Aperion Care Tolleston Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure acceptable parameters of nutrition were maintained related to obtaining a re-weight in a timely manner following a hospitalization for 1 of 4 residents reviewed for nutrition. (Resident H)Finding includes: The record for Resident H was reviewed on 2/19/26 at 2:20 p.m. Diagnoses included, but were not limited to, chronic kidney disease and anemia. The resident was admitted to the facility on [DATE].A Care Plan, dated 2/2/26, indicated the resident had a nutritional problem related to receiving a therapeutic diet and dietary restrictions. Interventions included, but were not limited to, provide and serve diet as ordered. The 2/7/26 5-Day Medicare Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision-making. The resident held food in his mouth, weighed 219 pounds, had a significant weight loss, and received a therapeutic diet.On 1/30/26 the resident weighed 237 pounds.On 2/7/26 the resident weighed 219…

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

Based on observation, record review, and interview, the facility failed to ensure residents with a gastrostomy tube (g-tube, the surgical insertion of a feeding tube) received the appropriate treatment related to administration of the tube feeding for 2 of 2 residents reviewed for tube feedings. (Residents 50 and 133)Findings include:1. On 2/16/26 at 3:09 p.m., Resident 50 was observed lying in bed. The tube feeding, Jevity 1.5 (tube feeding formula), was connected and infusing at 75 milliliters per hour (ml/hr).The resident's record was reviewed on 2/18/26 at 10:33 a.m. Diagnoses included, but were not limited to, gastrostomy, dysphagia, and adult failure to thrive.A Care Plan, updated 11/23/25, indicated the resident had a swallowing problem and required the tube feeding.The 5-Day Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively impaired and received the majority of their nutrition by tube feeding.A Physician's Order, dated 2/4/26, indicated the resident was to receive Jevity 1.5 at 75 milliliters per hour (ml/hr) continuously for 21 hours…

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 medications were not left unattended on top of the medication cart during medication administration for 2 of 6 residents observed during medication pass. (Residents 7 and 46)Findings include:1. On 2/18/26 at 3:52 p.m., a punch card containing two pills was observed unattended on top of the medication cart on the PCU Unit. There was no name on the punch card. At 4:03 p.m., the Assistant Director of Nursing and LPN 3 were observed sitting behind the nursing station and the medication was still on top of the medication cart. During an interview on 2/18/26 at 4:24 p.m., LPN 3 indicated she thought the pills were empty, she then pulled them out of the garbage can where she threw them away and indicated there were 2 pills left and they were Aricept (medication to manage dementia). 2. On 2/18/26 at 3:55 p.m., LPN 4 was observed completing a glucometer blood sugar check for Resident 46. The LPN gathered her supplies and entered the resident's room at 3:59 p.m. to wash her hands. She left the resident's insulin…

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

Based on record review and interview, the facility failed to ensure a medical record was complete and accurately documented related to a resident death for 1 of 5 residents reviewed for accidents. (Resident J)Finding includes:Resident J's record was reviewed on 2/20/26 at 2:36 p.m. Diagnoses included, but were not limited to, end stage renal disease.A Death in Facility Minimum Data Set (MDS) entry was completed on 12/11/25.A Progress Note, dated 12/11/25 at 9:39 a.m., indicated the resident had left the facility to go to dialysis. No acute distress noted at this time. There were no further progress notes documented.During an interview on 2/24/26 at 10:25 a.m., the Director of Nursing indicated the resident had gone out to dialysis and coded while there. She had passed away that day and had not returned to the facility. The resident's death had not been documented in the progress notes, but her discharge would have been reflected in the midnight census.This citation relates to Intake 2712287.3.1-50(a)(1)

Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to the storage of urinals and wash basins on 1 of 3 units. (The South Unit) The facility also failed to ensure a catheter port was cleansed prior to administering intravenous (IV) antibiotics for 1 of 1 resident observed for IV medication administration. (Resident 7)Findings include:1.On 2/16/26 at 2:30 p.m., two urinals were observed hanging from the grab bar in the bathroom. A yellow wash basin was observed on the floor underneath the bathroom sink. The urinals and wash basin were not contained. On 2/24/26 at 1:50 p.m., three urinals were observed hanging from the grab bar in the bathroom and the wash basin remained on the floor underneath the bathroom sink. Again, the urinals and wash basin were not contained. Two residents resided in the room and used the bathroom.During an interview on 2/24/26 at 3:45 p.m., the Director of Nursing indicated the urinals and wash basin should have been contained in plastic bags when not in use. 2. On…

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

Based on record review and interview, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident B)Finding includes:An Indiana Department of Health (IDOH) report form, dated 12/19/25 at 9:01 a.m., indicated Resident C had reported to the Administrator that a male entered his room several times during the night and touched his roommate, Resident B, inappropriately. Resident C became very agitated, was evaluated by the Nurse Practitioner, who indicated he was having an acute exacerbation of his mental illness. Investigation included review of staffing and camera footage. The preventive measure taken was sending Resident C to the ER for psychiatric evaluation. The incident follow-up documented that Resident C was admitted to the hospital, and the care plan would be adjusted upon his return to the facility.The facility investigation notes, received as complete from the Administrator on 12/30/25 at 11:20 a.m., indicated the Director of Nursing performed a head-to-toe assessment on Resident B on 12/19/25, and 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 record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers not being completed and documented for 2 of 3 residents reviewed for ADLs. (Residents B and D)Findings include:1.Resident B's record was reviewed on 12/15/25 at 10:00 a.m. The diagnoses included, but were not limited to, spinal cord disease, schizophrenia, gout, difficulty walking, depression, and bipolar disorder.The 8/8/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had impairment on one side of the lower extremity and required substantial/maximum assistance for eating, oral hygiene, and personal hygiene. All other ADLs required dependent care. The resident required substantial/maximum assistance for all transfers.The Care Plan, revised on 9/3/25, indicated the resident had an ADL self-care/mobility performance deficit related to gout. An approach indicated the resident was dependent with shower/bathing self.The record lacked any shower…

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

Based on record review and interview, the facility failed to ensure residents received necessary care and services, related to 72 hour assessments and neurological assessments not completed for a resident with an unwitnessed fall and medication not given as ordered for 1 of 3 residents reviewed for accidents and 1 of 3 residents reviewed for medication administration. (Residents C and G)Findings include:1.Resident C's record was reviewed on 12/15/25 at 3:00 p.m. The diagnoses included, but were not limited to, heart disease, copd, sepsis, depression, dementia, and anxiety.The 11/13/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The Medication Administration Records (MAR), from October and November 2025 indicated the medications were blank and not signed out as being completed on the following days:aspirin: blank on 10/25, 10/29, 11/8, and 11/28/25zoloft: blank on 10/25, 10/28, 11/8, and 11/28/25norco: blank on 11/8, 11/14, and 11/28/25A Physician's Order, dated 12/13/24, indicated to administer Aspirin 81…

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

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing, related to treatments not completed as ordered by the Physician for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: During an observation on 1/23/25 at 11:08 a.m., the Director of Nursing (DON) completed Resident C's pressure ulcer treatments with the assistance of Unit Manager 1. The DON indicated the pressure ulcer treatment on the coccyx was a duoderm (hydrocolloid dressing) and was to be changed every three days. She indicated the treatment had been completed on 1/22/25. The dressing on the coccyx at the time of the observation was a border gauze dressing with the date of 1/22/25 on the dressing. Resident C's record was reviewed on 1/23/25 at 11:02 a.m. The diagnoses included, but were not limited to, vascular dementia. A Physician's Order, dated 12/15/24, indicated a duoderm dressing was to be applied to the coccyx every three days. The order was discontinued on 1/22/25.…

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

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (Housekeeper 1) when cleaning a room where a COVID-19 positive resident resided (Resident F) and was in COVID-19 Transmission-Based Precautions, for one random observation for infection control. Finding includes: During an observation on 1/22/25 at 12:00 p.m., Resident F was lying in his bed in his room. There was a red sign on the door that indicated the resident's room was a Red Zone, which meant the resident was COVID-19 positive. The Red Zone sign indicated the resident should be asked to put a mask on when the staff were in the room and gloves, gown, face shield and a N95 mask were to be worn when in the room. Housekeeper 1 was observed in the room and mopping the floor. Housekeeper 1 had a surgical mask on and was not wearing a face shield. Housekeeper 1 was interviewed at the time and indicated she was unsure if she should have a N95 mask and face shield on. She indicated the resident was asleep so she had not asked him 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 record review and interview, the facility failed to complete adequate fall follow up related to missing neurological assessments for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: The record for Resident B was reviewed on 11/21/24 at 9:26 a.m. Diagnoses included, but were not limited to, malignant neoplasm (abnormal growth) of the head, face, and neck, malignant neoplasm of the tongue, dysphagia (difficulty swallowing) and tracheostomy status. The admission Minimum Data Set (MDS) assessment, dated 10/5/24, indicated the resident was cognitively intact. The resident was receiving tracheostomy care. A Care Plan, reviewed on 10/3/24, indicated the resident was a fall risk related to cancer and medications. Interventions included, but were not limited to, follow facility fall protocols and evaluate and treat as ordered or as needed. Resident B had an unwitnessed fall on 10/20/24. The Neurological 24 Hour Assessment was initiated on 10/20/24 at 12:25 p.m. The assessments were recorded as completed on the following dates and times: - On 10/20/2024 at 12:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and discolored floor tiles, marred walls, dirty and missing baseboards, broken mini blinds, dirty and rusty toilet bolts, missing toilet bolt covers, and caulk missing around the toilet for 3 of 3 units observed. (North, South and PCU) Findings include: During the environmental tour with the Maintenance and Housekeeping Supervisors on 9/20/24 at 3:23 p.m., the following was observed: 1. North Unit a. In room [ROOM NUMBER], the floor in the room was discolored and had an accumulation of dirt and debris along the baseboard throughout the room. The left closet door was off the track. There was dirt and debris along the track of the closet door. The bathroom floor had dirt and debris along the base board. There was no trash can in the room. b. In room [ROOM NUMBER], the entry way trim had build-up of dirt and debris. Behind the entry doorway there was a build-up of dirt and…

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

Based on observation, record review, and interview, the facility failed to ensure a resident's privacy was maintained related to staff not knocking on the door prior to entering the resident's room for 2 of 2 residents reviewed for privacy. (Residents 2 and 9) Findings include: 1. During an interview on 9/16/24 at 2:44 p.m., Resident 2 indicated staff do not always knock on her door prior to entering her room. On 9/16/24 at 2:55 p.m., CNA 3 opened the door to the resident's room without knocking. The CNA proceeded to close the door and exit the resident's room. On 9/16/24 at 2:58 p.m., a staff member, partially opened the door and then closed it. The staff member did not knock on the door prior to opening it. The record for Resident 2 was reviewed on 9/19/24 at 9:56 a.m. Diagnoses included, but were not limited to, bipolar, type 2 diabetes, major depressive disorder, and schizophrenia. The Quarterly Minimum Data Set (MDS) assessment, dated 6/15/24, indicated the resident was moderately impaired for daily decision making. During an interview on 9/18/24 at 4:10 p.m., the Director 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, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to dirty and long fingernails and the removal of facial hair for 3 of 10 residents reviewed for ADLs. (Residents 35, 58, and 236) Findings include: 1. During random observations on 9/16/24 at 9:32 a.m., 11:44 a.m., and 2:38 p.m., on 9/17/24 at 9:00 a.m., 1:38 p.m., and on 9/18/24 at 9:09 a.m., 11:15 a.m., and 1:57 p.m., Resident 35 was observed with dirty fingernails on her left hand and long and dirty fingernails on her right hand. On 9/19/24 at 8:15 a.m., the Assistant Director of Nursing (ADON) 2 was asked to observe the resident's fingernails. At that time, ADON 2 indicated her nails were long and dirty. The record for Resident 35 was reviewed on 9/17/24 at 2:05 p.m. Diagnoses included, but were not limited to, stroke, aphasia (a language disorder that makes it difficult to understand or express language), diabetes, hemiplegia (paralysis on one…

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

Based on observation, record review, and interview, the facility failed to ensure non-pressure ulcer treatments were completed as ordered for 3 of 4 residents reviewed for skin conditions and failed to obtain a psychiatric consult as ordered for 1 of 5 residents reviewed for unnecessary medications. (Residents 94 and 107) Findings include: 1. During a random observation on 9/16/24 at 10:26 a.m., Resident 94 was observed sitting on a couch in the dining/day room. The resident's left lower leg was observed to be scaly, with scabbed and inflamed red areas. There were no bandages on her left lower leg. The record for Resident 94 was reviewed on 9/18/24 at 9:45 a.m. Diagnoses included, buy were not limited to, schizophrenia, morbid obesity, cellulitis, high blood pressure, major depressive disorder, anxiety, osteoarthritis, and bipolar disorder. The 6/15/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Care Plan, revised on 3/25/24, indicated the resident was resistive to care and refused wound care. A 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.

Based on observation, record review, and interview, the facility failed to ensure a palm protector was donned as ordered by the physician for 1 of 1 residents reviewed for range of motion. (Resident 35) Finding includes: During a random observation on 9/16/24 at 9:32 a.m., Resident 35 was observed sitting in a geri chair, dressed in street clothes and finishing breakfast. At that time, her right hand was clenched like a fist and there was no anti-contracture device in her hand. On 9/16/24 at 11:44 a.m., the resident now was observed with a palm protector in her right hand The record for Resident 35 was reviewed on 9/17/24 at 2:05 p.m. Diagnoses included, but were not limited to, stroke, aphasia (a language disorder that makes it difficult to understand or express language), diabetes, hemiplegia (paralysis on one side of the body), heart disease, and high blood pressure. The 6/16/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making. The resident had a functional limitation of range of motion impairment to one side…

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 Foley (urinary) catheter bags and tubing were kept off of the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 58) Finding includes: During a random observation on 9/16/24 at 9:30 a.m., Resident 58 was observed in bed. Her anchored catheter bag was on the floor at the side of the bed. During an interview at that time, CNA 1 indicated the catheter bag should not be on the floor. During random observations on 9/18/24 at 9:12 a.m. and 10:04 a.m., the resident was up and dressed and observed sitting in her wheelchair. At those times the catheter bag and tubing was observed on the floor under the wheelchair. On 9/18/24 at 10:29 a.m., the Director of Rehabilitation entered the resident's room and asked if she was ready for therapy. The resident indicated she was, so the director pushed her out of the room to the therapy room. At that time, the catheter bag and tubing remained on the floor while being pushed down 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.

2. During an observation on 9/18/24 11:05 a.m. Resident 107 had asked to use the bathroom. At that time, he was wheeled out of the dining room by RN 1 and assisted back to his room. The Medical Record Supervisor (who was also a CNA) assisted RN 1 in placing the resident on the toilet. At that time, RN 1 was asked to lift up the resident's shirt so his peg tube (a tube that was inserted directly into the stomach for nutrition) could be observed. The peg tube was intact and there was dried crusty drainage around the stoma site. There was no bandage covering the stoma site. During an interview on 9/18/24 at 11:09 a.m., RN 1 indicated he has flushed the tube on his shift but he has never cleaned around it. After he had checked in the computer, he indicated there were no orders for the peg tube site to be cleaned. The record for Resident 107 was reviewed on 9/19/24 at 10:55 a.m. Diagnoses included, but were not limited to, Parkinson's disease, high blood pressure, psychotic disorder, major depressive disorder, dementia without behaviors, and type 2 diabetes. The resident transferred 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 2. On 9/16/24 at 11:18 a.m. and 12:22 p.m., Resident 55 was observed wearing oxygen via nasal cannula. The oxygen flow rate was on at 3 liters. The record for Resident 55 was reviewed on 9/17/24 at 3:11 p.m. The diagnoses included, but were not limited to, anoxic (no oxygen to the brain) brain damage, dysphagia (difficulty swallowing), hypertension (high blood pressure), vegetative state (severe brain damage), and chronic obstructive pulmonary disease (COPD). The Quarterly Minimum Data Set (MDS) assessment, dated 8/12/24, indicated the resident was severely impaired for daily decision making and the resident required oxygen therapy. A Care Plan, dated 2/8/24, indicated the resident required oxygen therapy. Interventions were to monitor signs of respiratory distress and to administer oxygen settings via nasal cannula per oxygen orders. A Physician's Order, dated 12/17/23, indicated to administer oxygen at 2 liters per nasal cannula continuously every shift. The Medication Administration Record (MAR) 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 a medication error rate of less than 5% for 2 of 6 residents observed during medication pass. Two errors were observed during 33 opportunities for errors during medication administration. This resulted in a medication error rate of 6.06%. (Residents 3 and 126) Findings include: 1. During an observation of medication pass on 9/18/24 at 4:00 p.m., LPN 1 prepared the insulin Fiasp flex touch pen for Resident 3. She opened the insulin pen, wiped the seal with an alcohol swab, attached the needle, dialed the pen to 10 units, and proceeded to administer the medication to the resident. The LPN did not prime the pen before administration of the insulin. During an interview on 9/20/24 at 9:25 a.m., the 200 Unit Manager indicated the insulin pen should have been primed prior to giving the insulin. The facility policy titled, Insulin Pen Procedure was reviewed on 9/20/24 at 1:54 p.m. The policy was provided by the nurse consultant and identified as current. The policy indicated the following, .7. Prime the…

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

Based on observation, record review, and interview, the facility failed to ensure a resident had seen the dentist at least yearly for 1 of 2 residents reviewed for dental care. (Resident 88) Finding includes: On 9/16/24 at 10:43 a.m., Resident 88 was observed with missing upper and lower teeth. During an interview at that time, the resident indicated he had not seen the dentist since he arrived at the facility in 2022. The resident expressed he wanted dentures and indicated he had been on the dental list for a long time. The record for Resident 88 was reviewed on 9/18/24 at 8:45 a.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), anemia (low iron), adult failure to thrive, respiratory failure, heart failure, kidney disease, and dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 7/28/24, indicated the resident was moderately impaired for daily decision making. There was no dental care plan. A Physician's Order, dated 2/5/24, indicated the resident could receive dental care as needed. During an interview on 9/19/24…

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 clinical records were accurate and complete related to 15 minute checks for a resident who had pushed another resident down to the ground for 1 of 1 residents reviewed for abuse. (Resident 94) Finding includes: The record for Resident 94 was reviewed on 9/18/24 at 9:45 a.m. Diagnoses included, buy were not limited to, schizophrenia, morbid obesity, cellulitis, high blood pressure, major depressive disorder, anxiety, osteoarthritis, and bipolar disorder. The 6/15/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Care Plan, dated 7/31/24, indicated the resident had the potential to be physically aggressive. A Social Service Progress Note, dated 7/31/24, indicated the resident had an altercation with her roommate. Resident 94 indicated she was in the bathroom sitting on the toilet and her roommate entered the bathroom and told the her she was going to hit her, so Resident 94 got off the toilet and hit her first and left the room. The other…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place related to hand hygiene during glove use for 1 of 1 glucometer blood sugar checks observed, staff failing to donn personal protective equipment (PPE) for a resident who was in enhanced barrier precautions (EBP), and ensuring Foley (urinary) catheter bags were not on the floor during random infection control observations. (Residents 3, 36, and 113) Findings include: 1. On 9/18/24 at 4:00 p.m., LPN 1 was observed completing a glucometer (a test to check the resident's blood sugar) procedure for Resident 3. The LPN entered the resident's room, proceeded to donn a pair of gloves and completed the glucometer check. The LPN sanitized her hands after removing her gloves. She did not wash her hands or use hand sanitizer upon entering the resident's room or before donning the gloves. During an interview on 9/20/24 at 2:28 p.m., the Nurse Consultant indicated hands should be washed and/or sanitized upon room entry so it would be expected for staff to sanitize their hands…

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 abuse was reported to the Indiana Department of Health (IDOH) immediately or within the 2 hour time period for 1 of 6 residents reviewed for abuse. (Resident B) The facility also failed to ensure the allegation submitted was not misleading with the facts reported, related to the dates of the allegation, names of residents possibly involved, description of the area at the time of the allegation, and the description of the allegation. (Residents B & C) Finding includes: During a family interview on 2/8/24 at 8:20 a.m., they indicated they came to visit on 2/6/24, and they thought Resident B was being abused by his roommate. They had been told by another resident at the facility, the roommate was burning him with a cigarette or a lighter. They also indicated the resident had bruises on both arms. During an interview on 2/8/24 at 10:46 a.m., Employee 3 indicated on 2/6/24 at approximately 4 p.m., she was in another room and saw the family member talking to another resident, and overheard…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident was discharged in a safe manner and the facility completed guardianship papers timely for 1 of 3 residents reviewed for discharge. (Resident B) Finding includes: The record for Resident B was reviewed on 11/6/23 at 9:35 a.m. The resident was admitted to the facility on [DATE] and, per facility documentation, was discharged Against Medical Advice (AMA) from the facility on 10/29/23. Diagnoses included, but were not limited to, COPD, vascular dementia with behavioral disturbances, osteoarthritis, cognitive communication, and cerebrovascular disease. The admission Minimum Data Set (MDS) assessment, dated 8/25/23, indicated the resident was not cognitively intact and needed supervision with most of her activities of daily living. The hospital History and Physical Notes, dated 8/16/23, indicated a social service consult would be needed for placement for suspected elder abuse. The resident had not seen a physician in 4 years and had minimal…

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 store and serve food under sanitary conditions related to expired food in the reach in cooler, a dirty oven hood, grease build up on the stove, as well as touching food items with a gloved hand and the lack of hand hygiene after glove removal. This had the potential to affect the 125 residents who received their meals from the kitchen. (The Main Kitchen) Findings include: 1. Observation during the initial kitchen tour, on 8/21/23 at 9:15 a.m. with the Dietary Food Manager (DFM), indicated the following: a. There were 3 bowls of pudding, dated 8/16/23, in the reach in cooler. b. The flour scoop was stored directly in the flour. c. The oven hood had a heavy accumulation of dirt and grease noted in all the slats. d. There was a heavy accumulation of grease build up on the back splash of the stove. e. The transportation cart that housed the dome lids for the plates was rusted out in many places. Interview with the DFM at that time, indicated all of the above was in need of cleaning. The current 2020 Food Storage (Dry,…

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 dependent residents received assistance with ADL's (activities of daily living) related to nail care for 4 of 7 residents reviewed for ADL's. (Residents 63, 27, 35, and 68) Findings include: 1. On 8/21/23 at 1:55 p.m., Resident 63 was observed in his room in bed. His fingernails on both hands were long and in need of trimming. On 8/22/23 at 9:04 a.m. and 2:10 p.m., the resident's fingernails remained long. On 8/23/23 at 7:55 a.m. and 11:04 a.m., the resident's fingernails remained long. On 8/24/23 at 9:15 a.m., 10:07 a.m., 1:35 p.m., and 2:45 p.m., the resident's fingernails remained long and were in need of trimming. The record for Resident 63 was reviewed on 8/24/23 at 1:44 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia (muscle weakness on one side of the body). The Annual Minimum Data Set (MDS) assessment, dated 6/23/23, indicated the resident was cognitively impaired for daily decision making and he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and stained floor tiles, marred walls, stained privacy curtains, dirty baseboards, and improper storage of wash basins and bed pans for 3 of 3 units. (North, South and PCU) Findings include: During the environmental tour with the Maintenance and Housekeeping Supervisors on 8/25/23 at 1:12 p.m., the following was observed. 1. North Unit a. In room [ROOM NUMBER], the room walls and bathroom walls were marred. There were rust stains on the floor around the toilet and there was a yellow bedpan and pink wash basin on the floor under the sink in the bathroom. The bed pan was placed inside the wash basin. There were 2 residents in the room and shared the bathroom. b. In room [ROOM NUMBER], the tube feeding pole located next to bed 2 had dried tube feeding spillage on the base. There was also dried tube feeding on the ceiling above the tube feeding pump. The wall behind bed 2 was…

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

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to wearing a hospital gown during the day for 1 of 2 residents reviewed for dignity. (Resident 63) Finding includes: On 8/21/23 at 1:55 p.m., Resident 63 was observed in his room in bed. The resident was awake and wearing a hospital gown. On 8/22/23 at 9:03 a.m. and 2:10 p.m., the resident was observed in his room in bed wearing a hospital gown. On 8/24/23 at 9:15 a.m., 10:07 a.m., 1:35 p.m., and 2:45 p.m., the resident was observed in his room in bed. He was wearing a hospital gown at those times. The record for Resident 63 was reviewed on 8/24/23 at 1:44 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia (muscle weakness on one side of the body). The Annual Minimum Data Set (MDS) assessment, dated 6/23/23, indicated the resident was cognitively impaired for daily decision making and he required extensive assistance with dressing. The resident did not have a care plan or documentation related to any preference of wearing a gown 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 observation, record review, and interview, the facility failed to ensure the Comprehensive Minimum Data Set (MDS) assessments were accurately completed related to hospice care, anticoagulant use, and tracheostomy care for 3 of 30 MDS assessments reviewed. (Residents 24, 37, and 60) Findings include: 1. The record for Resident 24 was reviewed on 8/22/23 at 1:50 p.m. Diagnoses included, but were not limited to, atherosclerotic heart disease, congestive heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 6/6/23, indicated the resident was cognitively impaired and he had received an anticoagulant (blood thinner) for 7 days during the assessment reference period. A Physician's Order, dated 10/27/21 and listed as current on the August 2023 Physician's Order Summary (POS), indicated the resident was to receive Plavix (an antiplatelet) 75 milligrams (mg) daily. The resident had no orders for an anticoagulant during the assessment reference period. Interview with the Director of Nursing on 8/24/23 at 3:00 p.m., indicated the resident's MDS had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident with diagnoses of mental illness received a new Level 1 PASARR (Preadmission Screening and Resident Review) for 1 of 1 residents reviewed for PASARR. (Resident 22) Finding includes: The record for Resident 22 was reviewed on 8/24/23 at 10:30 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, bipolar disorder and schizoaffective disorder. The 8/14/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A Level 1 PASARR, completed on 10/20/2016 (prior to the resident's admission to the facility), indicated a PASARR Level 2 was not required. There was no other Level 1 PASARR completed after 10/20/16. Interview with the Social Service Director on 8/22/23 at 11:45 a.m., indicated she was not aware the resident had a mental illness diagnosis and she did not have a Level 2 completed. 3.1-16(d)(1)(A)

Based on observation, record review, and interview, the facility failed to complete a Care Plan related to hospice care and oxygen use for 1 of 30 Care Plans reviewed. (Resident 37) Finding includes: On 8/21/23 at 10:40 a.m., Resident 37 was observed in his room. He was wearing oxygen by the way of a nasal cannula. The record for Resident 37 was reviewed on 8/24/23 at 9:34 a.m. Diagnoses included, but were not limited to, dementia without behavioral disturbance and Alzheimer's disease. The Significant Change Minimum Data Set (MDS) assessment, dated 7/19/23, indicated the resident was moderately impaired for daily decision making and he was not receiving hospice services while a resident of the facility. The resident was also identified as receiving oxygen. A Physician's Order, dated 7/6/23, indicated the resident was admitted to hospice. A Physician's Order, dated 7/7/23, indicated the resident was to receive oxygen at 2 liters per nasal cannula continuously. The resident's Care Plan was revised on 7/14/23. He had no Care Plan related to hospice care and oxygen use. Interview with…

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 an ongoing activity program was implemented for alert and oriented, cognitively impaired, and dependent residents for 2 of 5 residents reviewed for activities. (Residents 63 and 10) Findings include: 1. On 8/21/23 at 1:55 p.m., Resident 63 was observed in his room in bed. The resident was awake and his television was turned off. On 8/22/23 at 9:04 a.m. and 2:10 p.m., the resident was observed in his room in bed. The resident was awake and his television was turned off. On 8/23/23 at 7:55 a.m., the resident was observed in his room in bed. The resident was awake and his television was turned off. On 8/24/23 at 9:15 a.m., 10:07 a.m., 1:35 p.m., and 2:45 p.m., the resident was observed in his room in bed. The resident was awake and his television was turned off. The record for Resident 63 was reviewed on 8/24/23 at 1:44 p.m. Diagnoses included, but were not limited to, stroke and hemiplegia (muscle weakness on one side of the body). The Annual Minimum Data Set (MDS) assessment, dated 6/23/23, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure areas of skin discoloration and scabbing were assessed and monitored for 2 of 2 residents reviewed for skin conditions non-pressure related. (Residents 97 and 45) Findings include: 1. On 8/21/23 at 10:45 a.m., Resident 97 was observed with numerous areas of reddish purple discoloration to both of his arms and his right hand. He was wearing a short sleeve shirt at that time. No geri sleeves (a protective layer of fabric that is worn on the arms to prevent skin damage) were in use. On 8/22/23 at 9:04 a.m., the discoloration remained to his right arm and his right hand. The resident had a geri sleeve in place to his left arm but not his right. He was wearing a short sleeve shirt. Interview with the resident at that time, indicated he did not know how he got the areas but they wanted him to wear the sleeves on his arms. On 8/23/23 at 7:55 a.m., the resident was in his room in bed. No geri sleeves were in use and he was wearing a short…

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 fall precautions were in place for a resident with a history of falls for 1 of 2 residents reviewed for accidents. (Resident 52) Finding includes: On 8/21/23 at 10:35 a.m., Resident 52 was observed standing in her room reaching towards the over bed table. She was dressed in only a hospital gown and wearing plain gray socks. The socks did not have a non-skid surface. Her gown was falling off of her shoulder and she was unsteady on her feet. She was attempting to walk in the room and was redirected by the surveyor to sit back down on the bed. The resident's breakfast tray, which she had already finished, was on the over bed table. On 8/24/23 at 8:40 a.m., the resident was observed in bed with her eyes closed and dressed in a hospital gown. At 10:05 a.m., she was still in bed and her eyes were closed. The head of the bed was elevated, and her head was leaning to one side. The breakfast tray was placed in front of her on the over bed table. The record for Resident 52 was reviewed on 8/24/23 at 11:30 a.m.…

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

Based on observation, record review, and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 residents reviewed for intravenous care. (Resident 379) Finding includes: On 8/23/23 at 9:02 a.m., LPN 2 was observed passing medication to Resident 379. He prepared the cefepime (an antibiotic medication) 2 grams. He primed new intravenous (IV) tubing, cleaned the right upper arm PICC access lumen with an alcohol swab, flushed the PICC with 5 milliliters (ml) of normal saline, attached the IV tubing containing the cefepime, and started the IV infusion. At 9:44 a.m., LPN 2 was observed disconnecting the IV tubing after the medication had completed infusing. He flushed the PICC with 5 ml of normal saline, flushed the PICC with 5 ml of heparin (an anticoagulant), and applied a new cap to the lumen. Resident 379's record was reviewed on 8/23/23 at 9:56 a.m. Diagnoses included, but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide proper respiratory care and services related to oxygen at the correct flow rate for 2 of 2 residents reviewed for oxygen. (Residents 37 and 35) Findings include: 1. On 8/21/23 at 10:40 a.m., Resident 37 was observed with oxygen by the way of a nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters. On 8/22/23 at 9:19 a.m. and 2:10 p.m., the resident was wearing his oxygen per nasal cannula and his oxygen concentrator was set at 3 1/2 liters. On 8/23/23 at 7:55 a.m., the resident was in his room in bed. His oxygen per nasal cannula was in use and the concentrator was set at 4 liters. At 11:05 a.m., the resident was in the main dining room. His oxygen was in use and his portable oxygen tank was set at 4 liters. On 8/24/23 at 9:16 a.m., the resident was in his room in bed sleeping. His oxygen was in use and his concentrator was set at 1 1/2 liters. At 10:27 a.m., the resident was in the main dining room. 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 record review and interview, the facility failed to monitor a fluid restriction for a resident receiving hemodialysis for 1 of 1 residents reviewed for dialysis. (Resident 46) Finding includes: The record for Resident 46 was reviewed on 8/24/23 at 9:45 a.m. Diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. The 7/26/23 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and received dialysis while a resident. A Care Plan, revised on 8/1/22, indicated the resident received hemodialysis three times a week. The approaches were to check the perma cath (dialysis access port in the upper chest) site every shift and record and encourage diet as ordered. Physician's Orders, dated 4/26/23, indicated hemodialysis three times a week on Tuesday, Thursday, and Saturday. Provide a renal, no added salt regular texture diet. Serve double proteins every meal and follow a 1.8 liter fluid restriction with 600 milliliters (ml) every shift. The Treatment and Medication Administration Records (TAR) 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 there was an adequate indication for the use of a hypnotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 52) Finding includes: The record for Resident 52 was reviewed on 8/24/23 at 11:30 a.m. Diagnoses included, but were not limited, major depressive disorder, hallucinations, bipolar disorder, dementia, and catatonic disorder. The 7/7/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact. In the last 7 days, the resident had received an anti-anxiety medication 7 times. There was no Care Plan for a hypnotic medication. Physician's Orders, dated 7/26/23, indicated Temazepam (a hypnotic medication) oral capsule 15 milligrams (mg), give 1 capsule by mouth every day. An After Care Summary from the hospital, dated 7/26/23, indicated to continue the medication of Temazepam 15 mg daily. There was no indication for the use of the hypnotic medication. Interview with the Director of Nursing on 8/25/23 at 11:10 a.m., indicated she had just…

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 controlled substance was double locked at all times for 1 of 2 medication rooms observed. (PCU) Finding includes: On 8/22/23 at 1:23 p.m., the PCU Medication Room was observed with LPN 1. Inside the unlocked refrigerator was a black tackle box. The box was not locked. Inside the box was a medication card of dronabinol (Marinol) pills. Interview with LPN 1 at that time, indicated the black box was normally locked. She wasn't sure why it was not locked currently. She would notify the Director of Nursing (DON). Interview with the DON on 8/22/23 at 1:46 p.m., indicated earlier in the day the QMA had notified her the lock on the black box had broken. They had requested a new lock from the pharmacy, and it was coming in tonight. She had asked the Maintenance staff to go to the store and get a lock until the new lock arrived from pharmacy, but they had not gotten to it yet. A facility policy, titled Medication Storage, indicated, .12. Controlled substances storage .12.2. After receiving controlled…

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 follow the puree recipe for scrambled eggs, sausage, and waffles for the 1 resident who received a pureed diet from the kitchen. (Main Kitchen) Finding includes: On 8/23/23 at 7:41 a.m., [NAME] 1 was observed preparing the puree breakfast meal. The cook donned clean gloves to both hands and placed 2 scoops of scrambled eggs from the pan into the blender. She blended the mixture until smooth and stirred the contents. She added 1 piece of bread to the egg mixture and blended again. She removed the blender and stirred the eggs and put them in an aluminum pan. She washed the blender and utensils in the 3 compartment sink. She removed 17 sausage links from the steam table and put them into the blender and blended them. She added 1/2 cup of prepared chicken broth to the mixture and blended again. The cook removed the blender and stirred the contents and placed them into an aluminum pan. She washed the blender and the utensils in the 3 compartment sink. [NAME] 1 then removed 3 cooked waffles from the steam table 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 maintain clinical records that were complete and accurately documented related to medication administration and a dialysis access site for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for dialysis. (Residents 24 and 46) Findings include: 1. The record for Resident 24 was reviewed on 8/22/23 at 1:50 p.m. Diagnoses included, but were not limited to, atherosclerotic heart disease, congestive heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 6/6/23, indicated the resident was cognitively impaired and he had received an opioid medication during the assessment reference period. A Physician's Order, dated 5/5/23, indicated the resident was to receive Norco (a narcotic pain medication)10-325 milligrams (mg), 1 tablet three times a day for chronic pain. The August 2023 Medication Administration Record (MAR) indicated the resident's Norco was not signed out on the following dates and times: - 8:00 a.m. on 8/5/23 - 2:00 p.m. on 8/1, 8/5, and 8/11/23 - 10:00…

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.