 88 was observed sitting in a wheelchair in the memory care dining room. At that time, there was a large amount of facial hair observed on her face, chin and neck areas. On 12/14/23 at 9:45 a.m. and 1:50 p.m., on 12/15/23 at 8:08 a.m. and 12:50 p.m., and on 12/18/23 at 9:35 a.m. and 11:45 a.m., the resident was observed sitting in her wheelchair in the memory care dining room. At those times, she had a large amount of facial hair on her chin, face, and neck areas. The record for Resident 88 was reviewed on 12/15/23 at 1:07 p.m. Diagnoses included, but were not limited to, dementia, high blood pressure, anxiety, major depressive disorder, and psychotic disorder with delusions. The admission Minimum Data Set (MDS) assessment, dated 10/5/23, 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 treatments were obtained for non pressure ulcers, and bruises and sutures were assessed and monitored for 3 of 3 residents reviewed for skin conditions, and residents were assessed and monitored after falls for 1 of 3 residents reviewed for accidents. (Residents 51, 80 and 53) Findings include: 1. During an interview on 12/13/23 at 1:50 p.m., Resident 51 indicated he had 2 sores on his butt and they hurt really bad. They were putting something over them to cover them up but that was over a month ago and they have not done anything since then. At 2:03 p.m., CNA 3 was asked to remove the resident's brief and roll him onto his side so his buttocks could be viewed. The CNA removed his brief and rolled him over and at that time there were was a large reddened area on his sacrum with 2 open areas on the left buttock. The CNA cleaned the resident and removed peri cream from the drawer and put it all over the red area. The resident's legs were very dry with scaly skin. The record for Resident 51 was reviewed…

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

Based on record review and interview, the facility failed to ensure residents with impaired vision received the necessary services for 1 of 2 residents reviewed for vision. (Resident 72) Finding includes: During an interview on 12/13/23 at 10:25 a.m., Resident 72 indicated he had glasses, but had not seen the eye doctor for a while. He needed to see a specialist for his right eye as he was going blind in that eye. Resident 72's record was reviewed on 12/15/23 at 10:27 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, chronic kidney disease, and heart failure. The Quarterly Minimum Data Set assessment, dated 9/3/23, indicated the resident was cognitively intact. His vision was listed as adequate with no corrective lenses. A Physician's Order, dated 4/20/23, indicated the resident may receive services of eye care physician, audiologist, dentist, and podiatrist. Eye Care Consult Notes, dated 5/16/23 and 8/8/23, indicated the resident had been scheduled to be treated those days but was not as he was unavailable due to being at dialysis. There was a lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 completing treatments as ordered for 1 of 2 residents reviewed for pressure ulcers. (Resident 216) Finding includes: On 12/14/23 at 1:59 p.m., Resident 216 was observed lying in bed with eyes closed. Soft boots were in place to both feet. Record review for Resident 216 was completed on 12/14/23 at 9:17 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and cerebral infarction. The resident was admitted to the facility on [DATE]. Wound Rounds, dated 12/11/23, indicated the resident was admitted with a deep tissue injury to the left heel and a fluid filled blister to the left plantar foot. The Physician's Order Summary, dated 12/2023, indicated an order to cleanse the left heel with normal saline or wound cleanser, apply skin prep, and leave open to air daily. A separate order indicated…

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

Based on observation, record review, and interview, the facility failed to ensure a resident with a history of falls was wearing the proper footwear to prevent further falls and/or injury for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 12/13/23 at 11:00 a.m., Resident D was observed in bed wearing plain socks to both feet. At that time, there was a floor mat beside the bed and the other side of the bed was against the wall. On 12/14/23 at 9:46 a.m., the resident was observed in bed and attempting to get out with their legs hanging over the side of the bed. The resident was wearing plain socks to both feet with no non-skids. On 12/14/23 at 3:11 p.m., on 12/15/23 at 8:10 a.m. and 1:30 p.m., and on 12/18/23 at 9:36 a.m. and 11:45 a.m., the resident was observed in bed wearing plain sock with no non-skids to both feet. The record for Resident D was reviewed on 12/15/23 at 9:15 a.m. Diagnoses included, but were not limited to, malnutrition, weakness, psychotic disorder, alcohol dependence, high blood pressure, dementia, and adult failure to thrive. 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 ensure the Registered Dietitian's (RD) recommendations were acted upon in a timely manner for a resident with a history of weight loss for 1 of 2 residents reviewed for nutrition. (Resident 52) Finding includes: The record for Resident 52 was reviewed on 12/14/23 at 2:03 p.m. Diagnoses included, but were not limited to, congestive heart failure, repeated falls, restlessness and agitation, high blood pressure, atrial fibrillation, and dementia with behaviors. The Annual Minimum Data Set (MDS) assessment, dated 11/14/23, indicated the resident was not cognitively intact. The resident had complaints or difficulty swallowing and weighed 116 pounds. He received a mechanically altered diet and had no significant weight loss during the assessment period. A Care Plan, revised on 11/6/23, indicated the resident was at risk for impaired nutritional status due to a mechanically altered diet and a history of weight loss. The resident's current weight on 12/7/23 was 114 pounds. The resident weighed 117 pounds on 8/2/23 and 111 pounds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure oxygen was on and set at the correct flow rate, and tracheostomy care was completed as ordered by the Physician for 4 of 4 residents reviewed for respiratory care. (Residents 27, 6, 17, and 4) Findings include: 1. On 12/13/23 at 1:41 p.m., Resident 27 was observed in bed. At that time, her oxygen tubing was laying the bed next to her. The oxygen concentrator in the room was set at 2.5 liters per minute. On 12/14/23 at 9:37 a.m. and 1:49 p.m., the resident was observed in bed and the oxygen tubing was in both nares and the flow rate was set at 2.5 liters per minute. On 12/15/23 at 8:05 a.m., the resident was observed in bed and the oxygen tubing was laying in the bed and not in her nares. On 12/15/23 at 12:49 p.m. and 2:20 p.m., the resident was in bed and her oxygen was not in her nares and was turned off. On 12/18/23 at 9:30 a.m., the resident was observed in bed and her oxygen was in both nares with the concentrator set at 2.5…

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 care according to the Care Plan to prevent injury for a resident with dementia and who was combative with care for 1 of 2 residents reviewed for dementia care. (Resident 52) Finding includes: The record for Resident 52 was reviewed on 12/14/23 at 2:03 p.m. Diagnoses included, but were not limited to, congestive heart failure, repeated falls, restlessness and agitation, high blood pressure, atrial fibrillation, and dementia with behaviors. The Annual Minimum Data Set (MDS) assessment, dated 11/14/23, indicated the resident was not cognitively intact. The resident had complaints or difficulty swallowing and weighed 116 pounds. He received a mechanically altered diet and had no significant weight loss during the assessment period. A Care Plan, revised on 10/23/23, indicated the resident became combative with staff when given care, as evidenced by swinging arms and hitting staff. The approaches were to educate the resident of the necessity of care, ensure the resident was safe, provide emotional support regarding 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 medications were managed appropriately related to missed medications, the timing of medications, and no indication for the use of Morphine Sulfate for 2 of 5 residents reviewed for unnecessary medications (Residents D and B). Findings include: 1. The record for Resident D was reviewed on 12/15/23 at 9:15 a.m. Diagnoses included, but were not limited to, malnutrition, weakness, psychotic disorder, alcohol dependence, high blood pressure, dementia, and adult failure to thrive. The State Optional Minimum Data Set (MDS) assessment, dated 10/2/23 indicated the resident was not cognitively intact and was an extensive assist with a 1 person assist for bed mobility and transfers. The resident displayed physical and verbal behaviors 1 to 3 days during the reference period. The 10/2/23 Quarterly MDS assessment indicated the resident received an antidepressant medication. The resident received hospice services as of 12/1/23. Physician's Orders, dated…

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

Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted first before the administration of an anti-anxiety medication and the medication was documented on the Medication Administration Record (MAR) for 1 of 5 residents reviewed for unnecessary medications. (Resident D) Finding includes: The record for Resident D was reviewed on 12/15/23 at 9:15 a.m. Diagnoses included, but were not limited to, malnutrition, weakness, psychotic disorder, alcohol dependence, high blood pressure, dementia, and adult failure to thrive. The State Optional Minimum Data Set (MDS) assessment, dated 10/2/23, indicated the resident was not cognitively intact and was an extensive assist with a 1 person assist for bed mobility and transfers. The resident displayed physical and verbal behaviors 1 to 3 days during the reference period. The 10/2/23 Quarterly MDS assessment indicated the resident received an antidepressant medication. The resident received hospice services as of 12/1/23. Physician's Orders, dated 12/6/23, indicated Lorazepam concentrate 2…

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

Based on observations, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to isolation precautions for 1 of 1 resident reviewed for antibiotic use. (Resident 59) Finding includes: During an interview on 12/14/23 at 10:42 a.m., Resident 59 indicated she had a wound to her abdomen that recently became infected, and she was just started on an antibiotic. She was unsure if she was on any type of isolation precautions. There was no isolation signage posted on her door nor any PPE (personal protective equipment) bin outside her room. On 12/14/23 at 2:04 p.m., the resident was lying in bed with her eyes closed. There was no isolation signage posted on her door nor any PPE bin outside her room. On 12/18/23 at 11:20 a.m., the resident was lying in bed watching television. There was no isolation signage posted on her door nor any PPE bin outside her room. On 12/18/23 at 11:53 a.m., staff delivered the resident's lunch tray to her. They did not don PPE prior to entering the room. There was no isolation signage posted…

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 temperatures were monitored for each meal. This had the potential to affect the 100 residents who received their food from the kitchen. (The Main Kitchen) Finding includes: On 9/20/23 at 10:02 a.m., a kitchen sanitation tour was completed with the Dietary Food Manager (DFM). The food temperature binder was reviewed at that time. The food temperature logs for August and September 2023 were lacking documentation for the following dates and meals: - No documentation of lunch temperatures on 8/21/23. - No documentation of breakfast or lunch temperatures on 8/23/23 and 9/5/23. - No documentation of dinner temperatures on 9/1/23. - No documentation of any food temperatures on 9/2 and 9/3/23. The food temperatures that were documented from 9/5 through 9/20/23, were documented at the start of the meal service. Interview with the DFM at that time, indicated food temperatures were to be documented for each meal. The facility policy titled, Safe Food Handling was provided by the Administrator on 9/21/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was assessed and monitored prior to being sent to the hospital for a change in condition and hospice orders were followed as written for 1 of 3 residents reviewed for a change in condition and 1 of 1 residents reviewed for hospice. (Resident B) Finding includes: The closed record for Resident B was reviewed on 9/20/23 at 12:16 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (muscle weakness and/or paralysis on one side of the body) following a stroke affecting the left non-dominant side, palliative care, dysphagia (difficulty swallowing), type 2 diabetes, protein calorie malnutrition, and depression. The Significant Change Minimum Data Set (MDS) assessment, dated 5/17/23, indicated the resident was cognitively impaired for daily decision making and she was totally dependent for bed mobility and needed extensive assistance with transfers and eating. Nurses' Notes, dated 5/11/23 at 8:45 p.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 and interview, the facility failed to ensure food served to resident rooms was received hot for 1 of 2 units observed. This had the potential to affect the 56 residents who resided on that unit and received food from the kitchen. (East Unit) Finding includes: Interview with Resident J, who resided on the East Unit, on 11/14/22 at 1:43 p.m., indicated the food was not warm for a lot of the meals she had been served. On 11/21/22 at 12:34 p.m., the last tray from the East Unit food tray cart was removed. It was delivered with the plastic dome lid covering the plate. At that time, the Dietary Manager removed the plastic dome lid and used a food thermometer to obtain the following food temperatures: - Barbeque meatloaf: 127 degrees - Mashed potatoes with brown gravy: 125 degrees - Seasoned corn: 113 degrees Interview with the Dietary Manager at that time, indicated she would like the temperature to be a little warmer, approximately 135 degrees or warmer. 3.1-21(a)(2)

Based on observation and interview, the facility failed to serve and prepare food under sanitary conditions related to dirty food equipment, steam tables, wire racks, standing fans, and standing mixer for 1 of 1 kitchens observed. This had the potential to affect the 116 residents who received food from the kitchen. (The Main Kitchen) Findings include: During the Brief Kitchen Sanitation Tour on 11/14/22 at 9:18 a.m. with the Dietary Food Manager, the following was observed: a. There was a moderate amount of dirt and dust on the storage racks that housed clean pots and pans. b. There was a heavy accumulation of burned food and crumbs on the stove top. c. There was a heavy accumulation of food spillage and grease on the inside of both convection ovens and on the inside of the glass doors. There was grease noted on the sides of the ovens. d. There was a heavy accumulation of grease on the sides of the griddle, stove, and both ovens. e. The handles to the ovens were sticky to touch. e. There was a heavy accumulation of dirt and dust on the standing fan blades blowing directly at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to ensuring hand hygiene was completed before and after glove removal. The facility also failed to ensure lancets were disposed of properly for 2 of 2 glucometers observed, personal protective equipment (PPE) was worn correctly during COVID-19 testing, masks were worn correctly, wash basins were stored correctly, and multi-use equipment was disinfected for random observations for infection control. (Residents 58, 90, 102, 82, 85, 41, and G) Findings include: 1. On 11/17/22 at 4:08 p.m., RN 1 was preparing to check Resident 58's blood sugar. The RN washed her hands and donned a pair of gloves. She wiped the glucometer with a sani wipe, removed her gloves, did not hand sanitize, and donned a new pair of gloves. The RN then proceeded to punch the resident's pills from the punch card into the medication cup. When…

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 and interview, the facility failed to ensure the residents' environment as well as the kitchen area was clean and in good repair related to dirty floors, marred doors, lime build up, dirty heating unit covers, dirty baseboards, food build up on the baseboards, lime build up on pipes, dirty floor tile, and dirty transportation carts in 1 of 1 kitchen areas and on 3 of 4 units. (The Main Kitchen and East, West, and Memory Care Units) Findings include: 1. During the Environmental tour with the Director of Maintenance and the Director of Housekeeping on 11/16/22 at 10:00 a.m., the following was observed: East Unit a. The privacy curtain in room [ROOM NUMBER] was stained. b. Only one side of the window blind in room [ROOM NUMBER] pulled up. The front of the heating unit was loose and was coming off. One resident resided in this room. West Unit a. An accumulation of lime build up was observed on the bathroom faucet in room [ROOM NUMBER]. The floor tile in the bathroom was dirty and a black…

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 had Physician's Orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 32 and 38) Findings include: 1. On 11/18/22 at 8:50 a.m., Resident 32 asked QMA 1 for her Nystatin (an anti-fungal) powder. The QMA took the powder to the resident and left it in the room. The record for Resident 32 was reviewed on 11/22/22 at 9:21 a.m. Diagnoses included, but were not limited to, type 2 diabetes and functional quadriplegia. The 10/22/22 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. The resident did not have a Care Plan for self-administration of medications nor did she have an Self-Administration of medication assessment. A Physician's Order, dated 7/8/22, indicated the resident was to receive Nystatin powder 100,000 unit/gram, apply to affected areas daily as needed. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were invited to their Care Plan conferences for 2 of 2 residents reviewed for care planning. (Residents 38 and D) Findings include: 1. During an interview with Resident 38 on 11/14/22 at 10:19 a.m., he indicated he does not recall being invited to attend a care conference. The record for Resident 38 was reviewed on 11/15/22 at 2:20 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, dementia without behaviors, high blood pressure, atrial fibrillation, heart failure, and cognitive communication. The Quarterly Minimum Data Set (MDS) assessment, dated 10/16/22, indicated the resident was moderately impaired for decision making. There was no documentation of a care conference for the resident since admission. Interview with the Nurse Consultant on 11/21/22 at 12:45 p.m., indicated the resident had a care conference held today. 2. During an interview with Resident D on 11/14/22 at 10:50 a.m., she indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure dependent residents received help with Activities of Daily Living (ADLs) related to repositioning in bed, hair washed, and showers, for 2 of 9 residents reviewed for ADLs. (Residents D and B) Findings include: 1. During an interview with Resident D on [DATE] at 10:45 a.m., she indicated her hair was greasy and had not been washed in a very long time. Her bathing preference was a bed bath, which she received 2 times a week. On [DATE] at 11:15 a.m., the resident was observed lying in bed. The right side of the bed was against the wall. At that time, CNA 1 was observed standing next to the bed holding a bed pan in one hand. The resident indicated she had to have a bowel movement. The CNA instructed the resident to turn onto her right side so she could place the bed pan under her. The resident was very obese, and was unable to turn by herself onto her side. The CNA placed both of her hands on the resident's left hip and physically…

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 areas of bruising were assessed and monitored for 1 of 4 residents reviewed for skin conditions, non-pressure related. (Resident E) Finding includes: On 11/14/22 at 9:59 a.m., Resident E was observed sitting in a chair inside her room. At that time the resident's entire forehead, nose, around both eyes and her cheek bones were red and purple color. The record for Resident E was reviewed on 11/16/22 at 9:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, depression, fractured right femur, dementia with other behavioral disturbances, repeated falls, weakness, and high blood pressure. The Quarterly Minimum Data Set (MDS) assessment, dated 10/6/22, indicated the resident was not cognitively intact and had no mood or behaviors. The resident needed extensive assist with 2 person physical assist for transfers. The resident had no falls since the last assessment. Nurses' Notes, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure splints were applied as ordered and range of motion was completed for 3 of 3 residents reviewed for limited range of motion (ROM). (Residents 1, 30, and 90) Findings include: 1. On 11/14/22 at 10:00 a.m., Resident 1 was observed in his room seated in a broda chair. The resident's right hand had a splint in place. On 11/15/22 at 10:24 a.m., the resident's right hand was closed in a first and no anti-contracture device was in use. On 11/16/22 at 11:04 a.m. and 1:31 p.m., the resident was wearing a right hand splint. On 11/17/22 at 10:17 a.m., 11:44 a.m., and 3:50 p.m., the resident was not wearing the splint to his right hand. On 11/18/22 at 8:20 a.m., the splint was not in use. On 11/21/22 at 9:40 a.m. and 11:58 a.m., the splint was not in use. The record for Resident 1 was reviewed on 11/17/22 at 3:41 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis (muscle weakness and paralysis) affecting his right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for residents with a history of falls with and without injury related to a floor mattress and non-slip socks for 3 of 4 residents reviewed for falls. (Residents E, F, and C) Findings include: 1. On 11/14/22 at 9:59 a.m., Resident E was observed sitting in a chair inside her room. At that time the resident's entire forehead, nose, around both eyes and her cheek bones were red and purple color. On 11/15/22 at 10:06 a.m., the resident was observed in bed. At that time, the floor mattress was standing up on end and not on the floor beside the bed. At 10:08 a.m. the Restorative Nurse walked into the room and swabbed the resident for COVID-19. She left the room and left the mattress standing on end. At 10:21 a.m., the mattress was still standing on end and not on the floor beside the resident. At 10:45 a.m., LPN 1 entered the room and placed the mattress on the floor beside the bed. On 11/16/22 at 1:30…

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

Based on interview and record review, the facility failed to ensure a resident with a urinary catheter received the necessary treatment and services related to completing catheter care as ordered for 2 of 2 residents reviewed for urinary catheters. (Residents J and 84) Findings include: 1. Interview with Resident J on 11/14/22 at 1:48 p.m., indicated the resident did not always receive catheter care every shift. The record for Resident J was reviewed on 11/16/22 at 2:01 p.m. Diagnoses included, but were not limited to, high blood pressure, paraplegia, chronic lung disease, diabetes mellitus, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/22, indicated the resident was cognitively intact for daily decision making. The resident required extensive assistant with bed mobility, dressing, toilet use, and personal hygiene. She had an indwelling catheter and an ostomy. A Care Plan, dated 4/27/22, indicated the resident required an indwelling catheter. Interventions included, but were not limited to, provide catheter care as ordered and as needed, and provide…

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 reweights were obtained, food consumption logs were completed and supplements were provided for residents with a history of weight loss for 2 of 4 residents reviewed for nutrition. (Residents H and B) Findings include: 1. The record for Resident H was reviewed on 11/16/22 at 2:06 p.m. Diagnoses included, but were not limited to, hemiplegia (muscle weakness), stroke, dysphagia (difficulty swallowing), and type 2 diabetes. The Quarterly Minimum Data Set (MDS) assessment, dated 8/9/22, indicated the resident was cognitively intact and required extensive assistance with eating. The resident had no weight issues and received a mechanically altered diet. A Care Plan, reviewed on 11/10/22, indicated the resident required a mechanically altered diet. Interventions included, but were not limited to, obtain/record weight per facility protocol. Notify the Physician and family of any significant weight change. A Care Plan, reviewed on 11/10/22, indicated the resident was limited in functional status in regards 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 gastrostomy tube placement was checked prior to administering medications and the water flush and medications were instilled via gravity for 1 of 1 gastrostomy tube medication administrations. (Resident 24) Finding includes: On 11/18/22 at 11:27 a.m., LPN 2 was observed preparing medications for Resident 24. The resident was going to receive Oyster Shell Calcium 500 milligrams (mg), Prevacid (a medication for gastroesophageal reflux) 30 mg, and Sucralfate (an antacid) 1 gram by the way of her gastrostomy tube (G Tube). At 11:45 a.m., the LPN entered the resident's room. Prior to giving the medications, the LPN placed her stethoscope on the resident's abdomen and she listened to the resident's bowel sounds for placement of the tube. She did not instill an air bolus or check for residual. The LPN then proceeded to administer a water flush prior to giving the medications, she used the plunger of the syringe and pushed the water through the tube instead of letting the water instill via gravity. The LPN…

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 with complaints of pain received scheduled medication to relieve the pain for 1 of 3 residents reviewed for pain. (Resident J) Finding includes: Interview with Resident J on 11/14/22 at 1:53 p.m., indicated she did not always receive her pain medications. The record for Resident J was reviewed on 11/16/22 at 2:01 p.m. Diagnoses included, but were not limited to, high blood pressure, paraplegia, chronic lung disease, diabetes mellitus, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/22, indicated the resident was cognitively intact for daily decision making. The resident required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She had an indwelling catheter and an ostomy. She received a scheduled pain medication regimen. A Care Plan, dated 4/7/22, indicated the resident had complaints of chronic pain related to intractable back pain and wounds. Interventions included, but were not limited to, administer medications and monitor and record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure insulin was administered as ordered related to sliding scale insulin for 2 of 5 residents reviewed for unnecessary medications. (Residents G and J) Findings include: 1. The record for Resident G was reviewed on 11/17/22 at 1:30 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, stroke, high blood pressure, type 2 diabetes, repeated falls, major depressive disorder, syncope, specified dementia, unspecified severity, with other behavioral disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 10/4/22 indicated the resident was not cognitively intact. In the last 7 days the resident received insulin 7 times and an antipsychotic medication 7 times. A Care Plan, dated 11/9/22, indicated the resident received insulin related to diabetes mellitus. The approaches were to administer insulin per doctor's order. Physician's Orders, dated 11/8/22, indicated Insulin…

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 did not receive unnecessary medications without adequate indications for use and prn (as needed) anti-anxiety medication were only administered after non-pharmaceutical interventions were attempted for 2 of 5 residents reviewed for unnecessary medications. (Residents G and F) Findings include: 1. On 11/16/22 at 9:34 a.m., Resident G was observed sitting in a wheelchair in the memory care dining room. At that time, his head was low and his eyes were closed. At 11:15 a.m., the resident remained with his eyes closed. At 1:30 p.m., the resident was observed sitting in his wheelchair with his back facing the room door. At that time, his head was low and his eyes were closed. The record for Resident G was reviewed on 11/17/22 at 1:30 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, stroke, high blood pressure, type 2 diabetes, repeated falls, major…

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 medication carts were locked when out of view on 1 of 3 units throughout the facility. (The [NAME] Unit) Finding includes: On 11/17/22 at 4:27 p.m., RN 1 entered Resident 90's room to administer her medications. The medication cart was left unlocked and the cart was out of the RN's view when she was in the resident's room. At 4:44 p.m., the RN remained in the resident's room and the cart was still unlocked and out of her view. Interview with the Nurse Consultant on 11/21/22 at 2:15 p.m., indicated the medication cart should have been locked prior to entering the resident's room. A facility policy, titled Storage of Medications was provided by the Administrative Consultant on 11/22/22 at 3:04 p.m. The policy indicated medication rooms, carts, emergency kits/boxes, and medication supplies were to be locked when not attended by persons with authorized access. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to provide a resident with a nourishing and well-balanced diet and failed to provide special dietary needs for 1 of 3 residents reviewed for nutritional services. (Resident J) Finding includes: During an interview on 11/14/22 at 1:28 p.m., Resident J indicated she had an allergy to corn and corn products, but the facility staff were still serving her corn products. She indicated she often just ate less during her meals because of it. During an observation of a lunch meal on 11/21/22 at 12:42 p.m., the resident received her lunch which consisted of barbeque meat loaf, mashed potatoes with brown gravy, seasoned corn, cornbread, juice, and a S'Mores bar dessert. The resident's meal card was still on the tray, which indicated for lunch meals the resident was to receive double protein and juice with lunch. The resident was not to be served: corn, cornbread, soda, juice drinks, barbeque sauce, jelly, crackers, applesauce, syrup, any desserts, or grits. The residents allergies were listed as corn. The meal card…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or responsible parties were offered the opportunity to receive or decline an influenza and pneumococcal immunization and provided education on the benefits and potential side effects of the immunizations for 2 of 5 residents reviewed for immunizations. (Residents D and 72) Findings include: 1. The record for Resident D was reviewed on 11/17/22 at 1:30 p.m. Diagnoses included, but were not limited to, metabolic encephalopathy, respiratory syncytial virus, respiratory failure, high blood pressure, chronic obstructive pulmonary disease, and dementia. There was no documentation the resident was offered the influenza or pneumococcal immunizations or provided education regarding them. 2. The record for Resident 72 was reviewed on 11/16/22 at 2:14 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, stroke, high blood pressure, coronary artery disease, depression, and dysphagia. There was no documentation…

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.