Ashton Creek Health And Rehabilitation Center

Based on observation, interview and record review, the facility failed to provide effective pain management for 1 of 3 residents reviewed for pain (Resident O). Findings include: On 9/10/24 at 10:24 A.M., Resident O's record was reviewed. Diagnoses included fractures of the right arm and right hand, inflammatory arthritis, pain in right shoulder, and muscle weakness. Hospital notes indicated the resident had fallen at home and was later hospitalized due to intractable pain (severe pain that's difficult to manage/treat) prior to being admitted to the facility for rehabilitation. An admission Minimum Data Set (MDS) assessment, dated 9/1/24, indicated she had no cognitive impairments or behaviors. She'd indicated she had pain, rated at an 8, on a 1-10 scale with 10 being the worst pain. She required maximal assistance with her activities of daily living (ADL) and was receiving physical and occupational therapy. Care plans, revised on 9/4/24, indicated the resident had pain due to inflammatory arthritis and fractures and was prescribed opioid medications to treat her pain. Goals were 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, interview, and record review the facility failed to ensure hand hygiene was performed when necessary, in the meal preparation and service process. 110 of 110 residents residing in the facility consumed food prepared in the facility kitchen. Findings include: During an observation on 7/16/24 at 9:15 AM the Dietary Manager (DM) picked up a garbage can lid from the floor and placed it back on top of the garbage can. No hand hygiene was performed, and she continued the kitchen tour opening the ice machine door and the walk-in cooler door. During an observation on 7/16/24 at 10:31 AM [NAME] 25 was using a blender to prepare pureed chicken for the lunch meal. During the process, the lid became loose, splattering a small amount of pureed chicken onto [NAME] 25's hands. [NAME] 25 wiped her hands on her uniform and continued the puree process, then handled the clean container the pureed chicken was poured into and the clean utensils without performing hand hygiene. During an observation on 7/17/24 at 11:07 am in the 400-hall dining room, [NAME] 27 was placing plates of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure assistance was provided with managing denture care and grooming of facial hair for 1 of 6 residents reviewed (Resident 40). Findings include: On 7/16/24 at 9:48 AM Resident 40 was observed to have 5 coarse dark hairs on their chin. The hairs were approximately one-half inch long. Resident 40 was observed to be missing their upper front teeth. Resident 40's record was reviewed on 7/17/24 at 9:50 AM. Diagnoses included Alzheimer's, Disease, anxiety, depression and a cerebral infarction (stroke). Resident 40's Annual MDS dated [DATE] indicated their BIMS score was 12 (moderate cognitive loss according to CMS (CMS.gov, 2024). The MDS indicated Resident 40 required supervision or touching assistance with oral care and personal hygiene. The MDS indicated Resident 40 did not have issues with their dental health. Resident 40's Care Plan dated 10/9/23 indicated the resident required assistance with activities of daily living (ADLs) due 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, interview, and record review the facility failed to ensure meal intakes and weights were monitored for 2 of 3 residents reviewed (Resident B and Resident 305). Findings include: 1. During an interview on 7/16/24 at 11:13 AM, Resident B's family member indicated he was concerned about Resident B's nutritional status and meal intakes. He indicated Resident B was not offered meal trays at the dinner meal on 6/15/24 and the breakfast and lunch meals on 6/29/24. He indicated Resident B had poor meal intakes and was not provided assistance at many additional meals including breakfast on 6/22/24, the dinner meal on 6/24/24, the dinner meal on 6/26/24, the dinner meal on 6/27/24, and the dinner meal on 6/28/24. He was concerned additional meals may not have been offered and his father may not have been offered the assistance he needed to eat. Resident B's record was reviewed on 7/16/24 at 1:48 PM. Diagnoses included Alzheimer's disease with late onset, need for assistance with personal care, 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 interview and record review, the facility failed to report timely, a suspicious injury of unknown source for 1 of 3 residents reviewed (Resident N). Findings include: An Indiana Report, dated 11/12/23 at 11:52 a.m., indicated Resident N had been found with discoloration around her left eye and both wrists. A head to toe assessment was completed and no other injuries were observed. The resident denied pain and when asked, indicated she hadn't known how the injuries occurred. On 11/16/23 at 9:33 A.M., Resident N was observed seated in her room in a wheelchair with an overbed table positioned in front of her. She had a puffy black bruise below her left eye and dark discoloration around her right earlobe. She hadn't responded when asked how the bruise to her face occurred or when questioned if she had fallen. On 11/16/23 at 9:35 A.M., Resident N's roommate, identified as interviewable, was interviewed. The roommate indicated the night the injuries occurred, she hadn't heard the resident yell, raised voices or a scuffle behind the privacy curtain. On 11/16/23 at 10:09 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 interview and record review, the facility failed to assess timely and follow physician orders for treatment of a pressure ulcer for 1 of 3 residents reviewed (Resident O). Findings include: On 11/16/23 at 11:51 P.M., Resident O's record was reviewed. The resident admitted to the facility following hospitalization for sepsis from skin infection of his lower extremities' chronic wounds. Other diagnoses included, diabetes and heart disease. A hospital Discharge summary, dated [DATE] at 10:49 a.m., indicated the resident had been hospitalized for sepsis due to cellulitis of the lower extremities. While at his previous living facility, the wounds on his legs had become more swollen and red with increased drainage. Since admission to the hospital, his legs had improved significantly. Notably, the resident had buttock wounds. The wound care team had been consulted and planned to treat the buttock wounds with melgisorb, mepilex border and he was to continue with wound care in the outpatient setting. admission…

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 oral hygiene was completed for 1 of 3 dependent residents (Resident D). Findings include: In an interview on 8/23/23 at 10:07 AM, Resident D indicated she needed assistance with oral hygiene care, such as brushing her teeth. Resident D indicated she had not received assistance with brushing her teeth on 8/23/23. Resident D indicated she preferred to brush her teeth in the morning and afternoon. In an interview on 8/23/23 at 11:16 AM, Certified Nurse Aide (CNA) 2 indicated residents received oral hygiene care daily, usually in the morning or based on their preference. CNA 2 indicated Resident D needed assistance with oral hygiene care. CNA 2 indicated she had not assisted Resident D with oral hygiene care on 8/23/23. In an interview on 8/23/23 at 11:27 AM, Qualifed Medication Aide (QMA) 3 indicated oral hygiene care was performed during AM care and PM care or based on resident's preferences. QMA 3 indicated AM care should be completed by 11 AM. QMA 3 indicated Resdient D needed assistance with oral hygiene care. 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, interview, and record review the facility failed to ensure privacy for 4 of 32 residents reviewed. (Resident 13, Resident 38, Resident 48, and Resident 97) Findings include: 1.During an interview with Resident 97 and her husband on 7/6/23 at 10:24 AM, Registered Nurse (RN) 20 opened the door to Resident 97's room without knocking and offered her medicine. During the medication administration, Case Manager 21 opened the door without knocking and indicated she needed to speak to Nurse 20 when she finished her task. Resident 97's husband indicated it was not unusual for employees to come in the room without knocking. On 7/6/23 at 10:37 AM RN 20 opened the door and reentered Resident 97's room without knocking. Resident 97's record was reviewed on 7/10/23 at 3:09 PM. Diagnoses included traumatic subarachnoid hemorrhage with loss of consciousness for unspecified duration, cognitive communication deficit, and encephalopathy. A review of Resident 97's current quarterly Minimum Data Set (MDS) 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 interview and record review, the facility failed to ensure a resident received a shower/bed bath as scheduled for 1 of 23 residents reviewed. (Resident 61). Findings include: In an interview on 7/6/23 at 2:52 PM, Resident 61 indicated she had been receiving showers at the facility, but after a hospitalization in June she changed to bed baths due to a wound dressing. She indicated she had not been receiving bed baths consistently twice a week as preferred. Resident 61's record was reviewed on 7/7/23 at 9:17 AM. Diagnoses included a wedge compression fracture of T5-T6 vertebra, osteomyelitis of the thoracic vertebra, discitis, history of falling, unspecified abnormalities of gait and mobility, muscle weakness and the need for assistance with personal care. A review of Resident 61's current quarterly Minimum Data Set (MDS) assessment, dated 6/12/23, indicated the resident's Brief Interview for Mental Status (BIMS) score was 12 (moderately impaired), she was alert, oriented and interviewable. A review of Resident 61's current care plan, last revised 6/20/23, 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 interview and record review the facility failed to ensure care to a resident with a shunt, for one of one resident reviewed. (Resident 35). Findings included: During an interview on 7/7/23 at 10:23 AM, with DON (Director of Nursing), indicated Resident 35 was sent to the hospital on 7/5/23. The DON indicated nursing staff believed Resident 35 was having a stroke. The DON indicated as paramedics arrived Resident 35 had seizure activity. Resident 35 did not have a previous history of seizures. The DON indicated the hospital informed facility a shunt revision was needed. The hospital indicated the shunt was draining too quickly. A record review, on 7/7/23 at 11:56am, indicated there were no care plans in place specific to the shunt, no physician orders to watch for specific signs and symptoms of problems regarding the shunt, no nursing tasks regarding the shunt, and no diagnosis listed specific to the shunt. Resident 35 progress notes indicated she complained of a headache for 2 days prior to being sent to the hospital. Resident 35 ' s medication administration record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to manage tube feeding consistently for 1 of 4 residents reviewed. (Resident 32). Findings include: Resident 32's record was reviewed on 7/6/23 at 9:53 AM, indicated her diagnoses included dysphagia and malnutrition. Resident 32's current annual MDS (minimum Data Set) assessment dated [DATE], indicated her BIMS (Brief Interview of Mental Status) score was 7. A score of 7 indicated moderate cognitive decline. Resident 32's nutrition assessment dated [DATE] indicated the tube feeding provided from 8pm to 4am was to equal 440cc. The 440cc of Jevity 1.5 was to provide 660Kcal (11kg) with a 40ml flush 8pm to 4am to equal 714ml free water from formula and flush. Resident 32's tube feeding was in addition to continued poor oral intake. Dietary assessment indicated daily calories need 1850(30kg), protein needs 80g (1.3g/kg) and fluids need 1900ml. Resident 32's care plan during time of survey indicated a focus: Jejunostomy tube related to impaired nutrition…

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 safe medication storage for 2 of 8 residents reviewed. (Resident 25, and Resident 215) Findings include: 1.During an observation on 7/5/23 at 9:13 AM the following was observed: a clear plastic cup containing an oblong white pill was sitting on Resident 25's bedside table next to his breakfast tray. Resident 25 indicated it was given to him the night before by his nurse for sleep and he forgot to take it. In an observation and interview on 7/5/23 at 11:59 AM, the Assistant Director of Nurses (ADON) removed the pill from Resident 25's bedside. She identified the pill as Trazadone 150 mg, based on its color, shape and markings. She indicated Resident 25 did not have a self-administration of medication assessment and the pill should not have been at bedside. Resident 25's record was reviewed on 7/6/23 at 2:14 PM. Diagnoses included chronic obstructive pulmonary disease COPD), major depressive disorder, and polyneuropathy. A review 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.