Aperion Care Greenfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 5 of 5 residents reviewed for abuse. (Residents 2, 13, 31, 33, and 45) Findings include: 1. The clinical record for Resident 45 was reviewed on 8/28/24 at 12:15 p.m. Her diagnoses included, but were not limited to, dementia and major depressive disorder. She was admitted to the facility on [DATE] from another facility. The 8/1/24 Quarterly Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. An interview was conducted with Family Member 2 on 8/28/24 at 12:29 p.m. She indicated Resident 45 was transferred to her current facility from another facility. Family Member 2 received a voicemail from the previous facility that Resident 45 was being transferred the following day. By the time Family Member 2 received the voicemail, Resident 45 was already transferred to her current facility. Resident 45 had behaviors daily. She was combative and hallucinated. Another male resident…

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

Based on observation, interview, and record review, the facility failed to place soiled linen in bags when transported through the hallway; ensure soiled linen was contained in soiled utility bins located in the hallway of the facility; and ensure PPE (personal protective equipment) was properly discarded after resident care, prior to leaving the room for 2 of 2 soiled utility bins randomly observed; 1 of 1 random observation of soiled linen transportation by staff; and 7 of 7 residents who were or resided in rooms with a roommate who were in EBP (enhanced barrier precautions). (Residents 5, 11, 29, 30, 36, 45, and 150) Findings include: On 8/27/24 at 1:10 p.m., an observation of a soiled linen bin in the hallway was made. There was unbagged, soiled linen hanging out of the bin. The unbagged, soiled linen was piled so high within the bin, that the lid was unable to be closed and was resting on top of the soiled linen. On 8/29/24 at 10:16 a.m., an observation of a soiled linen bin in the hallway near the social services office was made. There was white linen hanging out of the bin,…

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 a homelike environment for 2 of 12 residents reviewed for a clean environment. (Resident 43 and Resident 31) Findings include: 1. Resident 43's clinical record, reviewed on 8/28/24 at 2:47 p.m., indicated diagnoses that included, but were not limited to, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, and schizophrenia. During an observation on 8/27/24 at 1:43 p.m., Resident 43's bathroom floor was sticky to walk on, a bedpan, uncovered, with an open bag of adult diapers were laying on the floor, and there was paint peeling off the walls behind the bed frames. During an interview on 8/30/24 at 2:00 p.m., the Executive Director (ED) indicated she was aware of the paint peeling on the wall. The ED indicated the two residents in the room kept moving their beds around and [scuffing] up the paint on the wall. The ED indicated maintenance had been in the room to repaint it several times. 2. Resident 31's clinical record, reviewed on 9/30/24 at 12:46 p.m., indicated diagnoses that 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 interview and record review, the facility failed to maintain documentation Resident 5's representative was provided with a bed hold policy for 1 of 1 resident reviewed for hospitalization. Findings include: The clinical record for Resident 5 was reviewed on 8/29/24 at 2:34 p.m. The diagnoses included stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 6/28/24, indicated Resident 5 was cognitively intact. The census flowsheet for Resident 5 indicated a therapeutic leave from 7/22/24 to 7/26/24. During an interview on 8/30/24 at 1:45 p.m., Resident 5 indicated he did not know what a bed hold policy was and did not receive any paperwork prior to going to the hospital in July of 2024. During an interview on 8/30/24 at 3:20 p.m., the Executive Director indicated the staff could not find the bed hold policy for Resident 5's July hospitalization. The expectation was nursing staff would provide the bed hold policy at the time of transfer to the resident or their representative. A blank copy of the Bed Hold Policy Notice was provided, on 8/30/24 at 3:20 p.m., 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 interview and record review, the facility failed to accurately encode Minimum Data Set (MDS) information for 2 of 19 residents reviewed from MDS accuracy. (Resident 5 and Resident 19) Findings include: 1. The clinical record for Resident 5 was reviewed on 8/29/24 at 2:34 p.m. The diagnoses included bipolar disorder. An admission MDS assessment, dated 2/1/24, indicated that Resident 5 did not have a PASARR (Preadmission Screening and Resident Review) Level II. A PASARR Level II, dated 6/21/19, indicated Resident 5 had a serious mental illness but did not need specialized services. During an interview on 8/30/24 at 11:45 a.m., the Social Services Director indicated Resident 5 had a serious mental illness and the most current Level II was the one dated 6/21/19. 2. The clinical record for Resident 19 was reviewed on 8/30/2024 at 1:30 p.m. The medical diagnoses included chronic obstructive pulmonary disease. A Quarterly MDS assessment, dated 7/26/24, indicated Resident 19 did not have a prognosis of six months or less but received hospice services. A hospice care plan, revised…

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 Resident 11 had a completed Preadmission Screening and Resident Review (PASARR) prior to admission to the facility for 1 of 3 residents reviewed for PASARR. Findings include: The clinical record for Resident 11 was reviewed on 8/30/24 at 12:15 p.m. The diagnoses included schizophrenia. An admission Minimum Data Set (MDS) assessment, dated 2/1/24, indicated Resident 11 did not have a PASARR Level II. Per the Indiana State Department of Family and Social Services Administration, all applicants to Medicaid-certified nursing facilities in Indiana are entered in the state's web-based PASARR system, and a Level I screen is completed to initiate the PASARR process. If indicated, a PASARR Level II evaluation is performed to identify the specialized needs of individuals with mental illness (MI), intellectual or developmental disability ID/DD, or both (MI/ID/DD). A PASARR Level I for Resident 11, dated 1/24/19, indicated that Resident 11 needed an on-site Level II review. During an interview on 8/30/24 at 12:55 p.m., 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 interview and record review, the facility failed to hold regularly scheduled care plan meetings for 1 of 2 residents reviewed for care planning. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 8/28/24 at 12:15 p.m. Her diagnoses included, but were not limited to, dementia and major depressive disorder. She was admitted to the facility, on 11/6/23, from another facility. The 11/6/23 nursing note read, Resident is a new admit from [name of previous facility,] came to the facility via facility van. Resident is alert to name but confused with place where she is and time of day . The 8/1/24 Quarterly Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired. An interview was conducted with Family Member 2 on 8/28/24 at 12:29 p.m. She indicated Resident 45 was transferred to her current facility from another facility. Family Member 2 received a voicemail from the previous facility that Resident 45 was being transferred the following day. By the time Family Member 2 received the voicemail, Resident 45 was already…

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 follow scheduled activities calendar or provide outside activities for 3 of 3 residents reviewed for activities. (Resident 34, Resident 41, and Resident 35). Findings include: 1. Resident 35's record, reviewed on 8/28/24 at 2:43 p.m., indicated Resident 35 had diagnoses that included, but were not limited to, fibromyalgia, type 2 diabetes, alcoholic cirrhosis, chronic obstructive pulmonary disease, and alcohol abuse. A Quarterly Minimum Data Set (MDS) assessment for Resident 35, dated 8/20/24, indicated he was cognitively intact for daily decision making. During an interview on 8/27/24 at 1:16 p.m., Resident 35 indicated that the activities director did not offer a variety of activities. We were supposed to play cards one day, which it was on the activities calendar, but no one had any cards, so we couldn't play. Resident 35 had requested to go on outings with the facility, but the facility told him no, because they do not have enough…

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, observation, and record review, the facility failed to date a dry dressing to a skin impairment (Resident 1) and failed to complete skin assessment as care planned (Resident 34) for 2 of 2 residents reviewed for skin impairments. Findings include: 1. The clinical record for Resident 1 was revied on 8/30/24 at 1:50 p.m. The medical diagnoses included schizophrenia. A Quarterly Minimum Data Set assessment, dated 8/15/24, indicated that Resident 1 was cognitively impaired. Resident 1 needed minimal to substantial assistance for activities of daily living and was at risk for developing skin alternations. A nursing assessment, dated 8/20/24, indicated that Resident 1 was at high risk of skin alternations. A wound evaluation, dated 8/28/24, indicated Resident 1 had a non-pressure wound to the scalp with undetermined thickness from a fall. Measurements for the wound were 3 centimeters (cm) x 2 cm x Not Measurable. A skin care plan, revised 8/28/24, indicated Resident 1 had an abrasion to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure optometry services were provided timely to a resident who consented to receive optometry services for 1 of 3 residents reviewed for vision or hearing services. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 8/28/24 at 1:00 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis, major depressive disorder, and hypertension. He was admitted to the facility on [DATE]. The 2/9/22 ancillary services care plan, revised 7/15/24, indicated he consented to receive optometry services through the facility's optometry provider with interventions for him to be seen by the appropriate provider to ensure any issue was resolved. The 10/30/22 physician's order indicated he may be seen by the optometrist, as needed. The 8/12/24 Ancillary Services Assessment form indicated Resident 34 needed assistance with corrective lenses. The 8/13/24 Significant Change Minimum Data Set assessment…

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, observation, and record review, the facility failed to complete quarterly smoking assessments for 1 of 1 resident reviewed for smoking safety. (Resident 23) Findings include: The clinical record for Resident 23 was reviewed on 8/29/24 at 2:00 p.m. The diagnoses included chronic obstructive pulmonary disease. An Annual Minimum Data Set assessment, dated 7/30/24, indicated Resident 23 was cognitively intact and utilized tobacco products. A smoking care plan, revised 12/5/23, indicated Resident 23 was a cigarette smoker with an intervention of smoking assessment upon admission, quarterly and as needed. During an interview on 8/30/24 at 2:15 p.m., the Executive Director indicated the staff could not locate the quarterly smoking assessment for Resident 23 for the last year. Activities and social services were to split the duty of completing smoking assessments. A policy entitled, Smoking Safety, was provided by the Social Service Director on 8/30/24 at 8:40 a.m. The policy indicated smoking assessment will be completed at the time of admission, quarterly, and as…

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 in interview, observation, and record review, the facility failed to supervise a dependent resident with administration of an aerosol generating procedure for 1 of 1 reviewed for respiratory care. (Resident 30) Findings include: The clinical record for Resident 30 was reviewed on 8/30/24 at 11:05 a.m. The diagnoses included Alzheimer's disease. An Annual Minimum Data Set assessment, dated 7/26/24, indicated Resident 30 was cognitively impaired. Resident 30 was dependent on staff for all activities of daily living. A respiratory care plan, revised 8/19/24, indicated Resident 30 had altered respiratory status related to a diagnosis of asthma with an intervention of administer medications as ordered. A physician order, dated 6/19/24, indicated to administer an aerosolized medication to Resident 30 every six hours. During an observation on 8/27/24 at 1:46 p.m., Resident 30 was sitting in a wheelchair in the resident's room. A nebulizer was running with the tubing detached from the face mask and the mask was placed under Resident 30's chin. During an observation and interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication storage rooms did not contain expired supplies for 2 of 2 medication rooms observed. (Facility) Findings include: An observation conducted of Medication Storage room [ROOM NUMBER], on [DATE] at 9:40 a.m., indicated a urinary catheter with expiration of 2022 and a box of tuberculin syringes with expiration of 2023. An observation conducted of Medication Storage room [ROOM NUMBER] with Registered Nurse (RN) 12, on [DATE] at 9:45 a.m., indicated a box of tuberculin safety syringes expired, on [DATE], and six safety syringes with an expiration date of [DATE]. RN 12 indicated there was a supply room with all needed medical supplies and the medication storage rooms would consist of medical supplies needed for the daily tasks. It was the nurses' responsibility to check the medication storage rooms to ensure the supply items were not expired. A policy titled Medication Storage, revised [DATE], was provided by the Executive…

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 Resident 19 had a routine lab drawn per physician order for 1 of 1 resident reviewed for laboratory services. Findings include: The clinical record for Resident 19 was reviewed on 8/30/24 at 1:30 p.m. The medical diagnoses included hypothyroidism. A Quarterly Minimum Data Set assessment, dated 7/26/24, indicated Resident 19 was cognitively impaired. A physician order, dated 5/23/24, indicated routine labs every six months to review Resident 19's thyroid levels. A nursing progress note, dated 5/23/24, indicated lab was unable to obtain blood for the routine tests and Will try next lab day . During an interview, on 8/30/24 at 2:15 p.m., the Executive Director indicated that the facility could not find where the labs were obtained for Resident 11's thyroid levels in May of 2024. The thyroid level lab was missed in May 2024. The nursing staff was responsible for obtaining labs per physician order. A policy entitled, Physician Notification of Laboratory/Radiology/Diagnostic Results, was provided by the Social Services…

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 dental services were provided timely to a resident with no bottom dentures for 1 of 2 residents reviewed for dental status and services. (Resident 34) Findings include: The clinical record for Resident 34 was reviewed on 8/28/24 at 1:00 p.m. His diagnoses included, but were not limited to, hemiplegia and hemiparesis, major depressive disorder, and hypertension. He was admitted to the facility on [DATE]. The 2/25/22 ancillary services consent form indicated Resident 34 consented to receiving dental services in the facility. The 2/9/22 dentures care plan, revised 7/15/24, indicated he wore upper dentures with an intervention to refer to the dentist routinely and as needed. The 10/30/22 physician's order indicated he may be seen by the dentist, as needed. The 8/12/24 Ancillary Services Assessment form indicated Resident 34 needed assistance with dental or dentures. The 8/13/24 Significant Change MDS (Minimum Data Set) Assessment…

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 an antibiotic was appropriate for the treatment of a urinary tract infection (UTI) for 1 of 2 residents reviewed for antibiotic therapy. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 8/30/24 at 11:30 a.m. The diagnoses included, but were not limited to, dementia, psychotic disorder, and recurrent UTIs. A progress note, dated 7/9/24 at 4:31 a.m., indicated a urine specimen was obtained for a urinalysis with culture and sensitivity (a diagnostic test to identify and quantify the microorganisms present in a urine sample and determine their sensitivity to various antibiotics). A physician note, dated 7/10/24, indicated a possible concern for a UTI. The urine culture was pending, and if the results were not available (on 7/10/24), the plan was to start Macrobid 100 milligrams twice daily for 7 days. A care plan, initiated 7/11/24, indicated Resident 45 had a UTI. The interventions included, but were not limited to, administer antibiotic therapy as prescribed and monitor laboratory…

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 a dignity bag to cover a catheter. This affected 1 of 3 residents reviewed for catheters. (Resident 13) Findings include: On 6/21/23, at 11:57 a.m., Resident 13 was observed sitting in a specialty chair, and the catheter bag was uncovered and hung from the underneath of the chair. During an observation, on 6/22/23, at 12:45 p.m., with the ADON, Resident 13's uncovered catheter bag hung from the side of her bed that faced the door. On 6/26/23, at 12:28 p.m., Resident 13 was seated in her specialty chair in the dining room and her catheter was uncovered and attached to the underneath of the chair. Resident 13's record was reviewed, on 6/22/23, at 10:44 a.m. The record indicated Resident 13 had diagnoses that included, but were not limited to, Parkinson's disease, high blood pressure, and anxiety. A Quarterly Minimum Data Set assessment, dated 5/8/23, indicated Resident 13 was cognitively intact, had an indwelling catheter, and did not walk. Resident 13 had physician's orders for a foley catheter, with a…

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 complete a grievance form to include the date of resident and/or responsible party notification of the resolution of a grievance and to list the disposition of the grievance for 1 of 2 residents reviewed for the grievance process. (Resident 22) Findings include: The clinical record for Resident 22 was reviewed on 6/26/2023 at 1:33 p.m. The medical diagnosis included quadriplegia. A Quarterly Minimum Data Set (MDS) Assessment, dated for 4/11/2023, indicated that Resident 22 was cognitively intact. A grievance form for Resident 22, dated for 6/20/2022, indicated that Resident 22 stated a staff member broke his tablet. The form did not indicate who the grievance was received by, department to resolve the issues, actions taken to resolve the outcome, date resolved, resolved by or date of the administrator's signature. An interview with Resident 22 on 6/26/2023 at 2:30 p.m. indicated he still did not know the resolution of the grievance for from June 2022. He stated a staff member had broken his tablet last year and 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 implement pressure relieving boots as ordered by the physician for a resident with a pressure ulcer for 1 of 3 residents reviewed for pressure ulcer (Resident 12). Finding include: During an observation on 6/21/23 at 10:42 a.m., Resident 12 was laying in bed with heels/feet laying on the bed. The resident had pressure relieving boots laying in a chair in across his room. During an interview with the Director Of Nursing (DON) on 6/26/23 at 1:35 p.m., indicated the nurse and CNA's were responsible to ensure Resident 12 had his pressure relieving boots in place. Review of the record of Resident 12 on 6/27/23 at 11:30 a.m., indicated the resident's diagnoses included, but were not limited to, osteoarthritis, weakness, diabetes and dementia. The physician recapitulation for Resident 12, dated June 2023, indicated the resident was to wear bilateral pressure relieving boots at all times every shift for healing (5/18/23). The admission Minimum Data Set (MDS) assessment for Resident 12, dated 5/24/23, 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 observation, interview and record review the facility failed to maintain a Foley catheter in a manner to prevent Urinary Tract Infection (UTI) by keeping it from being in contact with the floor for 1 of 5 residents reviewed for catheter (Resident 12). Finding include: During an observation on 6/21/23 at 10:40 a.m., Resident 12 was laying in bed. The resident's urinary Foley catheter was laying on the floor at the foot of his bed with no dignity bag. During an interview with the Director Of Nursing (DON) on 6/27/23 at 1:35 p.m., indicated the CNA's and Nurses were responsible to ensure Resident 12's catheter was in a dignity bag and not laying on the floor. Review of the record of Resident 12 on 6/27/23 at 11:30 a.m., indicated the resident's diagnosis included, but were not limited to, history of Urinary Tract Infection (UTI). The plan of care for Resident 12, dated 1/5/23, indicated the resident was at risk to develop a UTI related to having a history of UTI's and anchored Foley catheter. The plan of care of Resident 12, dated 1/5/23, indicated the resident had a Foley…

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 Registered Nurse (RN) was utilized for at least 8 hours a day on 1/14/23, 1/28/23, 2/25/23, 3/25/23, 6/4/23, and 6/18/23, upon review on the daily schedules for June of 2023 and the Payroll Based Journal Staffing Data Report for the quarter of January 1, 2023, to March 31, 2023. Findings include: Upon review of the Payroll Based Journal Staffing Data Report, dated January 1, 2023, to March 31, 2023, indicated there were no RN hours for 1/14/23, 1/28/23, 2/25/23, and 3/25/23. Upon review of the daily schedules for June of 2023, the following days were noted without RN hours or partial hours: 6/4/23- no RN hours & 6/18/23- only 5.5 hours. An interview conducted with the Director of Nursing (DON), on 6/22/23 at 2:35 p.m., indicated there was no RN coverage on the dates of 1/14/23, 1/28/23, 2/25/23, and 3/25/23. On 6/18/23, the DON indicated she came in at 12:30 p.m. and stayed until 6:00 p.m. 3.1-17(b)(3)