University Park Rehabilitation And Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications are stored and labeled properly in 2 of 4 storage areas. Findings include: During a continuous observation, on [DATE] at 1:57 PM - 2:10 PM, the following was observed: In the 200 hall medication room, 6 of 7 boxes of Pulmicort were found to be expired on 12/2024. In an interview, on [DATE] at 1:59 PM, Licensed Practice Nurse (LPN) 10 indicated third shift was supposed check for outdates and the expired medication removed from the current storage area. In the 200 hall medication cart, 2 open vials of insulin did not have an opened date. The insulin was delivered by the pharmacy on 1-2-25. A bottle of liquid Konvomep was expired on [DATE]. The bottle was labeled to refrigerate, but was not refrigerated. In an interview, on [DATE] at 2:05 PM, LPN 10 indicated insulin should be labeled, and the expired medication should be removed from the cart. In an interview, on [DATE] at 01:57 PM, the Director of Nursing indicated…

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

Based on interview and record review the facility failed to ensure notification of significant abnormal results for 1 of 2 reviewed. (Resident 12) Findings include: A review of Resident 12's record on 04/10/25 at 2:53 PM, indicated diagnoses of diabetes type 2, obesity, depression, and hypertension. During a record review, on 4/10/2024 at 2:53 PM, a blood glucose, dated 4/4/25 at 7:31 PM, measured 527 mg/dL. The progress notes did not indicate a physician was notified of a glucose measurement of > 500 mg/dL. During a record review, on 4/10/2024 at 2:53 PM, a blood glucose, dated 4/10/2025 12:01 AM, measured 560 mg/dL. The progress notes did not indicate a physician was notified of >500 blood glucose. In an interview, on 04/10/25 at 3:01 PM, LPN 11 indicated notifying a physician when a glucose measurement was over 500mg/dL was the facility policy. A current policy, dated 9/11/2023, provided by the Director of Nursing, on 4/9/25 at 1:32 PM, indicated the physician should be notified for a glucose > 500 mg/dL. 3.1-49 (2)

Based on observation, interview and record review the facility failed to ensure snacks were available at night for 3 of 24 residents reviewed (Resident B, Resident C and Resident D) Findings include: During an observation, on 4/8/25 at 10:18 AM, the west hall refrigerator contained a few packages of snacks with names of residents written on the packages. No general snacks available to all residents on the unit were observed. No dry storage of snacks was observed on the unit. In an interview, on 4/18/25 at 10:19 AM, Registered Nurse (RN) 7 indicated general snacks for all residents were not stored on the unit. She indicated snacks were delivered by the kitchen staff and given to residents when the snacks were received. During an interview, on 4/9/25 at 1:55 PM, Resident B indicated snacks were usually gone in the evening and there was nothing available during the night when a person was hungry. They indicated when snacks were available, they were not always diabetic friendly or easy for people without teeth to consume. During an interview, on 4/9/25 at 1:56 PM, Resident C indicated…

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

Based on observation, record review and interview, the facility failed to ensure garbage and refuse were contained inside the dumpster for 2 of 3 observations. Findings include: During an observation, on 4/7/25 at 9:05 AM, a dumpster lid was observed flipped up leaving the dumpster wide open and fully accessible. A large plastic bag was observed partially hanging out of the dumpster door. Multiple tears were observed in the trash bag with a fast-food cup, lid and straw partially hanging out of the bag. Cups, straws, snack and candy packages, gloves, and plastic bags were observed strewn throughout the lawn near the dumpster. Additional cups, candy and snack wrappers, cigarette packs and straw papers were observed in the parking lot, sidewalks, and grassy enclosures in the parking lot area. During an interview, on 4/7/25 at 9:32 AM, the Dietary Manager (DM) indicated all dumpster doors should be closed to prevent rodent access. The DM indicated trash should not be present in the lawn area. During an observation, on 4/7/25 at 1:22 PM, the side door of the dumpster was observed to be…

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 maintain procedures to help prevent the development and transmission of communicable diseases and infections during 3 of 3 observations. Findings include: 1. During an observation on 04/09/25 at 09:53 AM, Licensed practical nurse (LPN) 2 placed her laptop on the mattress of Resident 23. The resident's covered foot contacted the laptop during a blood glucose measurement. LPN 2 placed the laptop and the glucometer on top of the medication cart without disinfecting the devices. LPN 2 placed the glucometer into the drawer of the medication cart. In an interview, on 04/09/25 at 10:05 AM, LPN 2 indicated Resident 23 was the only resident that used the glucometer. 2. During an observation, on 04/09/25 at 10:42 AM, LPN 2 had gloves on, gave an intramuscular injection, removed the gloves, but did not perform hand hygiene before touching the medication cart. In an interview, on 04/09/25 at 10:59 AM, the Assistant Director of Nursing (ADON), indicated staff should perform hand hygiene before and after giving medications…

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

Based on interview and record review, the facility failed to ensure the physician was notified of a change in condition following a fall for 1 of 3 residents reviewed. (Resident R) Findings include: On 12/16/24 at 10:56 A.M., Resident R's record was reviewed. Diagnoses included, non-alcohol related cirrhosis of the liver with liver cancer, dementia, muscle wasting and atrophy, and protein-calorie malnutrition. He was admitted to the facility for rehabilitation services following hospitalization for a fall with fractured neck vertebrae. An admission Minimum Data Set (MDS) assessment, dated 10/1/24, indicated the resident had no cognitive impairment; no signs of delirium; and no behaviors. He required set-up assistance with eating, oral hygiene, and personal hygiene. He was independent with bed mobility and required moderate assistance with toileting hygiene, showering and dressing. He was able to walk with his walker and supervision to touch assistance. He was receiving therapy services with speech, physical, and occupational therapies. A care plan, revised on 11/13/24, indicated…

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

Based on interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was coded accurately for 1 of 3 residents reviewed for assessments (Resident F). Findings include: On 11/25/24 at 11:03 A.M., Resident F's record was reviewed. Diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, and lymph edema. The resident had been hospitalized 9/16-9/27/24 due to altered mental status, abnormal labs, and hypotension. An admission Observation form, dated 9/27/24 at 2:30 p.m., indicated the resident had been re-admitted to the facility following hospitalization for encephalopathy (altered brain function). Her skin assessment indicated she had a pressure area to her left heel measuring 6 centimeters (cm) by 6 cm and a pressure wound to her right ankle. The right ankle wound measured 0.5 cm by 0.5 cm. A quarterly MDS assessment, dated 10/3/24, indicated in Section M-Skin Condition, a formal and clinical assessment was completed and the resident was at risk for pressure ulcers. The assessment indicated Resident F had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure monitoring and assessments were completed for a resident with a history of substance use disorder, and multiple falls for 1 of 3 residents reviewed (Resident C). Findings include: A complaint, reported to the Indiana Department of Health on 11/4/24, indicated Resident C had been hospitalized following multiple falls at the facility and acute illness. While hospitalized , a urine drug test was completed and was positive for illegal drugs. The complainant indicated Resident C had a substance use disorder (SUD) but hadn't used any drugs or alcohol the past year. The complainant indicated they were unsure where the resident had gotten the illegal substances from. The complainant indicated the family hadn't been notified of the resident's deteriorating condition and multiple falls. The facility was aware of the resident's SUD prior to admission to the facility. On 11/22/24 at 11:45 A.M., Resident C's record was reviewed. Diagnoses included diabetes,…

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 effective behavior care plan, behavioral assessments, behavior monitoring and documentation was completed for 1 of 3 residents reviewed for behavioral health (Resident K). Findings include: On 6/25/24 at 10:26 A.M., Resident K's record was reviewed. Diagnoses included major depressive disorder, bipolar disorder, Schizophrenia, and diabetes. She had a history of urinary tract infections (UTI) and had been treated with antibiotics on 2/12/24 for a positive urinalysis and mild confusion and again, on 3/6/24 followed by hospitalization and treatment with intravenous (IV) antibiotics. A quarterly MDS (Minimum Data Set) assessment, dated 4/27/24, indicated the resident had no cognitive impairment and no behaviors, delusions, or hallucinations. She had several mood indicators including little interest or pleasure in doing things; feeling down, depressed or hopeless; trouble falling asleep or sleeping too much; feeling tired or little energy; poor appetite or overeating; feeling bad about herself; and…

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

Based on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner to promote food safety. 59 of 59 residents residing in the facility ate food prepared in the facility kitchen. Findings include: During an observation and interview on 6/2/24 at 9:41 AM red spots of dried liquid in a splattered pattern were observed on the wall containing the kitchen entry door. In the meal service area where bowls of cereal and condiments were stored, a partial piece of toast with jelly with missing portions in a bite pattern on a napkin. A Styrofoam cup filled with oatmeal and a spoon sat next to the toast. Dietary aide (DA) 2 indicated both items belonged to DA 3. The back door leading to the outside of the building was open, leading to a receiving area including the dumpsters. The closest dumpster had open lids and was located about 34 feet from the kitchen door. [NAME] 4 indicated the staff would leave the back door open to help keep the kitchen cool. She indicated she was not aware the door should be shut when not directly attended…

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

Based on observation, record review, and interview, the facility failed to ensure a process was in place to identify and correct deficiencies from re-occurring. 59 residents resided in the facility Findings include: The facility annual survey completed on 6/16/23 identified noncompliance regarding labeling and dating of food products. The facility indicated the noncompliance would be corrected by 7/5/23. See F812 for additional information about current kitchen sanitation findings. A QAPI (Quality Assurance Performance Improvement) committee list was provided by the Executive Director (ED) on 6/3/24 at 11:41 AM. The member list included Executive Director, DON, ADON, Admissions director, MDS coordinator, Medical Records in central supply, Therapy Director, Business Office manager, HR director, Director of Food services, Maintenance Director, Medical Director, Nurse practitioner. The 2nd quarter QAPI Plan, dated 5/24/24, was reviewed. The QAPI Plan indicated segments of care including Performance Improvement Plan (PIP) for environment, human resources, social services, operations,…

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 clean environment was maintained in 4 of 5 rooms reviewed. 4 residents resided in the 4 rooms affected (Resident 35, Resident 14, Resident 21, Resident 5, and Resident 32). Findings include: During an observation on 6/2/24 at 10:49 AM, Resident 35's floor (room [ROOM NUMBER]) had multiple dime to quarter sized yellow/orange spots on the right side of the bed. The resident had a foley catheter hanging in this location. The catheter was emptied by staff. On the left side of Resident 35's bed, near the top, 5 disposable chucks/chux pads (incontinence pad used under resident to protect mattresses by containing urine or feces) were observed wadded up and piled on the floor in the corner of the room by the left side near the head of the bed. A strong urine odor was in the room and radiated to the hall. A Mountain Dew and empty pop bottles were on the floor. During an observation on 6/2/24 at 10:32 AM, Resident 14's floor (room [ROOM…

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 services and assistance was provided to maintain correct posture for 1 of 1 resident reviewed (Resident 4). Findings include: On 6/2/24 at 12:08 PM, Resident 4 was observed sitting in their wheelchair in the hallway. Resident 4 was leaning to the far right bent over at the waist. On 6/2/24 at 12:10 PM a staff member was observed assisting Resident 4 into an upright position. On 6/2/24 at 1:38 PM, Resident 4 was observed sitting in their wheelchair in the hallway. Resident 4 was bent over at the waist leaning to the far right. Resident 4's lower body was nearly off the chair. A staff member instructed Resident 4 to straighten up. Resident 4 attempted to raise their torso and was not successful. Resident 4 did not assume an upright position in the wheelchair. On 6/2/24 at 1:40 PM, a staff member was observed assisting Resident 4 to an upright sitting position in the wheelchair. The staff member placed Resident 4's right foot into 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 adequate supervision for prevention of falls for 1 of 1 resident reviewed (Resident 4). Findings include: On 6/2/24 at 12:08 PM, Resident 4 was observed sitting in their wheelchair in the hallway. Resident 4 was leaning to the far right bent over at the waist. On 6/2/24 at 12:10 PM a staff member was observed assisting Resident 4 into an upright position. On 6/2/24 at 1:38 PM, Resident 4 was observed sitting in their wheelchair in the hallway. Resident 4 was bent over at the waist leaning to the far right. Resident 4's lower body was slightly off the chair. A staff member instructed Resident 4 to straighten up. Resident 4 attempted to raise their torso and was not successful. Resident 4 did not assume and was not assisted to an upright position in the wheelchair. On 6/2/24 at 1:45 PM, a staff member was observed assisting Resident 4 to an upright sitting position in the wheelchair. The staff member placed Resident 4's right foot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents respiratory equipment was maintained to prevent contamination for 1 of 2 residents reviewed respiratory care (Resident 38). Findings include: During an observation on 6/2/24 at 11:28 AM, on the bedside stand next to Resident 38's bed, a respiratory face mask was observed lying on top of a nebulizer machine, undated, unbagged, with cloudiness observed on edges of clear plastic mask. A suction machine with an attached suction container full of cloudy light tan liquid was observed next to the nebulizer machine on the bedside stand. The suction container had a clear, plastic tube extending from it open to air. No dates were found on the suction container or tubing. Resident 38's record was reviewed on 6/2/24 at 1:05 PM. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, type 2 diabetes mellitus with hyperglycemia, acute respiratory failure with hypoxia. Resident…

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 triggers were identified, communicated, and interventions in place to avoid or alleviate re-traumatization for 2 of 2 residents reviewed (Resident 2 and Resident 22). Findings include: 1) On 6/2/24 at 11:22 AM, Resident 2 was observed to have a flat facial expression. In an interview on 6/2/24 at 11:23 AM, Resident 2 avoided eye contact. Resident 2 answered 2 survey questions and abruptly ended the interview. Resident 2's record was reviewed on 6/5/24 at 1:28 PM. Diagnoses included anxiety, major depressive disorder, current nicotine use and post-traumatic stress disorder (PTSD). Resident 2's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) was 15 (no cognitive impairment). The MDS indicated Resident 2 sometimes displayed social isolation. The MDS indicated Resident 2 had not displayed behaviors of verbal aggression, physical aggression, wandering or resistance of care.…

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 medications were secured for 2 of 19 residents reviewed (Resident 21, and Resident 35). Findings include: 1) During an observation and interview on 6/2/24 at 11:42 AM, a cup containing two round white pills were observed on Resident 21's bedside table. Resident 21 indicated the pills were Tylenol and the nurse had left them for him to take when he was ready. He indicated he had never been told that medication needed to be secured if he was not ready to take it at the time it was offered. At the end of the interview, Resident 21 left the room with the pills remaining in the cup at his bedside. Residnet 21 had a roommate in the room. Resident 21's record was reviewed on 6/5/24 at 9:24 AM. Diagnoses included old myocardial infarction, lumbago with sciatica, and low back pain. Resident 21's current quarterly Minimum Data Set (MDS) dated [DATE] indicated his Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact).…

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 garbage and refuse were contained inside the dumpster for 1 of 2 observations. Findings include: During an observation and interview on 6/2/24 at 9:59 AM, the kitchen door leading to the outside loading dock was propped open. All kitchen staff had been at the opposite end of the kitchen performing meal service. The dumpster was located about 34 feet from the kitchen door. The dumpsters' lids were open with bags of trash inside. A bag of trash was observed on the ground in front of the dumpster torn open. Piles of food debris including partial pieces of pizza, open Chinese food containers with bits of food, fast food cups, straws, and bags, soda bottles and cans, used gloves, lip balm, plastic bags and other debris were lying on the ground around the dumpster, in the grassy area near the dumpster and scattered throughout the parking lot. Cigarette butts, too many to count, were observed on the pavement of the loading area in front of the dumpster area. [NAME] 4 indicated all departments should make sure…

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 menus were followed for 5 of 5 residents reviewed (Resident B, Resident C, Resident D, Resident E, and Resident F). Findings include: A resident roster was provided by the Administrator on 3/26/24 at 12:45 PM. The roster indicated Resident B, Resident C, Resident E and Resident F were interviewable. In an interview on 3/26/24 at 11:30 AM, Resident B indicated even though a meal ticket, matching the menu was completed, the facility did not serve what was on the menu. Resident B indicated many times she did not receive what was on the meal ticket or menu. She indicated the facility had not informed the residents of the menu change. In an interview on 3/26/24 at 11:47 AM, Resident F indicated often she didn't receive meals per the menu or meal tickets. She indicated the facility had not informed the residents of a menu change. In an interview on 3/26/24 at 12:11 PM, Resident E indicated there had been a few times when the meal served did not match the menu posted. The resident indicated the facility had 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 observation and interview the facility failed to ensure medication and treatment carts were secured/locked for 2 of 3 observations. Findings include: During an continuous observation on 12/5/23 at 1:10 PM - 1:13 PM, 2 medication carts on 200 hall were unlocked and 1 treatment cart on 300 hall was unlocked. There were no staff present at the medication or treatment carts. 3 staff and 2 residents were also observed walking past the carts. During an observation on 12/5/23 at 1:20 PM, the 100 hall treatment cart was unlocked. There were no staff present at the treatment cart. In an interview on 12/5/23 at 1:13 PM, Qualified Medication Aide (QMA) 2 indicated all medication carts should be locked when not in use. In an interview on 12/5/23 at 1:20 PM, Licensed Practical Nurse (LPN) 3 indicated all medication and treatment carts should be locked when not in use. A resident roster was provided by the Administrator on 12/5/23 at 1:40 PM. The roster indicated 17 residents resided on the 100 hall, 28 residents resided on the 200 hall and 46 residents resided on the 300 hall. A policy,…

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 follow physician orders for 1 of 3 residents reviewed (Resident G). Findings include: Resident G's record was reviewed on 12/5/23 at 2 PM. Diagnoses included atherosclerotic heart disease, edema and dementia. An active order, dated 5/27/2022, indicated weekly weights were to be completed every Friday. The weight log, reviewed 8/2/2023 - 12/2/2023, indicated Resident B was not weighed during the following weeks: 8/13/2023 - 8/19/2023 8/20/2023 - 8/26/2023 9/3/2023 - 9/9/2023 9/10/2023 - 9/16/2023 9/17/2023 - 9/22/2023 10/1/2023 - 10/7/2023 10/8/2023 - 10/14/2023 10/22/2023 - 10/28/2023 10/29/2023 - 11/4/2023 11/12/2023 - 11/18/2023 Resident G's nursing notes indicated there were no refusal and/or documentation of refusal of weights during the missed weekly weights above. During an interview on 12/5/23 at 1:13 PM, Qualified Medication Aide (QMA) 2 indicated orders were to be followed. QMA 2 indicated when the resident refused then the refusal was documented. A policy, dated 12/1/2023, titled Physician Services and Orders, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure elopement prevention interventions were in place for 1 of 3 residents reviewed. Findings include: During an observation on 10/12/23 at 9:18 AM, the surveyor pulled on the facility entrance door causing an alarm to sound. Resident A came to the front door, entered a code, and pushed the door open. 2 employees voices were heard coming from offices near the front door, but no employee was present in the office area when the surveyor entered the building. Within a few minutes, the Business Office Manager (BOM) came to the receptionist area and greeted the surveyor. She did not inquire how the surveyor as able to enter the facility. Resident A's record was reviewed on 10/12/23 at 11:22 AM. Diagnoses included depression, unspecified, generalized anxiety disorder, and hypothyroidism. A review of Resident A's current admission Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 15…

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.