South Shore Health & Rehabilitation Center

Based on observation, record review and interview, the facility failed to provide ongoing activities for dependent residents for 3 of 3 residents reviewed for activities. (Residents 14, 35 and 44)Findings include: 1. Resident 14 was observed in her bed on 9/15/25 at 11:45 a.m. and 3:00 p.m., 9/16/25 at 10:36 a.m., 1:55 p.m. and 3:49 p.m., and on 9/17/25 at 9:13 a.m., 1:21 p.m. and 3:24 p.m. There was no radio or television on in the room. On 9/18/25 at 9:26 a.m., the resident was up in her chair yelling out nonsensically, there was no radio or television on in the room. At 9:57 a.m. a staff member was in the resident's room attempting to calm her and had turned the radio on. The resident's record was reviewed on 9/18/25 at 9:00 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, severe protein calorie malnutrition and adult failure to thrive. The Annual Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident had severe cognitive impairment and was dependent for bed mobility, toileting and transfers. An Activity Care Plan, dated 12/11/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure blood pressure medications were administered and/or held per parameters as ordered. The facility also failed to ensure medications were administered as ordered and laboratory tests were obtained for 3 of 7 residents reviewed for unnecessary medications. (Residents F, E, and D)Findings include: 1. The record for Resident F was reviewed on 9/18/25 at 11:42 a.m. Diagnoses included, but were not limited to, end stage renal disease, hypotension (low blood pressure), and hypertension. The 8/27/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and he was receiving dialysis while a resident of the facility. A Care Plan, reviewed on 8/22/25, indicated the resident had hypotension with episodes of syncope (fainting) related to dialysis. Interventions included, but were not limited to, administer medications per physician's order. A Physician's Order, dated 8/21/25, indicated the resident was to receive Midodrine…

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 with limited range of motion received appropriate treatment and services to increase or prevent further decrease in range of motion for 2 of 4 residents reviewed for mobility. (Residents 44 and B)Findings include:1. During a random observation on 9/16/25 at 9:05 a.m., Resident 44 was observed lying in bed. He did not move his left arm or leg. His left knee appeared contracted. There was no visible intervention in place for the immobile limbs. The resident's record was reviewed on 9/17/25 at 3:04 p.m. Diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) following a stroke affecting the left side, seizures, and dementia.The 7/31/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs) and transfers.A 6/14/23 Physician's Order indicated the resident was to participate in the restorative care program.A Restorative Care Plan, updated 7/31/25, indicated the resident required…

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 tube feedings were infusing at the correct times and/or the head of the bed was elevated while tube feeding was infusing for 3 of 5 residents reviewed for tube feeding. (Residents 14, 9 and 64)Findings include:1. Resident 14 was observed in bed on 9/16/25 at 10:36 a.m., there was no tube feeding hanging or infusing at that time. On 9/18/25 at 9:26 a.m. and 11:04 a.m., the resident was observed in her chair in her room, there was no tube feeding hanging or infusing. The resident's record was reviewed on 9/18/25 at 9:00 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, severe protein calorie malnutrition and adult failure to thrive. The Annual Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident had severe cognitive impairment and was dependent for bed mobility, toileting and transfers. The Physician's Order indicated to give Jevity 1.2 (a type of tube feeding) continuously at 50 milliliters per hour for 18 hours a day. The September 2025 Medication Administration…

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 oxygen was set at the correct flow rate for 2 of 3 residents reviewed for respiratory care. (Residents 12 and 24)Findings include:1. During a random observation on 9/15/25 at 2:34 p.m., Resident 12 was observed in his room in bed. The resident had oxygen by the way of a nasal cannula in use. The oxygen concentrator was set at 8 liters. On 9/16/25 at 9:15 a.m., 11:50 a.m., 2:04 p.m., and 3:45 p.m., the resident was observed in his room in bed. Oxygen via nasal cannula was in use and the oxygen concentrator was set at 8 liters. The record for Resident 12 was reviewed on 9/18/25 at 3:32 p.m. Diagnoses included, but were not limited to, pleural effusion (a collection of fluid around the lungs), heart failure, and anxiety. The 5 day Medicare Minimum Data Set (MDS) assessment, dated 9/5/25, indicated the resident was cognitively intact and received oxygen while a resident of the facility. A Care Plan, dated 7/24/25, indicated the resident received oxygen therapy related to congestive heart failure, history…

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 Pharmacy recommendation was completed as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident D)Finding includes:Resident D's record was reviewed on 9/18/25 at 3:07 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction, diabetes mellitus, and atrial fibrillation. The Quarterly Minimum Data Set (MDS) assessment, dated 8/8/25, indicated the resident had moderate cognitive impairment and was dependent for toileting and transfers. A pharmacy review was completed on 5/11/25. A recommendation was made to the Physician to consider scheduling a complete blood count (CBC), comprehensive metabolic panel (CMP), A1c (test to measure sugar in the blood), Vitamin D level and lipids at the next convenient lab. The Physician agreed and signed the recommendation on 5/15/25. A CBC and CMP were completed on 5/29/25. The A1c, Vitamin D and lipid test had not been completed. During an interview on 9/22/25 at 9:18 a.m., the Director of Nursing indicated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were free of significant medication errors related to medications not administered as ordered for infections for 2 of 6 residents reviewed for unnecessary medications. (Residents C and B)Findings include: 1. The closed record for Resident C was reviewed on [DATE] at 10:55 a.m. Diagnoses included, but were not limited to, left below the knee amputation (BKA), diabetes, hypertension, pressure ulcers of the hip and buttock, and heart failure.The [DATE] Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact and was dependent for activities of daily living (ADLs) and transfers.The resident was admitted to the facility on [DATE] following a hospitalization related to the left BKA surgery. At that time, the resident had a unstageable pressure ulcers to the right thigh and buttock as well as a dehisced (reopened surgical incision) wound to the left leg stump. A Physician's Order, dated [DATE],…

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

Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) for two random resident care observations. (Residents 9 and 64 )Findings include:1. During a random observation on 9/15/25 at 10:28 a.m., CNA 1 was observed providing a partial bath with incontinence care for Resident 9, who had a gastrostomy tube (a feeding tube inserted through the abdomen). CNA 1 did not wear a gown when providing direct care for the resident. The resident's record was reviewed on 9/16/25 at 2:12 p.m. Diagnoses included, but were not limited to, dementia, Alzheimer's, and dysphagia (difficulty swallowing).The 8/15/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs), and required maximal assistance with transfers.A Physician's Order, dated 9/16/25, indicated the resident required enhanced barrier…

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 dignity was maintained related to knocking before entering a resident's room for 1 of 3 residents reviewed for dignity. (Resident E)Finding includes:On 8/4/25 at 5:55 a.m., Resident E was observed during incontinence care with LPN 1. LPN 1 did not knock on the door before entering the resident's room and did not announce herself when she entered. There were 2 residents residing in the room.During an interview at the time, LPN 1 indicated oops, I forgot to knock.Resident E's record was reviewed on 8/4/25 at 3:47 p.m. The diagnoses included, but were not limited to, Parkinson's, dementia, pressure ulcer sacral stage 4, heart disease, dysfunction of bladder, hypertension (high blood pressure), gastrostomy status, and psychotic disorder.The Quarterly Minimum Data Set (MDS) assessment, dated 5/8/25, indicated the resident was cognitively impaired for daily decision making and was dependent with all Activities of Daily Living and transfers.A policy, titled, Dignity and received as current from Nurse…

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

Based on observation, record review, and interview, the facility failed to ensure equipment was properly functioning and ensure fall precautions were in place to prevent injury from a fall for 1 of 3 residents reviewed for accidents. (Resident J)Finding includes: On 8/5/25 at 10:22 a.m. and 10:50 a.m., the resident was observed sitting up in bed asleep. There was no bolster on the bed, there were two pads sitting on the floor in front of the residents' bed.Resident J's record was reviewed on 8/5/25 at 3:21 p.m. The diagnoses included, but were not limited to, heart disease, hypertension (high blood pressure), congestive heart failure, psychotic disorder, depression, and anemia (low iron).The Significant Change in Status Minimum Data Set (MDS) assessment, dated 7/11/25, indicated the resident was moderately cognitively impaired. The resident required dependent assistance with all Activities of Daily Living (adls). The resident was dependent with tub and shower transfers.A Care Plan, dated 7/14/25, indicated the resident was at risk for falls related to impaired ability to stand,…

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' pain medications were administered as ordered and in a timely manner for 1 of 3 residents reviewed for pain. (Resident B)Finding includes:During an interview on 8/4/25 at 8:28 a.m., Resident B's daughter indicated the resident did not receive her pain medication on time on 7/28/25 and 7/29/25.The record for Resident B was reviewed on 8/4/25 at 9:30 a.m. The diagnoses included, but were not limited to, dementia, Alzheimer's, hypertension (high blood pressure), depression, anxiety, COPD, and adult failure to thrive.The 5/16/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired for daily decision making and received scheduled pain medication.A Care Plan, dated 4/23/25, indicated the resident had pain in her lower back. The approaches were to administer pain medications as ordered by the physician and monitor/record and report signs and symptoms of nonverbal pain.Physician's Orders, dated 7/21/25, indicated to administer Acetaminophen-Codeine 300-30 milligrams…

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 food was served and prepared under sanitary conditions related to touching food with ungloved hands, dirty food preparation equipment and greasy pipes for 1 of 1 residents observed for dining and 1 of 1 kitchens observed. (Resident L and the main kitchen) Findings include: 1. During a dining observation on 7/18/24 at 1:10 p.m., Resident L was observed in bed waiting for lunch. At that time, CNA 2 removed the lid off of the resident's tray. Resident L was served a hot dog on plain white bread. The CNA put ketchup on the hot dog and with her bare hands, broke the hot dog and bread in half and handed Resident L half of the sandwich to eat. During an interview at that time, the CNA was aware she should not use her bare hands to cut food in half. During an interview on 7/23/24 at 11:55 a.m., the Dietary Manager indicated staff were to use utensils to cut the resident's food in half. 2. During the brief kitchen sanitation tour on 7/18/24 at 9:22 a.m. with the Dietary Manager (DM), the following was observed: a. The deep…

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 administer medications according to physician's orders related to not following parameters for 2 of 6 residents reviewed for unnecessary medications (Residents H and J), failed to ensure areas of bruising and rashes were assessed and monitored for 2 of 2 residents reviewed for non-pressure related skin conditions (Residents C and G), failed to ensure new onset edema (swelling) was assessed and monitored for 1 of 1 resident reviewed for edema (Resident K), and failed to provide transportation to physician's appointments for 3 of 4 residents reviewed for transportation to outside appointments (Residents D, E, and F). Findings include: 1. The record for Resident H was reviewed on 7/22/24 at 3:59 p.m. Diagnoses included, but were not limited to, hypertension, type 2 diabetes, and vascular dementia with behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 6/17/24, indicated the resident was cognitively impaired for daily decision making. A Physician's Order, dated 6/25/24, indicated 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's preferences were honored related to turning up the volume on the television set for 1 of 1 resident reviewed for activities. (Resident 43) Finding includes: During random observations on 7/18/24 at 9:55 a.m. and 1:10 p.m., on 7/19/24 at 7:55 a.m. and 9:00 a.m., and on 7/22/24 at 9:00 a.m., Resident 43 was observed in his room in bed. At those times, the television was turned on and observed on top of a tall wardrobe closet and the volume was turned off. There was an air return vent observed by the television set making a very loud noise. During an interview on 7/19/24 at 9:00 a.m., the resident indicated he could not hear the television. The record for Resident 43 was reviewed on 7/19/24 at 2:48 p.m. Diagnoses included but were not limited to, stroke, type 2 dm, epilepsy, vascular dementia, anemia, major depressive disorder, and high blood pressure The Significant Change Minimum Data Set (MDS) assessment, dated 5/19/24, indicated the resident was not cognitively intact for daily decision…

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

Based on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of the onset of a new bruise and medication changes for 2 of 2 residents reviewed for notification of change. (Residents C and B) Findings include: 1. During a phone interview on 7/19/24 at 11:20 a.m., Resident C's Power of Attorney (POA) indicated she was notified on 7/17/24 the resident had a large purple bruise across her chest. The record for Resident C was reviewed on 7/22/24 at 10:50 a.m. Diagnoses included but were not limited to, respiratory failure, joint stiffness, COPD (chronic obstructive pulmonary disease), Parkinson's disease, heart disease, atrial fibrillation, anemia, and dementia. The 6/24/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and wore oxygen while a resident. A Nurses' Note, dated 7/14/24 at 6:39 p.m., indicated the resident was found sitting next to the bed Indian style. The resident indicated she was praying and the indwelling catheter was in the bed. 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 record review and interview, the facility failed to ensure a Functional Maintenance Program (FMP) was in place for continued ambulation and range of motion after a resident was discharged from physical therapy for 1 of 2 residents reviewed for rehabilitation services. (Resident C) Finding includes: During a phone interview on 7/19/24 at 11:20 a.m., Resident C's Power of Attorney (POA) indicated the resident used to walk with a walker before she entered the nursing home and now she could not walk. The record for Resident C was reviewed on 7/22/24 at 10:50 a.m. Diagnoses included but were not limited to, respiratory failure, joint stiffness, COPD (chronic obstructive pulmonary disease), Parkinson's disease, chronic bronchitis, and dementia. The 4/5/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident used a walker in the last 7 days and walking 10 feet was not attempted due to her medical condition. The resident needed substantial to maximum assist for transfers. The 6/24/24 Significant Change MDS assessment indicated the resident was moderately impaired for…

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

Based on observation, record review, and interview, the facility failed to ensure a dependent resident received assistance with activities of daily living (ADL's) related to the removal of facial hair for 1 of 2 residents reviewed for ADL's. (Resident 282) Finding includes: On 7/18/24 at 11:47 a.m., on 7/19/24 at 9:40 a.m. and 11:36 a.m., and on 7/22/24 at 2:17 p.m., Resident 282 was observed in bed. At those times, the resident had long black facial hair above her top lip. During an interview at the time of observation on 7/19/24, the resident indicated she did not want facial hair. The record for Resident 282 was reviewed on 7/19/24 at 11:02 a.m. The diagnoses included, but were not limited to, epilepsy (seizure disorder), diabetes, depression, anemia, hypokalemia (low potassium), and psychotic disorder. The Quarterly Minimum Data Set (MDS) Assessment, dated 5/14/24. Indicated the resident was cognitively intact for daily decision making. The resident had impairment on both sides of the upper and lower extremities and used a wheelchair. The resident required dependent assistance…

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 meal consumption logs were completed for a resident with a history of significant weight loss for 1 of 2 residents reviewed for nutrition. (Resident 68) Finding includes: On 7/23/24 at 12:32 p.m., Resident 68 was observed in his room seated on the side of his bed. He was served an open faced turkey sandwich, potatoes, and cauliflower. The resident was eating his lunch with his fingers. The record for Resident 68 was reviewed on 7/19/24 at 2:10 p.m. Diagnoses included, but were not limited to, lung cancer, dysphagia (difficulty swallowing), and vascular dementia with behavior disturbance. The 5 day Medicare Minimum Data Set (MDS) assessment, dated 6/21/24, indicated the resident was severely impaired for daily decision making and he needed set up or clean up assistance with eating. He also received a mechanically altered diet. A Care Plan, revised on 6/20/24, indicated the resident had a nutritional problem or potential nutritional problem related to a past medical history of stroke, abnormal finding of…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and a resident was transported to the Pulmonologist's office for an appointment for 1 of 2 residents reviewed for respiratory care. (Resident C) Finding includes: During a phone interview on 7/19/24 at 11:20 a.m., Resident C's POA (power of attorney) indicated her mother had missed a cardio/pulmonologist appointment due to the facility not having transportation. The appointment was made over a year ago for the resident to be evaluated for a c-pap (continuous positive airway pressure) machine (a machine used that used mild air pressure to keep breathing airways open while sleeping). During random observations on 7/22/24 at 1:20 p.m., 3:30 p.m., and 4:48 p.m., the resident was observed wearing oxygen per nasal cannula at 0.75 liters per minute. The resident was connected to a portable oxygen tank. During random observations on 7/23/24 at 7:50 a.m. and 11:55 a.m., the resident was observed wearing oxygen per nasal cannula at 2 liters per minute on the portable tank.…

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 nonpharmacological interventions were offered, documented, and the pain assessment lacked a pain scale when monitoring for 1 of 1 resident reviewed for pain. (Resident 45) Finding includes: During an interview on 7/18/24 at 10:52 a.m., Resident 45 indicated he was having pain in his stomach and penis and the nurses would not give him Tylenol. On 7/19/24 at 11:29 a.m., the resident was observed lying in bed. He indicated he was in a lot of pain but did not request medicine since the nursing staff always refused his requests. On 7/22/24 at 2:15 am., the resident was observed in bed. He indicated he still had pain in his lower stomach and penis and was not offered Tylenol when pain was expressed to the staff. The record for Resident 45 was reviewed on 7/19/24 at 10:56 a.m. The diagnoses included, but were not limited to, stroke, hypertension (high blood pressure), anxiety, hemiplegia (paralysis on one side of the body), benign prostatic hyperplasia (enlarged prostate gland), and opioid abuse. 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 each resident saw the dentist at least yearly for 2 of 2 residents reviewed for dental care. (Residents K and D) Findings include: 1. On 7/18/24 at 1:23 p.m., Resident K's teeth were observed to be decayed. During an interview at that time, the resident indicated he has asked to see a dentist but still has not. The record for Resident K was reviewed on 7/19/24 at 3:02 p.m. Diagnoses included, but were not limited to, heart failure, acute respiratory failure, atrial flutter, high blood pressure, COPD (chronic obstructive pulmonary disease), type 2 diabetes, and anemia. The 5/5/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had no oral issues with his teeth. There was no care plan for any dental issues. An Oral Assessment, dated 3/12/24 and completed by a dental hygienist, indicated the patient had intact teeth, broken teeth, missing teeth and root tips on both arches. The patient also had inflamed or bleeding…

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 the residents' environment was clean and in good repair, related to dirt and debris in the corners and around the base board in resident rooms and bathrooms, unlabeled/uncovered personal care items stored in the bathroom, dried liquid feeding on pump poles and floors, stains on the floor, dirty and stained privacy curtains, cobwebs, trash on the floor, trash and equipment stored behind closets and in unused bathtubs, dirty unused bathtubs, dim bathroom lights, loose baseboard, missing bathroom tile, holes in the tile floor in the bathroom, and a full water pitcher liner used for urine elimination for 14 of 15 rooms and /or bathrooms observed randomly on 4 of 4 halls. (Rooms 214, 213, 206, 204, 205, 311, 310, 308, 306, 408, 410, 402, 404, and 510.) Findings include: Random observations of resident rooms and bathrooms indicated the following: 1. 200 Hall a. On 4/28/24 at 8:43 a.m., the floor behind the door in room [ROOM NUMBER] (two…

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, and record review, the facility failed to maintain an effective pest control program related to dead bugs/water bugs and mice droppings in the resident rooms and bathrooms for 4 of 15 rooms randomly observed. (Rooms 310, 408, 402, and 213) Findings include: During random observations, the following was observed: a. On 4/29/24 at 10:55 a.m., there were dead bugs on the floor in the corner under the cabinets in room [ROOM NUMBER]. There were 2 mouse traps under the heater located under the window and there were mice droppings seen by the trap in the corner of the room by the window. b. On 4/29/24 at 11:18 a.m., there were mouse droppings in the corner behind the bed by the window in room [ROOM NUMBER]. c. On 4/29/24 at 11:28 a.m., there were mouse droppings behind the bathroom door next to the bathtub in room [ROOM NUMBER] and a dead bug in the bathtub. d. During an observation on 4/30/24 from 10:04 a.m. to 10:40 a.m., with the Administrator present. room [ROOM NUMBER] had glue…

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

Based on record review and interview, the facility failed to ensure the right of a resident/Guardian to direct his or her own medical treatment, related to medication given after the legal Guardian expressed she did not want the treatment to continue, for 1 of 3 residents reviewed for resident rights. (Resident B) Finding includes: Resident B's record was reviewed on 4/29/24 at 11:41 a.m. The diagnoses included, but were not limited to, dementia and osteoarthritis. A court appointed guardianship, dated 9/29/22, indicated there were two Permanent Co-Guardians appointed for the resident. A Physician's Order, dated 3/8/24, indicated Remeron (antidepressant) 15 mg (milligrams) was to be given nightly at bedtime for major depressive disorder. A Psychiatric Nurse Practitioner's (NP) Progress Note, dated 3/8/24, indicated a call was received from the Director of Nursing (DON) in regards to the resident having had a significant weight loss, comments about wanting to die, and a decreased appetite. An order for Remeron 15 mg to be administered at bedtime was given and the resident's weight…

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 resident with pain received a routine pain medication as ordered by the Physician, related to not re-ordering the pain medication from the Pharmacy in a timely manner for 1 of 1 resident reviewed for pain medications. (Resident B) Finding includes: Resident B's record was reviewed on 4/29/24 at 11:41 a.m. The diagnoses included, but were not limited to, dementia and osteoarthritis. An Annual Minimum Data Set assessment, dated 12/27/23, indicated a moderately intact cognitive status and pain status had not been assessed. A Care Plan, dated 1/27/23 and revised on 3/6/24, indicated pain was present in the resident's lower back with a medical history of osteoarthritis, and the resident's family would sometimes administer pain medications to the resident during a leave of absence from the facility. The interventions included pain medications would be administered as ordered. A Pain Assessment, dated 3/18/24, indicated pain was frequently present. The pain affected her sleep at night and limited her day to day…

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 were free from unnecessary medications, related to medications administered when the blood pressure was out of prescribed parameters and multiple pain patches applied to a resident, for 2 of 2 residents reviewed for unnecessary medications. (Residents B and F) Findings include: 1. During an observation on 4/28/24 at 9:26 a.m., Agency LPN 1 was administering Resident B's morning medications, which included a Lidocaine patch 4% (pain patch). The resident was observed to have undated patches on her right upper arm, right hip, right thigh, right outer buttock, and her right upper buttock. Agency LPN 1 indicated there were no dates on the patches and that the resident had a lot of pain. She then placed the dated lidocaine patch on the resident's lower back. Resident B's record was reviewed on 4/29/24 at 11:41 a.m. The diagnoses included, but were not limited to, dementia and osteoarthritis. An Annual Minimum Data Set assessment, dated 12/27/23, indicated a moderately intact cognitive status 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 notify the resident and/or the resident's Responsible Party in writing of an intrafacility transfer, as well as the lack of notification of a new roommate, for 2 of 4 residents reviewed for infection control. (Residents B and H) Findings include: 1. The record for Resident B was reviewed on 1/29/24 at 12:00 p.m. Diagnoses included, but were not limited to, dementia with behaviors, Alzheimer's disease, depressive disorder, adult failure to thrive, mood disorder, anxiety and high blood pressure. The 12/27/23 Annual Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for decision making. A Nurses' Note, dated 12/6/23 at 6:28 p.m., indicated the resident left the facility with her daughter and would return later that evening. On 12/7/23, the resident received a new roommate, however, there was no documentation in the clinical record, informing the resident she was getting a new roommate. On 12/8/23, the roommate tested positive for COVID-19, and they moved Resident B to a different room, however,…

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 meal consumption logs were completed for a resident with a history of a significant weight loss, for 1 of 3 residents reviewed for a significant change in condition. (Resident C) Finding includes: The record for Resident C was reviewed on 1/30/24 at 9:30 a.m. Diagnoses included, but were not limited to, right humerus fracture, heart disease, high blood pressure, heart failure, pressure ulcer of the sacrum, cardiac pacemaker, vision loss of both eyes, and a history of falls. The admission Minimum Data Set (MDS) assessment, dated 11/21/23, indicated the resident was moderately impaired for decision making, and weighed 88 pounds. The resident needed partial assistance with eating. The resident's weights were as follows: 11/14/23 - 88 pounds 11/22 - 94 pounds 11/22 - 94 pounds 11/29 - 101 pounds 11/29 - 101 pounds 12/6 - 99 pounds 12/13 - 100 pounds 12/14 - 100 pounds 12/20 - 101 pounds 12/30 - 88 pounds 1/3/24 - 84 pounds The meal consumption logs indicated the breakfast meal was not documented on 11/20, 11/27, 12/5,…

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 resident was free from misappropriation of resident property, related to missing narcotics/controlled medication, for 1 of 2 residents reviewed for misappropriation of property. (Resident E) The deficient practice was corrected by 8/18/23, prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the missing narcotic medication, as well as notified the police. A report was initiated by the police department. LPN 4 is no longer employed by the facility. Nurses and QMA's were educated on the policy for receiving controlled substances and shift to shift counting. Staff with access to the missing narcotics were interviewed. Audits were completed on all medications carts and for residents who had narcotics in the past 30 days. Unit Managers are to monitor their Units for policy compliance. Finding includes: An incident reported to the Indiana Department of Health (IDOH), dated 8/14/23, indicated a medication card of hydrocodone-acetaminophen (narcotic pain medication),…

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 recipes were followed for a mechanical soft diet. This had the potential to affect the 9 residents who received a mechanical soft diet from the kitchen. (The Main Kitchen) Finding includes: On 6/8/23 at 10:02 a.m., [NAME] 1 was observed preparing the mechanical soft food for 9 residents for lunch. [NAME] 1 found the recipe for ground chicken tenders with broth, washed his hands, and donned gloves. He removed 10 servings of chicken breast tenders (20 chicken breast tenders) and placed them into the food processor. He proceeded to add two cups of water and blended to the appropriate consistency for a mechanical soft diet. Interview with [NAME] 1 on 6/8/23 at 10:08 a.m., indicated they had run out of chicken broth so he only had water to add to the chicken breast tenders to make the correct consistency. The recipe for Ground Chicken Tenders with Broth, received from the Dietary Food Manager on 6/8/23 at 2:35 p.m., indicated 10 servings required 1 and 1/4 cups of chicken broth and 20 chicken breast tenders. 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 and interview, the facility failed to serve and prepare food under sanitary conditions related to dirty food equipment, cooking items stored incorrectly, and improper hand hygiene during food preparation for 1 of 1 kitchens observed. This had the potential to affect the 79 residents who received food from the kitchen. (The Main Kitchen) Findings include: 1. During the Brief Kitchen Sanitation Tour on 6/5/23 at 9:00 a.m. with the Dietary Food Manager, the following was observed: a. There were knives stored on the bottom shelf under prep sink uncontained. b. The oven had built up food debris and was dirty. c. The stove top grates had an accumulation of food debris. d. There were 3 pots stored upright underneath the prep sink. Interview with the Dietary Food Manager on 6/5/23 at 9:32 a.m., indicated the above areas were in need of cleaning and she would in-service staff on proper storage of kitchen utensils. 2. During an observation of food preparation on 6/8/23 at 10:02 a.m., [NAME] 1 was observed preparing a puree diet. He had prepared a pureed macaroni and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment as well as the kitchen area was clean and in good repair related to dirty pipes and debris along the floor/baseboards, dirty ceiling vents, floor tiles dirty and broken, marred walls, doors, and closets, gouges in walls, dirty ceiling tiles, missing transition pieces and trim, chipped caulk, and chipped paint in 1 of 1 kitchen areas and on 2 of 4 units. (The Main Kitchen, 200, and 400 Units) Findings include: 1. During the Brief Kitchen Sanitation Tour on 6/5/23 at 9:00 a.m. with the Dietary Food Manager, the following was observed: a. There was debris on the floor and the pipes were dirty under the 3-compartment sink. b. There was debris noted on the floor under the steam table and behind the oven, stove, and drink station along the baseboards. Interview with the Dietary Food Manager on 6/5/23 at 9:32 a.m., indicated the above areas were in need of cleaning. 2. During the Environmental Tour with the Housekeeping…

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 a resident lying exposed in her room with no privacy curtains or doors closed for 1 of 2 residents reviewed for dignity. (Resident 70) Finding includes: On 6/5/23 at 11:04 a.m., Resident 70 was observed lying in bed with a hospital gown open exposing her upper and lower body. The curtains in the room were not pulled closed and the room door was open. There were two other residents also residing in the same room. On 6/6/23 at 1:41 p.m., the resident was observed lying in bed with a hospital gown open exposing her upper body. The curtains in the room were not pulled closed and the room door was open. On 6/7/23 at 9:54 a.m., the resident was observed lying in bed with a hospital gown open exposing her upper and lower body. The curtains in the room were not pulled closed and the room door was open. Resident 70's record was reviewed on 6/7/23 at 12:58 p.m. Diagnoses included, but were not limited to, hemiplegia (one sided weakness) following a stroke 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 residents had an assessment to self-administer their own medications for 1 random resident reviewed for self-administration of medication. (Resident 75) Finding includes: On 6/5/23 at 10:09 a.m., Symbicort and Ventolin inhalers were observed in Resident 75's room. One inhaler was on the over-bed table and the other was on top of his dresser. Interview with the resident at that time, indicated both inhalers were prescribed to him, he received the Symbicort twice a day and the Ventolin as needed. On 6/8/23 at 11:39 a.m., the Ventolin inhaler was observed on top of the resident's dresser. The resident indicated at that time, the Symbicort was in his dresser drawer. He also indicated he had used the Ventolin inhaler a couple of times in the past week. The record for Resident 75 was reviewed on 6/7/23 at 2:27 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and anxiety. The Quarterly Minimum Data Set (MDS) assessment, dated 5/17/23, indicated the resident 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 dependent residents received assistance with ADL's (activities of daily living) related to getting out of bed for 1 of 2 residents reviewed for ADL's. (Resident 48) Finding includes: On 6/5/23 at 10:30 a.m. and 1:30 p.m., Resident 48 was observed in his room in bed. The resident was wearing a hospital gown at the time. On 6/6/23 at 10:32 a.m., 1:27 p.m., 2:30 p.m., and 3:25 p.m., the resident was again observed in his room in bed wearing a hospital gown. On 6/7/23 at 9:51 a.m., 11:45 a.m., and 1:30 p.m., the resident was observed in his room in bed wearing a hospital gown. On 6/8/23 at 9:00 a.m., 10:30 a.m., and 2:00 p.m., the resident was observed in his room in bed wearing a hospital gown. The record for Resident 48 was reviewed on 6/6/23 at 1:33 p.m. Diagnoses included, but were not limited to, stroke, seizures, and dementia with behavior disturbance. The Annual Minimum Data Set (MDS) assessment, dated 5/16/23, indicated the resident was cognitively impaired for daily decision making and required…

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 cognitively impaired and dependent residents for 3 of 4 residents reviewed for activities. (Residents 48, 21, and 70) Findings include: 1. On 6/5/23 at 10:30 a.m. and 1:30 p.m., Resident 48 was observed in his room in bed. The resident was wearing a hospital gown at the time. There was 1 television located in the corner of the resident's room which was turned on. On 6/6/23 at 10:32 a.m., 1:27 p.m., 2:30 p.m., and 3:25 p.m., the resident was again observed in his room in bed wearing a hospital gown. The television was also turned on. On 6/7/23 at 9:51 a.m., 11:45 a.m., and 1:30 p.m., the resident was observed in his room in bed wearing a hospital gown. The television was also turned on. On 6/8/23 at 9:00 a.m., 10:30 a.m., and 2:00 p.m., the resident was observed in his room in bed wearing a hospital gown. The television was also turned on. The record for Resident 48 was reviewed on 6/6/23 at 1:33 p.m. Diagnoses included, but were not limited to, stroke,…

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 floor mats were in place for a resident who was a fall risk for 1 of 1 residents reviewed for accidents. (Resident 48) Finding includes: On 6/6/23 at 10:32 a.m. and 1:27 p.m., Resident 48 was observed in his room in bed. The bed was in the low position. A floor mat was observed on the floor next to the left side of his bed. The floor mat on the right side of the resident's bed was pushed next to his roommate's bed. The floor tile was visible on the right side of the resident's bed. The record for Resident 48 was reviewed on 6/6/23 at 1:33 p.m. Diagnoses included, but were not limited to, stroke, seizures, and dementia with behavior disturbance. The Annual Minimum Data Set (MDS) assessment, dated 5/16/23, indicated the resident was cognitively impaired for daily decision making and required extensive assistance with bed mobility. He was totally dependent for transfers. The resident had one fall since his last assessment with no injury. A current Care Plan, which was reviewed on 5/19/23, indicated 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 record review and interview, the facility failed to ensure a dialysis access site was assessed for 1 of 1 residents reviewed for dialysis. (Resident 49) Finding includes: The record for Resident 49 was reviewed on 6/7/23 at 9:13 a.m. Diagnoses included, but were not limited to, dementia and dependence on renal dialysis. The Significant Change Minimum Data Set (MDS) assessment, dated 3/29/23, indicated the resident was severely impaired for daily decision making and he was receiving dialysis while a resident at the facility. A Care Plan, dated 12/10/20 and reviewed on 4/19/23, indicated the resident had a right subclavian permacath (dialysis access site). Interventions included, but were not limited to, monitor dressing to right subclavian permacath every shift and monitor/document/report as needed (prn) signs and symptoms of infection at the site: drainage, inflammation, swelling, redness, and warmth. A Physician's Order, dated 4/18/23, indicated the resident was to attended dialysis 5 times a week, Monday through Friday. A Physician's Order, dated 6/2/23, indicated 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 record review and interview, the facility failed to ensure signs and symptoms of anxiety were monitored, anti-anxiety medications were available, and interventions were implemented based on an individualized interdisciplinary approach to care with resident involvement for 1 of 1 residents reviewed for mood/ behavior. (Resident 81) Finding includes: Interview with Resident 81 on 6/5/23 at 10:49 a.m., indicated he was on Ativan (an anti-anxiety medication) for 14 days. He indicated the medication took the edge off and he slept better when he was receiving it. He had asked to get back on the medication but no one had done anything about it. The record for Resident 81 was reviewed on 6/7/23 at 10:28 a.m. Diagnoses included, but were not limited to, diabetes and anxiety disorder. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 3/29/23, indicated the resident was cognitively intact. A Care Plan, dated 3/28/23, indicated the resident used anti-anxiety…

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 labeled properly for 1 of 2 medication carts observed. (Cart 1 on the 500 Unit) Finding includes: On 6/8/23 at 2:18 p.m., Medication Cart 1 on the 500 Unit was observed with RN 1. There was a bottle of Omega XL (extended release) (a medication for joint pain), Hemp pain relief cream maximum strength, Vitamin D3 5,000 IU (international unit), Breztri Aerosphere (an inhaler) 160 mcg/9 mcg/4.8 mcg (micrograms) and Antacid extra strength observed at the bottom of the medication cart. The bottles were only labeled with the type of medication and not any information regarding the residents or specific orders. Interview with RN 1 at that time, indicated she did not normally work on that cart and she had no knowledge of the medications. The medications were removed from the cart. Interview with the Director of Nursing (DON) on 6/8/23 at 2:43 p.m., indicated the nursing staff should have discarded any medication that was not completely labeled in the cart. The facility policy titled Medication…

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 menu was followed as written and resident preferences were honored for 1 of 5 residents reviewed for food. (Resident 75) Finding includes: Interview with Resident 75 on 6/5/23 at 10:20 a.m., indicated he did not get the food that was listed on his tray ticket. Additional interview with the resident on 6/8/23 at 9:19 a.m., indicated he was not aware of any food choices and he just got what he was served. On 6/8/23 at 12:44 p.m., the resident received his lunch tray. He was served in his room. The resident received Salisbury steak and mashed potatoes. Interview with the resident at that time, indicated he didn't want that meal. His tray ticket indicated he was to receive chicken tenders and macaroni and cheese. Interview with the Dietary Food Manager on 6/8/23 at 12:48 p.m., indicated they ran out of chicken tenders but they had chicken parts which consisted of legs and thighs. She indicated she would go and talk to the resident. The resident indicated to her that he only wanted macaroni and cheese.…

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 infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to not completing respiratory assessments and not testing a symptomatic resident timely for COVID-19 for 2 of 3 residents reviewed for COVID-19. (Residents 39 and 12) Findings include: 1. The record for Resident 39 was reviewed on 6/7/23 at 10:00 a.m. The resident was diagnosed with COVID-19 on 5/31/23. A Physician's Order, dated 5/31/23, indicated the resident was to have a respiratory assessment completed every shift for 9 days. The only respiratory assessment completed on 5/31/23 was at 8:27 a.m. No respiratory assessments were completed for the evening shift on 6/3, 6/5, and 6/6/23. A Care Plan, dated 6/5/23, indicated the resident tested positive for COVID-19 on 5/31/23. Interventions included, but were not limited to, assess respiratory status and vital signs every shift and notify the Physician of abnormal findings. Interview with the Director of Nursing on 6/9/23 at 9:00 a.m., indicated 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.