Valley View Healthcare Center

Based on observation, interview and record review, the facility failed to ensure showers, hair care and/or nail care were provided for 2 of 6 residents. (Resident L- showers and hair care, Resident K- nail care) Findings include: 1. During an observation and interview, on 3/23/2025 at 1:51 P.M., Resident L indicated she could not recall the last shower she had been offered and had had bed baths only. She indicated the last bed bath she had received was given about a week ago. Resident L had a mass of hair that was matted. The matted hair was the size of a softball and was located at her back of her head. Resident L indicated she had only been offered disposable shower caps in regards to shampooing and does not remember the last time her hair was washed in a shower or was brushed. During an observation and interview, on 3/25/2025 at 9:14 A.M., Resident L indicated she still had not had a shower. The back of Resident L's hair still had a softball-sized hair matt present. During an interview, on 3/25/2025 at 11:10 A.M., CNA 9 indicated she had frequently offered her residents daily bed…

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

Based on observation, interview, and record review the facility failed to ensure freedom from verbal abuse for 2 of 8 residents reviewed (Resident F and Resident G). Findings include: 1) A complaint filed with the Indiana Department of Health, dated 1/13/25 indicated Resident G filed a grievance alleging Licensed Practical Nurse (LPN) 5 had been rude and used foul language to Resident F during a medication pass. The report indicated Resident F asked LPN 5 to bring her some water to take her medication when the nurse entered the room with her pills. LPN 5 grabbed the pills from her bedside table and indicated Resident F should let her know when she wanted to take her pills. She indicated Resident F could not have a breathing treatment because her heart rate was too high. Resident F told LPN 5 her heart rate might not be so high if LPN 5 was not being a b. The complainant indicated LPN 5 closed the door, and then reopened it, put her head in the doorway, called Resident F a b and closed the door. The complainant indicated the Administrator rewrote the grievance, changing what…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 occurrence of verbal abuse was reported to the Department of Health for 1 of 8 residents reviewed (Resident F). Findings include: A complaint filed with the Indiana Department of Health, dated 1/13/25, indicated Resident G filed a grievance alleging Licensed Practical Nurse (LPN) 5 had been rude and used foul language to Resident F during a medication pass. The report indicated Resident F asked LPN 5 to bring her some water to take her medication when she entered the room with her pills. LPN 5 grabbed the pills from the resident's bedside table and indicated Resident F should let her know when she wanted to take her pills. The nurse indicated Resident F could not have a breathing treatment because her heart rate was too high. Resident F told LPN 5 her heart rate might not be so high if LPN 5 was not being a b. The complainant indicated LPN 5 closed the door, then reopened it, put her head in the doorway, called Resident F a b and closed the door. The complainant indicated the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 allegation of verbal abuse was investigated for 2 of 8 residents reviewed (Resident F, Resident G). Findings include: 1) A complaint filed with the Indiana Department of Health indicated Resident G filed a grievance alleging Licensed Practical Nurse (LPN) 5 had been rude and used foul language to Resident F during a medication pass. Resident F asked LPN 5 to bring her some water to take her medication when she entered the room with her pills. LPN 5 grabbed the pills from her bedside table and indicated Resident F should let her know when she wanted to take her pills. She indicated Resident F could not have a breathing treatment because her heart rate was too high. Resident F told LPN 5 her heart rate might not be so high if LPN 5 was not being a b. The complainant indicated LPN 5 closed the door, then reopened it, put her head in the doorway, called Resident F a b and closed the door. The complainant indicated the Administrator rewrote the grievance, changing what had been originally stated.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 assessment, education and care planning were accurately recorded pertaining to smoking for 1 of 4 residents reviewed (Resident D). Findings include: A complaint addendum filed with the Department of Health, dated 1/16/25, indicated some residents had been smoking in their rooms the previous night. The complainant indicated the Administrator had told the nursing staff on duty not to document the indoor smoking in the residents' charts. The complainant also alleged the Administrator instructed the department heads and corporate staff present in the morning meeting the following day not to chart anything about the indoor smoking. During an observation, on 1/29/24 at 1:45 PM, Resident D was observed in the smoking area with a lit cigarette smoking An unidentified staff member was supervising several residents in the smoking area at the time. During an interview ,on 1/29/25 at 1:46 PM, Resident D indicated he smoked at the designated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 store food and maintain equipment in a sanitary manner related to foods not sealed tightly, mold in a refrigerator, cookware with chipped Teflon and a resident's personal water container with mold (Resident G). This deficient practice had the potential to affect 84 of 84 residents who received meals out of the kitchen. Findings include: 1. During an interview on 4/18/2024 at 11:32 A.M., Resident G indicated he had a plastic water container that he used to use, but the water from the bathroom where the staff would get the water from turned his straw black. Resident G indicated staff had never washed it. He had stopped them from using it and had a water pitcher staff would put ice in now. A plastic clear water jug with a plastic ringed straw sitting in the container was observed on the resident's night stand. The straw was noted to have black around the rings of the straw. A record review was completed on 4/23/2024 at 5:00 P.M. Resident G was cognitively intact. During an observation on 4/24/2024 at 9:57 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to develop comprehensive/person centered care plans for residents with behaviors and dementia care, for 6 of 23 residents whose care plans were reviewed. (Residents 66, 17, 77, 5, E & F) Findings include: 1. A record review was completed on 4/22/2024 at 10:27 A. M. Resident 66's diagnoses included, but were not limited to, dementia, depression anxiety, mood disorder and psychosis. A Quarterly MDS (Minimum Data Set) assessment, dated 3/18/2024, indicated the resident was moderately cognitively impaired. A current Care Plan, dated 3/27/2023, indicated the resident was at risk for Psychosocial well-being related to: Adjustment to new admission, Anxiety, Loss of Independence, dementia with behavioral disturbances, paranoia, auditory hallucinations, anxiety, and depression. A current Care Plan, dated 4/2/2023, indicated the resident had a behavior problem related to Psychosocial issues, dementia with behavioral disturbances, auditory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medication cart was kept locked when unattended during a random observation of the medication cart. This had the potential to affect the 22 residents residing on the memory care unit. (400 Hall Medication Cart) Finding includes: During a random observation on 4/18/2024 at 11:10 A.M., the 400 hall medication cart on the memory care unit was unlocked with no staff in the vicinity. During an interview on 4/18/2024 at 11:12 A.M., LPN 14 indicated the cart should have been locked. On 4/24/2024 at 8:37 A.M., the Corporate Nurse provided the policy titled, Storage of Medications, dated 8/2020, and indicated the policy was the one currently used by the facility. The policy indicated .Medications and biologicals are stored safely, securely, and properly . 2. Medication rooms, carts and medication supplies are locked when they are not attended by persons with authorized access 3.1-25(m)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, clean and comfortable environment was maintained related to missing dresser drawer handles, a missing bathroom door knob, broken window blinds, and mold in a closet, as well as dirty microwaves, drawers, an oven, and cabinets/drawers for 2 of 4 halls observed. (200 & 400 halls) Findings include: An environmental tour was conducted on 4/24/2024 at 11:16 A.M. with the Maintenance Director, Administrator and the (AIT) Administrator in training. 1. The following was observed on the 400 hall: - room [ROOM NUMBER]: there was a broken window blind. - room [ROOM NUMBER]: the dresser was missing 8 handles. - room [ROOM NUMBER]: the bathroom door had no handle. - room [ROOM NUMBER]: there was a window blind setting on the floor and not covering the window. - The 400 unit dining room had 4 broken blinds, an oven that was not plugged in with dried food particles in the oven and the oven door had dried grease stains, and kitchenette…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 1 of 1 resident's Level One PASARR (Preadmission Screening and Resident Review) assessment was completed accurately and failed to complete an updated Level 1 review. (Resident 66) Finding includes: A record review was completed on 4/18/2024. Resident 66 was admitted on [DATE]. The resident's March and April 2023 medication orders included the medication Quetiapine (antipsychotic) 50 mg (milligrams) 1 tablet by mouth nightly for psychosis. The Medication Administration Records (MARs), dated March and April 2023, indicated the resident had received the antipsychotic medication daily. A Preadmission Screening and Resident Review form, dated 4/7/2023, indicated Resident 66's diagnoses included major depressive disorder and dementia. There were no known mental health behaviors that affect interpersonal interactions. There were no known or suspected developmental conditions or diagnoses that affects intellectual and /or adaptive functioning. Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 requiring assistance with Activities of Daily Living (ADL) receive adequate assistance with hair and nail care and bathing for 2 of 5 residents reviewed for ADLs. (Residents E and M) Findings include: 1. During an observation on 4/18/2024 at 10:07 A.M. Resident E's hair was oily and she had long fingernails on both her hands. Resident E's finger nails were dirty on her right hand. An observation of Resident E was completed on 4/19/2024 at 9:45 A.M. Resident E's hair was oily and she had long fingernails on both her hands. Resident E's finger nails were dirty on her right hand. Resident E's record review was completed, on 4/22/2024 at 9:00 A.M. Resident E's diagnoses included, but were not limited to: vascular dementia, major depressive disorder, mood disorder, anxiety disorder, cerebral vascular accident, contracture of left wrist and left hand, and contracture of muscle of left lower leg and left lower hand. A Quarterly Minimum Data Set (MDS) assessment , dated 2/17/2024, indicated Resident E…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain oxygen equipment in a sanitary manner related to a dirty air filter on an oxygen concentrator for 1 of 2 residents who were reviewed for the use of oxygen. (Resident 21) Finding includes: An observation of Resident 21 was completed on 4/17/2024 at 02:52 P.M. Resident 21 was wearing a nasal cannula connected to an oxygen concentrator. The oxygen concentrator's filter had a thick layer of dust. During an observation on 4/19/2024 at 1:30 P. M., Resident 21 was wearing a nasal cannula connected to an oxygen concentrator. The oxygen concentrator's filter had a thick layer of dust. During an observation of Resident on 4/22/2024 at 2:14 P.M., Resident 21 was wearing a nasal cannula connected to an oxygen concentrator. The oxygen concentrator's filter had a thick layer of dust. A record review for Resident 21 was completed on 4/22/2024 at 2:45 P.M. His diagnoses included, but were not limited to: chronic respiratory failure with hypoxia, congestive heart failure, and chronic obstructive pulmonary disease. A…

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

Based on interview and record review the facility failed to assess a resident upon return from dialysis procedures for 1 of 1 resident reviewed for dialysis. (Resident 34) Finding includes: A record review for Resident 34 was completed on 4/19/2024 at 2:08 P.M. Diagnoses included, but were not limited to, end stage renal dialysis and dependence on dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 2/26/2024, indicated Resident 34's cognition was intact and she received dialysis services. Physician orders included, but were not limited to: - 4/29/2022 Obtain pre-dialysis weight, and post dialysis weights on every Monday, Wednesday, and Friday, related to end stage renal disease. - 8/25/2022 Dialysis Monday, Wednesday, and Friday at [name of] Dialysis Center. A Care Plan problem, initiated on 10/6/2020 and revised on 6/21/2023, indicated Resident 34 had end stage renal disease and required hemodialysis with the potential for complications. Interventions included, but were not limited to: -If the resident refuses to go to dialysis, provide education as to the risks of…

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

Based on observation, interview, and record review, the facility failed to provide residents with appropriate serving sizes for 1 of 4 residents reviewed for pureed meals. Finding includes: During an observation of the dining room on 4/17/2024 at 12:55 P.M., there were four residents who received pureed meals. When the last resident received their meal, QMA 4 removed the lid of the bowl and there was approximately one tablespoon of green beans in the resident's bowl. During an interview, on 4/17/2024 at 12:56 P.M., QMA 4 indicated there was not ½ cup of pureed green beans in the bowl. During an interview on 4/17/2024 at 1:25 P.M., the Dietary Manager (DM) indicated the portion of green beans that was served was not a full serving of ½ cup. After telling the cook to remove what was in the bowl and then scoop out a full amount of the green beans, the DM indicated the amount did not meet the dietary requirements. On 4/18/2024 at 8:50 A.M., the Corporate Infection Prevention Nurse provided the pureed menu for week four, which indicated the lunch meal was for pureed cheese ravioli 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 physician's orders were followed when medications were not documented as administered for 1 of 3 residents reviewed for medications, (Resident B). Findings include: On 10/26/23 at 2:00 P.M., Resident B's clinical records were reviewed. Resident B's admission Record indicated the resident was admitted to the facility on [DATE]. The resident's admission MDS (Minimum Data Set) dated 8/07/23, indicated Resident B was cognitively intact and required extensive assistance with activities of daily living. The resident was admitted to the facility following a right femoral-popliteal bypass surgery, and had diagnoses which included cardio-respiratory conditions, coronary artery disease, peripheral vascular disease, diabetes mellitus, depression, chronic obstructive pulmonary disease, left leg above the knee amputation, and a diabetic ulcer to the right great toe. Review of Physician's Orders for medications and supplement to be administered, included the…

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

Based on observations and interviews the facility failed to ensure kitchen equipment was free of lime build up and dishes were stored to prevent cross contamination. This deficient practice had the potential to affect 83 of 83 residents. Findings include: During an observation and interview on 03/10/23 at 12:39 P.M., with the FSS there was an lime build up on the bottom of the dish rack and prongs on the inside of the dishwasher. The FSS indicated they de-lime the dishwasher every Friday after the last meal of the day. In addition, pots, pans and bowls were stored on the bottom shelf of the kitchen prep tables, in an upside down manner. He indicated the bowls pots and pan should not be located on the bottom rack because of the dirt and debris on the floor. During an observation, on 3/13/2023 at 2:15 P.M. the pots and bowls remained inverted on the bottom shelf and debris remained on the floor underneath the pots/pan and bowls. During an interview on 3/13/2023 at 2:45 P.M. the FSS provided the policy titled Environment dated 9/20/2017, and indicated the policy was the one currently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, the facility failed to ensure mail was delivered to residents on Saturdays. (Residents 36, 39, 63 and 71) Finding includes: During the resident council/surveyor meeting, on 3/10/2023 at 2:00 P.M., 4 of 4 alert and oriented residents attending the meeting (Residents 36, 39, 63 and 71) indicated the resident mail was not delivered on Saturdays or Sundays. The residents indicated the mail, delivered to the facility, sat in a box in the front of the building. On 3/13/2023 at 9:03 A.M., on a Monday morning, a stack of mail with a large rubberband around it was observed on the receptionist's desk. During an interview with Employee 19, on 3/13/2023 at 9:04 A.M., she confirmed the stack of mail had been delivered on Saturday and no one sorted and delivered the mail to the residents on Saturdays. Employee 19 indicated the post office usually delivered the facility mail to the building around 5:00 P.M. and she sorted the mail the next weekday morning and placed any resident mail on a shelf in the copy room office. She indicated the Activity Director was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observation, record review and interviews, the facility failed to ensure care plan meetings, involving the resident and/or their representative, were completed when a comprehensive assessment and/or quarterly review of the assessment was completed. This deficient practice affected (Residents C, D, 13, 19 and 25) and the facility failed to ensure care plans were revised after a resident declined for 1 of 2 residents reviewed for Activities of Daily Living declines. (Resident 70). Findings include: 1. The record for Resident C was reviewed on 3/7/2023 at 2:30 P.M. Resident C was admitted to the facility on [DATE] with diagnoses, including but were not limited to: hemiplegia and hemiparesis, epiilepsy and epileptic syndromes with seizures, asthma, obstructive sleep apnea, obesity, dysphagia, gastostomy, history of falling, difficulty walking, unsteadiness on feet, sleep disorder and muscle weakness. An admission MDS assessment was completed on 2/3/2023. During an interview with alert and oriented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 residents received personal hygiene such as shaving and nail care for 5 of 8 residents reviewed for activities of daily living. (Residents 10, 13, 17, 27 & 56) Findings include: 1. The review for Resident 13 was reviewed on 3/7/2023 at 3:45 P.M. Diagnoses included, but were not limited to: Parkinson's, chronic obstructive pulmonary disease, peripheral vascular disease, atrial fibrillation, and post-traumatic stress disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 2/14/2023, indicated he was totally dependent for bathing and extensive assist of one person for personal hygiene, extensive assist of two for bed mobility, transfers, and toilet use. During an observation and interview, on 3/6/2023 at 9:09 A M., Resident 13 was eating, raising a fork and had tremors, and was observed with facial hair that was more than a couple days of growth. He indicated that he could not get a shave, it was not offered. During an observation, on 3/7/2023 at 10:18 A.M., he was in his room bent over in 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.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of greater than 5% for 1 of 7 residents observed during medication pass. Two medication errors were observed during 25 opportunities. This resulted in a medication error rate of 8 percent. (Resident 20) Finding includes: The record for Resident 20 was reviewed on 3/10/2023 at 9:29 A.M. A Physician Order, dated 12/10/2021, included but were not limited to: Albuterol Sulfate HFA Aerosol Solution 90 MCG/ACT, 2 puffs inhale orally four times a day. A Physician Order, dated 12/11/2021, included, but were not limited to: Mometasone Furoate Aerosol Powder Breath Activated 220 MCG/INH, 1 puff orally two times a day for breathing treatment. During an observation on 3/8/2023 at 7:16 A.M., the Registered Nurse (RN) 9 handed Resident 20 the albuterol inhaler and the resident administered the medication per self. She gave herself a puff, then she was handed the other inhaler Mometasone Furoate. There was no wait time between the inhalation, only one puff of albuterol 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 place open dates on medication for 1 out of 2 carts reviewed for medication storage and labeling. This deficient practice affected 9 residents. (Residents 2, 8, 30, 36, 37, 55, 64, 69 and 74) Finding includes: The 100-hall medication cart had 7 bottles of opened nasal sprays and 3 inhalers without an open date on the packaging. There was a Symbacort inhaler for Resident 8, with delivery date of 3/1/2023 and no open date. There was an Albuterol inhaler for Resident 74, with a delivery date of 2/23/2023 and no open date. There was an Albuterol inhaler for Resident 30 with no open date There was a Flucotisone nasal spray for Resident 2 with a delivery date of 1/22/2023 and no open date. There was a Flucotison nasal spray for Resident 36 with a delivery date of 9/26/2022 and no open date. There was a Oxymerazoline nasal spray for Resident 69 with a delivery date of 3/3/2023 and no open date. There were two Fluticansone nasal sprays for Resident 55 with a delivery date of 12/10/2022 and 2/11/2023 and no open date…

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

Based on observations, and interviews the facility failed to identify concerns with palatability and temperature of food served for the residents. This deficient practice had the potential to affect 83 of 83 residents. Findings include: During an observation of the meal service, conducted on 3/6/2023 at 11:56 A.M., an insulated meal cart was delivered to the main dining room. From 11:56 A.M. - 12:23 P.M., the cart's doors were wide open and staff were moving covered meal trays in and out of the cart in an attempt to locate meal trays for the residents who were waiting on meals in the dining room. At 12:23 P.M., all of the meal trays left were placed back into the cart, the doors of the cart were shut and the cart was delivered to the 300 hall. The cart was then moved to the 100 hall and finally the 200 hall before all of the meals were delivered, at 1:02 P.M. In addition, at 12:34 P.M. a second cart was delivered to the 300 unit and the process was repeated with the cart leaving the 300 unit and being delivered to the 100 unit. During an interview with alert and oriented Resident D,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 wear appropriate personal protective equipment (PPE) when entering a transmission based precaution (TBP) room (Resident 81) and failed to ensure infection control practices were followed during medication administration and dressing change (Resident 20, 236 and 17). Findings include: 1. During the initial tour of the facility on 3/6/2023 from 9:45 A.M. - 11:15 A.M., Resident 81's door had signage indicating it was a Red Zone, instructing staff in PPE (Personal Protective Equipment) usage and indicated the resident was on Droplet precautions. Resident 81 was readmitted to the facility on with diagnoses, including but not limited to: acute and chronic respiratory failure with hypercapnia and human metapneumovirus. On 3/7/23 at 9:30 A.M., the Regional Nurse Consultant was observed to answer Resident 81's call light. She propped the door open and asked Resident 81 what she needed. After hearing the resident's response, the Administrative nurse then donned an N95 mask, a disposable gown and gloves. The nurse did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 perform a dressing change in a private area for 1 out of 1 reviewed for dignity. (Resident 17) Finding includes: The record for Resident 17 was reviewed on 3/7/2023 at 9:00 A.M. Diagnoses included, but not limited to: dementia without behavioral disturbances, psychotic disturbances, mood disturbances and anxiety disorder. A Physician Order, dated 3/1/2023 indicated staff were to apply skin prep to the left heel and cover the blister with a border gauze dressing daily, while the blister was intact. The order was discontinued on 3/8/2023 A Physician Order, dated 3/8/2023 indicated staff were to apply to a topical dressing to the left heel, once a day and apply skin prep daily. During an observation, on 3/7/2023 at 9:27 A.M., Registered Nurse (RN) 9 removed Resident 17's left boot, sock and dressing in the common area with six resident's presents. She proceeded to clean the area, apply the treatment and cover with a dressing to a pressure ulcer. During an observation, on 3/8/2023 at 9:50 A.M., Registered Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, the facility failed to ensure a significant change assessment was completed after a significant decline in transfer, ambulation, bed mobility, toileting and bowel and bladder continency was noted for 1 of 2 residents reviewed for ADL (Activities of Daily Living) declines and bowel and bladder continency. (Resident 70) Finding includes: Resident 70 was observed, on 3/9/2023 continuously from 8:53 A.M. - 12:00 P.M. The resident was noted to sit herself up independently and feed herself when her meal tray was delivered. Nursing staff were observed administering medication, asking her about her personal hygiene supplies and trimming her nails but otherwise, no nursing care was observed for Resident 70. She was not observed to be assisted to toilet or to toilet herself. During an interview with CNA 22, on 3/10/2023 at 9:30 A.M., she indicated Resident 70 was independent for dressing, wore underwear and was continent and toileted herself. CNA 22 indicated the only help she gave Resident 70 was supervision and washing her back 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 interviews, the facility failed to ensure a care plan was initiated to address medications utilized for behaviors and insomnia for 1 of 5 residents reviewed for medication use. (Resident 70) Findings include: The record for Resident 70 was reviewed on 03/09/23 at 7:40 A.M. Resident 70 was admitted to the facility with diagnosis, including but not limited to: dementia with other behavioral disturbance, vascular dementia without behavioral disturbance, major depressive disorder, single episode, insomnia, anxiety disorder and adult personality and behavior disorder. The current physician's orders for medications included the antipsychotic medication, Quetiapine Fumarate 50 mg in the morning for vascular dementia with behavioral disturbance, the antiepileptic medication, Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) Give 500 mg orally three times a day for Vascular dementia with behavioral disturbance and the antidepressant, TraZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 125 mg orally at bedtime for Insomnia. 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 interview and record review, the facility failed to have a discharge care plan for 1 of 2 closed records reviewed for care plans. (Resident 75) Finding includes: The record for Resident 75 reviewed on 3/13/2023 at 2:10 P.M., indicated his diagnoses included, but not limited to: chronic kidney disease stage 3, atrial fibrillation, and type 2 diabetes. During an interview, on 3/13/2023 at 2:27 P.M., the Social Service Designee indicated when there was a new admission, she wrote a care plan for code status and for discharge planning. She indicated she had initiated a care plan for code status but did not initiated a care plan for his discharge. She confirmed the resident should have had a care plan implemented for discharge planning. On 3/13/2023 at 3:09 P.M., the Regional Nurse provided a policy titled, Plan of Care Overview, undated, and indicated the policy was the one currently used by the facility. The policy indicated . The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of…

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

Based on observation, interview and record review the facility failed to identify and assess the use of an AFO (ankle foot orthosis) splint for 1 of 3 residents reviewed for splint use and range of motion issues. (Resident 3) Findings include: During an observation, on 3/6/2023 at 12:20 P.M., Resident 3 was sitting up in her wheelchair in the dining room wearing an AFO splint to her left lower leg. The record was reviewed on 3/6/2023 at 2:30 P.M. Diagnosis, included but were not limited to acquired deformity of left lower Alleghenies and hemiparesis following cerebral infarction affecting left non-dominant side. and Type 2 diabetes mellitus with diabetic neuropathy. An order for the AFO splint had been discontinued 2/9/2019. During an observation, on 3/7/2023 at 10:00 A.M., the resident was sitting up in her wheelchair in her room wearing an AFO to her left lower leg. A care plan, dated 1/24/2023 indicated the resident was to wear a left AFO daily each shift when out of bed. During an observation and interview, on 3/8/2023 at 11:15 A.M., the resident was sitting up in her wheel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 hand splints were applied for 1 of 4 residents reviewed for limited range of motion. (Resident 27) Finding includes: The record for Resident 27 was reviewed on 3/8/2023 at 8:32 A.M. Diagnoses included, but were not limited to: type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, and post- traumatic stress disorder. A Physician Order, dated 12/7/2022, indicated the facility was to apply a splint to the left hand before bed and remove the splint in the morning and/or if it becomes uncomfortable. A Care Plan, dated 12/7/2022, indicated the resident had hemiplegia related to a stroke, had a left lower extremity knee contracture and was to have a splint to the left hand. The left hand splint was to be applied at bedtime and removed in the morning. During a resident interview, on 3/6/2023 at 9:22 A.M., Resident 27 indicated he used to wear a splint to his left hand but they no longer put it on. No splint was visible in the room. During an observation, 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 interviews, the facility failed to implement interventions to prevent recurrent falls for 1 of 4 residents (Resident 13) and failed to ensure hot water temperatures were maintained at a safe level for 1 of 4 halls. Finding includes: 1. The record for Resident 13 was reviewed on 3/7/2023 at 3:45 P.M. Diagnoses included, but not limited to: Parkinson's, chronic obstructive pulmonary disease, peripheral vascular disease, atrial fibrillation and post-traumatic stress disorder. The record indicated that he had a fall on 1/26/2023, 3/5/2023 and 3/12/2023. A Care Plan, dated 10/17/2020, and current, indicated the residennt was at risk for falls related to Parkinson's and muscle weakness. There was an intervention, dated 3/6/2023 to evaluate the resident for an urinary tract infection and labs. During a resident interview, on 3/6/2023 at 11:04 A.M., he indicated he rolled out of bed two days ago and they did not do anything to prevent it from happening again There was no…

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

Based on observation, interview and record review the facility failed to ensure that all respiratory equipment was available, labeled and dated at the bedside for immediate use. This deficient practice affected 1 of 2 residents reviewed for respiratory care. (Resident 3) Findings includes: During an observation and interview on 03/06/23 at 11:44 AM, Resident 3's tracheostomy site was clean and dry. There was no suction machine located in the resident's room. The resident indicated if she needed it, the staff would bring one to her. During an observation on 03/08/23 at 09:28 AM, Resident 3 was sitting up in her chair. There was no suction machine noted in her room. The record for Resident 3 was reviewed on 3/8/23 at 9:47 A.M. Diagnosis, included but were not limited to: Chronic Respiratory failure, Hypoxia or Hypercapnia. Physician's orders, dated 11/29/2023 included .suction canister and catheters in room at all times . During an interview, with the Regional nurse on 3/9/2023 at 2:45 P.M., she indicated they should have provided resident 3 with a suction machine. She 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 interviews, the facility failed to document and communicate behavioral triggers to prevent re-traumatization for 1 of 1 residents reviewed for post traumatic stress disorder. (Resident 45) Finding includes: Resident 45 was observed on 3/6/2023 at 11:00 A.M., seated in her wheelchair in her room. The resident was dressed in a hospital gown, had disheveled hair and was able to answer routine questions. There was a large pile of what looked like used and clean briefs, books, papers and hygiene items on he floor in her room. The record was reviewed on 3/7/2023 at 2:30 P.M. Resident 45 was admitted to the facility with diagnoses, including but not limited to: adult failure to thrive, , low back pain, adjustment disorder with mixed anxiety and depressed mood, personality disorder, major depressive disorder and post traumatic stress disorder. A quarterly MDS assessment, dated 1/18/2023, indicated displayed feeling down, depressed or hopeless, trouble falling and/or staying asleep, sleeping too much, feeling tired or having little energy, feeling bad…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, the facility failed to ensure adequate monitoring was documented in regards to multiple orders for antibiotic eye drops for 1 of 2 residents reviewed for antibiotic medications. (Resident C) Finding includes: Resident C was admitted to the facility with diagnoses, including but not limited to: hemiplegia and hemiparesis. During an interview with Resident C, on 3/6/2023 at 9:48 A.M., he indicated he had experienced a recent stroke that had affected his balance and his hearing on the left side and his eye on the left side. The resident was noted to be wearing prescription eye glasses and his left eye was not opening as far as his right eye. A physician's order, dated 2/17/2023 included the following antibiotic eye drop: Ciloxan Ophthalmic Solution 0.3 % (Ciprofloxacin HCl (Ophth)) Instill 1 drop in left eye every 4 hours for right eye redness for 7 Days A nursing progress note, dated 2/27/2023 at 5:00 P.M. indicated the following: Returned from Dr's appointment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, the facility failed to ensure there were adequate indications and monitoring of use for psychotropic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 70) Finding includes: The record for Resident 70 was reviewed on 3/7/2023 at 2:50 P.M. Resident 70 was admitted to the facility with diagnoses, including but not limited to: , dementia with other behavioral disturbance, vascular dementia with other behavioral disturbance, major depressive disorder, single episode, post traumatic stress disorder, insomnia, anxiety disorder, Adult personality and behavior disorder, , visual hallucinations, and cognitive communication deficit The current physician's orders for medication included the antipsychotic medication, Quetriapine Fumarate 50 mg orally in the morning and 100 mg at bedtime for vascular dementia with behavioral disturbance. In addition, the resident received the antiepileptic medication, Divalproex Sodium Oral Tablet Delayed Release 500 MG (Divalproex Sodium) 500 mg orally three times 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.

Based on observation, record review and interviews, the facility failed to ensure the menus were followed 4 of 83 residents (Residents C, D, 8 and 54) and 3 of 4 residents who attended the resident council meeting. (Residents 36, 39 and 63) Finding includes: 1. During the observation and interview of the meal service, on 3/6/2023 at 11:56 A.M., alert and oriented Resident 8 indicated she was never served the right food per the menu. Observation of her meal tray and food ticket indicated she was supposed to be served Caprices vegetables and was served carrots. She was also supposed to be served pureed rice and was served mashed potatoes. 2. During an observation and interview with Resident 54, on 3/6/2023 at 12:45 P.M., indicated he had not received the correct food items. Review of his meal ticket indicated he was supposed to have received two hamburger patties with grilled onions and gravy, double portions of rice pilaf and Caprise vegetables. He was observed to have only received two plain hamburger patties with gravy, the rice was supposed to be rice pilaf but was just plain…

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