Chateau Rehabilitation And Healthcare Center

Based on observation, interview and record review, the facility failed to ensure a mechanically altered diet was served as ordered for 1 of 12 residents reviewed (Resident 31).Findings include: During a dining observation on the dementia unit, on 07/23/2025 at 12:01 PM, Resident 31 reached into an unattended meal tray cart, partially pulled out a tray, lifted the plate cover, pulled out a bratwurst sausage on a bun and began to eat. The bratwurst was whole and not chopped or ground. Registered Nurse (RN) 10 approached Resident 31 read the tray card, assisted him to the table and placed the remaining items on the tray on the table in front of Resident 31. During an interview, at on 07/23/25 at 12:03 PM, RN 10 indicated the tray served to Resident 31 was prepared for another resident. She indicated it was not an issue because both residents were on the same diet.During an observation, on 07/23/25 at 12:04 PM, RN 10 pulled the tray prepared for Resident 31. The tray contained a bun filled with ground bratwurst. The tray card with Resident 31's name indicated Resident 31 should receive…

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 ceiling return air ducts were free from debris for 3 of 10 vents observed. Findings include: During an environmental tour on 1-24-25 at 11:01 AM, the following was observed: On Hall 100 south of the dining room, the ceiling air intake had gray, feathery debris. On Hall 100 on the memory unit, the ceiling air intake had gray, feathery matter in strings across the grate. On Hall 100 by nurse's station, the ceiling air intake had gray feathery matter on the grate. In an interview on 1-24-25 at 11:21 AM, the Administrator indicated the ceiling air intake vents should be free of debris. A review of an undated Deep Clean List, provided by the Administrator on 1-24-25 at 11:32 am, did not indicate the ceiling air intakes should be cleaned. This citation is related to complaint IN00448990. 3.1-19(e)

Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment, evaluation and non-pharmacological approaches were identified and implemented, prior to decreasing a resident's anti-psychotic medication prescribed to treat behavior symptoms for 1 of 2 residents reviewed (Resident B). Findings include: An Indiana reported incident, dated 8/28/24 at 6:01 p.m., indicated Resident B was agitated while walking around in the dining room of the secured memory care unit (MCU), had thrown silverware at staff and then threw herself onto the floor. She was sent to the hospital and treated for a right hip fracture. On 9/24/24 at 2:35 P.M., Resident B was observed lying in bed in her room. She was confused but articulate and appeared to enjoy visiting. She indicated she had retired from a state hospital, had spent most of her life caring for children with mental illness and had always been a caregiver. When asked, she denied pain; she indicated some female doctor had cut open her hip and she had a huge wound. She was irritated with the doctor who…

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 qualified/registered dietician was licensed in Indiana. This deficient practice had the potential to affect 70 of 70 residents in the facility who received dietary services. Findings include: The employee records were reviewed on 8/18/24 at 11:40 AM. The employee records indicated Registered Dietician (RD) 6 was hired by the facility on 6/1/2024. Review of the Indiana Professional Licensing Agency website on 8/19/24 at 11:53 AM indicated, effective 7/1/2019, Dieticians would receive licensures instead of certifications through the Medical Licensing Board of Indiana. RD 6's undated resume indicated she provided Dietician coverage for Long Term Care/Rehabilitation facilities as needed remotely through a nationwide dietician staffing service since 4/2024. The RD 6's resume indicated she was a RD/Licensed Dietician/Nutritionist in the states of North Carolina, South Carolina, and Florida. On 8/19/24 at 11:55 AM the Indiana Professional Licensing Agency website, 2024, was used to search for and verify RD 6's license.…

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 fall interventions were recorded and communicated for 1 of 6 residents reviewed (Resident 67). Findings include: Resident 67's record was reviewed on 8/13/24 at 11:48 AM. Diagnoses included Alzheimer's disease, major depressive disorder, and unilateral primary osteoarthritis, right hip. Resident 67's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was not conducted as he was rarely if ever able to make himself understood. The MDS indicated Resident 67 required assistance with activities of daily living and had fallen since admission to the facility. An admission fall risk assessment dated [DATE] indicated Resident 67 had fall risk factors including disorientation, 1-2 falls in the past 3 months, incontinence, decreased muscular coordination, use of medications that had side effects including drowsiness and dizziness, recent medication changes, and diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a shared glucometer was cleaned between uses for 3 of 12 residents reviewed (Resident 19, Resident 29, and Resident 30). Findings include: During a medication pass observation on 8/16/24 at 8:37 AM, Licensed Practical Nurse (LPN) 9 removed a glucometer (handheld device designed to measure blood glucose levels), lancet (small needle designed to poke the skin to produce a drop of blood), a test strip, and an alcohol swab from the top drawer of the medicine cart on the 300-hall of the C-wing. LPN 9 entered the room of Resident 19, cleaned her finger with an alcohol swab, obtained a drop of blood, applied it to the test strip inserted in the glucometer and obtained a reading. After the test, LPN 9 placed the glucometer in the top drawer of the cart, completed her documentation, and proceeded to prepare medications for the next resident who required medicine at that time. The glucometer was not cleaned before or after use. Upon…

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 flooring panels were complete and intact for 1 of 24 residents reviewed (Resident 11). Findings include: During an observation on 8/13/24 at 9:51 AM, an approximately 15 inch by 30 inch area of floor paneling was missing in front of the heating unit and near the end of Resident 11's bed. One floor panel was lying loose across a small portion of the uncovered area. Resident 11's record was reviewed on 8/14/24 at 9:49 AM. Diagnoses included multiple sclerosis, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and type 2 diabetes mellitus without complications. Resident 11's current quarterly Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 4 (cognitively impaired). During an observation and interview on 8/13/24 at 12:16 PM, Registered Nurse (RN) 4, and Certified Nurse Aide (CNA) 5 and CNA 6 indicated they…

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 notify the Power of Attorney of a significant change in condition for 1 of 3 residents reviewed for notification (Resident C). Findings include: An Indiana report, dated 1/16/24, indicated Resident C had been sent to the hospital on 8/15/23 for a life threatening condition. The resident's POA (Power of Attorney) indicated the hospital had received no clinical information from the facility regarding the resident including his advanced directives or POA. They alleged an ICU (Intensive Care Unit) nurse was finally able to contact them the morning after he was transferred to the hospital after reviewing the resident's previous hospitalizations and POA contact information. On 2/2/24 at 2:27 P.M., Resident C's record was reviewed. Diagnoses included demyelinating disease of the central nervous system and neuromuscular dysfunction of the bladder. His face sheet indicated he was responsible for himself and had a family contact phone number listed. The face sheet did not have a POA listed nor their contact information. A 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 interview and record review, the facility failed to provide information to the hospital upon transfer for 1 of 3 residents reviewed. (Resident C). Findings include: An Indiana report, dated 1/16/24, indicated Resident C had been sent to the hospital on 8/15/23. The resident's POA (Power of Attorney) indicated the hospital had received no clinical information from the facility regarding the resident including his advanced directives or POA. On 2/2/24 at 2:27 P.M., Resident C's record was reviewed. Diagnoses included demyelinating disease of the central nervous system and neuromuscular dysfunction of the bladder. A nurse progress note, dated 8/15/23 at 10:27 p.m., indicated the resident complained of discomfort and leakage of urine. Unsuccessful attempts were made to flush his indwelling catheter. The NP (Nurse Practitioner) was notified and ordered to change the resident's catheter. When the old catheter was removed, there were blood clots on the catheter. The new catheter was inserted and urine returned. When the bulb of the catheter was inflated, the resident complained 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 interview and record review, the facility failed to ensure physician orders were followed for pressure ulcer care for 1 of 3 residents reviewed (Resident E). Findings include: On [DATE] at 10:52 A.M., Resident E's family member was interviewed. She indicated the resident was recently deceased and had previously resided at the facility in June and July of 2023. While at the facility, she alleged the resident got pressure ulcers. She indicated the resident was moved from the facility due to lack of care for the ulcers. On [DATE] at 11:24 A.M., Resident E's record was reviewed. Diagnoses included diabetes and peripheral vascular disease. He admitted to the facility following hospitalization. Hospital records indicated the resident was observed with a reddened coccyx and red areas to his right hip and no open areas. A nurse note, dated [DATE] at 2:47 p.m., indicated the resident was admitted to the facility. He was alert, oriented and able to verbalize his needs and wants clearly. He was continent of bowel…

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 dialysis related medications were given as ordered for 3 of 3 residents reviewed (Resident F, Resident K, and Resident L). Findings include: On 2/5/24, Dialysis was retrieved from the website kidney.org (National Kidney Foundation). the website indicated dialysis is a type of treatment to help the body remove extra fluid and waste products from the blood when the kidneys are not able to do so. Dialysis helps to keep safe levels of electrolytes and minerals in the blood such as potassium, sodium, calcium, and bicarbonate and helps to regulate blood pressure. Dialysis is an effective treatment for clearing waste products and extra fluid from the blood however, it doesn't fully replace the kidney's functions. Certain steps could help increase effectiveness of dialysis treatments including completing treatments as scheduled and taking medications and supplements as ordered. 1. An Indiana report, dated 1/30/24, indicated Resident F had been a resident at the facility in 2023. A family member alleged the resident, who 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 interview and record review, the facility failed to provide care and services for chronic conditions to 1 of 3 residents reviewed (Resident C). Findings include: On 12/12/23 at 11:04 A.M., Resident C's record was reviewed. Diagnoses included diabetes, hypothyroidism, and Addison's disease with history of Addisonian crisis. Adrenal Insufficiency and Addison's Disease was retrieved on 12/12/23 from the National Institute of Health website (niddk.nih.gov). Adrenal insufficiency or Addison's disease, is a disorder that occurs when the adrenal glands don't make enough of certain hormones which affects the body's ability to respond to stress and maintain other life functions. One of these hormones, cortisol, is sometimes called the stress hormone because it helps the body respond to stress and helps to control blood pressure and blood sugar. The disease is treated with daily medications that replace the hormones the adrenal glands aren't making. The most serious complication of adrenal insufficiency is called adrenal crisis or Addisonian crisis which can cause death if 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.

Based on interview and record review the facility failed to ensure a stool sample was collected, processed and followed up for 1 of 3 residents reviewed (Resident C). During an interview on 11/3/23 at 11 AM, Resident C indicated a stool sample was collected sometime last week. Resident C indicated he was not updated on the collection results. During an interview on 11/2/23 at 2:44 PM, Registered Nurse (RN) 4 indicated the Nurse Practioner or Medical Director ordered a stool sample if needed. Once the order was placed into the resident's chart, the sample was collected as soon as possible. RN 4 indicated once the sample was collected, the sample was placed in the lab collection box. RN 4 indicated the lab collected samples every morning. RN 4 indicated the nurse on the floor followed up on the results. RN 4 indicated results were available within 24 hours. In an interview on 11/3/23 at 11:07 AM, Unit Manager 2 indicated Resident C was interviewable. Unit Manager 2 indicated there was an ordered sample, the sample was collected and the nurse and unit manager should have followed up…

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 provide care and services for non-pressure related wound and skin impairments for 1 of 1 residents reviewed (Resident C). Findings include: On 10/4/23 at 9:48 A.M., Resident C's significant other was interviewed. The resident was admitted to the facility following a month long hospitalization for sepsis with septic shock resulting in kidney failure and need for dialysis. She wanted to come to the facility for in-house dialysis treatment but was told it wasn't possible. The facility indicated they would provide transportation to and from an off-site dialysis center. At the first treatment, the resident had been sent back to the facility, prior to dialysis, due to leaking fluids from several wounds. After returning to the facility, she was bandaged up and sent back to dialysis where she received a partial treatment due to scheduling issues at the center. Her 2nd dialysis treatment was on 10/2/23 and she continued to leak fluids from her wounds. During…

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 ongoing communication an with a dialysis facility for 1 of 2 residents receiving dialysis services (Resident C). Findings include: On 10/4/23 at 9:48 A.M., Resident C's significant other was interviewed. The resident was admitted to the facility following a month long hospitalization for sepsis with septic shock resulting in kidney failure and need for dialysis. She wanted to come to this facility for in-house dialysis treatment but were told it wasn't possible. The facility indicated they would provide transportation to and from an off-site dialysis center. He alleged since being admitted to the facility, she had only received 2 dialysis treatments. At the first treatment, the resident had been sent back to the facility, prior to dialysis, due to leaking fluids from several wounds. After returning to the facility, she was bandaged up and sent back to dialysis where she received a partial treatment due to scheduling issues at the center. The resident hadn't received the next 2 treatments due to breakdown 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 observation, interview and record review, the facility failed to implement an effective behavioral care plan for 1 of 1 resident's reviewed (Resident Y). Findings include: On [DATE] at 2:01 P.M., Resident Y was observed lying in bed in her room. Her room had several cardboard boxes sitting on the floor and furniture. There was an empty glass, liquid on the floor and privacy curtain near her bed. She was wearing a hospital gown, was crying, expressed anger, and indicated she was being neglected. She had issues with incontinence and alleged staff refused to clean her up. She sat up in a bariatric bed with folded blankets, clothes, and papers piled up around her. She complained of staff not repositioning her becasue getting off her left side difficult. She always had to lie on her back and it caused her pain. She indicated she had been neglected in several nursing homes over the past 4 years and had hoped this one would be different but it wasn't and she was ready to give up. She began to cry harder 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 ensure a process was in place to identify and correct quality deficiencies from reoccurring. This had the potential to affect 2 of 2 residents residing in the facility. See F698 for additional information regarding Resident 34 and Resident 144. Findings include: A (QAPI) committee member list was provided on 8/2/23 at 11:30 AM by the Administrator. The member list included the Medical Director, Executive Director, Director of Nursing, Assistant Director of Nursing, B/C Wings Unit Manager, Social Service Director, Business Office Manager, Human Resource Director, Admissions Coordinator, Scheduler, Dietary Manager, Laundry/Housekeeper Supervisor, Maintenance Director, Central Supply/Medical Records Director, Minimum Data Set (MDS) Coordinator, Quality of Life Director, and Therapy Director. In an interview on 08/08/23 at 1:43 PM, the Administrator indicated problems and issues in the facility were tracked and trended through the QAPI committee at monthly meetings. She indicated the QAPI process was utilized to improve…

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 facial hair was properly restrained on staff in the kitchen. 86 of 87 residents currently residing in the building ate food prepared in the dining room. Findings include: During an observation in the kitchen next to a steam table filled with food on 8/2/23 at 11:37 AM, [NAME] 2 was observed with a full beard wearing no covering. The Regional Director of Operations for Dining Services (RDODS) was also observed with a full beard wearing no covering. In an interview on 8/2/23 at 11:37 AM, the RDODS indicated beard hair should be covered in the kitchen. A current policy title Food and Nutrition Services Quick Resource Tool dated 9/1/21 provided by the RDODS indicated facial hair must be restrained in the kitchen. 3.1-21(i)(3)

Based on observation, interview and record review the facility failed to ensure privacy related to medical treatments for 1 of 24 residents reviewed. (Resident 144). Findings include: During an observation on 8/2/23 at 9:25 AM the following was observed: Resident 144 was sitting in a reclining chair in their room. Taped to the chair was an 8 x 11 sign titled Dialysis. The sign indicated the resident's first initial, last name and 9:45 AM. Resident 144's record was reviewed on 8/2/23 at 2:14 PM. Diagnoses included diabetes and chronic kidney disease. A review of Resident 144's current Comprehensive Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 7 (severe cognitive impairment). The MDS indicated the resident received dialysis. In an interview on 8/823 at 1:13 PM, QMA 8 indicated it was the facility's normal practice to label dialysis transport chairs with the resident's name and time of dialysis. A current policy (no date) provided by the Administrator indicated confidential resident information was to be disclosed only to those authorized 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 interview and record review the facility failed to provide the resident with a written explanation of the Notice of Transfer or Discharge within 24 hours of a hospital transfer for 2 of 18 residents reviewed (Resident 34 and Resident 20). Findings include: 1.Resident 34's record was reviewed on 8/3/23 at 2:48 PM. Diagnoses included end stage renal disease, acquired absence of left fingers, 3rd 4th, and 5th digits, and type 2 diabetes mellitus with diabetic neuropathy, unspecified. A review of Resident 34's current quarterly Minimum Data Set (MDS) indicated their BIMS (Basic Interview for Mental Status) score was 15 (cognitively intact). The MDS indicated Resident 34 received dialysis. A review of a Notice of Transfer or Discharge form dated 6/14/23 did not contain a resident signature or indication the resident was unable to sign at transfer or indication of a copy being given to or mailed to a resident representative. During an interview on 8/8/23 at 10:26 AM the Social Services Director indicated upon discharge from the facility nursing staff should call the resident or…

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 nurse's permission was obtained prior to the administration of a pro re nata (prn or as needed) medication by a Qualified Medication Aide for 1 of 16 residents observed during medication pass (Resident 143). Findings include: During a continuous medication pass observation on 8/7/23 at 11:20 AM a family member approached Qualified Medication Aide (QMA) 4 and indicated Resident 143 needed pain medicine. After finishing the task she was completing, QMA 4 interviewed resident 143 for his pain level and administered Hydrocodone/Acetaminophen 5/325 mg, 2 tablets (a controlled substance for pain). Resident 143 answered questions correctly indicating alertness and orientation to person, place, and time. QMA 4 did not consult a nurse prior to the administration of the medication. Resident 143's record was reviewed on 8/7/23 at 2:21 PM. Diagnoses included partial traumatic amputation of the left foot, level unspecified, subsequent encounter, type 2 diabetes with diabetic neuropathic arthropathy, and peripheral…

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 assessment and implementation of care according to individualized resident needs for 2 of 19 residents reviewed. (Residents 48 and 144) Findings include: 1. Resident 144's record was reviewed on 8/2/23 at 2:14 PM. Diagnoses included diabetes and chronic kidney disease. A review of Resident 144's current Comprehensive Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 7 (severe cognitive impairment). The MDS indicated the resident received dialysis. A review of physician orders dated 7/27/23 indicated Resident 144's dialysis access site was to be monitored for pain, redness, warmth, swelling or abnormal drainage every shift. The physician order did not include an order for a dressing to the site. A review of Resident 144's dialysis communication book indicated the resident's dialysis catheter site was to have a clean dressing applied if the dressing became soiled or dislodged between treatments. A review of Resident 144's dialysis communication book indicated on 7/27/23 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 record review and interview the facility failed to ensure consistent respiratory care for 1 of 3 residents reviewed with respiratory therapy. (Resident 25). Findings include: Resident 25's record was reviewed on 8/7/23 at 9:32 AM. Diagnoses included diagnoses dementia, senile degeneration of brain, essential hypertension, unspecified edema, oropharyngeal phase of dysphagia, and anxiety. A review of Resident 25's current quarterly Minimum Data Set (MDS) assessment indicated her Basic Interview for Mental Status (BIMS) score was 5 (moderately impaired) and not interviewable. The MDS indicated the resident was on oxygen therapy while at the facility. A review of Resident 25's current Care plan indicated the resident had a problem of chronic conditions with a risk for discomfort, complications, and decline, with a goal to attain or maintain her highest practicable level of well-being and minimize risk of complications. Interventions included for cardiopulmonary issues to provide oxygen per physician orders. A review of Resident 25's physician order dated 9/9/21 at 11:00 PM…

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, the facility failed to provide assessments before and after dialysis treatments for 2 of 3 residents reviewed. (Residents 144 and 34). Findings include: 1. Resident 144's record was reviewed on 8/2/23 at 2:14 PM. Diagnoses included diabetes and chronic kidney disease. A review of Resident 144's current Comprehensive Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 7 (severe cognitive impairment). The MDS indicated the resident received dialysis. A review of physician orders dated 7/26/23 indicated Resident 144's blood pressure and pulse were to be obtained before and after the resident received dialysis treatments. A review of Resident 144's dialysis communication book indicated assessments before and after dialysis were not competed on 7/20/23, 7/21/23, 7/24/23, 7/25/23, 7/26/23, 7/27/23, 7/28/23, 7/31/23, 8/1/23, 8/2/23, 8/3/23 and 8/4/23. In an interview on 8/4/23 at 3:33 PM, the Assistant Director of Nursing (ADON) indicated physician…

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 appropriate social service interventions for Notice of Transfer or Discharge, Preadmission Screening and Resident Review (PASRR) for 3 of 4 residents reviewed. (Resident 20, Resident 81 and Resident 34). Findings include: 1. Resident 20's record was reviewed on 8/3/23 at 2:17 PM. Diagnoses included unspecified dementia, unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, recurrent major depressive disorder, and type 2 diabetes mellitus. A review of Resident 20's current quarterly Minimum Data Set (MDS) assessment indicated his BIMS (Basic Interview for Mental Status) score was 11 (mild cognitively impaired). A review of a Notice of Transfer or Discharge form dated 4/29/23 did not contain a resident/representative signature, indicate the resident was unable to sign at the time of transfer or indicate a copy was mailed/given to the resident/representative. A review of progress notes dated 4/29/23 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 interview, and record review the facility failed to ensure non-pharmacological interventions were attempted prior to obtaining orders for anti-psychotic medication for of 1 of 5 residents reviewed (Resident 21). Findings include: Resident 21's record was reviewed on 8/3/23 at 1:58 PM. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and anxiety, bipolar disorder, unspecified, and mood disorder due to known physiological condition with depressive features. A review of Resident 21's current quarterly MDS (Minimum Data Set) dated 7/3/23 indicated her BIMS (Basic Interview for Mental Status) score was 14 (cognitively intact). The MDS indicated Resident 21 received antipsychotic medication daily. A review of Resident 21's current care plan titled Risk for Impaired Psychosocial Well-being indicated the resident had a problem of anxious behaviors with a goal date of 10/24/23. Interventions included encouraging calm conversation in quiet spaces, attempt to redirect when exhibiting behaviors, and monitor 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.