Greencroft Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to ensure a resident who was at risk for pressure ulcers did not develop a stage II pressure ulcer and failed to implement a treatment for 1 of 2 residents reviewed for pressure ulcers. (Resident 94) Finding includes: During an interview, on 5/21/2025 at 9:19 A.M., CNA 18 indicated she thought Residnet 94 had a very small area on his bottom last week. She indicated it's an independence thing with him. He always wants to stay in his wheelchair because he knows he can go whenever he wants to. She indicated therapy had been working with him on self-transfers in and out of bed. During an observation, on 5/21/2025 at 9:26 A.M., Resident 94 was assisted to the bathroom where he was able to stand upright while holding onto the toilet seat riser bars. The aide pulled his pants down and Resident 94 had an opened area to the left inner buttock cheek. The area was approxamately a half inch in diameter with red colored tissue to the center of the wound.…

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 safe smoking assessment was completed, smoking materials were locked up and safe disposal of cigarette butts was designated for 1 of 1 resident reviewed for accidents and hazards. (Resident 73) Finding includes: During an observation, on 5/20/2025 at 10:50 A.M., Resident 73 was observed taking himself out of the building to smoke. He was observed on the sidewalk of the facility between South 13th Street and the main entrance. During an observation, on 5/22/2025 at 8:59 A.M.-9:24 A.M., Resident 73 was observed outside smoking. He smoked three cigarettes and was observed putting the cigarette out on his wheelchair by the front wheel and held the smoked cigarette butts in his hand. During an observation, on 5/22/2025 at 2:06 P.M., Resident 73 was in his room. His cigarettes and lighter were lying inside his hat on a table in his room. During an observation, on 5/23/2025 at 9:02 A.M., Resident 73 was observed outside smoking on the facility campus. A record review for Resident 73 was completed, 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 observation, record review and interview, the facility failed to provide identified interventions to promote consumption of meals for 1 of 3 residents reviewed for nutrition. (Resident 31) Finding includes: A record review for Resident 31 was completed on 5/21/2025 at 9:12 A.M. Diagnoses included, but were not limited to: cerebral infarction, dysphagia and hemiplegia of the left side. A Significant Change Minimum Data Set (MDS) assessment, dated 2/22/2025, indicated Resident 31 had severe cognitive impairment, required mechanically altered foods and had impairment to the upper and lower extremity on one side. A review of Resident 31's weights indicated the following: -5/19/2025 1:54 P.M. 108.4 pounds -4/15/2025 9:11 A.M. 116.0 pounds -2/18/2025 9:20 P.M. 125.2 pounds -11/25/2024 3:04 P.M. 131.0 pounds The weights reviewed indicated a 6.55 percent weight loss in one month, a 13.42 percent weight loss in three months and a 15.31 percent weight loss in months. A Nursing Progress Note, on 5/13/2025 at 8:05 A.M., indicated Resident 31 appeared to be overwhelmed by plates of…

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

Based on record review and interview, the facility failed to follow and administer physician ordered hydration orders for 1 of 1 resident reviewed for tube feeding. (Resident 52) Finding includes: A record review for Resident 52 was completed on 5/21/2025 at 1:04 P.M. Diagnoses included, but were not limited to: functional quadriplegic, adult failure to thrive and protein-calorie malnutrition. A Quarterly Minimum Data Set (MDS) assessment, dated 5/6/2025, indicated Resident 52 had moderate cognitive impairment and received tube feeding with 51 percent of calories from the feedings and 501 cc/day (cubic centimeter per day or equal to one milliliter per day) or more of hydration from the feeding tube. A Physician's Order, dated 3/1/2024, indicated flushing the feeding tube with 120 mL (milliliters) before and after Jevity feedings, totaling a 240 mL flush. A Physician's Order, dated 3/13/2024, indicated Jevity 1.5 tube feeding two cartons (474 mL) daily and Jevity 1.5 tube feeding one carton (237 mL) three times daily. The May 2025 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 store respiratory equipment in a sanitary manner for 1 of 2 residents reviewed for respiratory care. (Resident 66) Finding includes: During an observation, on 5/19/2025 at 10:45 A.M., Resident 66's nebulizer mask and tubing had not been dated or bagged, and the dirty mask with white colored specs of dried debris was laying on the bed side table. During an observation, on 5/21/2025 at 9:10 A.M., Resident 66's nebulizer mask and tubing had not been dated or bagged, and the dirty mask with white colored specs of dried debris remained on the bedside table. During an observation, on 5/22/2025 at 9:02 A.M., the nebulizer mask and tubing had not been dated or bagged, and the dirty mask with white colored specs of dried debris remained on the bedside table. The record for Resident 66 was reviewed on 5/21/2025 at 11:51 A.M. Diagnoses included, but were not limited to diabetes, depression, dementia, anxiety and chronic obstructive pulmonary disease. Resident 66's current Physician Orders included: Ipratropium-albuterol…

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 provide daily fistula checks for 1 of 1 resident reviewed for dialysis. (Resident 75) Finding includes: During an interview, on 5/20/2025 at 9:28 A.M., Resident 75 indicated she received dialysis on Mondays, Wednesdays and Fridays. Resident 75's fistula access site was observed in her left bicep. A record review for Resident 75 was completed on 5/21/2025 at 2:22 P.M. Diagnoses included, but were not limited to: end stage renal disease, diabetes mellitus type 2 and anemia. An Annual Minimum Data Set (MDS) assessment, dated 4/4/2025, indicated Resident 75 was cognitively intact and received dialysis treatments. A Physician's Order, dated 7/11/2024, indicated the dialysis access site was in the left bicep. A Care Plan, dated 5/3/2024, indicated Resident 75 has end stage renal disease and required hemodialysis three times per week. Interventions included, but were not limited to: assess, observe and document care of the access site and to document in the interdisciplinary notes monitoring for complications. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 8. During an observation in Resident 94's bathroom, on 5/21/2025 at 2:50 P.M., there was a small bottle sitting on the sink counter. The container had a label indicating it was nystatin powder for the residents' abdominal folds. The record for Resident 94 was completed on 5/21/2025 at 3:16 P.M. Diagnoses included but were not limited to hypertension, hemiplegia, anxiety, depression, and renal insufficiency. Current Physician Orders included 100,000 unit/gram topical powder-apply topical twice a day (BID) as needed for rash and redness in abdominal folds. During an observation of Resident 94's bathroom, on 5/22/2525 at 3:33 P.M., the Nystatin bottle remained on the counter in the bathroom. During an interview, on 5/22/2025 at 3:35 P.M., the Households Unit manager indicated the nystatin should not have been in the residents' room. On 5/23/2025 at 11:08 A.M., the DON provided the policy titled, Labeling of Medications and Biological's, dated 4/13/2024 and indicated it was the policy currently being used by 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 provide enhanced barrier precautions for 1 of 2 residents reviewed for urinary catheters. (Resident 36) Finding includes: During an interview, on 5/19/2025 at 1:47 P.M., Resident 36's wife indicated Resident 36 had a suprapubic catheter and had had the urinary catheter for the past two and a half years. A record review for Resident 36 was completed on 5/21/2025. Diagnoses included, but were not limited to: retention of urine and pressure ulcer of sacral region. A Significant Change Minimum Data Set (MDS) assessment, dated 4/22/2025, indicted Resident 36 had severe cognitive impairment, had an indwelling urinary catheter, had an unstageable pressure ulcer and received hospice services. A Physician's Order, dated 5/23/2024, indicated enhanced barrier precautions (EBP) every shift for a suprapubic catheter. A Care Plan, dated 5/24/2024, indicated Resident 36 required enhanced barrier precautions for an indwelling medical device and a pressure ulcer to the sacral region. Interventions included, but were not…

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

Based on interviews and record review, the facility failed to ensure hot food temperatures were assessed and logged consistently in the main kitchen to ensure food was served at palatable temperatures. This deficient practice had the potential to affect 155 of 155 residents in nursing care who were served from the main kitchen. Finding includes: During an interview, on 9/16/24 at 12:28 P.M., the Dietary Team Lead staff member indicated food was prepared in the main kitchen and then delivered to the unit servery kitchens, where it was held in steam tables. She indicated she had heard some concerns the food was not always as warm as it should be when served. She indicated hot foods should be held and served at at least 140 degrees Fahrenheit. During an interview, on 9/17/24 at 10:20 A.M., Resident B indicated he/she had been served cold food many times. Resident B indicated when food that was supposed to be served hot was served cold, he/she lost their appetite. Residen Bt indicated he/she had refused to eat cold food and planned to throw their tray across the dining room if food was…

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

Based on interview and record review, the facility failed to ensure a resident's responsible party was notified in a timely manner after a fall for 1 of 3 residents reviewed for falls, (Resident C). Finding includes: During an interview on 9/17/24 at 2:40 P.M., Resident C's Responsible Party indicated she heard from an unnamed Certified Nursing Assistant (CNA) that Resident C had fallen over a recent weekend. Resident C's responsible party indicated the facility had not notified her of the fall. During an interview, on 9/20/24 at 9:00 A.M., the Director of Nursing indicated Resident C had a fall on 8/23/24 without injuries. The Director of Nursing indicated the physician was notified at the time, but the family was not notified though they should have been notified. The Director of Nursing indicated the Nurse called the family on 9/19/24 to apologize for the oversite. A record review for Resident C was completed on 9/20/24 at 9:42 A.M. Diagnoses included, but were not limited to: repeated falls, congestive heart failure, restlessness and agitation, chronic obstructive pulmonary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident rights were respected regarding photos taken by a facility staff member posted on social media without the resident's knowledge or permission for 1 of 3 resident's reviewed for resident's rights, (Resident F) Finding Includes: A record review for Resident F was completed on 6/14/24 at 1:00 P.M. Diagnoses included but were not limited to: dementia, breast cancer, heart failure, spinal stenosis, depression, and cerebrovascular disease. An Annual Minimum Data Set (MDS) assessment, dated 5/3/24, indicated Resident F was cognitively intact, required moderate assistance for most Activities of Daily Living (ADLs), and utilized a wheelchair for locomotion. A review of an incident reported to the Indiana State Department of Health Survey Report System, submitted by the facility Administrator indicated on 5/28/24 at 4:35 P.M., Certified Nursing Assistant (CNA) 7 reported Employee (E) 3 posted a picture of Resident F on her social media. 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 develop a person-centered care plan for the use and refusal of a splint for 1 of 30 residents whose care plans were reviewed. (Resident 90) Finding includes: During an observation on 5/23/24 at 2:26 P.M., Resident 90's left hand was contracted (a permanent tightening of muscles that prevents normal movement) and she was not able to open it fully without using her right hand to pull her fingers open. A splint was noted on the table next to her bed. She nodded her head yes when asked if she usually wore the splint during the day. A record review was conducted on 5/29/24 at 9:23 A.M. for Resident 90. Diagnoses included, but were not limited to, a cerebrovascular accident with hemiplegia. A Quarterly Minimum Data Set (MDS) assessment, dated 4/30/24, indicated the resident's cognition was severely impaired, she refused care between 1 and 3 days during the assessment period, her range of motion was limited on one side in both upper and lower extremities, and she was dependent on staff for dressing, bathing, 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 interview and record review, the facility failed to update a care plan regarding the use of a Continuous Positive Airway Pressure (CPAP) machine for 1 of 33 residents reviewed for care plans. (Resident 254) Finding includes: A record review was completed on 5/28/2024 at 1:13 P.M., for Resident 254. Diagnoses included, but were not limited to: interstitial lung disease, and atrial fibrillation. Resident admitted on [DATE]. A Care Plan, dated 2/12/2024, indicated the resident was at risk for respiratory distress related to allergies, cough and COVID. Interventions did not indicate a CPAP machine was in use. During an interview on 5/28/2024 at 1:38 P.M., LPN 5 indicated the care plan should have mentioned the CPAP machine and the settings. On 5/31/2024 at 8:30 A.M., the DON provided a policy titled, Comprehensive Care Plans, revised 1/29/2024, and indicated the policy was the one currently used by the facility. The policy indicated .5. The comprehensive care plan will be reviewed and revised by 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, interview, and record review, the facility failed to ensure physician orders were in place for a resident using a Continuous Positive Airway Pressure (CPAP) for 1 of 1 resident reviewed for quality of care. (Resident 254) Finding includes: During an observation on 5/23/2024 at 2:40 P.M., Resident 254's CPAP mask and tubing was hanging over the headboard and a container of distilled water was on the bathroom floor under the sink, opened without an open date. During an observation and interview on 5/28/2024 at 1:03 P.M., Resident 254 indicated the mask and tubing had never been placed in a plastic bag, and the tubing had not been cleaned. The water was kept on the floor in the bathroom under the sink. She did not always get the water put in the machine, there are times she ran it without the water. The mask/tubing was hanging over the headboard and the distilled water was on the bathroom floor undated. She indicated she has been using the CPAP machine for years. A record review was completed on 5/28/2024 at 1:13 P.M., for Resident 254. 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.

Based on observation, interview and record review, the facility failed to provide proper G-tube (artificial opening placed in the stomach to provide nutritional support and/or gastric decompression) care per professional standards and facility policy related to G-tube feedings for 1 of 1 resident who was reviewed for G-Tube feeding. (Resident 67) Finding includes: During an observation of a G-Tube feeding on 5/29/2024 at 1:00 P.M., LPN 3 checked the residuals (the quantity left over in the stomach between feedings) of the resident's stomach. She pulled 60 mL (milliliters) of gastric contents from the G-Tube and left the contents in the graduated cylinder on the bedside table. After giving the resident his prescribed tube feeding and flushing the tubing with water, LPN 3 asked the resident if she could perform oral care on him. The resident's gastric content was still in the graduated cylinder on the bedside table. An interview with LPN 3 was completed on 5/29/2024 at 1:08 P.M. LPN 3 indicated she would be dumping the resident's 60 mL gastric residual down the toilet. She was not…

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

Based on observation, interview, and record review, the facility failed to ensure continuous positive airway pressure (CPAP) equipment was properly stored when not in use, cleaned and the distilled water was dated when opened for 1 of 1 resident reviewed for respiratory care. (Resident 254) Finding Includes: During an observation on 5/23/2024 at 2:40 P.M., Resident 254's CPAP mask and tubing was hanging over the headboard and the distilled water container was on the bathroom floor under the sink, opened without an open date. During an observation and interview on 5/28/2024 at 1:03 P.M., Resident 254 indicated the mask and tubing had never been placed in a plastic bag, and the tubing had not been cleaned. The water was kept on the floor in the bathroom under the sink. She did not always get the water put in the machine, there were times she ran it without the water. The mask/tubing was hanging over the headboard and the distilled water container was on the bathroom floor, undated. Resident 254 indicated she has been using the CPAP machine for years. A record review was completed 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 observation, interview and record review, the facility failed to provide ongoing assessment of the resident and monitoring for complications by completing Pre Dialysis Evaluations and Post Dialysis Evaluations assessments for 2 of 2 residents reviewed for dialysis. (Residents 354 & 88 ). Findings include: 1. Resident 354's record was reviewed on 5/29/24 at 9:11 a.m. Diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. Physician's Orders, dated 5/21/24, indicated the following: -. Fresenius Kidney care Dialysis, Monday, Wednesday, and Friday. - Assess dressing to dialysis port every shift. - Weight before dialysis - Weight after dialysis The facility's electronic charting system included a Pre Dialysis and Post Dialysis Evaluation form which was to be completed with the resident name, date, time of assessment, most recent weight and most recent vital signs and placed in the resident's dialysis book. Questions included presence of redness at access site, presence of swelling at access site, presence of bleeding at access site,…

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

Based on interview and record review, the facility failed to prevent a significant medication error related to a resident being given an incorrect insulin pen for 1 of 2 residents who were reviewed for insulin use. (Resident 101) Finding includes: During an interview on 5/29/2024 at 9:00 A.M., Resident 101 indicated he was given the wrong insulin pen on 5/28/2024 and had self-injected the insulin before he realized it was another resident's insulin pen. Resident 101 normally self injected 40 units of insulin using a Basaglar Kwick Pen. This was not the first time he was given another resident's insulin pen, but it was the first time he had injected the insulin with another resident's insulin pen. The DON had visited Resident 101 and he was no longer upset with the mistake but did not want it to happen again. Resident 101 understood why the physician ordered blood work but refused the laboratory tests to check for hepatitis and HIV. Resident 101's record review was completed on 5/29/2024 at 9:45 A.M. Diagnoses included, but were not limited to: type 2 diabetes, chronic kidney disease…

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 properly label medications with an open date for 3 of 5 medication carts observed. ([NAME] Vesta cart 2, [NAME] cart 1, [NAME] cart 2) In addition, the facility failed to ensure treatments, and inhaler were separated from oral medication for 2 out of 5 medication carts and 1 out of 3 medication room refrigerators reviewed. Findings include: 1. During an observation of the medication cart for [NAME] Vesta cart 2 with QMA 9 on 5/31/2024 at 8:32 A.M., the following was observed:: -An opened bottle of Fiberwell gummies for Resident 108 without an open date. -An opened bottle of Peg 3350 Powder for Resident 16 without an open date. -An opened bottle of Reguloid 28 grams for Resident 98 without an open date. -An opened bottle of antacid chew 750 milligram (mg) for Resident 57 without an opened date. During an interview on 5/31/2024 at 8:45 A.M., QMA 9 indicated they should have been dated when they were opened. 2. During an observation of the…

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

Based on record review and interview, the facility failed to obtain a declination form for a resident who refused the pneumococcal vaccine for 1 of 5 residents reviewed for vaccinations. (Resident 101) Finding includes: On 5/31/24 at 9:06 a.m., Resident 101's record was reviewed for vaccine compliance. An Immunization Report indicated Resident 101 refused the pneumococcal vaccine on 10/10/2023. The record lacked the documentation showing a declination form was signed by the resident and/or their representative. During an interview on 5/31/24 at 12:12 p.m., the IP (Infection Preventionist) Nurse indicated the resident did not have a signed declination form for the pneumococcal vaccine and one should have been obtained. 3.1-13(a)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to report allegations of alleged verbal abuse for 1 of 1 resident reviewed for abuse. (Resident 90) Finding includes: During an initial interview, on 5/17/2023 at 10:28 A.M., Resident 90 indicated he had a certified nursing assistant (CNA), go off on a tangent the prior week. He indicated he informed the Unit Manager of the situation, and the Director of Nursing (DON) came to his room and spoke with him for approximately an hour. He indicated the interaction didn't make him feel good, was rude in nature, and he felt the CNA was being verbally abusive. On 5/17/2023 at 12:32 P.M., the administrator was informed of the allegations Resident 90 had made. A record review was completed on 5/22/2023 at 10:21 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease, and idiopathic neuropathy. An admission Minimum Data Set (MDS) Assessment, on 2/28/2023 indicated Resident 90 was cognitively intact, and had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to throughly investigate an allegation of alleged verbal abuse for 1 of 1 resident reviewed for abuse. (Resident 90) Finding includes: During an initial interview, on 5/17/2023 at 10:28 A.M., Resident 90 indicated he had a certified nursing assistant (CNA), go off on a tangent the prior week. He indicated he informed the Unit Manager of the situation, and the Director of Nursing (DON) came to his room and spoke with him for approximately an hour. He indicated the interaction didn't make him feel good, was rude in nature, and he felt the CNA was being verbally abusive. On 5/17/2023 at 12:32 P.M., the administrator was informed of the allegations Resident 90 had made. A record review was completed on 5/22/2023 at 10:21 A.M. Diagnoses included, but were not limited to: congestive heart failure, chronic kidney disease, and idiopathic neuropathy. An admission Minimum Data Set (MDS) Assessment, on 2/28/2023 indicated Resident 90 was cognitively…

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 complete interventions ordered for pressure ulcer prevention for 1 of 4 resident's reviewed for pressure ulcers. (Resident 159) Finding includes: A record review was completed on 5/22/2023 at 9:37 A.M. Diagnoses included, but were not limited to: dementia, unstageable left heel ulcer, and generalized anxiety. A Significant Change Minimum Data Set (MDS) Assessment, dated 3/9/2023, indicated Resident 159 had severe cognitive impairment, and required extensive assistance with two or more staff members for bed mobility and dressing. Resident 159 received hospice care, and had a stage 2 pressure ulcer. During an observation, on 5/22/2023 at 10:11 A.M., Resident 159 was observed to be lying in bed with non-skid socks on, and heels not floated. On 5/23/2023 at 9:34 A.M., Resident 159 was lying in bed with non-skid socks on, and heels not floated. A Physician's Order, on 2/24/2023, indicated to ensure resident's heels were floated at all times every shift. A Care Plan, dated 2/24/2023, indicated Resident 159 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, observation and interview, the facility failed to ensure a resident on restorative nursing received her hand splint and carrot device per plan of care for 1 of 3 residents reviewed for position and mobility. (Resident 30) Finding includes: A record review for Resident 30 was completed on 5/19/2023 at 1:14 P.M. The diagnoses included, but were not limited to: cerebral infarction, and cerebrovascular disease affecting the left side. An Annual Minimum Data Set (MDS), dated [DATE], indicated she was receiving restorative nursing for splinting and passive range of motion. A Care Plan, dated 1/7/2022, indicated left hand splint applied in A.M. and removed in P.M. and to apply hand roll with carrot. A Care Plan, dated 1/13/2022, indicated passive range of motion to left upper extremity, elbow, shoulder, wrist, hand and fingers. A Physician Order, dated 12/19/2017, indicated to place a carrot in the left hand between noon and 5 P.M. as tolerated. During an observation, on 5/17/2023 at 9:58 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 ensure proper storage of nebulizer masks, obtain orders for nebulizer and oxygen tubing changes, and failed to have an identifier on the door indicating oxygen was in use for 2 out of 3 residents reviewed for respiratory care. (Resident 91 & 159) Findings include: 1. During an observation, on 5/17/2023 at 10:05 A.M., Resident 91 was receiving 2 liters of oxygen via a nasal cannula, the tubing was undated and a storage bag was unavailable to place tubing in when not in use. A identifier on the door indicating oxygen use was not visualized. During an observation, on 5/19/2023 at 11:47 A.M., the resident was receiving oxygen there was no identifier on the door indicating oxygen is in use and the zip lock bag is lying on the bathroom floor. The record review for Resident 91 was completed on 5/19/2023 at 2:00 P.M. The diagnoses included, but were not limited to: congestive heart failure, angina and atrial fibrillation. A Physician Order, dated 2/13/2023, indicated oxygen 1-2 liters nasal cannula as needed 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.