Aperion Care Hanover

Based on interview and record review, the facility failed to ensure a resident's whole emotional and mental well-being was closely monitored during a followed accelerated behavior to support and prevent further behaviors for 1 of 3 residents reviewed for behavior health services. (Resident D) Findings include:The clinical record for Resident D was reviewed on 03/12/2026 at 02:40 P.M. An Annual Minimum Data Set (MDS) assessment, dated 02/23/2026, indicated the resident was unable to complete the cognition interview. The resident's diagnoses included, but were not limited to, anxiety, depression, and Huntington's disease (progressive brain disorder). He experienced disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) behavior continually. A current Care Plan, with the start date 02/04/2026, indicated Resident D had the potential to be physically aggressive hitting, kicking, punching, choking staff and other residents related to impulse control disorder. The interventions included, but were…

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 observation, the facility failed to provide a safe and homelike environment for 2 of 4 residents reviewed. (Residents C and E)Findings include:1.During an interview, on 8/29/2025 at 11:20 A.M., Resident C indicated her room had flooded four different times since she came to the facility three months ago. One morning she woke up to two inches of water in her room that continued out into the hallway. The rooms on either side of her were also flooded. When there was heavy rainfall, the water came in through the heating and cooling unit. When it started raining heavy staff would come in and put towels under the unit. It flooded about a month ago, and they moved Resident C and her roommate into a different room for the night. The following day they had to move back into their room. A different time it flooded Resident C had to sit out in the hallway for an hour while they cleaned it all up. She now puts all of her things in waterproof bags, because anything on the floor would get ruined. 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 document medications being administered for 1 of 4 residents reviewed. (Resident D)Findings include:The clinical record for Resident D was reviewed on 8/29/25 at 12:38 P.M. An admission Minimum Data Set (MDS) assessment, dated 06/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, end-stage renal failure, and heart failure. A current open ended physician's order, with the start date of 7/14/25 at 5:00 P.M., indicated Resident D was to have his dialysis port on his abdomen soaked with a non woven sponge for five minutes before hooking up his dialysis catheter every 24 hours.The July 2025 and August 2025 Electronic Medication Administration Record (EMAR) indicated the following dates lacked documentation the resident received his dialysis port care: July 17, July 20, July 25, July 27, July 29, August 6, August 7, and August 24, 2025.The current undated facility policy, titled Medication Administration General Guidelines, was provided by the Director of…

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

Based on observation, interview, and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 4 residents reviewed. (Resident B) Findings include: During an interview, on 06/27/25 at 11:59 P.M., Resident D indicated that Certified Nursing Assistant (CNA) 2 yelled, Shut up at Resident B multiple times while trying to give the resident a shower a few weeks ago. Resident D explained that her room was next to the shower room, so she could hear her yelling so loud that it was echoing down the hallway. The clinical record for Resident D was reviewed on 06/27/25 11:51 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/26/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, depression and anxiety. During an interview and observation, on 06/27/25 at 08:27 A.M., Resident B indicated that staff were always nice to her, and nobody had ever verbally abused her at the facility. She had no concerns with care. The resident appeared well groomed and happy. The clinical record for Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure an effective pest control was in place for residents' bathrooms and bedrooms related to gnats or drain flies. This deficient practice had the potential to affect 70 of 70 residents that resided in the facility. Findings include: During an observation of Wing 2, on 03/21/25 through 03/25/25, the following concerns were observed on the following dates and times: - On 03/21/25 at 10:25 A.M., the Wing 2 Shower Room had sticky floors; a strong urine odor; the toilet base had one inch by eight-inch band of black debris around toilet base; and a one-foot-long, a two-foot-long, and a three-foot-long stripe of black/brown residue around the tile areas in the shower stall. - On 03/21/25 at 10:33 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had a swarm of gnats flying about the room and multiple gnats on the walls. - On 03/21/25 at 10:39 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had several gnats flying about…

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 have the State survey results available to view for 2 of 6 days during the survey. Findings include: During an observation, on 03/25/25 at 3:24 P.M., a laminated piece of paper on a corkboard outside the Administrator's office indicated the survey results were in a white binder in the living room. The living room and front entrance were observed, and no white binder or survey results were visible. During an observation, on 03/26/25 at 11:21 A.M., the living room and front entrance lacked visible survey results. During an observation, on 03/26/25 at 1:49 P.M., the living room and front entrance lacked visible survey results. During an interview, on 03/26/25 at 1:52 P.M., the Minimum Data Set (MDS) Coordinator indicated the State survey results were sitting in a pile in the Administrator's office and were not accessible for visitors to view without having to ask for them. They should be available for them to view without asking the staff. During an interview, on 03/27/25 at 10:02 A.M., the Administrator indicated the facility…

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 provide a clean and safe environment related to a dirty shower room and safe walkways for 2 of 4 facility areas reviewed. (Wing 2 and the outside courtyard) Findings include: 1. During an observation of Wing 2, on 03/21/25 through 03/25/25, the following concerns were observed on the following dates and times: - On 03/21/25 at 10:25 A.M., the Shower Room had sticky floors; a strong urine odor; the toilet base had a one inch by eight-inch band of black debris around toilet base; and a one-foot-long, a two-foot-long, and a three-foot-long stripe of black/brown residue around the tile areas in the shower stall. - On 03/21/25 at 10:33 A.M., the bathroom shared by Resident rooms [ROOM NUMBERS], had a baseball size shallow pit in the bathroom floor where tiles were missing. A resident in room [ROOM NUMBER] was observed to be independent with toileting and unsteady on his feet. - On 03/24/25 at 10:26 A.M., the Shower Room had sticky floors; 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 store medications appropriately for 1 of 2 medication storage rooms (Wing 2 Medication Storage Room) and 3 of 4 medication carts observed (Wing 2 Medication Cart and Wing 3 Medication Carts). Findings include: During an observation, on 03/21/25 at 10:16 A.M., the Wing 2 Medication Storage Room had three unopened bags of g-tube feeding formula that were not in a box that were sitting on the bare floor and six unopened boxes sitting on the bare floor. The Director of Nursing (DON) indicated the boxes were supplies. During an observation, on 03/21/25 at 10:19 A.M., a Wing 2 Medication Cart contained a loose round tan pill inside a drawer. Licensed Practical Nurse (LPN) 7 removed the pill and disposed of it at that time. During an observation and interview, on 03/21/25 at 10:43 A.M., a Wing 3 Medication Cart contained the following loose pills inside the drawers: - a white round pill, LPN 10 indicated it was a Tylenol, - an oval pill, LPN 10 indicated was a coenzyme, - a small white pill, LPN 10 indicated was risperidone, 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 and interview, the facility failed to follow appropriate guidelines related to the use of hairnets in the kitchen for 3 of 3 kitchen observations. (Dietary Manager, Cooks 4 and 5, and the Corporate Dietary Consultant) Findings include: 1. During a tour of the kitchen, on 03/20/25 at 11:01 A.M., the Dietary Manager (DM) had three inches of hair outside of her hairnet on each side and the back of her head while she was in the food preparation area. During an observation, on 03/26/25 at 11:54 A.M., the DM had three inches of hair exposed outside the hairnet while in the food preparation area. During a kitchen observation, on 03/27/25 at 11:42 A.M., [NAME] 4 had six inches of hair exposed outside her hairnet on the right side of her face, [NAME] 5 had two inches of hair exposed outside the hairnet around her face, the DM had three inches of hair exposed outside the hairnet on both sides of face and on the back of her neck, and the Corporate Dietary Consultant had three inches of bangs and two inches of hair exposed outside the hairnet on both sides of her face while…

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 administer prescribed medications related to insulin administration for 1 of 19 residents reviewed for Quality of Care. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 03/27/25 at 10:45 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/07/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, diabetes, hypertension, dementia, and paranoid schizophrenia. The January 2025 Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) was provided by the Director of Nursing (DON) on 03/27/25 at 11:37 A.M. The physician's order, with a start date of 11/13/24 and a discontinued date of 01/14/25, indicated the resident was to receive Humalog (insulin) 12 units, to be administered after meals. The January 2025 Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR) for Resident 12 indicated the resident's Humalog was scheduled for 9:00…

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

Based on record review and interview, the facility failed to monitor meal consumption's and have supplements available for 1 of 3 residents reviewed for nutrition. (Resident 43) Findings include: 1a. The clinical record for Resident 43 was reviewed on 03/25/25 at 11:46 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 01/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Huntington's disease, anemia, seizure disorder, anxiety, depression, and abnormal weight loss. The Meal Consumption Record for the resident lacked documented meals for the following dates and times: - On 01/02/25 at dinner, - On 01/07/25 at dinner, - On 01/11/25 at dinner, - On 01/16/25 at dinner, - On 01/23/25 at dinner, - On 01/28/25 at dinner, - On 02/01/25 at dinner, - On 02/05/25 at dinner, - On 02/09/25 at dinner, - On 02/11/25 at dinner, - On 02/13/25 at dinner, - On 02/17/25 at dinner, - On 02/20/25 at dinner, - On 02/27/25 at dinner, - On 03/03/25 at dinner, - On 03/09/25 at dinner, - On 03/11/25 at dinner, - On 03/18/25 at dinner, and -…

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

Based on record review and interview, the facility failed to ensure a medication was available for 1 of 19 residents reviewed for pharmacy services. (Resident 56) Findings include: The clinical record for Resident 56 was reviewed on 03/27/25 at 1:44 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/10/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Huntington's disease, chorea (neurological disorder that causes involuntary muscle movements), hypertension, and depression. A physician's order, dated 09/13/24 through 09/25/24, indicated the resident was to receive Austedo (a medication for chorea) 18 milligrams (mg), twice a day. The September 2024 Electronic Medication Administration Record (EMAR) indicated the resident had not received the medication on the following dates and times: - On 09/20/24 at bedtime, - On 09/21/24 at bedtime, - On 09/22/24 at bedtime, and - On 09/23/24 at bedtime. A physician's order, dated 10/19/24 through 11/13/24, indicated the resident was to receive Austedo XR (extended release)…

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.

3. The clinical record for Resident 4 was reviewed on 03/26/25 at 3:08 P.M. An Annual MDS assessment, dated 03/06/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, Parkinson's disease, hypertension, diabetes, dementia, anxiety, and psychotic disorder. The pharmacist reviewed the resident's medications monthly and made the following recommendations: - A Consultant Pharmacist Recommendation to Prescriber, dated 12/20/24, indicated the resident currently received Mirtazapine (antianxiety) 15 mg every night, Sertraline (antidepressant) 50 mg every night, and Trazadone (antidepressant) 50 mg every night. A trial dose reduction was recommended. There was no indication the physician or prescriber responded to the pharmacist's recommendation. During an interview, on 03/27/25 at 10:25 A.M., the DON indicated she did not see anything in the resident's clinical record that addressed the pharmacy recommendation. The current facility policy, titled Psychotropic Medication-Gradual Dose Reduction, revised on 02/01/18, 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, interview, and record review, the facility failed to follow infection control guidelines related to enhanced barrier precautions for 3 of 3 wound care observations. (Residents 75, 4, and 31) Findings include: 1. The clinical record for Resident 75 was reviewed on 03/24/25 at 11:34 A.M. An admission Minimum Data Set (MDS) assessment, dated 01/27/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, metastasized bone cancer, hypertension, dementia, and chronic obstructive pulmonary disease. An open-ended physician's order, with a start date of 03/18/25, indicated the resident was in enhanced barrier precautions (for a chronic wound. During an observation, on 03/26/25 at 11:22 A.M., the resident's door had a sign on it that indicated to STOP that they were in enhanced barrier precautions. Everyone must wear gloves and a gown when providing wound care. Licensed Practical Nurse (LPN) 2 entered the resident's room and provided wound treatment care without donning a gown. 2. The clinical…

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 care planned interventions were updated related to a resident's behaviors for 1 of 3 residents reviewed for care plan revision. (Resident C) Findings include: The clinical record for Resident C was reviewed on 01/13/25 at 10:56 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 12/21/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anxiety, depression, and Huntington's disease. A Behavior Note, dated 12/01/24 at 8:45 A.M., indicated Resident C was involved in a physical altercation with another resident. Resident C hit another resident in the dining room. A Behavior Note, dated 12/11/24 at 9:17 A.M., indicated Resident C walked to the dining room for breakfast and began calling staff curse words. Once the resident saw what he was served for breakfast he became irate and banged his fist on the table threatening to hurt Registered Nurse (RN) 2. The staff attempted to offer alternatives, but Resident C continued to yell profanities at staff and…

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

Based on record review and interview, the facility failed to ensure a resident who displayed psychosocial adjustment difficulties and a history of trauma received appropriate treatment to attain the highest practicable mental well-being for 1 of 3 residents reviewed for psychosocial services.(Resident C) Findings include: The clinical record for Resident C was reviewed on 09/04/24 at 11:50 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/15/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, renal insufficiency, diabetes, anxiety, and depression. The resident received dialysis. A progress note, dated 06/28/24 at 6:03 A.M., indicated Resident C was slamming his bedroom door out of anger. When it was explained that his roommate was trying to sleep, he stated A da*n train won't wake him up. A progress note, dated 06/28/24 at 12:13 P.M., indicated Social Services would make referrals to mental health services for Resident C. A progress note, dated 06/29/24 at 7:33 P.M., indicated Resident C was in his doorway when another…

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 thoroughly investigate 1 of 1 abuse allegations reviewed. (Resident B) Findings include: The clinical record for Resident B was reviewed on 08/19/24 at 12:35 P.M. An admission MDS (Minimum Data Set) assessment, dated 06/21/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, diabetes, hypertension, depression, and bipolar disorder. During an interview on 08/19/24 at 3:43 P.M., Resident B indicated a couple of weeks ago, he had been upset with the kitchen and CNA (Certified Nurse Aide) 3 had cursed at him during dinner time. During an interview on 08/20/24 at 11:17 A.M., LPN (Licensed Practical Nurse) 2 indicated on the evening of 07/31/24, she was in the hall outside of Resident B's room when CNA 3 exited the room. The resident's door was open, and CNA 3 said F--- You to the resident as she was leaving his room. She told CNA 3 to clock out and go home because she couldn't talk to a resident like that. LPN 2 phoned the Administrator and advised her of the situation.…

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, record review, and observation, the facility failed to ensure a resident's rights were honored related to their personal possessions for 1 of 3 residents reviewed for resident rights. (Resident E) Findings include: On 07/12/24 at 2:11 P.M., a Complainant indicated the facility had COVID-19 in the building. Resident E was moved to a different room so that her room could be used for a COVID-19 resident. Resident E was not able to take all of her belongings to the new room and she was upset. During an interview on 07/18/24 at 12:17 P.M., the DON (Director of Nursing) indicated the facility had to temporarily move some residents to different rooms due to COVID-19. Resident E had been in a room without a roommate. They moved her down the hall to a room with another female resident and moved a male resident (Resident J) that had been exposed to COVID-19 (his roommate tested positive) into her room. They moved several of Resident E's belongings into the new room but left non-essential items in her…

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

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the facility was free of rodents. This deficient practice had the potential to affect 65 of 65 residents that resided in the facility. Findings include: During an observation and interview on 04/24/24 at 2:14 P.M., while in the Social Service Director's (SSD) office a gray colored mouse ran from the doorway along the baseboard of the wall, towards the back corner of the office, behind a filing cabinet. The SSD apologized and indicated there was a mouse that had ran across the room and that the pest control company had been there to set up a trap in her office, but she didn't feel like it was doing any good. During an observation on 04/25/24 at 9:03 A.M., the following was observed: - The service hallway doors that lead to the kitchen were open. The dishwasher room door from the hallway was open and was 44 feet from the social service office and no staff were present. The dish room lead to the main kitchen with the door open between the rooms and no…

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

Based on observation, interview, and record review, the facility failed to provide a clean and sanitary kitchen for 2 of 2 kitchen observation. This deficient practice had the potential to affect 63 of 65 residents that resided in the facility. Findings include: During an observation on 04/25/24 at 9:03 A.M., the following was observed: - The service hallway doors that lead to the kitchen were open. The dishwasher room door from the hallway was open and no staff were present. The dish room lead to the main kitchen with the door open between the rooms and no staff were present. The main kitchen door was open to the hallway and 42 feet from the kitchen door an exterior door was open. - The dry storage room had a cardboard box of cheerios on the floor. The bottom of the baseboard and the floor were black with food debris. - A trash can between a milk cooler and the ice machine was overflowing with trash and the lid was lying on the floor. - Behind the stove was an open and empty jelly container and numerous dried cooked green beans and other food debris. - The serving room contained…

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 all investigations and outcomes of the investigations were reported to the Indiana Department of Health (IDOH), within 5 working days of the incident, for 9 of 9 reported incidents. (Residents B, C, D, E, F, G, H, J, K, L, M, and N) Findings include: 1. On 02/15/24 at 2:23 P.M., a possible drug diversion that involved Residents F and Resident G was reported to IDOH. The 5 day follow-up outcome of the investigation was not reported until 04/24/24. 2. On 03/08/24 at 1:01 P.M., a resident to resident incident between Resident H and Resident J was reported to IDOH. The 5 day follow-up outcome of the investigation was not reported until 04/24/24. 3. On 03/14/24 at 1:01 P.M., a resident to resident incident between Resident B and Resident C was reported to IDOH. The 5 day follow-up outcome of the investigation was not reported until 04/24/24. 4. On 03/22/24 at 10:01 P.M., a resident fall with injury that involved Resident J was reported to IDOH on 03/26/24. The 5 day follow-up outcome of the investigation was not reported…

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 administer medications and monitor and residents with behavioral health concerns for 2 of 4 residents reviewed for behavioral health. (Residents B and D) Findings include: 1a. During an observation and interview on 04/24/24 at 9:59 A.M., Resident B was sitting in his recliner in his room. The resident indicated he felt safe and liked his new room. In March there was an incident where he had accidentally bumped into another resident's wheelchair and that resident was rude to him. The clinical record for Resident B was reviewed on 04/24/24 at 10:45 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 02/20/24, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Huntington's Disease, anxiety, depression, and psychotic disorder. A physician's order, dated 03/13/24 through 03/14/24, indicated the resident was to receive Haldol (an antipsychotic medication) 2 mg (milligrams) in the morning 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, interview, and record review, the facility failed to store food safely, monitor the dishwasher, and provide a clean kitchen environment for 3 of 3 kitchen observations. This deficient practice had the potential to effect 67 of 67 residents that resided in the facility. Findings include: During an initial tour of the kitchen on 01/04/24 at 10:48 A.M., the following areas of concern were observed: The walk-in refrigerator contained the following: - an undated, five pound bag of shredded cheddar cheese, 1/3 full. The bag was open to air. - an undated, gallon sized bag of sliced Swiss cheese. The bag was open to air, several slices of cheese were dry around the edges, and - a box that contained a 20 pound plastic bag of ground beef on the third shelf up from the bottom of the rack. The box was dry and the seal on the plastic bag was intact, without leakage. The box was stored directly over a shelf that contained sealed packages of pre-cooked ham and deli turkey. During an interview on 01/04/24 at 10:50 A.M., the Kitchen Manager indicated the ground beef 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 record review and interview, the facility failed to provide appropriate transfer/discharge paperwork and assessments for 4 of 4 residents reviewed for transfer/discharge. (Residents 52, E, 69, and B) Findings include: 1. The clinical record for Resident 52 was reviewed on 01/04/24 at 10:08 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 11/02/2023, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, Huntington's disease, anxiety, depression, and psychotic disorder. The census report for the resident indicated the resident discharged from the facility on 12/21/23. A Progress Note, dated 12/21/23 at 6:39 P.M., indicated the resident was discharged to another facility. The clinical record lacked a discharge assessment. 2. The clinical record for Resident E was reviewed on 01/05/24 at 10:53 A.M. An Annual MDS assessment, dated 10/21/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, Huntington's disease, hypertension, and depression. The census report for 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.

4. The clinical record for Resident E was reviewed on 01/08/24 at 10:46 A.M. An Annual MDS assessment, dated 10/21/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, Huntington's disease, hypertension, depression, and pressure ulcers to the right foot. A Physical Therapy Wound Assessment, dated 10/12/23, indicated the resident's right foot had 3 pressure wounds on the areas of the right Achilles (heel area), dorsal (top) foot, and medial (inside) ankle. All wound beds were covered with pale pink good tissue. A Weekly Skin Condition Report for the resident's right heel, was provided by LPN 6 on 01/10/24 at 1:34 P.M. The assessments included the following: - Dated 09/29/23, the resident's Stage 2 wound measured 3.0 cm x 2.5 cm x 0.2 cm, - Dated 10/20/23, the resident's Stage 2 wound measured 1.8 cm x 2.2 cm x <0.2 cm. There was a small amount of drainage. A second wound measured 2.2 cm x 1.3 cm x <0.2 cm. There was a small amount of drainage. The documentation lacked explanation as to which wound was measured and why there…

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 track antibiotic use for 3 of 6 residents reviewed for antibiotic stewardship. (Residents D, 6, 32, and 16) Findings include: 1. The clinical record for Resident D was reviewed on 01/09/24 at 10:36 A.M. A Quarterly MDS (Minimum Data Set), dated 12/20/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, dementia, anemia, heart failure, hypertension, non-Alzheimer's dementia, anxiety, depression, and psychotic disorder. The November 2023 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident had received Clindamycin (an antibiotic) 600 mg (milligrams), twice a day from 11/02/23 through 11/08/23. The Antibiotic Stewardship tracking and trending records for November 2023 were provided by the Administrator on 01/08/24 at 3:07 P.M. The records lacked documentation of the prescribed antibiotic of Clindamycin for the resident. 2. The clinical record for Resident 6 was reviewed on 01/09/24 at 10:36 A.M. An…

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 a resident that self-administered medications was appropriately assessed for self-administration for 1 of 6 residents reviewed for medications. (Resident 44) Findings include: Resident 44 was observed in her bed, in her room, on 01/02/24 at 12:34 P.M. There were three unidentified medications lying on the floor near the resident's over the bed table. The resident indicated the pills spilled from the medication cup and fell on the floor when she was taking them that morning. QMA (Qualified Medication Aide) 10 entered the resident's room on 01/02/24 at 12:41 P.M. She observed the medications on the floor and identified two of the pills as gabapentin (a medication used for nerve pain). She was unsure of what the third pill was. During an interview on 01/02/24 at 12:42 P.M., QMA 10 indicated when she administered medications, she would watch to ensure residents took all their pills, she wouldn't leave the room until she was sure. LPN (Licensed Practical Nurse) 7 administered the resident's medications that…

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 thoroughly investigate and have the appropriate monitoring in place for an alleged resident to resident abuse for 1 of 25 residents reviewed. (Resident 29) Findings include: During an interview on 01/09/24 at 9:28 A.M., the Administrator indicated the previous afternoon, on 01/08/24, Resident 29 was being propelled back to her room on Wing 2 from a Resident Council meeting. She advised an activity aide that Resident 53, who was in front of her and lived on Wing 2, had raped her the night before, on 01/07/24. Resident 29 was taken to her room and placed on 1:1 (one staff to one resident) observation. She interviewed Resident 29 where she had said the men in the walls were out to hurt her, Resident 53 and 55, had raped her the night before when she was sleeping. There had been ongoing concerns with Resident 29 and they had contacted the psych NP (Nurse Practitioner). Resident 29 was sent to a neuropsych unit. She had interviewed other residents and staff and had no concerns. She did not place Residents 53 or 55…

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 update a resident's plan of care related to preferences for 1 of 17 residents reviewed for care plans. (Resident 36) Findings include: During an interview on 01/03/24 at 10:27 A.M., Resident 36 indicated he was a bit of a germaphobe, especially when it came to the bathroom that he shared with the other residents in the facility. The housekeeping staff routinely cleaned the bathroom, but he liked to clean it as well. He had bleach wipes and a floor mop with a cleaning solution that he purchased with his own money that he kept in his room. Some time ago, management came through and told him he couldn't have those items in his room, and they took them. The resident's clinical record was reviewed on 01/04/24 at 3:27 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 10/19/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, anxiety, depression, and cirrhosis of the liver. During an interview on 01/08/24 at 2:18 P.M., the Social Services Director indicated she 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 record review and interview, the facility failed to properly assess a resident after a fall for 1 of 6 residents reviewed for Quality of Care. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 01/04/24 at 3:01 P.M. An Annual MDS (Minimum Data Set) assessment, dated 12/07/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, non-Alzheimer's dementia, anxiety, and depression. A Progress Note, dated 10/16/23 at 2:45 A.M., indicated a CNA (Certified Nurse Aide) called to inform the nurse that she had just picked Resident 25 up off the floor and put her back to bed. When the nurse arrived in Wing 1 and to the resident's room the resident was in bed resting quietly. The resident's vital signs were obtained, and she complained of back pain when getting up which was not a new complaint, and her back was not hurting at that time. The resident denied hitting her head and neurological checks were initiated. The DON (Director of Nursing), MD, and family were notified. During an interview on 01/08/24 at…

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 with a urinary tract infection received antibiotic treatment in a timely manner for 1 of 3 residents reviewed for Urinary Tract Infections. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 01/09/24 at 10:36 A.M. An admission MDS (Minimum Data Set) assessment, dated 08/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, renal insufficiency, and obstructive uropathy. The resident had a urinary tract infection within the last 30 days. During an interview on 01/08/24 at 2:34 P.M., LPN (Licensed Practical Nurse)12 indicated the resident had frequent UTIs (Urinary Tract Infections). They had multiple UTIs in October. The resident went out to the urologist to have their indwelling urinary catheter changed out monthly and as needed. If a resident's urinalysis indicated an infection, a C&S (Culture and Sensitivity) would be obtained to check for 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 post nurse staffing daily for 3 of 7 days observed. (1/2, 1/8, and 1/9/24) Findings include: During an observation on 01/02/24 at 10:40 A.M., the nurse staffing was posted on a table by the front door and dated for 12/29/23. During an observation on 01/08/24 at 10:48 A.M., the nurse staffing was posted on a table by the front door and dated for 01/05/24. During an observation on 01/08/24 at 4:02 P.M., the nurse staffing was posted on a table by the front door and dated for 01/05/24. During an observation on 01/09/24 at 9:40 A.M., the nurse staffing was posted on a table by the front door and dated for 01/05/24. During an interview on 01/10/24 at 11:41 A.M., the Business Office Manager indicated she receives a copy of the daily nursing schedule each morning and updates the staff posting. She works Monday through Friday. Currently no one updates the staff posting on the weekends or when she is off work. The current facility policy titled, Posting Direct Care Daily Staffing Numbers, with a revision date of July 2016, 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 record review and interview, the facility failed to accurately reconcile a resident's medications upon readmission to the facility and to verify a diagnosis was appropriate for the administration of an antibiotic for 2 of 6 residents reviewed for pharmacy services. (Residents 6 and 32) Findings include: 1. The clinical record for Resident 6 was reviewed on 01/09/24 at 10:36 A.M. An admission MDS (Minimum Data Set) assessment, dated 08/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, atrial fibrillation, coronary artery disease, diabetes, renal insufficiency, obstructive uropathy, anxiety, depression, bipolar disorder, and PTSD (Post Traumatic Stress Disorder). A progress note, dated 10/26/23 at 5:25 P.M., indicated the resident was complaining of severe testicular pain and was sent to the local hospital for evaluation. A progress note, dated 10/27/23 at 4:32 A.M., indicated the resident was admitted to the hospital for urosepsis following a UTI (Urinary Tract Infection) and scrotal pain. The resident's physician's orders…

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 follow pharmacy recommendations for 1 of 5 residents reviewed for medication irregularities. (Resident 6) Findings include: The clinical record for Resident 6 was reviewed on 01/09/24 at 10:36 A.M. An admission MDS (Minimum Data Set) assessment, dated 08/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, atrial fibrillation, coronary artery disease, diabetes, renal insufficiency, obstructive uropathy, anxiety, depression, and bipolar disorder. Findings include: 1. The clinical record for Resident 6 was reviewed on 01/09/24 at 10:36 A.M. An admission MDS (Minimum Data Set) assessment, dated 08/02/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, atrial fibrillation, coronary artery disease, peripheral vascular disease, diabetes, renal insufficiency, and obstructive uropathy. The resident was hospitalized on [DATE] and returned to the facility on [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to appropriately store medications for 1 of 2 medication rooms (Unit 1 medication room) and 2 of 4 medication carts reviewed. (Wing 1 Medication Cart and Wing 2 Medication Cart) Findings include: 1. The medication room on Wing 1 was observed on 01/05/24 at 11:25 A.M., with QMA (Qualified Medication Aide) 2. The refrigerator contained a vial of Tuberculin serum that was half full and had no open date on the vial or box containing the vial. The QMA indicated staff were to date items when they were opened. During an interview on 01/08/24 at 9:44 A.M., on Wing 1, RN 3 indicated he had been working on the unit since October of 2023, he usually worked day shift, and he had not used the TB serum. He had not completed any new admissions since he had been on the unit but there had been one admission on [DATE], Resident 58. The Tuberculin serum package insert was provided by the Regional Director of Operations on 01/09/24 at 3:42 P.M. The insert indicated, .Vials in…

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 provide a COVID-19 immunization in a timely manner for 1 of 6 residents reviewed for immunizations. (Resident 64) Findings include: The clinical record for Resident 64 was reviewed on 01/10/24 at 10:16 A.M. The resident was admitted on [DATE]. A Quarterly MDS (Minimum Data Set) assessment, dated 10/24/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, Huntington's disease, anxiety, and depression. The CONSENT TO COVID-19 VACCINE record, signed by the resident's representative on 06/19/23, indicated the resident had received a copy of the most current COVID-19 Emergency Use Authorization. The resident's representative understood the benefits and risks associated with the vaccine and consented to receive the vaccination as determined by current CDC guidelines. The clinical record lacked documentation the resident had received a COVID-19 vaccine since admission on [DATE]. The Progress Notes,…

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, observation, and interview, the facility failed to accurately inventory residents' personal property for 2 of 15 residents reviewed for personal property. (Residents F and G) Findings include: 1. Resident F's clinical record was reviewed on 11/17/23 at 1:08 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 08/03/23, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, stroke, non-Alzheimer's dementia, diabetes, anxiety, depression, and psychotic disorder. The assessment indicated an admission date of 03/11/21 and admission/reentry into the facility date of 01/04/22. The resident was observed on 11/15/23 at 2:19 P.M. The resident was in bed in her room. A large black purse was tucked under the resident's right arm. The resident indicated that was her purse; she had the purse for a long time. The resident was observed on 11/20/23 at 10:04 A.M. The resident was in bed asleep. A large black purse was laying on the bed in the upper left corner near the resident's head. During an interview on 11/20/23…

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 behavior health services for a resident's psychological needs (Resident J), and to complete ongoing monitoring for residents with behaviors (Residents C and B) for 3 of 15 residents reviewed for behavior health. Findings include: 1. The clinical record for Resident J was reviewed on 11/15/23 at 2:30 P.M. An Annual MDS (Minimum Data Set) assessment, dated 10/21/2023, indicated the resident was moderately cognitively impaired. The diagnoses included, but were not limited to, Huntington's disease, hypertension, and depression. A progress note, dated 10/20/2023 at 2:45 P.M., indicated the SSD (Social Service Director) asked the resident questions from Section D (Mood) of the MDS assessment, including the PHQ-9 (a questionnaire used for screening, diagnosing, monitoring, and measuring the severity of depression). The resident reported he had little interest or pleasure in doing things, had been having a difficult time falling asleep, had been feeling tired every day, and had been having thoughts that he would be better…

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 accommodate a resident receiving familial visitors late at night for 16 of 71 residents reviewed for visitation. (Dementia Unit/Wing 1) Findings include: During a confidential interview on 9/21/23 at 9:23 a.m., a resident's family member indicated they received a call from the facility a few days ago. The facility indicated they could not visit their family member on the unit since there was a Covid outbreak. The Health Status Note, dated 8/19/2023 at 8:10 p.m., indicated Resident H's visitors at this time were asked to leave by nightshift QMA (Qualified Medication Aide) on duty. The Health Status Note, dated 8/19/2023 at 8:15 p.m., indicated Resident H's visitors were asked again to leave the facility per new guidelines regarding visiting hours. During an observation on 9/25/23 at 10:10 a.m., there was an 8 inch by 11 inch paper sign on the exit door to the Dementia unit. The paper was taped on the inside facing outside. The sign indicated visiting hours were restricted to 8:00 a.m. to 8:00 p.m. During an interview with…

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

Based on observation, interview, and record review, the facility failed to develop and implement individualized activities programming to meet individual resident needs for 2 of 3 specialized resident units reviewed for activities. This deficient practice had the potential to affect 42 of 71 resident that reside in the facility. (Huntington's unit and the Dementia unit) Findings include: Review of the September activity schedule indicated there was one monthly schedule for the whole facility. The activities planned for 9/23/23 (Saturday) were as followed: Daily Chronicle at 9:30 a.m., Question Ball at 10:00 a.m., Exercise at 11:00 a.m., and Musical Social at 1:00 p.m. During an interview on 9/23/23 at 9:34 a.m., the Activity Director indicated today she was working as a CNA. The unit was short on staff, and she had to work the floor. They have been short staffed frequently and there was no possible way for her to provide activities to the whole facility. The facility had recently hired a staff member to do activities with the residents, but she had not started yet. The activities 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 record review and interview, the facility failed to have adequate supervision to prevent frequent resident falls and negative behaviors, ensure a metal unit exit door was repaired timely and secured, chemicals and hazardous supplies were secured for 1 of 3 resident units reviewed for accidents. This deficient practice had the potential to affect 26 of 71 residents who reside in the facility. (Wing 2/Huntington's Unit) Finding includes: 1. During an observation on 9/21/23 at 1:58 p.m., the exit door from the Huntington's unit/Wing 2 to Wing 3 was hanging with the door frame cracked on the top and bottom, hinges broken, and rubber shins were under the door. There was a piece of paper on the door that indicated to not use the door. During an interview on 9/21/23 at 10:28 a.m., the ADON (Assistant Director of Nursing) indicated staff cannot exit through the secured door leading to the Wing 3 unit. On 9/9/23, Resident Q did a full body ram into the door and busted the frame, and the door was just hanging by…

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 staffing levels were adequate related to abuse prevention, falls, dining assistance, meal timing, and call lights for 42 of 71 residents reviewed for staffing. (Wing 1 and Wing 2) Findings include: 1. During an interview on 9/21/23 at 10:10 a.m., the ADON (Assistant Director of Nursing) indicated there was a reportable on 8/24/23 related to Resident D and Resident C. Two CNAs (Certified Nurse Aide) went into the central bathroom to wash their hands. The CNAs walked into the bathroom/shower room, and they turned to their right to face the sink. There was a mirror above the sink and the mirror showed a reflection of the bathroom stall across from the sink. The bathroom stall had a curtain pulled and the CNAs saw a set of feet and a pair of pants on the floor under the curtain. They noticed a second pair of feet and opened the curtain. Resident D had his pants down with no brief or underwear on. He was standing with his feet slightly…

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

Based on interview and record review, the facility failed to ensure the appropriate temperature and palatability of food served for 1 of 3 resident wings/units served for dietary services. (Wing 2) This deficient practice had the potential to affect 14 of 26 residents that resided on the Huntington's unit. Findings include: Review of the current facility meal service schedule indicated the following: - Breakfast was to be served to Wing 2 at 8:15 a.m., Wing 3 at 8:20 a.m. and Wing 1 at 8:25 a.m. - Lunch was to be served to Wing 2 at 12:15 p.m., Wing 3 at 12:20 p.m., and Wing 1 at 12:25 p.m. - Dinner was to be served to Wing 2 at 5:15 p.m., Wing 3 at 5:20 p.m., and Wing 1 at 5:25 p.m. During an interview on 9/24/23 at 8:03 a.m., RN 7 indicated with only two to three staff to feed all 14 residents that required total assistance and the other residents who must be monitored the food was almost always cold when they served the residents that required assistance were feed. During an interview on 9/24/23 at 8:15 a.m., CNA 6 indicated she was from an agency and the only aide working 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 interview, record review, and observation, the facility failed to follow appropriate infection control guidelines related to droplet isolation/Covid for 10 of 35 residents reviewed for Infection Control. (Resident D, Resident G, Resident H, Resident C, Resident J, Resident K, Resident B, Resident DD, Resident EE, and Resident CC) Findings include: An observation on the smoking area on 9/21/23 at 2:30 p.m., there was two smoking buckets with tubing in the courtyard. The tubing with mouth pieces was lying on the ground. No covering or cleaning of the mouth pieces was completed, prior to the resident's use. Staff were observed to pick up the mouthpiece of the tubing off the ground and hand it to the residents. During an observation on 9/23/23 at 9:11 a.m., Resident D walked out into the hallway. He was carrying his breakfast tray. The resident was not wearing a mask. He carried his tray past the nurses' station and placed it in the food cart. RN 7 walked up to the resident and informed the resident he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a sanitary and safe environment related to wet floors, missing privacy curtains, gouged wall with exposed wires, broken security door, flies around food, and damaged bed side tables on 1 of 3 units observed. (Wing 2) Findings include: During an observation on 9/21/23 at 1:58 p.m.2:21 p.m., the metal exit door from the Huntington's unit to Wing 3 had the door frame cracked with rubber shins under the door. The door hinges were broken. During an observation and interview on 9/23/23 at 9:03 a.m., the clean utility door was not shut and locked. At 9:05 a.m., the CNA indicate the door was supposed to be shut and locked and the door was now locked. During an interview on 9/24/23 at 8:32 a.m., CNA 6 indicated she was from an agency and the only aide since 8:00 a.m. The food tray sitting on a bed side table in the hallway was from last night. The food tray had food and two drink cups with dead flies in the liquid. Beside the food tray was an area 5 feet…

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 interventions were effective and appropriate interventions were implemented to prevent recurrent resident aggressive/attention seeking behaviors for 1 of 4 residents reviewed for behaviors. (Resident D) Findings include: 1.a. The clinical record for Resident D was reviewed on 9/21/23 at 11:21 a.m. A Quarterly MDS (minimum data set) assessment, dated 8/29/23, indicated the resident was cognitively intact and he was independent with locomotion requiring only supervision oversight. His diagnoses included but were not limited to, Huntington's, mood affective disorder, anxiety, depression, and attention deficit hyperactivity disorder. The Care Plan, dated 6/5/23, indicated the resident was at risk of psychosocial well-being issues related to being less than [AGE] years of age. The interventions were for the activities department to encourage participation and offer resident activities of interest. The Care Plan, dated 6/5/23, indicated the 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.