Great Lakes Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the resident's environment was clean and in good repair related to dirty floors, bed rails, tables, and enteral feeding poles, as well as torn privacy curtains and uncontained wash basins, urinals and plastic cylinders for 3 of 3 units. (The South, West, and East units).Findings include:During the Environmental Tour on 3/24/26 at 10:45 a.m., with the Administrator, the Maintenance Director, the Housekeeping Director, and the District Manager of Housekeeping, the following was observed: South Unit a. room [ROOM NUMBER] - the return ceiling vent was dirty as well as the entire floor. The base of tube feeding pole observed by bed two had a large amount of dried enteral feeding on top on it. There were two residents who resided in the room. [NAME] Unit a. room [ROOM NUMBER] - the over bed table was dirty and there was a pink wash basin observed on the floor in the bathroom as well as a clear cylinder container on the back of the toilet. There were two…

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 dependent resident received the alternate meal choice they requested for 1 of 1 resident reviewed for choices. (Resident L)Finding includes:During an interview on 3/16/26 at 11:25 a.m., Resident L indicated she did not get to choose what she ate. Her meal trays were brought to her room by the aide, and if she did not want what was brought, she would request the alternate meal. She indicated more than half of the time, the aides would not bring the alternate meal, and she would not eat. The resident's record was reviewed on 3/18/26 at 2:50 p.m. Diagnoses included, but were not limited to, diabetes, and need for assistance with personal care. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact for daily decision making, and required maximal assistance with activities of daily living (ADLs). During an interview on 3/20/26 at 10:21 a.m., the Kitchen Manager indicated alternate meals were always…

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

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded related to the resident's use of oxygen for 1 of 26 resident records reviewed. (Resident M)Finding includes:During random observations on 3/17/26 at 11:00 a.m., 3/18/26 at 10:17 a.m., 3/19/26 at 2:25 p.m., and 3/20/26 at 10:00 a.m., Resident M was observed wearing oxygen via a nasal cannula. During an interview on 3/20/26 at 10:01 a.m., LPN 6 indicated the resident always wore oxygen. The record for Resident M was reviewed on 3/20/26 at 10:12 a.m. Diagnoses included, but were not limited to, quadriplegia.A Physician's Order, dated 2/17/26, indicated oxygen to be delivered at 2 liters per minute per nasal cannula.The Quarterly Minimum Data Set (MDS) assessment, dated 3/7/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living (ADLs). The MDS assessment did not indicate the resident was on oxygen. There was no care plan for oxygen.During an interview on 3/24/26 at 11:05 a.m., MDS 1 indicated she…

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

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to a CNA placing an enteral tube feeding on hold before a change in position for 1 of 3 residents reviewed for tube feeding. (Resident E)Finding includes:During a pressure ulcer treatment observation on 3/20/26 at 2:45 p.m., CNA 3 and CNA 4 were in Resident E's room to help the Wound Nurse with a bandage change. The resident was lying in bed with an enteral tube feeding infusing into the peg tube (a tube that was directly inserted into the stomach for nutrition) and his head of the bed was elevated to 45 degrees. At that time, the Wound Nurse told the CNAs they could position the resident onto to his right side. CNA 3 then walked over to the tube feeding pump and placed it on hold. She lowered the head of the bed to a flat position and both CNAs repositioned the resident onto his right side. The record for Resident E was reviewed on 3/19/26 at 11:55 a.m. Diagnoses included but were not limited to, stroke, dysphagia (difficulty swallowing) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure cardiopulmonary resuscitation (CPR) was not initiated as requested by the resident who had a signed Do Not Attempt Resuscitation (DNR) form for 1 of 1 resident reviewed for death. (Resident 119) Finding includes:Record review for Resident 119 was completed on [DATE] at 10:59 a.m. Diagnoses included, but were not limited to, stroke, hypertension, end stage renal disease, and diabetes mellitus.An Indiana Physician Orders For Scope Of Treatment (POST), form indicated it was a physician's order for scope of treatment based on the patient's current medical condition and preferences. The form had the section CPR: patient had no pulse and not breathing. The CPR section was not checked. The DNR section was checked. The form was signed and name printed by the resident on [DATE]. The form was also signed by the treating Physician.The admission Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively intact. A Physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident who had a pressure ulcer received the care and services to promote healing related to treatments not being completed as ordered by the physician and signed out on the treatment records for 3 of 6 residents reviewed for pressure ulcers. (Residents F, E, B)Findings include:1. During an observation on 3/19/26 at 9:25 a.m., Resident F was observed in bed with his eyes closed. At that time an IV was infusing into a port in his right chest. CNA 5 and CNA 6 entered the room to reposition the resident in bed. The CNAs positioned the resident onto his left side and removed his brief. At that time there was an open bloody wound on the resident's coccyx area. There was no evidence of any cream or a bandage covering the wound. The record for Resident F was reviewed on 3/18/26 at 9:10 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, severe protein malnutrition, adult failure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident who was admitted with a limited range of motion received the necessary treatment and services to prevent decline related to application of an orthotic device by the Physical Therapy (PT) for 1 of 3 residents reviewed for range of motion. (Resident B)Finding includes: During a random observation on 3/17/26 at 8:40 a.m., CNA 1 was asked to remove the bed linens from the resident so his lower extremities could be observed. At that time, the resident was observed with a serve contracture to his right leg. His leg was completely bent and he was unable to fully extend it.The record for Resident B was reviewed on 3/19/26 at 1:30 p.m. The resident was admitted to the facility on [DATE], discharged to hospital on 3/3/26 and returned on 3/10/26. Diagnoses included, but were not limited to, severe protein malnutrition, stroke, pressure ulcer, contracture of right lower leg, and seizures.The admission Minimum Data Set (MDS)…

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

Based on record review and interview, the facility failed to ensure residents with a urinary catheter received the necessary treatment and services related to not assessing urinary output as ordered for 2 of 3 residents reviewed for urinary catheters. (Residents D and 53)Findings include:1. Record review for Resident D was completed on 3/18/26 at 1:42 p.m. Diagnoses included, but were not limited to atrial fibrillation, hypertension, and hypotension.The admission Minimum Data Set (MDS) assessment, dated 2/1/26, indicated the resident was cognitively intact. The resident was dependent on staff for bed mobility, transfers, and toileting hygiene. The resident had an indwelling urinary catheter.A Physician's Order, dated 1/28/26, indicated to measure and record output every shift from the indwelling urinary catheter.The February and March 2026 Treatment Administration Records (TARs) indicated the urinary output was not recorded on the following days and shifts: - Days: 2/1, 2/2, 2/7, 2/12, 2/16, 2/17, 2/20, 2/23, 2/26, 2/27, 3/3, 3/7, 3/13, 3/14 and 3/17/26- Evenings: 2/3, 2/19, 3/3,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident with a physician's order for intravenous (IV) fluids received the correct amount over a 24 hour period for 1 of 1 resident reviewed for hydration. (Resident F)Finding includes:During a random observation on 3/16/26 at 10:49 a.m., Resident F was observed in bed with an IV infusing into a port located in his right chest. The IV fluid was a one liter bag of 0.9% Normal Saline and the date on the bag was 3/16/26. The IV fluid was flowing to gravity rather than via an infusion pump. During a random observation on 3/17/26 at 11:13 a.m., the resident was observed in bed with the same IV bag of 0.9% Normal Saline, dated 3/16/26, hanging and infusing per gravity into the resident's port. At 2:57 p.m., the same IV of 0.9 Normal Saline, dated 3/16/26 was still infusing per gravity into the resident's port. During a random observation on 3/18/26 at 8:05 a.m., the resident's IV of 0.9% Normal Saline, dated 3/16/26, was still infusing…

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 bolus enteral feeding was administered correctly for 1 of 3 residents reviewed for Tube Feeding. (Resident K)Finding includes: The record for Resident K was reviewed on 3/18/26 at 10:38 a.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), gastrostomy (a feeding tube inserted through the abdomen), and protein calorie malnutrition.The Quarterly Minimum Data Set (MDS) assessment, dated 1/20/26, indicated the resident had severe cognitive impairment, required maximal assistance with ADLs, and received all nutrition via a feeding tube.During observation of a bolus tube feeding administration on 3/19/26 at 10:43 a.m., LPN 1 flushed Resident K's feeding tube with water, plunged through a syringe. She then administered 237 ml (milliliters) of tube feeding formula, plunged via a syringe, followed by another plunged water flush. At that time, LPN 1 indicated she administered all feeding tube bolus feedings, flushes, and medications, by plunging with a syringe, not via gravity.…

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 supplemental oxygen was set at the correct flow rate for 1 of 2 residents reviewed for respiratory care. (Resident M)Finding includes:During random observations on 3/17/26 at 11:00 a.m. and 3/20/26 at 10:01 a.m., Resident M was observed wearing oxygen via a nasal cannula at 1 lpm (liter per minute). During an interview on 3/20/26 at 10:01 a.m., LPN 6 indicated the resident's oxygen should have been set at 2 lpm, and she did not know why it was not. The resident was unable to change the flow rate herself. The record for Resident M was reviewed on 3/20/26 at 10:12 a.m. Diagnoses included, but were not limited to, quadriplegia.A Physician's Order, dated 2/17/26, indicated oxygen to be delivered at 2 liters per minute per nasal cannula.The Quarterly Minimum Data Set (MDS) assessment, dated 3/7/26, indicated the resident had severe cognitive impairment, and was dependent in activities of daily living (ADLs). During an interview on 3/20/26 at 10:50 a.m., the Divisional Director of Clinical Services and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create and follow a care plan including specific interventions to address the mental health of a resident who recently lost their mother for 1 of 1 resident reviewed for Mood/Behavior. (Resident 77)Finding includes:During an interview on [DATE] at 12:48 p.m., Resident 77 indicated his mother passed away two weeks ago. He felt very sad and hopeless and had been crying a lot. During an interview on [DATE] at 9:04 a.m., the resident indicated he had been feeling paranoid and anxious since his mother died two weeks and one day ago, and he was unable to sleep. Listening to the radio his mother gave him or drinking soda sometimes helped him feel a little better. He indicated he was not aware of anything different staff was doing to help him with his grief. The record for Resident 77 was reviewed on [DATE] at 2:07 p.m. Diagnoses included but were not limited to, bipolar disorder, depression, schizophrenia, and anxiety. The Quarterly Minimum Data Set (MDS)…

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

Based on record review and interview, the facility failed to ensure there was adequate monitoring of a resident's heart rate per the physician's orders prior to the administration of a blood pressure medication for 1 of 5 residents reviewed for unnecessary medications. (Resident D)Finding includes: Record review for Resident D was completed on 3/18/26 at 1:42 p.m. Diagnoses included, but were not limited to atrial fibrillation, hypertension, and hypotension.A Physician's Order, dated 1/26/26, indicated to give metoprolol tartrate (medication to lower blood pressure) 50 mg (milligrams) two times a day for hypertension. Hold for SBP (systolic blood pressure, top number of blood pressure reading) less than 100. Hold for a heart rate less then 60.The January, February and March 2026 Medication Administration Records (MARs) did not have a section on the MAR to document the heart rate prior to administering the metoprolol. The heart rate was not monitored on the PM times prior to administering the metoprolol for the months of January, February, and March 2026. During an interview on…

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

Based on record review and interview, the facility failed to identify a resident with continued significant weight loss and provide interventions/care planning for the weight loss for 1 of 3 residents reviewed for nutrition and weight loss. (Resident D)Finding Includes:Resident D's record was reviewed on 2/5/26 at 11:41 a.m. The diagnoses included, but were not limited to, Parkinson's disease, diabetes mellitus, and morbid obesity.A Significant Change Minimum Data Set assessment, dated 12/14/25, indicated a moderately impaired cognitive status, no behaviors, was able to feed herself after set up, was dependent for toileting, bathing, and transfers, and required maximum assistance with hygiene and bed mobility. The weight was 294 pounds and had no known significant weight loss or gain. She received a therapeutic diet and a hypoglycemic.A Care Plan, revised on 12/23/25, indicated there was a nutritional problem. The reasons for the nutritional problem included, but not limited to, an increased body mass index (BMI) over 40, received a therapeutic diet, and had a weight gain. The goal…

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 timely laboratory (lab) services were provided as ordered, related to urinalysis (UA) testing (testing for a urinary tract infection), for 1 of 3 residents reviewed for lab testing. (Resident G)Finding includes:Resident G's record was reviewed on 1/13/25 at 2:12 p.m. The diagnoses included, but were not limited to, stage 3 chronic kidney disease, history of urinary tract infections (UTI), and a left nephrostomy catheter (catheter placed into the kidney to drain urine).A Quarterly Minimum Data Set assessment, dated 12/5/25, indicated an intact cognitive status and an indwelling urinary catheter was present.A Care Plan, dated 10/30/25, indicated a nephrostomy catheter was present. The interventions indicated signs and symptoms of a UTI would be monitored.A Nurse's Progress Note, dated 12/10/25 at 12:34 p.m., indicated a urine sample was collected for testing.The lab results indicated the tests ordered were a UA with a culture and sensitivity of the urine. The collection date was 12/10/25 at 1:08 p.m. and the reported…

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

Based on record review and interview, the facility failed to document incontinence care for a resident who was dependent on staff for activities of daily living (ADLs) for 1 of 3 residents who were reviewed for ADLs. (Resident C) Finding includes:Resident C's record was reviewed on 9/29/25 at 10:18 a.m. Diagnoses included, but were not limited to, hemiplegia (paralysis of one side of the body), stroke, and Parkinson's.The Quarterly Minimum Data Set (MDS) assessment, dated 7/18/25, indicated the resident was cognitively intact for daily decision making, required maximal assistance with ADLs and was frequently incontinent of bowel and bladder.A Care Plan, revised on 8/28/24 and identified as current, indicated the resident was incontinent of bowel and bladder. Interventions included checking the resident for incontinence every 2 hours and as needed. A review of the Point of Service documentation for September 2025, received from the Director of Nursing on 9/30/25 at 10:40 a.m., lacked documentation of incontinence care on the following days/shifts: day shift on 9/2/25, 9/4/25,…

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

Based on observation, record review, and interview, the facility failed to keep the kitchen clean and in good repair related to dirty oven doors, dry storage bin, light fixtures, vents, and floors for 1 of 1 kitchen. Finding includes: During the Initial Kitchen Sanitation Tour on 2/17/25 at 9:09 a.m. with the Kitchen Manager, the following was observed: a. There was a dark, dripping substance along the bottom of the oven door. b. There was an accumulation of dirt on the edges of the ceiling light fixtures above the food preparation area. c. There was an accumulation of dirt on the vents in the ceiling above the food preparation area. d. There was a tan, sticky substance on the handle of the sugar storage bin. e. There was an accumulation of dust and debris under the shelves in the dry storage room. During an interview on 2/17/25 at 9:12 a.m., the Kitchen Manager indicated they needed to do some deep cleaning and maintenance may need to come in with a ladder to clean the light fixtures and vents. A policy titled Environment, received as current from the Administrator on 2/24/25 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 the Minimum Data Set (MDS) comprehensive assessment was accurately completed related to pressure ulcers and medication use for 4 of 30 MDS assessments reviewed. (Residents 59, 86, D, and F) Findings include: 1. The record for Resident 59 was reviewed on 2/20/25 at 2:34 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the resident was cognitively intact and she had two Stage 3 pressure ulcers (full thickness tissue loss but bone, tendon, and muscle are not exposed) which were present on admission. The resident was readmitted to the facility on [DATE]. A Skin and Wound Note, dated 1/2/25 at 12:04 p.m., indicated the resident had new skin concerns for wounds to the sacrum. The wounds were identified as Stage 3 pressure ulcers that had developed in the facility. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to shaving, washing hair, providing showers, and providing nail care for 6 of 10 residents reviewed for ADLs. (Residents E, D, C, B, F, and L) Findings include: 1. During a random observation on 2/17/25 at 10:46 a.m., Resident E was observed with long and dirty fingernails. During an interview on 2/18/25 at 11:25 a.m., the resident indicated she wanted her fingernails cleaned and cut. She also indicated she did not always receive a bed bath or a shower. During random observations on 2/19/25 at 9:10 a.m. and 2:50 p.m., and on 2/20/25 at 9:45 a.m. and 11:45 a.m., the resident was observed with long dirty fingernails and greasy hair. She indicated she had not received a shower or bed bath. During an interview on 2/21/25 at 8:17 a.m., the resident indicated she received a bed bath the previous day and her hair was finally washed. She was observed in bed 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 observation, record review, and interview, the facility failed to ensure medications were administered and/or held per blood pressure parameters for 4 of 6 residents reviewed for unnecessary medications. The facility also failed to ensure pre and post respiratory assessments were completed for 1 of 2 residents reviewed for hospitalization, and areas of discoloration, peeling skin, and edema were assessed and monitored for 2 of 9 residents reviewed for skin conditions non-pressure related and 2 of 2 residents reviewed for edema. (Residents 59, M, 65, 87, F, 81, 75, and 24) Findings include: 1. The record for Resident 59 was reviewed on 2/20/25 at 2:34 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the resident was cognitively intact. A current Care Plan indicated the resident had altered cardiovascular status related to hypertension,…

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 proper medication storage related to insulin pens and multi-dose vials not labeled when opened or expired, and loose pills observed in the medication carts and medication rooms for 2 of 2 units (The [NAME] and East Units) Findings include: 1. The medication cart on the [NAME] unit was observed with the Assistant Director of Nursing (ADON) on [DATE] at 9:02 a.m. At that time, there were eight loose pills observed inside the medication drawers. The [NAME] medication room was also observed at that time and inside the refrigerator was an opened multi-dose vial of Aplisol (a medication used for tuberculin vaccines). The vial was not dated when opened. During an interview at that time, the ADON indicated pharmacy came out every Thursday and cleaned the carts and checked the medication rooms. 2. A medication cart was observed on [DATE] at 9:15 a.m. with LPN 2 on the East unit. At that time, there were 22 loose pills noted inside the…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to medications touched with bare hands, disposal of a used lancet into the garbage can, glucometers not disinfected after use for 1 of 2 glucometers observed, and not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP). (Residents C, 20, 12, 146, and G ) Findings include: 1. During medication pass on 2/18/25 at 8:03 a.m., LPN 1 was observed removing Resident C's medications from the punch cards into her bare hands and then placing all of the pills into the medication cup. After finishing pouring all of the medications, she picked up the glucometer from a basket on top of the medication cart, a lancet, a test strip and an alcohol pad, and walked into the room to administer the resident her medications as well as check her blood sugar. After checking the resident's blood sugar, she put the glucometer into her shirt pocket and picked up the used lancet, walked into the bathroom and wrapped it in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty resident equipment, floors, curtains, personal and hygiene items not contained, and a clock not working for 2 of 2 units. (East Unit and [NAME] Unit) Findings include: During the Environmental Tour on 2/24/25 at 1:34 p.m., with the Maintenance Director, Account Manger, and the Administrator, the following was observed: 1. East Unit a. room [ROOM NUMBER] A: The resident's bed handrails had a build up of a dark brown substance. One resident resided in the room. 2. [NAME] Unit a. room [ROOM NUMBER] B: A tube feeding pole was observed next to the bed. There was spillage of tube feeding on the floor and the bottom of the tube feeding pole. Two residents resided in the room. b. room [ROOM NUMBER] A: The resident had a Broda chair that had a dried up brown substance on the side and on the front of the Broda chair. Two residents resided in the room. c. room [ROOM NUMBER] A: 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.

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 3 residents reviewed for dignity. (Resident L) Finding includes: On 2/17/25 at 10:24 a.m. and 11:50 a.m., Resident L was observed in the dining room wearing a hospital gown. On 2/18/25 at 10:38 a.m., the resident was observed in his room in a broda chair wearing a hospital gown. On 2/18/25 at 2:35 p.m., the resident was observed in dining area wearing a hospital gown. The record for Resident L was reviewed on 2/19/25 at 3:57 p.m. Diagnoses included, but were not limited to, dementia, type 2 diabetes, and adult failure to thrive. The 11/30/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment for daily decision making and he required substantial/maximum assistance with dressing. A Care Plan, revised on 12/4/24, indicated the resident had self-care deficits and required maximum assistance with dressing. There was no care plan related 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 a resident was assessed to self-administer medications and had physician's orders to self-administer for 2 of 2 residents reviewed for self-administration of medication. (Residents 83 and G) Findings include: 1. During observations on 2/17/25 at 11:28 a.m. and 1:20 p.m., a medicine cup containing two chewable antacids was observed on Resident 83's bedside table. During an interview on 2/17/25 at 11:28 a.m., the resident indicated the nurse gave him the antacids because his stomach got upset sometimes, and he took them when he wanted. The record for Resident 83 was reviewed on 2/19/25 at 2:58 p.m. Diagnoses included, but were not limited to, post-laminectomy syndrome (a chronic pain syndrome that can develop after spinal surgery), depression, and anxiety. The 2/4/25 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and required set-up assistance for ADLs and transfers. A Physician's Order, dated 12/18/24, indicated Tums Oral Tablet…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide reasonable accommodations of needs related to a resident's bed being long enough so his feet were not touching the foot board for 1 of 2 residents reviewed for positioning. (Resident D) Finding includes: During an interview on 2/18/25 at 10:17 a.m., Resident D indicated he stayed in bed most of the time. At that time, the resident was observed high up in his bed and both feet were observed touching the foot board. At 11:28 a.m., the resident was observed lying on his back and positioned high up in the bed and his feet were touching the foot board. On 2/19/25 at 1:42 p.m., the resident was observed lying on his back in bed. Both feet were touching the foot board. On 2/20/25 at 9:52 a.m., and 11:36 a.m., the resident was observed lying flat on his back in bed. At those times, he was positioned high up in the bed, however, both feet were touching the foot board. On 2/21/25 at 8:29 a.m., the resident was observed lying flat on his…

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's family received the resident's medical record in a timely manner after the request was processed for 1 of 1 resident reviewed for medical records. (Resident H) Finding includes: The closed record for Resident H was reviewed on 2/20/25 at 3:35 p.m. Diagnoses included but were not limited to, multiple sclerosis, respiratory failure, type 2 diabetes, pressure ulcers, and anxiety. The resident admitted to the facility on [DATE] and discharged home on 5/28/24. The 4/12/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. A Nurse's Note, dated 5/28/24 at 2:30 p.m., indicated the resident left the facility with all of her belongings from the room. Nursing staff spoke with the resident's son regarding her medications and he indicated he would be in later to pick them up. The Release of Information Log, provided by the Administrator on 2/21/25 at 2:30 p.m., indicated on…

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

Based on observation, record review, and interview, the facility failed to ensure professional standards of quality were maintained related to the intent to borrow medications from another resident during medication pass for 1 of 6 residents and 1 of 5 nurses observed during medication pass. (Resident C and LPN 1) Finding includes: During medication pass on 2/18/25 at 8:03 a.m., LPN 1 was observed removing Resident C's medications from the punch cards and then placing all of them into the medication cup. After pouring all of the medications, she entered the resident's room and administered all of the medications to her. At that time, the resident had requested Tylenol for pain. The LPN told the resident she would be back with her Tylenol in just a minute. She walked back to the medication cart, opened the drawer and removed 2 white round tablets into her bare hands from a medication card and placed them into a medication cup and closed the medication drawer. The LPN was asked to remove the card where she had punched the Tylenol from to verify the pills and label. LPN 1 opened 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 treatments were completed as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident 59) Finding includes: During an interview on 2/17/25 at 1:53 p.m., Resident 59 indicated she had a sore on her bottom and staff didn't always do her treatment. The record for Resident 59 was reviewed on 2/20/25 at 2:34 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 1/30/25, indicated the resident was cognitively intact and she had two Stage 3 pressure ulcers (full thickness tissue loss but bone, tendon, and muscle are not exposed). A Care Plan, dated 1/7/25, indicated the resident had an actual alteration in skin integrity related to pressure areas to the left buttock and sacrum. Interventions included, but were not limited to, administer treatments as ordered by the medical provider. A Skin and Wound Note, dated 1/2/25 at 12:04 p.m., indicated the resident had new skin…

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 limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents reviewed for mobility. (Resident L) Finding includes: On 2/17/25 at 10:24 a.m. and again on 2/19/25 at 9:26 a.m., Resident L was observed in the dining room. His right wrist was fixed in a hyperextended (bent backwards) position, and was supporting his head. His fingers appeared contracted (bent or curled). There was nothing in his right hand. On 2/18/25 at 10:38 a.m., the resident was observed in a Broda chair in his room. He was in the same position, leaning to his right side, supporting his head with his hyperextended hand. There was nothing in his right hand. During observations on 2/19/25 at 1:35 p.m., 2/20/25 at 9:26 a.m., and 2/21/25 at 10:29 a.m., the resident was in a similar position, with nothing in his right hand. The record for Resident L was reviewed on 2/19/25 at 3:57 p.m. Diagnoses included, but were…

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

Based on observation, record review, and interview, the facility failed to ensure smoking materials were secured for 1 of 1 resident reviewed for smoking. (Resident 56) Finding includes: During an interview on 2/17/25 at 2:20 p.m., Resident 56 indicated he was supposed to lock up his cigarettes and lighter when he was done smoking in the mail box located across from the smoking area. The resident indicated he knew he was going to get into trouble, but he rarely locked his cigarettes up because he lost the key to his mail box before and it made him nervous. When asked where his cigarettes were, the resident patted his coat pocket and indicated he had them along with his lighter in his pocket. The resident indicated that he knew better than to smoke in his room. During an interview on 2/19/25 at 1:40 p.m., the resident indicated that his cigarettes and lighter remained in his coat pocket. The record for Resident 56 was reviewed on 2/19/25 at 11:53 a.m. Diagnoses included, but were not limited to, respiratory failure, tracheostomy status, sleep apnea, and nicotine dependence. 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, interview, and record review, the facility failed to ensure an indwelling Foley (urinary) catheter collection bag was kept off of the floor and documentation of urinary output was completed for 1 of 1 resident reviewed for urinary catheters. (Resident 73) Finding includes: On 2/17/25 at 10:44 a.m. and 1:54 p.m., Resident 73 was observed lying in bed. The resident's catheter collection bag was lying on the floor next to his bed. During an interview on 2/17/25 at 1:55 p.m., RN 3 indicated the resident's catheter collection bag should not have been laying on the floor. She then went into the resident's room to pick the catheter collection bag off of the floor and hang it so it did not touch the floor. Record review for Resident 73 was completed on 2/21/25 at 9:46 a.m. Diagnoses included, but were not limited to, prostate cancer, end stage renal disease, and obstructive uropathy (obstruction of urine flow). The Quarterly Minimum Data Set (MDS) assessment, dated 12/28/24, indicated the resident was moderately cognitively impaired. The resident had an indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 2 of 2 residents reviewed for nutrition. (Residents 65 and 67) Findings include: 1. During an interview on 2/17/25 at 10:57 a.m., Resident 65 indicated she had a recent weight loss. The record for Resident 65 was reviewed on 2/19/25 at 3:04 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) high blood pressure, anxiety, dehydration, and alcohol abuse. The admission Minimum Data Set (MDS) assessment, dated 2/5/25, indicated the resident was cognitively intact for daily decision making, held food in her mouth, and had complaints of pain when she swallowed. The resident weighed 85 pounds, received a mechanically altered diet, and has had a significant weight loss. The Care Plan, revised on 2/10/25, indicated the resident had the potential for an altered…

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) water flushes and medications were instilled via gravity, and enteral feedings were started at the correct time for 2 of 2 residents reviewed for tube feeding. (Residents 147 and 58) Findings include: 1. On 2/19/25 at 4:21 p.m., LPN 5 was observed preparing a medication for Resident 147. The resident received his medications by the way of a gastrostomy tube. Upon entering the room, the LPN donned gloves and an isolation gown and placed the cups containing the medication on the over bed table. The LPN checked for placement by pulling back any residual in the peg tube. She then proceeded to flush the resident's gastrostomy tube by plunging (pushing) 30 milliliters (mls) of water rather than instilling the water via gravity. She diluted all of the medications with 10 ml of water and added them one at time, and rather than administering them completely via gravity, she pushed most of the…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 4 residents reviewed for oxygen. (Resident 59) Finding includes: On 2/17/25 at 1:56 p.m. and 2:30 p.m., Resident 59 was observed with oxygen in use by the way of a nasal cannula. The resident's portable oxygen tank was set at three liters. At 3:52 p.m., the resident was observed in her room in bed. The resident's oxygen remained in use and her oxygen concentrator was set at three liters. On 2/18/25 at 10:27 a.m. and 11:55 a.m., the resident was observed with her oxygen per nasal cannula in use. The resident's portable oxygen tank was set at three liters. On 2/19/25 at 1:35 p.m., the resident was observed in her room in bed. Her oxygen was in use and the oxygen concentrator was set at three liters. On 2/20/25 at 9:57 a.m. and 2:14 p.m., the resident was observed in her recliner with her oxygen per nasal cannula in use. The portable oxygen tank was set at three liters. On 2/21/25 at 9:18 a.m., the resident was observed in her room in bed. The resident's oxygen…

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

Based on observation, record review, and interview, the facility failed to ensure a resident's pain was controlled with over the counter medications for 1 of 5 residents reviewed for pain. (Resident E) Finding includes: During an observation on 2/17/25 at 10:46 a.m., Resident E was observed in her room lying in bed and crying out that she was in pain. During an interview on 2/18/25 at 11:30 a.m the resident indicated an area on her bottom hurt constantly, and all they had given her was over the counter medications, however, she would like something stronger. On 2/19/25 at 9:10 a.m. and 2:50 p.m., the resident was observed lying in bed. At those times, the resident indicated her current pain level was a six out of 10 and all she had received was over the counter Tylenol. She had stopped using the Lidoderm patches because they made her back raw and tender, however, no one had offered any other topical cream for pain. On 2/20/25 at 9:45 a.m., the resident was observed in bed and indicated her pain level was around a five. At 11:45 a.m., her pain was at a six out of 10. The record for…

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

Based on observation, record review, and interview, the facility failed to monitor for signs and symptoms of an infection of a resident's perma cath (a long, flexible tube that's inserted into a vein in the neck or chest) used for dialysis for 1 of 2 residents reviewed for dialysis. (Resident M) Finding includes: During a random observation on 2/19/25 at 2:50 p.m., Resident M was observed in bed and dressed in a hospital gown. At that time, there was a clear bandage over his perma cath located on his right upper chest. The resident indicated the perma cath was used for dialysis. The record for Resident M was reviewed on 2/20/25 at 3:08 p.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes, stroke, and high blood pressure. The 1/17/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and received dialysis while a resident. A Care Plan, revised on 7/1/24, indicated the resident had direct access to the circulatory system related to a right subclavian perma cath. The approaches were…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 6 residents observed during medication pass. Two errors were observed during 28 opportunities for errors during medication administration. This resulted in a medication error rate of 7.14% (Residents 12 and 147) Findings include: 1. During medication pass on 2/18/25 at 11:27 a.m., LPN 2 was preparing to check Resident 12's blood sugar. The resident's blood sugar was 335 and the LPN indicated she was to receive 33 units of Lispro Insulin. She removed the insulin pen from the medication cart and dialed it to 2 units and primed the pen. She then dialed the pen to 30 units, as it would not dial any further. She administered 30 units to the resident and then removed the needle, placed a new one on the pen and dialed the pen to 3 units and administered the remaining 3 units. She did not prime the second needle before administering the remaining 3 units of insulin. The record for Resident 12 was reviewed on 2/18/25 at 1:10 p.m. Diagnoses included, but were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident was free from a significant medication error related to the administration of a sliding scale insulin for 1 of 6 residents and 1 of 5 nurses observed during medication pass. (Resident 12 and LPN 2) Finding includes: During medication pass on 2/18/25 at 11:27 a.m., LPN 2 was preparing to check Resident 12's blood sugar level. The resident's blood sugar was 335 and the LPN indicated she was to receive 33 units of Lispro Insulin. She removed the insulin pen from the medication cart and dialed it to 30 units, as it would not dial any further. She administered 30 units to the resident and then dialed the pen to 3 units and administered the remaining 3 units. There was no other insulin administered to the resident. The record for Resident 12 was reviewed on 2/18/25 at 1:10 p.m. Diagnoses included, but were not limited to, type 2 diabetes. A Physician's Order, dated 1/16/24, indicated Humalog [NAME] Kwik Pen, inject as per…

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 that every resident received specialized rehabilitative services as determined by their comprehensive plan of care to restore their highest practicable level of physical well-being for 1 of 1 resident reviewed for rehabilitative services. (Resident G) Finding includes: During an observation of a physical therapy session on 2/18/25 at 10:55 a.m., Resident G was observed in bed. He had a dressing intact to his left upper arm AV fistula (an access port for dialysis), and a large gauze wrap around his left forearm with a baseball-sized area bleeding through. There were large areas of bruising to both sides of his neck and his chest. His right arm was swollen. Physical Therapist (PT) 1 had the resident hold his hands and pull his upper body toward him multiple times. The resident then fell back on the bed and complained that his chest hurt. PT 1 left the room to look for an aide to help him reposition the resident in bed. The record for…

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

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to documentation of medications given for 1 of 5 residents reviewed for unnecessary medications (Resident F) and percentage of tube feeding given for 1 of 2 residents reviewed for tube feeding. (Resident 75) Findings include: 1. Record review for Resident F was completed on 2/19/25 at 9:11 a.m., Diagnoses included, but were not limited to, diabetes mellitus, atrial fibrillation (irregular heart beat), heart failure, hypertension, Parkinson's disease, anxiety, depression, and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS) assessment, dated 11/15/24, indicated the resident was cognitively intact. The February 2025 Physician's Order Summary (POS) indicated orders for Metoprolol Succinate ER (heart medication) 50 mg (milligrams) in the morning and Glimepiride (anti-diabetic medication) 4 mg in the morning. The February 2025 Medication Administration Record (MAR) indicated the following: - Metoprolol Succinate ER…

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

Based on record review and interview, the facility failed to accurately and thoroughly report an allegation of resident to resident abuse to the Indiana Department of health (IDOH), related to location of altercation, circumstances of the altercation, diagnoses of the residents, injury, and results of the investigation in the five day follow-up, for 1 of 2 abuse incidents reviewed. (Residents C and D) Findings include: An IDOH reported incident, dated 9/2/24 with a follow-up date of 9/6/24, indicated Residents C and D had a physical altercation that resulted in Resident C falling to the ground and Resident D receiving a scratch to his left eye. The diagnosis listed for Resident C was bi-polar disorder. The injury of the incident indicated Resident C had a hematoma (bruise) to the back of his head and Resident D had a scratch under his eye. Resident C refused treatment and Resident D was transferred to the emergency room for an evaluation and treatment as needed. The follow-up, dated 9/6/24, indicated there were no further issues noted between the residents, they remained at baseline…

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 have a current smoking assessment completed for 1 of 3 residents reviewed who smoked independently. (Resident C) Finding includes: Resident C's record was reviewed on 9/17/24 at 1 p.m. The diagnoses included, but were not limited to, alcohol dependency. The most current smoking assessment was completed on 9/20/23 at 4 a.m. and indicated the resident was assessed to smoke independently. During an interview on 9/17/24 at 2:56 a.m., Social Service 1 indicated there had not been a current smoking assessment completed. An undated resident smoking policy, received as current from the Director of Nursing on 9/17/24 at 2:06 p.m., indicated the residents would be assessed by the interdisciplinary team for smoking assistance status upon admission, quarterly, and with a significant change of condition. 3.1-45(a)

Based on record review and interview, the facility failed to monitor a resident with a history of substance abuse for signs and symptoms of alcohol use and the resident had an altercation with another resident while intoxicated, for 1 of 2 residents reviewed for behaviors. (Resident C) Finding includes: Resident C's record was reviewed on 9/17/24 at 1 p.m. The diagnoses included, but were not limited to, alcohol dependency. A Nurse's Progress Note, dated 5/6/24 at 9:11 a.m., indicated the resident signed out of the facility on a pass. A Nurse's Progress Note, dated 5/6/24 at 4:51 p.m., indicated a nearby store employee observed the resident to be slumbering and he appeared to be intoxicated. The employee notified Emergency Management Services (EMS) and the resident was transferred to the hospital. A Nurse's Progress Note, dated 5/6/24 at 7:46 p.m., indicated a report from the hospital was received. The blood alcohol was measured at 108 (over 50 = intoxicated) and a bottle of vodka had been confiscated from the resident. He was administered a liter of normal saline intravenous fluid…

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 complete and accurate related to an intrafacility transfer for 1 of 9 residents reviewed for medical record accuracy. (Resident J) Finding includes: Resident J's record was reviewed on 9/18/24 at 11:41 a.m. The diagnoses included, but were not limited to, paraplegia. An Annual Minimum Data Set assessment, dated 7/17/24, indicated an intact cognitive status A Notification of Room Change form, dated 8/8/24 at 12:00 a.m., indicated a transfer from one room to another. The reason for the room transfer was listed as long term bed, the resident was satisfied with room change and the new roommate. The form was not signed by the resident. The instructions at the bottom of the form indicated signatures were to be obtained and the form was to be uploaded into the electronic health record. During an interview on 9/18/24 at 11:50 a.m., Social Service 1 indicated the resident was not happy about the intrafacility transfer. There was no documentation the resident had been given prior notice of an impending…

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

Based on interview and record review, the facility failed to ensure a resident's privacy was respected, related to Employee 1 using her private cell phone to take a video of the cognitively impaired resident (Resident B), without the approval of the resident's Court Appointed Guardian for 1 of 1 residents reviewed for privacy. Finding includes: During an interview on 8/19/24 at 8:45 a.m., the Administrator indicated Receptionist 1 had taken a Snapchat video of Resident B. The video had been sent to one of the Housekeeping Supervisors. The resident had given approval for the facility to take pictures and/or videos. During an interview on 8/19/24 at 8:58 a.m. Receptionist 1 indicated Resident B came to the Receptionist Desk often and visited. On 7/10/24, she asked the resident if she could make a video about what she was going to do over the weekend and the resident agreed. The resident was usually funny and told jokes. When asked by Receptionist 1 what she was going to do over the weekend, the resident indicated, I don't know. I may just kill myself. The video was ended after the…

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

Based on record review and interview, the facility failed to act upon a suicidal ideation of a cognitive impaired resident in a timely manner, related to the resident's statement of wanting to kill herself on 7/10/24 and Social Service and the Administrator not notified until 7/23/24, for 1 of 1 dementia resident reviewed with suicidal ideation. (Resident B) Finding includes: During an interview on 8/19/24 at 8:58 a.m. Receptionist 1 indicated on 7/10/24, she asked Resident B if she could record a video of her. Resident B agreed. When resident B was asked what she was going to do over the weekend, the resident answered, I don't know. I may just kill myself. Receptionist 1 indicated she ended the video and sent the video to Housekeeping Supervisor 2 via Snapchat because she and the resident talked frequently. Receptionist 1 indicated she did not think the resident meant it and Social Service 3 was notified. During an interview, on 8/19/24 at 9:14 a.m., Housekeeping Supervisor 2, indicated she did not look at Snapchat often and saw the video on either 7/14/24 or 7/15/24. The video 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 record review and interview, the facility failed to promptly notify the resident's Power of Attorney (POA) of the onset of new non-pressure skin areas and a transfer to the hospital. The facility also failed to promptly notify the resident's physician of abnormal labs for 1 of 3 residents reviewed for non-pressure sores and 1 of 3 residents reviewed for a change in condition. (Resident E) Finding includes: The closed record for Resident E was reviewed on 7/15/24 at 12:40 p.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on 6/13/24. Diagnoses included, but were not limited to, stroke, hemiplegia, heart disease, dysphagia (swallowing difficulties), peg tube (a tube inserted directly into the stomach for nutrition), chest pain, high blood pressure, and vascular dementia. The 5/9/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident had a limited range of motion with impairment to one…

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 initiate neurological checks after an unwitnessed fall for 1 of 3 residents reviewed for falls. (Resident D) Finding includes: The record for Resident D was reviewed on 7/16/24 at 8:15 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, dysphagia (swallowing difficulties), peg tube (a tube inserted directly into the stomach for nutrition), hemiplegia, type 2 diabetes, and high blood pressure. The admission Minimum Data Set (MDS) assessment, dated 5/1/24, indicated the resident was not cognitively intact for daily decision making. The resident was dependent on staff for toilet hygiene and had an indwelling foley (urinary) catheter. The resident had no history of falls while at the facility. A Care Plan, dated 4/26/24, indicated the resident was at risk for falls. A nursing approach was to ensure the resident was wearing appropriate non-skid footwear. A Care Plan, dated 5/2/24, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident with a history of falls was wearing the proper footwear to prevent further falls and/or injury for 1 of 3 residents reviewed for falls. (Resident D) Finding includes: During a random observation on 7/16/24 at 8:00 a.m., Resident D was observed sitting in a geri recliner with both feet elevated. At that time, he was observed wearing plain black ankle socks to both feet. During random observations on 7/16/24 at 10:05 a.m. and 11:30 a.m., the resident was observed lying in bed. At those times, he was wearing plain black ankle socks to both feet. The record for Resident D was reviewed on 7/16/24 at 8:15 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, dysphagia (swallowing difficulties), peg tube (a tube inserted directly into the stomach for nutrition), hemiplegia, type 2 diabetes, and high blood pressure. The admission Minimum Data Set (MDS) assessment, dated…

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

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to improper PPE (personal protective equipment) prior to providing care to a resident on enhanced barrier precautions (EBP) and hand hygiene not completed after direct resident care, for 2 of 5 residents observed for infection control practices. (Residents C and G) This had the potential to affect the residents on 2 of 3 Units (East and West) and residents who required treatment for pressure wounds. Findings include: 1. Prior to entering Resident C's room on 4/22/24 at 8:27 a.m., there was no sign on the door that indicated enhanced barrier precautions were to be used. There was a container of PPE located on the wall inside the door. During an observation on 4/22/24 at 8:27 a.m., Resident C was lying in bed. The resident had urinary catheter. CNA 2 donned gloves and unstuck the tabs on the incontinent brief. He was then stopped prior to any other care completed and asked if he should have any other special PPE on for care. CNA 2…

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

Based on observation, record review, and interview, the facility failed to meet residents' needs related to a call light not placed within reach for 2 of 7 residents observed for call light placement. (Residents G and K) Findings include: 1. During an observation on 4/22/24 at 9:52 a.m., Resident G was lying in bed with the head of the bed up and his breakfast tray sitting in front of him on the over the bed table. The call light was draped over the bedside dresser on the right side of the bed and was out of reach of the resident. During an observation on 4/22/24 at 10 a.m., CNA 3 and CNA 4 entered the room, and removed the meal tray. The call light remained draped over the bedside dresser. During an observation on 4/22/24 at 10:10 a.m., the call light remained draped over the bedside dresser. During an observation on 4/22/24 at 10:22 a.m., CNA 3 and CNA 4 entered the room. They indicated they had been checking on the resident every one to two hours. After repositioning the resident, CNA 4 placed the call light within reach of the resident. CNA 3 indicated at the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and/or the resident's Responsible Party in writing of an intrafacility transfer related to changing rooms due to a COVID-19 outbreak for 3 of 3 residents reviewed for infection control. (Residents D, M, N) Findings include: 1. During an interview on 4/22/24 at 11:14 a.m., Resident D indicated he was moved to a different room when he had COVID-19. He was in the other room for 20 days and they kept telling him he was going to move back tomorrow. The record for Resident D was reviewed on 4/22/24 at 12:18 p.m. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) hemiplegia, stroke, heart failure, venous insufficiency, vascular dementia, anxiety disorder, and chronic kidney disease. The Quarterly Minimum Data Set (MDS) assessment, dated 2/16/24, indicated the resident was cognitively intact for daily decision making. Nurses' Notes, dated 3/20/24 at 11:33 a.m., indicated the resident had tested…

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

Based on observation and interview, the facility failed to ensure a clean and homelike environment, related to stained, dirty, and tattered bed linens for 3 of 6 residents reviewed for a homelike environment. (Residents D, C, and H) Findings include: 1. During an observation on 4/22/24 at 11:14 a.m., Resident D was sitting up in a wheelchair at the bedside. He had requested to be transferred back to bed after his bed was made. His bed had been stripped and two CNAs entered the room and made the bed. There was a hole in the bottom sheet that had been placed on the bed. The CNAs transferred the resident to bed after the bed was made and left the room. During an observation on 4/23/24 at 10:10 a.m., the bottom sheet with hole in the sheet remained on the resident's bed. 2. During an observation on 4/22/24 at 3:48 p.m., Resident J was lying in bed with the head of the bed slightly elevated. There were two pillows under the resident's head. There was a brownish/tan dried stain on the pillow case of the bottom pillow. 3. During an observation on 4/23/24 at 7:55 a.m., Resident C was lying…

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 recapitulation of the resident's stay was documented on the discharge summary provided to the resident at the time of discharge for 3 of 3 residents reviewed for discharge. (Residents B, E, and F) Findings include: 1. The record for Resident B was reviewed on 4/22/24 at 9:53 a.m. Diagnoses included, but were not limited to, high blood pressure, atrial fibrillation, heart disease, heart failure, adult failure to thrive, hallucinations, and anemia. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 1/10/24, indicated the resident was moderately impaired for daily decision making. Physician's Orders, dated 3/21/22, indicated may discharge to an assisted living facility on 3/22/24. The Discharge summary, dated [DATE], indicated the Course of illness/Progress (include any complications experienced) had N/A documented in the space. There was no documentation of a recapitulation of the resident's stay on the discharge summary.…

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 who were dependent and/or required assistance with activities of daily living (ADL's) received assistance with their meals, for 2 of 6 residents reviewed for ADL's. (Residents L and C) Findings include: 1. During a random observation on 4/22/24 at 1:00 p.m., CNA 1 delivered a lunch tray to Resident L. The CNA placed the tray on the over bed table and left the room. At 1:13 p.m., 1:23 p.m. and 1:30 p.m., the tray remained in the same place, untouched, and the resident had not been assisted to eat. During an interview on 4/22/24 at 1:30 p.m., CNA 1 indicated she delivered the tray to the resident who was asleep at the time, and asked her if she was ready to eat. The resident told staff she was not ready to eat, so the tray was left on the over bed table. The CNA indicated she was going to check on the resident to see if she was ready to eat before she left for the day at 2:00 p.m. She was unaware that no other staff 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.

Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, related to dressings not present as ordered by the Physician, for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: During an observation on 4/22/24 at 8:27 a.m., Resident C was lying in bed. CNA 2 and CNA 7 entered the room to provide repositioning and check for incontinence. The incontinent brief was undone and the resident was rolled onto her left side. The pressure area on the sacrum/coccyx area had foam inside of the area and the wound vacuum was not in place. There was no dressing covering the area. The pressure area on the left ischium had no dressing covering it, and there was no dressing on the right ischium pressure ulcer. CNA 2 indicated he started his shift at 6:30 a.m. and the resident was last checked by him, there were no dressings on the pressure wounds. CNA 7 indicated the dressings were on the resident on 4/21/24 during the day shift. During an interview on…

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

Based on observation, record review, and interview, the facility failed to ensure residents' with pressure ulcers received the necessary treatment and services to promote healing, related to dressings not present, treatments not completed as ordered, and preventative interventions not completed correctly, for 3 of 3 residents reviewed for pressure ulcers. (Residents C, B, and D) Findings include: 1) During an observation, on 2/12/24 at 8:54 a.m., Resident C was lying on her left side. LPN 1 indicated the resident was admitted into the facility with multiple pressure ulcers. She then unfastened the resident's incontinence brief and pulled the urine soaked brief away from the skin. She indicated there was no dressing present on the pressure area on the sacral area. The sacral area was observed to have two pressure areas that were pinkish-red and without drainage. There was no dressing located in the brief. She then reapplied the soiled brief, and indicated she would need to have help with the care. She indicated the Wound Nurse would not be in the facility today, but the Wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication was labeled correctly, insulin bottles were not expired, and expired medication were discarded timely for 2 of 3 medication carts and 1 of 2 medication rooms. (South and [NAME] Unit medication Carts, and the East Unit medication room) Findings include: 1. On [DATE] at 10:20 a.m., the East Unit Medication room was observed with LPN 3. Inside the top cabinet were 2 bottles of Tums with the order administration label visibly peeled off, there was a bottle of expired ear wax, dated [DATE], with administration details to administer for 14 days, there was an enema box, a bottle of deep sea nasal spray, and a bottle of polyethylene glycol (Miralax). During an interview on [DATE] at 10:24 a.m., LPN 3 indicated she was unsure why the medications were in the cabinet. Medications to be returned were to be placed in a bag and put into a bin located on the counter where they would get sent back to the pharmacy. 2. On [DATE] at 10:53…

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 improper use of personal protective equipment (PPE) prior to entering and leaving a COVID-19 room, cleaning of reusable equipment, hand hygiene after direct resident contact and glove removal, and the storage of wash basins and tooth brushes for random observations of infection control. (Residents 264, 213, 63, and 12) Findings include: 1. On 1/10/24 at 9:47 a.m., Resident 264, who had COVID-19, had pressed his call light. The Admissions Director proceeded to the resident's room. Prior to entering the room, the Admissions Director donned an isolation gown, gloves, and an N95 mask. She did not don a face shield, which was available in the isolation bin, prior to entering the resident's room. A CNA took a cup of coffee to the resident's room and she knocked on the door. The Admissions Director opened the door to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the kitchen area, as well as the residents' environment, was clean and in good repair related to an accumulation of rust, dirty baseboards, dirty floors, stained curtains, discolored floor tile, and urine odors in 1 of 1 kitchen areas and on 1 of 3 units. (The Main Kitchen and [NAME] Unit) Findings include: 1. During the Initial Kitchen Sanitation Tour on 1/8/24 at 9:13 a.m., with the Dietary Food Manager (DFM), the following was observed: A steel dish rack located in the dish room had an accumulation of rust along the edges. 2. During the Kitchen Sanitation Tour on 1/10/24 at 11:29 a.m. with the DFM, the following was observed: a. An accumulation of dirt and debris was observed along the baseboard underneath the handwashing sink. b. An accumulation of dirt was observed along the baseboard underneath the steamer and extended to behind the oven. During an interview with the DFM on 1/12/24 at 11:20 a.m., indicated the dish rack was thrown away and…

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

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 3 of 4 residents reviewed for self-administration of medication. (Residents 43, 52, and 15) Findings include: 1. During random observations on 1/8/24 at 10:30 a.m., and 2:10 p.m., Resident 43 was observed in bed. At those times, there was a tube of Bacitracin ointment on the over bed table. The record for Resident 43 was reviewed on 1/10/24 at 10:25 a.m. Diagnoses included, but were not limited to, bipolar disorder, atrial fibrillation, anxiety, major depressive disorder, dementia, and schizophrenia. The 12/30/23 Annual Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. There was no Care Plan for the resident to self-administer her own medications. There was no Physician's Order for the Bacitracin ointment or for the resident to self-administer her own medications. There was no self-administer of medications assessment completed. During an…

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

Based on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of a change in condition for 1 of 1 residents reviewed for notification of change. (Resident 63) Finding includes: The record for Resident 63 was reviewed on 1/10/24 at 3:30 p.m. Diagnoses included, but were not limited to, stroke, COPD, high blood pressure, kidney failure, and muscle weakness. The 10/8/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact, had no behaviors, and received oxygen. The resident had no oral problems and received 51% or more of his nutrition through a peg tube (a tube inserted directly into the stomach for nutrition). A Nurses' Note, dated 12/19/23 at 7:45 a.m., indicated the resident's peg tube was dislodged and was infusing in the resident's bed. At that time, a foley catheter was placed in the insertion site. There was clumpy enteral feeding running out of the tubing. The cap was placed on the tubing and the NP and Unit Manager were made aware. A Nurses' Note, dated 12/19/23 at 8:05 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 had privacy during a physical exam by the Nurse Practitioner (NP) for 1 of 1 residents reviewed for privacy. (Resident 63) Finding includes: During a random observation on 1/10/24 at 9:50 a.m., the NP was observed performing an assessment on Resident 63 in the lounge area on the [NAME] Unit. At that time, there were 2 other residents sitting in their wheelchairs in the room. The NP proceeded to assess the resident as he lifted up the resident's shirt and pressed on his abdomen with his bare hands. He then lifted up his pant leg and felt his calves with his bare hands. He took his stethoscope and placed it on the resident's bare abdomen and listened and then listened to his heart. The resident was observed with a peg tube (a tube inserted directly into the stomach for nutrition). He documented his findings on an IPad and then stood up and left the lounge area. The record for Resident 63 was reviewed on 1/10/24 at 3:30 p.m. Diagnoses included, but were not limited to, stroke, dysphagia, high…

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 8 residents reviewed for ADL's. (Residents 12, 47, and 63) Findings include: 1. On 1/8/24 at 1:52 p.m., on 1/9/24 at 11:00 a.m. and 2:05 p.m., and on 1/10/24 at 9:36 a.m., Resident 12 was observed with long and dirty fingernails as well as a full beard. The record for Resident 12 was reviewed on 1/10/24 at 9:45 a.m. Diagnoses included, but were not limited to, dementia, type 2 diabetes, high blood pressure, adult failure to thrive, osteoarthritis, sleep apnea, COPD and coronary graft. The 10/15/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact. The 10/15/23 State Optional MDS assessment, indicated the resident was an extensive assist with ADL's. There was a current Care Plan indicating the resident needed assistance with personal hygiene. There was no Care Plan indicating the resident refused care or that he…

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 areas of bruising were assessed and monitored for 1 of 4 residents reviewed for skin conditions non-pressure related. (Resident 96) Finding includes: On 1/8/24 at 11:15 a.m., Resident 96 was observed with two fading bruises to her left upper arm. During an interview with the resident at that time, she indicated she was not sure how she got the bruises and maybe they were from my insulin shots. The record for Resident 96 was reviewed on 1/11/24 at 9:39 a.m. Diagnoses included, but were not limited to, fracture of the lower end of the left and right femurs, diabetes mellitus, and acute embolism and thrombosis. The admission Minimum Data Set (MDS) assessment, dated 10/16/23, indicated the resident was cognitively intact and she was receiving an anticoagulant (blood thinner) medication. The resident had no order to monitor the bruising to the left upper arm. A Physician's Order, dated 10/11/23, indicated the resident was to receive Brilinta (an antiplatelet medication) 90 milligrams (mg) twice a day for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing, related to treatments not completed as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident 213) Finding includes: During a pressure ulcer treatment on 1/10/24 at 8:10 a.m., Resident 213 was observed with 6 pressure ulcers. The right inner knee, left inner knee, right hip, and right shoulder were noted with black eschar (necrotic tissue) and had pink tissue on the surrounding skin. The right cheek was pink in color with yellow slough (necrotic tissue) noted and the right ear had hard black necrotic tissue. The record for Resident 213 was reviewed on 1/9/24 at 2:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, fall, intellectual disabilities, high blood pressure, and reduced mobility. The admission Minimum Data Set (MDS) assessment was in progress and not completed.…

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 urostomy was documented and monitored for 1 of 2 residents reviewed for catheters. (Resident D) Finding includes: On 1/8/24 at 10:49 a.m., Resident D was observed in his room in bed. The resident indicated he had an urostomy bag. The resident's daughter indicated the resident continued to get urinary tract infections because the staff only changed the urostomy bag every month. The record for Resident D was reviewed on 1/10/24 at 10:55 a.m. Diagnoses included, but were not limited to, end stage renal disease, malignant neoplasm of the bladder, acquired absence of the kidney and an urostomy to the left lower quadrant. The Quarterly Minimum Data Set (MDS) assessment, dated 11/16/23, indicated the resident was moderately impaired for daily decision making, required substantial assistance with toileting, and had an urostomy. A Care Plan, updated on 11/16/23, indicated the resident had an urostomy related to bladder cancer and a history of urinary tract infections. Interventions included, but…

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

Based on observation, record review, and interview, the facility failed to ensure enteral tube feeding was infusing at the correct flow rate through a peg tube (a tube inserted directly into the stomach for nutrition) for 1 of 2 residents reviewed for tube feeding. (Resident 63) Finding includes: On 1/8/24 at 11:25 a.m., and 3:03 p.m., on 1/9/24 at 10:54 a.m., and 2:04 p.m., and on 1/10/24 at 9:20 a.m., 9:34 a.m.,and 9:50 a.m., Resident 63 was observed with an enteral tube feeding infusing at 65 cubic centimeters (cc) per hour into his peg tube. On 1/10/24 at 2:30 p.m., the resident was observed in bed and the tube feed was off and not infusing. The record for Resident 63 was reviewed on 1/10/24 at 3:30 p.m. Diagnoses included, but were not limited to, stroke, dysphagia, high blood pressure, kidney failure, and muscle weakness. The 10/8/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact, received a mechanically altered diet and had feeding tube in which he received 51% or more of his nutrition. A Care Plan, revised on 12/18/23, 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 oxygen was on and set at the correct flow rate, and nebulizer treatments were completed in a timely manner for 2 of 3 residents reviewed for respiratory care and 1 of 1 nebulizer treatments observed. (Residents 63 and 312) Findings include: 1. On 1/8/24 at 11:25 a.m., and 3:03 p.m., Resident 63 was observed sitting in a broda chair in his room. At those times, he was wearing oxygen per nasal cannula and the portable tank was set at 2.5 liters per minute. On 1/9/24 at 10:54 a.m., and 2:04 p.m., the resident was observed in bed and his oxygen tubing was not in his nares. On 1/11/24 at 8:05 a.m., the resident was observed sitting in the broda chair waiting for breakfast. The oxygen flow rate was set at 2.5 liters per the portable tank. The record for Resident 63 was reviewed on 1/10/24 at 3:30 p.m. Diagnoses included, but were not limited to, stroke, COPD, high blood pressure, kidney failure, and muscle weakness. The 10/8/23 Quarterly…

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

Based on observation, interview, and record review, the facility failed to ensure a meal was served at an appetizing temperature related to the temperature of the hot foods served for a breakfast meal for 1 of 3 Units (East), which has the potential to affect the 30 residents who resided on the Unit. Finding includes: During interviews with Resident E on 9/11/23 at 4:31 a.m., Resident J on 9/11/23 at 12:29 p.m., and Resident L on 9/11/23 at 2:55 p.m., they indicated the meals were often cold when served. During an observation on 9/12/23 at 8:36 a.m., the breakfast trays arrived on the East Unit. The staff began passing the meal out to the residents in their rooms. All breakfast meals were delivered to the residents at 8:55 a.m. and there were two trays left in the cart, which were identified as one of the trays, the resident was not in the facility and the other tray, the resident refused the meal. The aide had taken the tray into Resident N, and immediately walked back out of the room with the plate covered when the resident indicated he had not wanted the tray. She then 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 and interview, the facility failed to ensure an employee completed proper hand hygiene after coughing and blowing their nose for 1 staff member on 1 of 3 units (East Unit) during a random observation for infection control, which had the potential to affect the 30 residents on the unit. (LPN 5) Finding includes: During an observation on 9/12/23 at 8:39 a.m., LPN 5 was assisting with the passing of the breakfast trays to the residents. She was standing in the hallway near the tray cart and covered her mouth with her hand and coughed. She then removed a tissue from her pocket and blew her nose. She placed the tissue back into her pocked and then went to the food cart to obtain a tray without performing hand hygiene. LPN 5 was asked to complete hand hygiene. The Unit Manager was informed without further information provided. 3.1-18(b)(1)

Based on observation, record review, and interview the facility failed to care for a PICC (peripherally inserted central catheter) line in accordance with professional standards of practice, related to not obtaining line flush orders, lack of aseptic technique with care of the line, and dressing changes, for 1 of 3 residents reviewed for PICC line care. (Resident F) Finding includes: During an observation on 9/11/23 at 5 a.m., Resident F was in bed with his eyes opened. There was a PICC line located in the left upper arm with a dressing dated 9/5/23. There was a bag of 0.9% normal saline with a 3.375 gram bottle of piperacillin (antibiotic) hanging on the normal saline bag. There was liquid approximately in a quarter of the bottle that the piperacillin medication was diluted with. The normal saline bag was empty and the IV (intravenous) infusion pump was beeping and with a warning there was air in the line. LPN 4 entered the room and indicated she had ensured all the medication was in the IV bag before starting the medication and squeezed the bottle into the IV bag to allowed the…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents reviewed during 5 medication pass observations. 3 errors in medications were observed during 33 opportunities for errors in medication administration. This resulted in a medication error rate of 9.09%. (Residents L & M) Findings include: 1) During a morning Medication Pass Observation on 9/11/23 at 7:24 a.m., RN 2 prepared Resident L's medication for administration, which included vitamin D3 (cholecalciferol) (supplement), 1000 IU (international units), 1 tablet. The label on the vitamin D3 indicated 2000 IU (two tablets) were to be administered. RN 2 indicated there were nine pills in the medication cup to be administered (count should have been 10 if the second vitamin D3 had been included), and then proceeded to administer the medications to the resident. Resident L's record was reviewed on 9/11/23 at 10:22 a.m. The diagnoses included, but were not limited to, fractured right femur and hypertension. A Physician's Order, dated 11/10/22,…

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

Based on observation, record review, and interview, the facility failed to provide residents with diets as care-planned, ordered, and per preferences, for 3 of 3 residents reviewed for nutritional services. (Residents J, K, and L) Findings include: 1. During an interview on 9/11/23 at 12:29 p.m., Resident J indicated she did not like what food was being served. She did not receive what she was supposed to get for her meals and her food was cold when she ate her meals in her room. During an observation of the breakfast meal on 9/12/23 at 8:42 a.m., she received a cheese omelet, bacon and a cinnamon roll. There was a carton of 2% milk and a glass of apple juice on the tray also. The Dietary Card on the tray indicated a Regular diet and was to receive a baked cheese omelet, two slices of bacon, 6 ounces of fortified hot cereal of choice, a English muffin, one packet of jelly, one packet of margarine, and eight ounces of whole milk. There was no fortified hot cereal, English muffin, jelly, margarine, or whole milk on the breakfast tray. The resident indicated at the time of the…

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

Based on record review and interview, the facility failed to ensure a resident's record was accurately documented, related to documenting a medication was administered when the medication had been omitted, for 1 of 3 residents reviewed for documentation of medications. (Resident D) Finding includes: Resident D's record was reviewed on 9/11/23 at 9:33 a.m. Diagnoses included, but were not limited to, stroke, hypertension (high blood pressure), seizure disorder, anxiety, and asthma. A Physician's Order, dated 8/23/23, indicated to administer Nystatin Mouth/Throat Suspension 100000 UNIT/ML (antifungal), 5 milliliters was to be administered by mouth four times a day for a fungal infection. The Medication Administration Record, dated 9/2023, indicated the Nystatin was signed out as administered by QMA 1 on 9/1/23 at 9 a.m. An interview with QMA 1 on 9/12/23 at 9:00 a.m., indicated she had not administered the Nystatin to the resident on 9/1/23. An interview with the Director of Nursing on 9/12/23 at 12:19 p.m., indicated the QMA shouldn't have documented a medication 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 change in condition related to edema was assessed and monitored, a fall follow up assessment and neurological checks were completed, and an assessment including vital signs was documented prior to hospitalization for 1 of 3 residents reviewed for falls and 2 of 3 residents reviewed for a change in condition. (Residents E and K) Findings include: 1. The closed record for Resident E was reviewed on 8/1/23 at 2:00 p.m. Diagnoses included, but were not limited to, wedge compression fracture, paraplegia, uropathy, depressive disorders, urine retention, schizophrenia, history of falling, and anemia. The Annual Minimal Data Set (MDS) assessment, dated 6/15/23, indicated the resident was moderately impaired for decision making. The resident was an extensive assist with 1 person physical assist for bed mobility and toilet use. She needed supervision for transfers and was independent for locomotion off the unit. A Care Plan, revised on 6/16/23, indicated the resident was at risk for falls related to a decline in functional…

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 daily wound assessments and treatments were completed as ordered and treatments were initiated in a timely manner for 2 of 3 residents reviewed for pressure ulcers. (Residents M and J) Findings include: 1. On 8/3/23 at 9:28 a.m., Resident M was observed in his room in bed. His feet were elevated on a pillow and bilateral heel boots were in use. The record for Resident M was reviewed on 8/3/23 at 11:09 a.m. Diagnoses included, but were not limited to, stroke and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 7/20/23, indicated the resident was moderately impaired for daily decision making. The resident required extensive assistance with bed mobility and was totally dependent for transfers. He had three Stage 3 (full thickness tissue loss) pressure ulcers. The resident did not have a current care plan related to the pressure ulcers. A Physician's Order, dated 6/12/23, indicated the resident was to have a daily wound assessment completed for his left heel. Any…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 5 residents observed during medication pass. Two errors were observed during 29 opportunities for errors during medication administration. This resulted in a medication error rate of 6.89% (Residents N and P) Findings include: 1. On 8/3/23 at 9:44 a.m., RN 1 was observed preparing Resident N's medications. She dispensed one Extra Strength Tylenol 500 milligrams (mg), one Vitamin D3 25 micrograms (mcg)/1,000 units tablet, one Gabapentin (a medication used for nerve pain), and one Docusate Sodium 100 mg tablet. A total of 4 pills were observed in the medication cup. The record for Resident N was reviewed on 8/3/23 at 10:30 a.m. Diagnoses included, but were not limited to, dementia without behavior disturbance, depressive disorder, and alcohol abuse. A Physician's Order, dated 4/5/23, indicated the resident was to receive a Cholecalciferol tablet 1,000 units, give 2 tablets by mouth daily for Vitamin D deficiency. Interview with the Director of Nursing on…

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

Based on record review and interview, the facility failed to ensure specimens for laboratory testing were collected as ordered by the Physician and abnormal results were reported to the Physician in a timely manner for 1 of 3 residents reviewed for laboratory testing. (Resident E) Finding includes: The closed record for Resident E was reviewed on 8/1/23 at 2:00 p.m. Diagnoses included, but were not limited to, wedge compression fracture, paraplegia, uropathy, depressive disorders, urine retention, schizophrenia, history of falling, and anemia. The Annual Minimal Data Set (MDS) assessment, dated 6/15/23, indicated the resident was moderately impaired for decision making. The resident was an extensive assist with 1 person physical assist for bed mobility and toilet use. She needed supervision for transfers and was independent for locomotion off the unit. A Nurses' Note, dated 6/16/23 at 12:44 p.m., indicated the resident's POA (Power of Attorney) phoned in with medical concerns regarding the resident's condition. The Physician was notified and new orders were received for labs of a…

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