Casa Of Hobart

Based on record review and interview, the facility failed to ensure clinical records were complete and accurately documented related to dietary supplement consumption for 1 of 1 resident reviewed for nutrition and a dental assessment for 1 of 1 resident reviewed for dental. (Resident 20 and B)Findings include: 1. The record for Resident 20 was reviewed on 2/31/26 at 2:24 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, adjustment disorder, dementia with psychotic disturbance, vascular dementia, high blood pressure, atrial fibrillation, and chronic kidney disease. The 12/31/25 Modification of the Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making and had no oral problems or weight loss. A Physician's Order, dated 3/5/26, indicated High-Calorie liquid Supplement two times a day for weight. The Medication Administration Records (MAR) for 3/2026 and 4/2026 indicated the high calorie liquid supplement was signed out as being administered, however, the amount consumed was not documented. During 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 record review and interview, the facility failed to ensure laboratory tests were completed as ordered, related to a vancomycin trough for 1 of 3 residents reviewed for laboratory testing. (Resident D)Finding includes: Resident D's closed record was reviewed on 2/3/26 at 1:36 p.m. Diagnoses included, but were not limited to, cellulitis, diabetes mellitus, atrial fibrillation and osteoarthritis. The resident had been discharged to the hospital on 1/20/26 due to abnormal labs. The Quarterly Minimum Data Set assessment, dated 12/13/25, indicated the resident was cognitively intact and required moderate assist with transfers.A Physician's Order, dated 1/14/26, indicated to give vancomycin HCL (an antibiotic), 1 gram, intravenously daily for cellulitis.A lab result, dated 1/14/26, indicated the resident had a vancomycin trough (a blood test to determine medication level) of less than 3.0.A Nurse Note, dated 1/15/25, indicated the vancomycin trough results had been communicated to the pharmacy and the next vancomycin trough should be done on 1/19/26. There was no order 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 record review and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to showers for 2 of 3 residents reviewed for ADLs. (Residents D and B) Findings include: 1. The record for Resident D was reviewed on 6/17/25 at 10:11 a.m. Diagnoses included, but were not limited to epilepsy, psychotic disorder with delusions, high blood pressure, and alcohol dementia. The Quarterly 5/15/25 Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and was dependent on staff for bathing. The Care Plan, revised on 2/13/24, indicated the resident required assistance with ADLs. The showers in the CNA Task Section indicated the resident was to receive a shower on Wednesday and Saturday evenings. The resident did not receive a shower on 4/2, 4/5, 5/17, 5/28, and 6/7/25. During an interview on 6/17/25 at 11:55 a.m., the Director of Nursing indicated the resident was to receive at least two showers a week. 2. Resident B's record was reviewed on 6/17/25 at 9:05 a.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 observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the opening of a medication capsule without gloves during medication administration for a random observation for infection control. Finding includes: On 6/16/25 at 12:07 p.m., medication administration was observed with LPN 1 for Resident G. The resident received his medication crushed. LPN 1 opened a Gabapentin (given for nerve pain or anticonvulsant) 300 mg capsule with her bare hands and emptied the powder contents inside the medication cup with another crushed medication. During an interview on 6/16/25 at 12:17 p.m., the Assistant Director of Nursing (ADON) indicated she understood the concern and had no further information to provide. During an interview on 6/16/25 at 1:10 p.m., the Director of Nursing (DON) indicated she understood the concern and would re-educate the staff. She indicated LPN 1 thought it was okay to touch the outside capsule since she did not touch the inside contents. This Citation relates to Complaint…

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

Based on observation, record review, and interview, the facility failed to provide a safe and sanitary environment to help prevent the potential for transmission of communicable diseases and infections related to a glucometer (blood sugar monitor) not sanitized after it was used for 1 of 2 glucometer tests observed. (LPN 3, Resident S) This had the potential to affect 5 residents with glucometer orders assigned to the nurse. The facility also failed to ensure correct Personal Protective Equipment (PPE) was used by a staff member (CNA 4) when providing care to a resident (Resident F) who was in Enhanced Barrier Precautions (EBP) for 1 random observation for infection control. Findings include: 1. During an observation on 5/12/25 at 8:07 a.m., LPN 3, entered Resident S's room and performed a glucometer test. After the test was completed, LPN 3 removed her gloves and exited the room and placed the glucometer in the top drawer of the medication cart with sanitizing the monitor. During an interview on 5/12/25 at 8:15 a.m., LPN 3 indicated the glucometer was to be sanitized after each…

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

Based on record review and interview, the facility failed to ensure the resident's physician was notified of medication being held for 1 of 1 resident reviewed for notification of change. (Resident T) Finding includes: The record for Resident T was reviewed on 5/14/23 at 12:33 p.m. Diagnoses included, but were not limited to, kidney failure, hypotension (low blood pressure), and heart failure. The admission Minimum Data Set (MDS) assessment, dated 3/31/25, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 3/25/25, indicated the resident was to receive Midodrine (medication that increases blood pressure) 5 milligrams (mg) three times a day for hypotension. A Nurses Note, dated 5/2/25 at 8:10 a.m., indicated a medication administration note documented a blood pressure (BP) of 156/86. A Nurses Note, dated 5/2/25 at 1:14 p.m., indicated a medication administration note documented a blood pressure of 155/92. A Nurses Note, dated 5/12/25 at 9:07 a.m., indicated a medication administration note documented a blood pressure of 156/86. The…

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

Based on observation, record review and interview, the facility failed to assist a dependent resident with incontinent care in a timely manner related to a delay in answering the call light for 1 of 5 residents reviewed for activities of daily living (ADLs). (Resident J) Finding includes: During an observation on 5/12/25 at 5:15 a.m., the call light for Resident J's room was activated. At 5:47 a.m., the Director of Nursing (DON) responded to the call light and indicated Resident J had reported he had a bowel movement and needed care. At 5:49 a.m., CNA 2 entered the resident's room and began care. The resident had been incontinent of bowel. Resident J's record was reviewed on 5/14/25 at 8:04 a.m. The diagnoses included, but were not limited to, end stage renal disease with dialysis required and stroke. A Care Plan, dated 1/31/25, indicated there was a risk for skin breakdown. The intervention included assistance with incontinent care would be provided. A Quarterly Minimum Data Set (MDS) assessment, dated 3/14/25, indicated a moderately impaired cognitive status and was dependent 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 record review and interview, the facility failed to ensure residents received appropriate treatment and care to meet their needs related to blood sugars not monitored, insulin not administered, treatment not given for a low blood sugar, and a blood pressure medication not held as ordered for low blood pressure for 3 of 3 residents reviewed for medications/diabetic care. (Residents D, K, and L) Findings include: 1. Resident D's record was reviewed on 5/12/25 at 10:51 a.m. The diagnoses included, but were not limited to, diabetes mellitus. A Care Plan, dated 6/19/24, indicated a risk for complications related to insulin depended diabetes mellitus. The interventions included, signs and symptoms of hyperglycemia and hypoglycemia were to be monitored. A Physician's Order, dated 11/22/24, indicated the blood sugar (BS) level was to be checked at 8 a.m. and 8 p.m. The physician was to be notified if the BS was below 70 or above 400. A Physician's Order, dated 11/22/24, indicated lantus insulin 35 units was to be administered two times a day for diabetes mellitus. A Physician's…

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

Based on observation and interview, the facility failed to ensure medications were properly labeled and stored for 1 of 3 medication carts observed. (Cherry Lane medication cart). Finding includes: On 5/12/25 at 2:15 p.m., the Cherry Lane Medication Cart was observed with RN 1. The following medications were not labeled or stored properly: a. There were 9 Albuterol sulfate inhalation packets that were stored in the bottom drawer; there was no label on any of the 9 packets. During an interview at the time, RN 1 indicated she did not know to which residents the Albuterol packets belonged. b. There were 2 inhalers in the top drawer that had no name or label. c. There was an inhaler in the top drawer with Resident U's name and room number listed, but there were no administration instructions. d. There was an Albuterol Sulfate Inhalation packet in the top drawer with no label. During an interview at the time, RN 1 indicated she was unsure why the medications were not labeled because the medication cart had been audited recently. During an interview on 5/12/25 at 2:30 p.m., the Director…

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 urinalysis (UA) was collected as ordered for 1 of 1 resident reviewed for infections. (Resident M) Finding includes: The record for Resident M was reviewed on 5/13/25 at 11:17 a.m. The diagnoses included, but were not limited to, cellulitis, diabetes, and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/5/25, indicated the resident was cognitively intact for daily decision making. A Nurse's Note, dated 4/27/25 at 11:30 p.m., indicated the Resident's daughter had called and explained her mother was confused and thought she had to go to work. The resident's daughter indicated she believed she had a urinary tract infection (UTI). A Nurse's Note, dated 4/28/25 at 10:19 a.m., indicated the resident was exhibiting increased intermittent confusion. Labs and a UA were ordered. A Physician's Order, dated 4/29/25, indicated to obtain a urinalysis related to altered mental status. A Physician's Order, dated 5/1/25, indicated to obtain a lab urinalysis with reflex culture for increased confusion. 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 observation, record review and interview, the facility failed to ensure proper medication storage related to medications prepared in advance, pre-filled saline syringes used to flush PICC (peripherally inserted central catheter) lines and not stored securely, medications and keys left unattended, insulin pens not labeled when opened, and loose pills observed in the medication carts for 1 of 2 units (The Main Station Unit) This had the potential to affect all residents receiving medications from LPN 2. Findings include: 1. During a random observation on 1/23/25 at 5:29 a.m., an unattended medication cart was observed on the Main Station unit. There were seven pre-poured medications in plastic cups on the top of the medication cart with the resident's first name on each of the cups. The medication cart keys were on top of the cart, as well as a box of Ciprofloxacin eye drops, and two bingo (punch out) cards of 30 pills each of Losartan (a medication used to lower the blood pressure) and Finasteride (a medication used for prostate enlargement). During an interview on 1/23/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to a Nurse Practitioner (NP) failing to perform hand hygiene after glove removal, enhanced barrier precautions (EBP) not followed while emptying an indwelling Foley catheter and for a resident with a peripherally inserted central catheter (PICC), disposal of a lancet in the garbage can, and glove use in the hallway during random infection control observations. (Residents 82, C, 12, and F) Findings include: 1. During a random observation on 1/22/25 at 1:25 p.m., Resident 82 was observed in his room getting dressed. At 1:30 p.m., an Intravenous (IV) nurse entered the room to insert a PICC line so the resident could start his IV antibiotic therapy for an Urinary Tract Infection. At 1:33 p.m., the IV nurse walked out of the room wearing gloves to both of his hands and continued to walk all the way down the hallway to the nurses' station. At 1:35 p.m., he walked back into…

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 keep the resident's environment clean and in good repair related to marred walls, marred and dirty floors, marred and dirty heat registers, missing toilet paper holders, feces on bed linen, feces on a shared room divider, cracked ceiling tile, a call light not working, and hot water temperatures above 120 degrees on 5 of 5 units throughout the facility. (Cherry Lane, Cherry Court, Blueberry Lane, Apple Lane and Bakersfield Lane). Findings include: During the Environmental tour with the Maintenence Director on 1/29/25, the following was observed: 1. Cherry Lane a. room [ROOM NUMBER]: The room divider between the resident beds had smeared feces on it. The divider was shared between 2 residents. b. room [ROOM NUMBER]-2: The residents bed linen had visible feces stains on them. The resident asked multiple times for clean bed linen and was not granted clean bed linen. Two residents shared this room. c. room [ROOM NUMBER]-2: The room had marred walls along the…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had Physician's Orders to self-administer for 1 of 1 resident reviewed for self-administration of medication. (Resident G) Finding includes: During random observations on 1/21/25 at 11:28 a.m. and 2:56 p.m., on 1/22/25 at 9:45 a.m., 1:31 p.m. and 3:10 p.m., and on 1/23/25 at 5:45 a.m., an Albuterol hand-held inhaler was observed on Resident G's over bed table. During an interview on 1/21/25 at 11:30 a.m., the resident indicated she used the inhaler for rescue breathing at least daily. The record for Resident G was reviewed on 1/22/25 at 4:23 p.m. Diagnoses included, but were not limited to COPD (Chronic Obstructive Pulmonary Disease), acute respiratory failure, Alzheimer's disease, anxiety disorder, high blood pressure, and bipolar disorder. The 11/14/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident's vision was adequate and she wore glasses. A Care Plan,…

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

Based on observation and interview, the facility failed to ensure a resident's privacy was maintained related to a Nurse Practitioner (NP) completing an assessment of a peg tube (a tube inserted directly into the stomach for nutrition) in a common area for 1 of 1 resident reviewed for tube feeding. (Resident C) Finding includes: During a random observation on 1/28/25 at 11:34 a.m., a CNA removed Resident C from the dining room when the lunch trays had arrived, due to the resident being NPO (nothing my mouth). The resident was placed in the hallway right outside of the room. At that time, an NP entered the memory care unit and asked the Infection Prevention Nurse for a pair of gloves. The NP donned the pair of gloves and lifted up the resident's shirt to observe the peg tube (a tube inserted directly into the stomach for nutrition) in the middle of the hallway. She did not take the resident to a private area to make her assessments. The resident's stomach and peg tube were exposed for all to see. The record for Resident C was reviewed on 1/27/25 at 2:03 p.m Diagnoses included, but…

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

Based on record review, and interview, the facility failed to file a grievance form, thoroughly investigate, and resolve grievances for missing personal items that were reported to staff for 1 of 1 resident reviewed for grievances. (Resident 23) Finding includes: During an interview on 1/21/25 at 9:52 a.m., Resident 23 indicated she was missing a teal blue outfit and had told many people about the issue. The outfit had been missing for over 2 months and nothing was done about it. On 1/27/25 at 10:23 a.m., The resident was observed in her wheelchair watching she television. She indicated she had not filed a grievance for the missing clothing. She indicated she spoke with laundry staff and she had no follow up. The record for Resident 23 was reviewed on 1/27/25 at 10:00 a.m. Diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body), hypertension (high blood pressure), depression, anemia (low iron), and stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 10/27/24, indicated the resident was cognitively intact. The resident had impairment on…

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

Based on record review and interview, the facility failed to ensure residents were involved in decisions about their care related to informing them of new medications for 1 of 7 residents reviewed for participation in care planning. (Resident D) Finding includes: During an interview on 1/21/25 at 2:49 p.m., Resident D indicated the staff did not always tell or inform him of new medications or new physician's orders. The record for Resident D was reviewed on 1/22/25 at 4:10 p.m. Diagnoses included, but were not limited to, acute respiratory failure, COPD (Chronic Obstructive Pulmonary Disease) type 2 diabetes mellitus (DM), heart failure, high blood pressure, chronic kidney disease, osteoarthritis, and depression. The 12/2/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed substantial to maximal assistance with bathing and/or showering. A Physician's Order, dated 12/4/24, indicated Amlodipine 10 milligrams (mg), give one tablet in the morning for high blood pressure. Physician's Orders, dated 1/9/25,…

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

Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to receiving showers and assistance with eating for 3 of 9 residents reviewed for ADLs. (Residents D, C, and E) Findings include: 1. During an interview on 1/21/25 at 2:44 p.m., Resident D indicated he was not getting showers on Saturdays. He indicated his showers were supposed to be Wednesdays and Saturdays in the evening time. The record for Resident D was reviewed on 1/22/25 at 4:10 p.m. Diagnoses included, but were not limited to, acute respiratory failure, COPD (Chronic Obstructive Pulmonary Disease) type 2 dm, heart failure, high blood pressure, chronic kidney disease, osteoarthritis, and depression. The 12/2/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed substantial to maximal assistance with bathing and/or showering. The resident did not receive a shower at least two times a week for the months of 10/2024, 11/2024, and 1/2025. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure non-pressure areas were monitored, assessed, and bandages were changed for 1 of 1 resident reviewed for skin conditions non-pressure related, blood pressure parameters were followed for 1 of 1 resident reviewed for dialysis, and a resident was assessed and monitored post cataract surgery for 1 of 1 resident reviewed for vision and hearing. (Residents G and 82) Findings include: 1. During an interview 1/21/25 at 11:28 a.m., Resident G indicated her double vision was back and she had told the staff about it. She indicated she had cataract surgery a couple of months prior and was afraid something else was wrong. The record for Resident G was reviewed on 1/22/25 at 4:23 p.m. Diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), acute respiratory failure, Alzheimer's disease, anxiety disorder, high blood pressure, and bipolar disorder. The 11/14/24 Quarterly Minimum Data Set (MDS) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure pressure ulcer treatments were completed as ordered and IV (intravenous) antibiotics for a wound infection were administered as ordered for 1 of 1 resident reviewed for pressure ulcers. (Resident F) Finding includes: On 1/21/25 at 10:15 a.m., Resident F was observed lying in bed. At that time, he was observed with a PICC (peripherally inserted central catheter) in his right upper arm. There were no IV antibiotics infusing at that time. From 10:15 a.m. until 11:40 a.m., there was no IV antibiotic administered to the resident. On 1/22/25 at 9:45 .a.m., the resident was observed in bed. At that time, there was an IV antibiotic bag hanging on the pole that had already infused. The medication was Meropenem with 1/22/25 at 5:00 a.m. handwritten on the label. During a random observation on 1/23/25 at 6:55 a.m. of the medication room on the main station, there were 2 IV antibiotic bags of Vancomycin in one plastic bag that had arrived to the facility on…

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

Based on observation, record review, and interview, the facility failed to ensure the resident received the necessary treatment and foot care related to podiatry visits for 1 of 1 resident reviewed for podiatry care. (Resident 69) Finding includes: On 1/22/25 at 2:37 p.m., Resident 69 indicated he wanted his toe nails cut down and they were too long. He had told every staff member who entered his room this request multiple times. On 1/23/25 at 2:30 p.m., Resident 69 was observed lying in bed watching television. He indicated again that he wanted his toes nails cut and felt his request was going unheard. He indicated he was not senile, his mind was sharp, and he knew what he needed and wanted. Resident 69's toe nails were observed to be long and unkempt looking. He indicated the podiatrist had not cut his nails in months and the staff would not cut his toe nails either. The record for Resident 69 was reviewed on 1/23/25 at 1:39 p.m. Diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic…

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

Based on observation, record review, and interview, the facility failed to ensure smoking materials were locked in a safe place and not in the residents' rooms for 2 of 2 residents reviewed for smoking and halos were on a resident's bed as ordered for 1 of 1 resident reviewed for falls. (Residents G, F and H) Findings include: 1. During a random observation on 1/21/25 at 11:18 a.m., Resident G was sitting on the side of the bed. At that time, there was a vape (electronic cigarette) laying on the bed next to her. During an interview at that time, the resident indicated she kept the vape with her at all times, but only used it when she went outside to smoke. The record for Resident G was reviewed on 1/22/25 at 4:23 p.m. Diagnoses included, but were not limited to COPD (Chronic Obstructive Pulmonary Disease), acute respiratory failure, Alzheimer's disease, anxiety disorder, high blood pressure, and bipolar disorder. The 11/14/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Care Plan, revised on 10/23/23,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an interview on 1/21/25 at 2:23 p.m., Resident 49 indicated the staff does not drain his catheter bag all night or day, he had to call 911 to get his catheter exchanged, and they do not flush or clean his catheter. On 1/21/25 at 3:39 p.m., the resident had lifted his shirt to show his stomas site and catheter. The catheter was dirty and dried crusted blood around insertion site. On 1/22/25 at 2:58 p.m., the resident indicated no one had cleaned his catheter site today, and they did not flush his catheter yet. The resident lifted his shirt to show his catheter. The catheter was dirty and dried crusted blood remained around the insertion site. The record was reviewed for Resident 49 on 1/22/24 at 2:11 p.m. Diagnoses included, but were not limited to, depression, chronic obstructive pulmonary disease (COPD), quadriplegia, muscle wasting and anxiety. The Quarterly (MDS) assessment, dated 12/18/24, indicated the resident was cognitively intact for daily decision making. Resident had an indwelling catheter.…

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 food consumption logs and supplements were completed for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents F and 82) Findings include: 1. During an interview on 1/21/25 at 10:51 a.m., Resident F indicated he had lost a lot of weight. He was supposed to receive double portions for all the meals, but breakfast was skimpy at times. He had only received 1 serving of scrambled eggs for breakfast that morning. The record for Resident F was reviewed on 1/22/25 at 1:35 p.m. Diagnoses included, but were not limited to, sepsis, osteomyelitis, arthritis, anxiety, major depressive disorder, pressure ulcer, paraplegia, schizophrenia, and neuromuscular of the bladder. The 10/10/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had a Foley (urinary) catheter. The resident had no oral problems, weighed 118 pounds with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor a fluid restriction for 1 of 1 resident reviewed for dialysis. (Resident 82) Finding includes: The record for Resident 82 was reviewed on 1/23/25 at 6:17 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute myocardial infarction, renal and perinephric abscess, renal dialysis, anemia, chronic kidney disease, depression, and, end stage renal disease. The 12/24/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making. He had an indwelling Foley catheter and received dialysis on admission and while a resident. A Care Plan, revised on 12/18/24, indicated the resident was at risk for altered fluid balance related to dialysis and fluid restriction. A Physician Order, dated 12/8/24, indicated for the resident to only have 1200 cubic centimeters (cc) of fluids per day for chronic kidney disease: dietary 780 cc and nursing 420 cc every…

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

Based on observation, record review, and interview, the facility failed to ensure a resident received routine dental services related to decayed and broken teeth for 1 of 3 residents reviewed for dental services. (Resident 73) Finding includes: During an interview on 1/21/25 at 2:57 p.m., Resident 73 indicated the facility was supposed to follow up with the dentist after she cracked her tooth. She had seen a dentist over a year ago and he indicated she needed an extraction. There had been no follow up since. The record for Resident 73 was reviewed on 1/22/25 at 1:55 p.m. Diagnoses included, but were not limited to, anxiety disorder, depression, kidney failure, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 12/24/24, indicated the resident was cognitively intact. The resident had no cracked, loosed, or chipped teeth. There was no dental care plan. A Dental Note, dated 11/22/23, indicated the resident required an oral surgeon for extraction of #14 and #16 root tips. A Social Service Note, dated 12/7/2023 at 11:59 a.m., indicated the…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was given the opportunity to participate in their treatment, including understanding the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, related to medication administration for 1 of 4 residents observed during medication administration. (Resident F) Finding includes: On 12/18/24 at 8:25 a.m., LPN 1 was observed preparing medications for Resident F. She prepared five tablets and gave them to the resident. She did not have the resident's inhaler. She exited the room and signed the medications out on the electronic medication record. She indicated at that time he did not get his inhaler, as he always refused it. The resident's record was reviewed on 12/18/24 at 9:15 a.m. A Physician's Order indicated to give Anora Ellipta (medication used to treat chronic obstructive pulmonary disease) 62.5/25 micrograms one inhalation daily. During an interview on 12/18/24 at 9:50 a.m., the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident with ongoing sexual behaviors was monitored and behaviors were documented for 1 of 3 residents reviewed for abuse. (Resident C) Finding includes: An Indiana State Department of Health Reportable Event, dated 10/24/24, indicated Resident C had entered Resident B's room and displayed inappropriate sexual behaviors. Resident B alerted staff and Resident C left the area. The Physician was contacted and orders were received to send Resident C out for psychiatric monitoring and stabilization. The resident was hospitalized from [DATE] to 11/5/24. The record for Resident C was reviewed on 12/17/24 at 2:10 p.m. Diagnoses included, but were not limited to, multiple sclerosis, tachycardia and mood disorder. The Quarterly Minimum Data Set assessment, dated 11/15/24, indicated the resident was cognitively intact and required supervision for toileting, eating and bed mobility. No behaviors were noted. A Physician's Order, dated 11/13/24, indicated…

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

Based on observation, record review, and interview, the facility failed to ensure medications were ordered and available timely, including staff being aware of stocked backup medications for 2 of 4 residents observed during medication administration. (Residents G and H) Findings include: 1. On 12/18/24 at 8:39 a.m., QMA 1 was observed preparing medications for Resident G. She indicated the resident was out of the prednisone 5 milligram (mg) tablet. She indicated she would notify the nurse. During an interview on 12/18/24 at 9:50 a.m., LPN 2 indicated prednisone 5 mg was in the Capsa (automated device that stores routine medications) machine. She was made aware Resident G had not received the prednisone and indicated she would give it at that time. A Medication Note, dated 12/18/24 at 8:59 a.m., was created at 10:00 a.m. by the DON. The note indicated prednisone 5 mg had been ordered from the pharmacy and would be delivered stat (asap). The Physician had been notified and indicated to give the medication when it arrived. During an interview on 12/18/24 at 9:50 a.m., the DON indicated…

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

Based on record review and interview, the facility failed to ensure a resident-initiated discharge was documented in the resident's medical record and appropriate information was given to the resident for continuation of care, related to a list of medications the resident received at the facility not sent with a resident and no documentation of the resident's status at the time of discharge. Finding includes: Resident B's record was reviewed on 9/16/24 at 9:12 a.m. The diagnoses included, but were not limited to, anterior cervical discectomy and fusion of the cervical 5-6 and 6-7 discs. The facility admission date was 8/28/24. A Social Service Assessment, dated 8/29/24, indicated an intact cognitive status. A Release of Responsibility for Discharge Against Advice form, signed by the resident on 9/5/24, indicated the resident assumed full responsibility for being discharged against the advice of the Attending Physician and Facility Administration. The resident was informed of the risks involved in discharging AMA. The signed form released the Attending Physician and the facility from…

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

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to foley catheter drainage bags not being covered for 1 of 2 residents with urinary catheters. (Resident H) Finding includes: On 8/13/24 at 11:55 a.m., 2:00 p.m., and 4:25 p.m., Resident H was observed in their room in bed. The resident's foley catheter drainage bag contained yellow urine and the bag was visible from the doorway. On 8/14/24 at 8:30 a.m., 9:37 a.m., and 10:38 a.m., the resident was observed in their room in bed. The resident's foley catheter drainage bag contained yellow urine and the bag was visible from the doorway. On 8/15/24 at 8:29 a.m. and 11:03 a.m., the resident was observed in their room in bed. The resident's foley catheter drainage bag contained yellow urine and the bag was visible from the doorway. The record for Resident H was reviewed on 8/14/24 at 10:21 a.m. Diagnoses included, but were not limited to, chronic kidney disease and pressure ulcer of the sacrum (a triangular bone at the base of the spine). The Quarterly Minimum…

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

Based on observation, record review, and interview, the facility failed to ensure a Physician's Order for self administration of medications and an assessment to self-administer medications was completed, for 1 of 1 resident reviewed for self-administration of medications. (Resident B) Finding include: On 8/13/24 at 1:16 p.m., LPN 1 was observed leaving a medicine cup with 14 white circular pills on the bedside table in the room with Resident B. LPN 1 walked out of Resident B's room. Resident B began to administer their own medications. During an interview at that time, the resident indicated the pills were Methadone and they always took the medication independently. During an interview on 8/13/24 at 1:19 p.m., LPN 1 indicated she walked away from the resident while administering her medication, she had no reason and was aware the resident did not have a self administration order. Resident B's record was reviewed on 8/13/24 at 9:45 a.m. Diagnoses included, but were not limited to, end stage renal disease, diabetes, hypertension, and renal dialysis. The admission Minimum Data Set…

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

Based on observation, record review, and interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL's) received assistance with incontinence care in a timely manner for 1 of 3 residents reviewed for ADL's. (Resident G) Finding includes: During an interview on 8/13/24 at 1:19 p.m., Resident G indicated they were not checked or changed every 2 hours and they had not been changed all day. LPN 2 and CNA 1 entered the resident's room on 8/13/24 at 1:35 p.m. to provide incontinence care. CNA 1 indicated the resident's assigned CNA was giving a bed bath so she was going to provide care. The resident's brief was saturated with urine and the bath blanket underneath the resident was wet as well. At the completion of incontinence care, the resident indicated that was the first time they were changed for the day and the last time was around 2:00 a.m. During an interview on 8/13/24 at 1:56 p.m., CNA 3, who was assigned to the resident, indicated she had not provided incontinence care for the resident because the resident would tell her when…

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

Based on observation, record review, and interview, the facility failed to ensure treatments were completed as ordered for non-pressure skin conditions for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident G) Finding includes: During an observation of incontinence care on 8/13/24 at 1:35 p.m., Resident G had a hydrocolloid (a bandage used to treat uninfected wounds) bandage in place to the left ischial area (the lower hip bone area). During an interview at that time, CNA 1 indicated the dressing was dated 8/12/24. LPN 2, who was also in the room, indicated the dressing was a hydrocolloid dressing and it was dated 8/12/24. The record for Resident G was reviewed on 8/14/24 at 8:55 a.m. Diagnoses included, but were not limited to, morbid obesity, cellulitis (a bacterial skin infection), and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 7/2/24, indicated the resident was cognitively intact. The resident was dependent on staff for toilet transfers and was frequently incontinent of bladder and bowel. A Physician's Order, dated 8/7/24, indicated…

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

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for a resident with a history of falls related to the bed being in a low position for 1 of 3 residents reviewed for falls. (Resident H) Finding includes: On 8/14/24 at 8:30 a.m., Resident H was observed in their room in bed eating a piece of toast. The bed was in a high position and a floor mat was present on the left side of the bed. At 9:37 a.m. and 10:38 a.m., the resident remained in bed. The bed was positioned at a medium height and was not low to the floor. On 8/15/24 at 8:29 a.m., the resident was in their room in bed. The resident's breakfast was on the over bed table and they were asking to be repositioned. The resident's bed was at a medium height at the time. CNA 2 entered the resident's room to provide assistance. During an interview at that time, CNA 2 indicated the resident's bed could go lower. She then demonstrated how low the bed could go, then indicated she didn't want to lower the bed all the way to the floor, otherwise the resident's foley catheter…

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

Based on observation, record review, and interview, the facility failed to ensure urinary catheter drainage bags were not placed on the floor for a resident with a history of urinary tract infections for 1 of 2 residents reviewed for urinary catheters. (Resident F) Finding includes: On 8/14/24 at 8:28 a.m., Resident F was observed in their room in bed. During an interview at that time, the resident indicated to look at their urinary catheter drainage bag. The drainage bag was observed on the floor next to the bed and in need of emptying. The resident indicated the midnight shift did not empty the drainage bag or pick the bag up off of the floor. Resident B had requested a wash basin to put their drainage bag in so it wouldn't rest on the floor but was told that wasn't allowed. On 8/14/24 at 10:30 a.m., the resident's catheter drainage bag had been emptied but remained on the floor. On 8/15/24 at 8:27 a.m., the resident was again observed in bed. The catheter drainage bag was full and on the floor next to the bed. At 8:31 a.m., Nurse Consultant 1 was brought to Resident F's room 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 clinical records were complete and accurately documented related to insulin administration for 1 of 3 residents reviewed for insulin use. (Resident L) Finding includes: The record for Resident L was reviewed on 8/15/24 at 10:10 a.m. Diagnoses included, but were not limited to, type 2 diabetes and vascular dementia. The Annual Minimum Data Set (MDS) assessment, dated 7/20/24, indicated the resident was moderately impaired for daily decision making and was receiving insulin. A Care Plan, reviewed on 7/14/24, indicated the resident was at risk for complications related to the diagnosis of diabetes mellitus. Interventions included, but were not limited to, diabetes medication as ordered by the physician. Monitor/document for side effects and effectiveness. A Physician's Order, dated 7/14/24, indicated the resident was to receive Lantus insulin 10 units at bedtime. The July 2024 Medication Administration Record (MAR) indicated the insulin was not signed out as being given on 7/14, 7/22, 7/27, and 7/31/24. During 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 record review and interview, the facility failed to ensure employees (Confidential Interview 2 and Terminated Employee 6) reported allegations of abuse by an employee (Employee 7) toward residents of the Memory Care Unit to the Administrator. This had the potential to affect 18 residents who resided on the Memory Care Unit. Finding includes: During an interview, Confidential Interview 5 indicated Employee 7 would make fun of the residents and would call the residents by derogatory names. They had never seen physical harm done to the residents. They indicated this had been going on but it had not been reported. They felt when abuse was reported nothing was ever done and the facility didn't care. The Administrator was immediately notified and indicated this was the first time she had been made aware of this allegation. During an interview on 7/2/24 at 11:51 a.m., Terminated Employee 6 indicated Employee 7 had told her she would hit the resident when no one could see her. Terminated Employee 6 was unable to provide names of residents. Employee 7 would threaten other staff if…

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

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by a staff members (RN 8), when providing care to a resident (Resident D) who was in Enhanced Barrier Precautions (EBP). This had the potential to affect 21 residents who reside on the Blueberry Lane Unit ( 1 of 5 Units) Finding includes: During an observation on 7/1/24 at 10:02 a.m., Resident D was observed lying in bed #2 in the room. The resident had an indwelling urinary catheter and the drainage bag was covered. There was a sign on the door that indicated the resident was in EBP and PPE was to be worn during care. There was PPE located next to the door outside of the room. Resident D's record was reviewed on 7/1/24 at 1:14 p.m. The diagnoses included, but were not limited to, fracture of the left femur. A Physician's Order, dated 6/28/24 at 4:24 p.m., indicated a urinary catheter was present and was to be changed every month and as needed for leakage or blockage. During an observation on 7/2/24 at 6:13 a.m., RN 8 was standing next 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.

Based on observation, interview, and record review, the facility failed to ensure care planned interventions to prevent falls were in place, related to anti-roll brakes not initiated in a timely manner for 1 of 4 residents reviewed for falls and accidents. (Resident D) Finding includes: During an observation on 7/1/24 at 3 p.m., Resident D was sitting in her wheelchair in activities. There were no anti-roll back brakes on the wheelchair. During an observation on 7/2/24 at 5:04 a.m., the resident was in bed. The wheelchair was beside the bed and there were no anti-roll back brakes on the wheelchair. During an observation on 7/2/24 at 6:13 a.m., there were no anti-roll back brakes on the wheelchair. RN 8 was in the room and acknowledged the anti-roll back brakes were not on the wheelchair. During an interview on 7/2/24 at 6:15 a.m., the Director of Nursing (DON) indicated the Fall Care Plan indicated the anti-roll back brakes would be used when available and they had been ordered. She presented an e-mail, dated 6/26/24 that indicated the brakes had been requested. The e-mail, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident who was admitted with a urinary catheter had a correct assessment of the catheter, physician orders for the catheter, and a documented reason for the catheter. The facility failed to ensure urinary catheter care was completed and the urinary catheter was monitored, for 1 of 2 residents reviewed for urinary catheter care. (Resident G) Finding includes: Resident G's closed record was reviewed on 7/1/24 at 3:12 p.m. The diagnoses included, but were not limited to, cellulitis of the left lower limb and benign prostatic hyperplasia (BPH). A Hospital Discharge summary, dated [DATE], indicated the resident would be discharged with a urinary catheter. An admission Nursing Assessment, dated 6/5/24 at 10:55 p.m., completed by LPN 1, indicated the resident was continent of urine and a toilet and incontinent briefs were used. The resident's urine was clear and the resident did not have a urinary catheter. The Baseline Care Plan, dated 6/5/24,…

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

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and Wound Nurse), when providing care to a resident who was in Enhanced Barrier Precautions (EBP), and failed to remove soiled gloves before touching clean surfaces for 1 of 1 random observations for infection control. (Resident D) This had the potential to affect the residents on 4 of 5 Units (Cherry, Blueberry, Apple, and Cherry Lane) and 18 residents who received wound care where staff should use EBP. Finding includes: During an observation on 5/28/24 at 8:27 a.m., Resident D had a sign on the outside of the entry door to her room, which indicated Enhanced Barrier Precautions (EBP) were to be used when providing care. The sign indicated the EBP was to be used for Bed 1 and 2. There was a storage cart with the PPE in the hallway outside of the entry door. Resident D's record was reviewed on 5/28/24 at 12:19 p.m. The diagnoses included, but were not limited to, end stage kidney disease with hemodialysis. A Quarterly Minimum…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was treated with respect and dignity related to not assisting the resident to the bathroom upon request, for 1 of 6 residents reviewed for respect and dignity. (Resident G) Finding includes: During an observation on 5/29/24 at 8:02 a.m., Resident G had activated the call light. On 5/29/24 at 8:09 the call light was observed not on. During an observation and interview on 5/29/24 at 8:12 a.m., Resident G had activated the call light. The resident was sitting on the side of the bed and the wheelchair was next to the bed. She indicated she needed to use the bathroom. Human Resources entered the room and asked the resident if she needed help and was informed by the resident she needed to use the bathroom. Human Resources left the call light on and informed the resident she would get a staff member to help her and left the room. The resident then indicated a man had came into her room earlier and she informed him she needed to use the bathroom. He had informed her she would have to wait because…

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

Based on observation, record review, and interview, the facility failed to ensure a resident who required maximum to dependent care received incontinent care in a timely manner, for 1 of 3 residents reviewed for incontinent care. (Resident D) Finding includes: During an observation and interview with Resident D on 5/28/24 at 8:27 a.m., she was lying on her back in bed wearing a hospital gown. The head of the bed was elevated. She indicated the facility staff checked her 2-3 times a day for incontinence of bowel and bladder. Resident D's record was reviewed on 5/28/24 at 12:19 p.m. The diagnoses included, but were not limited to, vascular dementia and bilateral above the knee amputations. A Quarterly Minimum Data Set (MDS) assessment, dated 4/8/24, indicated an intact cognition, no behaviors, impairment of the bilateral lower extremities, dependent for transfers, required maximum assistance for toileting, and was always incontinent of bowel and bladder. A Care Plan, revised on 1/22/24, indicated the resident had bowel and bladder incontinence. The interventions 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.

Based record review and interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, related to a fracture after a fall not investigated thoroughly for 1 of 6 residents reviewed for quality of care. (Resident E) Finding includes: Resident E's record was reviewed on 5/29/24 at 8:39 a.m. The diagnoses included, but were not limited to fractured left femur 4/11/24 and falls. A Significant Change MDS assessment, dated 4/18/24, indicated a severely impaired cognitive status, required moderate assistance with bed mobility and maximum assistance with transfers, and had no falls since re-admission into the facility. A Nurse's Progress Note, dated 4/4/24 at 10:30 p.m., indicated the resident was observed laying on the floor in front of the wheelchair. Emergency Medical Services (EMS) were notified. There were no obvious signs of injury. The level of consciousness was at baseline. The resident denied hitting her head. There was limited range of motion to the bilateral upper extremities and range of motion was tolerated…

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 care planned interventions to prevent injuries due to a fall were in place, related to floor mats not in place next to the bed and anti-roll brakes not on the wheelchair. The facility also failed to ensure an intervention initiated to prevent further falls was completed related to a urinalysis not obtained, for 2 of 3 residents reviewed for falls. (Residents D and E) Findings include: 1. During observations on 5/28/24 at 8:27 a.m. and 1:25 p.m., Resident D was lying in bed with the head of the bed elevated. The bed was elevated approximately two and a half feet off the ground. There was no mat on floor next to the bed. Resident D's record was reviewed on 5/28/24 at 12:19 p.m. The diagnoses included, but were not limited to, vascular dementia and bilateral above the knee amputations. A fall risk assessment, dated 4/3/24, indicated a high risk for falls. A Quarterly Minimum Data Set (MDS) assessment, dated 4/8/24, indicated an intact cognition, no behaviors, impairment of the bilateral lower extremities,…

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

Based on observation, record review, and interview, the facility failed to ensure a resident had Physician's Orders and an assessment to self-administer medication, for 1 of 1 resident reviewed for self-administration of medications. (Resident C) Finding includes: During an observation, on 3/25/24 at 1:22 p.m., Resident C was observed in bed in her room. There was a canister of fluticasone propionate and salmeterol (inhaler for difficulty breathing) 100 mcg (micrograms)/50 mcg on her over the bed table in front of her. She indicated that she self-administered the inhaler. During an observation, on 3/27/24 9:27 a.m., the resident was in bed. There was a canister of fluticasone propionate and salmeterol on the over the bed table. She indicated she self-administered the inhaler twice a day and it was her own personal medication brought from home. The record for Resident C was reviewed on 3/27/24 at 10:05 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and asthma. The Quarterly Minimum Data Set (MDS) assessment, dated 3/13/24, indicated the resident was…

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

Based on record review and interview, the facility failed to ensure a resident's Responsible Party was notified of a change in condition, related to pressure sores, for 1 of 3 residents reviewed for notification of family/Responsible Party. (Resident D) Finding includes: Resident D's closed record was reviewed on 3/25/24 at 2:02 p.m. The diagnoses included, but were not limited to, pneumonia, respiratory failure, and dementia. The resident was re-admitted from the hospital on 2/8/24. Cross reference F686. A Nurse Practitioner (NP) Progress Note, dated 2/13/24 at 9:08 a.m., indicated the resident was observed in a soiled bed and an unstageable pressure ulcer was observed on the coccyx. The Wound Care Nurse and Director of Nursing were notified and the resident was placed on a low air loss bed. The area was described by the NP as a bruising wound. There was no documentation that indicated the family/Responsible Party had been notified of the new pressure ulcer. A facility skin condition policy, dated 9/1/20 and received as current from the Nurse Consultant, indicated, at the earliest…

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 identify unresolved quality deficiencies, some of which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiencies through the quality assessment and assurance (QAA) process, as evidenced by the number of repeated deficiencies cited for pressure ulcers related to not completing treatments as ordered and not completing weekly wound assessments. This deficient practice had the potential to affect 94 of 94 residents residing in the facility. Finding includes: Interview with the Administrator on 11/2/23 at 2:05 p.m., indicated the Quality Assessment and Assurance (QAA) Committee had a meeting on 10/19/23 and the committee consisted of the Medical Director, the Administrator, the Director of Nursing (DON), Infection Control Nurse, the Minimum Data Set (MDS) Nurse, the Food Sanitation Supervisor, the Social Service Director, the Activity Director and Maintenance. The Department Heads also met on a monthly basis. The Quality Assurance and Performance Improvement…

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 a resident with pressure ulcers received the treatment and services necessary to promote healing related to completing treatments as ordered and obtaining weekly measurements for 5 of 5 residents reviewed for pressure ulcers. (Residents 34, 46, 17, 41, and 85) Findings include: 1. On 10/30/23 at 2:20 p.m., Resident 34 was observed in his room in bed. The resident was positioned on a low air loss mattress and he had bilateral heel boots in place. The record for Resident 34 was reviewed on 10/31/23 at 10:04 a.m. Diagnoses included, but were not limited to, mild intellectual disabilities, history of behavioral disorder, schizophrenia, and palliative care. The Significant Change Minimum Data Set (MDS) assessment, dated 7/17/23, indicated the resident was cognitively impaired for daily decision making. He required extensive assistance with bed mobility and he was admitted to the facility with 2 Stage 4 (full thickness tissue loss with…

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

Based on observation, record review, and interview, the facility failed to store food under sanitary conditions related to outdated food in the reach in cooler and walk in cooler, clean lids stacked on top of each other, and a dirty griddle and convection ovens for 1 of 1 kitchens. (The Main Kitchen) This had the potential to affect the 91 residents who received food from the kitchen. Findings include: During the initial kitchen sanitation tour with [NAME] 1 on 10/29/23 at 8:47 a.m., the following was observed: a. The griddle was dirty with grease on the sides. All the convection oven doors were dirty on the inside as well crumbs on the top of the ovens. b. There were 4 homemade pizzas dated 10/24/23, 9 cheese sandwiches, and 8 peanut butter and jelly sandwiches dated 10/25/23 in the reach in cooler. c. There were containers of puree bread, cheese soup, and tossed salad all dated 10/24/23 in the walk in cooler. Interview with [NAME] 1 at that time, indicated they should have been discarded after 3 days. d. There were 50 clean dome lids that were stacked wet on top of each other.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a sanitary, safe, and homelike environment related to greasy kitchen pipes, rusty equipment, adhered dirt on floors, marred walls, scuffed doors and floors, cracked tile and missing window blinds for 1 of 1 kitchens and on 4 of 5 halls. (Main Kitchen, and Cherry, Apply, Blueberry and Bakersfield Hallways) Findings include: 1. During the initial kitchen sanitation tour with [NAME] 1 on 10/29/23 at 8:47 a.m., the following was observed: a. There was a large amount of lime build up on the faucet in the hand washing sink. b. The pipes behind the food equipment had a large amount of caked on grease and grime. c. The steamer was observed with rusty and broken knobs. d. There were rust spots on the shelf below the steamer and there was adhered dirt under the food prep tables and under the dish machine. Interview with the Dietary Food Manager on 11/1/23 at 9:30 a.m., indicated all of the above was in need of cleaning and/or repair. 2. During 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, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 76 and 195) Findings include: 1. During a random observation on 10/29/23 at 1:45 p.m., a bottle of Milk of Magnesia (MOM) was observed on Resident 76's bedside stand. Interview with the resident at that time, indicated he took the MOM once or twice a week for constipation. During random observations on 10/30/23 at 2:21 p.m. and 3:30 p.m., the MOM remained on the resident's bedside stand. During random observations on 10/31/23 at 9:58 a.m., 11:25 a.m., and 2:05 p.m., the MOM remained on the resident's bedside stand. During random observations on 11/1/23 at 9:20 a.m. and 11:15 a.m., the MOM remained on the resident's bedside stand. The record for Resident 76 was reviewed on 11/1/23 at 11:01 a.m. Diagnoses included, but were not limited to, type 2…

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

Based on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of medication changes for 1 of 1 residents reviewed for notification of change. (Resident B) Finding includes: The record for Resident B was reviewed on 10/31/23 at 2:46 p.m. Diagnoses included, but were not limited to, stroke, history of falls, and legally blind. The Quarterly Minimum Data Set (MDS) assessment, dated 7/13/23, indicated the resident was cognitively impaired for daily decision making. A Physician's Order, dated 6/17/23, indicated the resident was to receive Haloperidol Lactate Concentrate (an antipsychotic medication) 2 milligrams (mg) per milliliter (ml), give 2.5 mg daily. There was no documentation of the resident's Responsible Party being notified of the new medication order. A Physician's Order, dated 7/4/23, indicated the resident was to receive Zoloft (an antidepressant) 25 mg daily for major depression. There was no documentation of the resident's Responsible Party being notified of the new medication order. Interview with Nurse Consultant 2 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were invited to attend and participate in care planning conferences for 3 of 4 residents reviewed for participation in care planning. (Residents 76, 17, and 61) Findings include: 1. Interview with Resident 76 on 10/29/23 at 1:45 p.m., indicated he did not recall being invited to his care conference. The record for Resident 76 was reviewed on 11/1/23 at 11:01 a.m. Diagnoses included, but were not limited to, type 2 diabetes, and end stage renal disease. The Significant Change Minimum Data Set (MDS) assessment, dated 8/1/23, indicated the resident was cognitively intact. Social Service Progress Notes, dated 8/1/23 at 2:19 p.m., indicated the staff member met with the resident to discuss his annual assessment. There was no documentation about inviting the resident to his care conference. Social Service Progress Notes, dated 12/21/22 at 10:37 a.m., indicated the resident's plan of care was reviewed with him and his Power of Attorney (POA)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure dependent residents were provided assistance with activities of daily living (ADL's) related to assistance with shaving for 1 of 6 residents reviewed for ADL's. (Resident 85) Finding includes: On 10/29/23 at 1:05 p.m., Resident 85 was observed sitting in a broda chair in his room. He was unshaven. Interview with the resident at that time, indicated he could use a shave and he liked to be clean shaven. On 10/31/23 at 8:30 a.m., 2:00 p.m., and on 11/1/23 at 7:45 a.m., the resident was observed unshaven. The record for Resident 85 was reviewed on 10/30/23 at 2:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke, end stage renal disease, sepsis, renal dialysis, high blood pressure, chronic kidney disease, and left leg below the knee amputation. The admission Minimum Data Set (MDS) assessment, dated 8/24/23, indicated the resident was moderately impaired for decision making.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were able to see the Audiologist and Optometrist on a regular basis and referrals had follow up completed for 2 of 2 residents reviewed for communication and sensory. (Residents 17 and 61) Findings include: 1. During an interview on 10/29/23 at 9:42 a.m., Resident 17 indicated he had seen the eye doctor, however, he had not received his glasses. He also indicated he had trouble hearing but had not seen anyone for that issue. The record for Resident 17 was reviewed on 10/31/23 at 3:35 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, sepsis, type 2 diabetes, pressure ulcer, adult failure to thrive, renal dialysis, colostomy, high blood pressure, major depressive disorder, and neuromuscular dysfunction of the bladder. The Quarterly Minimum Data Set (MDS) assessment, dated 9/16/23, indicated the resident had some moderate impairment for decision making. His hearing and vision 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.

Based on random observations, record review, and interview, the facility failed to ensure oxygen humidification canisters were changed weekly for 1 of 2 residents reviewed for oxygen. (Resident 41) Finding includes: During random observations on 10/29/23 at 1:10 p.m. and 3:00 p.m., Resident 41 was observed in bed wearing oxygen at 2 liters with a humidification bottle on the concentrator. The bottle was dated 10/5/23. The record for Resident 41 was reviewed on 10/31/23 at 2:30 p.m. Diagnoses included, but were not limited to, chronic kidney disease, high blood pressure, angina, Parkinson's disease, atrial fibrillation, and anorexia. The 8/24/23 Modification of the Annual Minimum Data Set (MDS) assessment, indicated the resident rarely understood or understands and was severely impaired for decision making. He used oxygen as a resident of the facility. A Care Plan, revised on 8/21/23, indicated the resident required oxygen therapy. Physician's Orders, dated 7/6/23, indicated oxygen via nasal cannula at 2 liters per minute continuously. Change Oxygen tubing, mask, or cannula one time…

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 pain medications were available when requested, side effects were monitored, and the medication was signed out on the Medication Administration Record (MAR) as being administered for 2 of 2 residents reviewed for pain. (Residents 195 and 12) Findings include: 1. During an interview with Resident 195 on 10/29/23 at 1:26 p.m., he indicated he had a lot of pain in his left knee due to a fall and infection. When he first arrived at the facility, they told him they did not have his pain medication. He was not able to get any pain medication until 10/25/23 (3 days after admission). He also indicated he had not had a bowel movement in 3 days. On 10/31/23 at 8:30 a.m. the medication cart was observed with QMA 1. She removed the Oxycodone (a narcotic pain medication) blister pack from the locked box. The date on the medication was 10/25/23 (arrival to the facility) and there were 14 pills gone and there were 16 left in the card. The record…

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 manage medications appropriately related to not administering Ambien (a hypnotic) and not obtaining labs to monitor an anticoagulant medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 195) Finding includes: The record for Resident 195 was reviewed on 10/31/23 at 9:36 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, difficulty walking, infection of the left knee, hypertensive kidney disease, gout, diverticulosis of the large intestine, osteoarthritis, heart failure, atrial fibrillation, and contusion of the left knee. The admission Minimum Data Set (MDS) assessment, dated 10/29/23, indicated the resident was cognitively intact. The resident received anticoagulant and opioid medications. A Care Plan, dated 10/23/23, indicated the resident was at risk for complications, such as bleeding or bruising, secondary to anticoagulant therapy. The approaches were to obtain labs 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 on observation, record review, and interview, the facility failed to ensure medications were labeled correctly related to inhalers and an antacid bottle for 1 of 4 medication carts observed. (Blueberry Lane Medication Cart) Findings include: On 10/30/23 at 10:59 a.m., the Blueberry Lane Medication Cart was observed with LPN 2. The following medications were found in the cart: a. Albuterol Sulfate HFA Inhalation Aerosol Solution (an inhaler) 108 (90 Base) microgram (MCG) was labeled with the resident's name but no administration orders were listed on the inhaler. b. There was a Spiriva HandiHaler Inhalation Capsule 18 MCG (inhaler) in a drawer with no label. c. There was a bottle of Calcium Carbonate (tums) that was labeled with a first name only. There was no physician name or last name of the resident listed on the bottle. Interview at the time with LPN 2, indicated she was unaware the medication required the physician's name on the tums bottle and directions for use on the inhalers. Interview with the [NAME] President of Operations on 11/1/23 at 1:40 p.m., indicated the…

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

Based on observation, record review, and interview, the facility failed to ensure a resident was seen by the dentist for routine dental services for 2 of 3 residents reviewed for dental services. (Residents 63 and 61) Findings include: 1. During an interview with Resident 63 on 10/29/23 at 8:52 a.m., he indicated he requested to see the dentist and he had not heard anything else about it. Some of the resident's teeth were observed to be missing and broken. The record for Resident 63 was reviewed on 11/1/23 at 10:30 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, chronic obstructive pulmonary disease, anxiety disorder, and schizoaffective disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 9/21/23, indicated the resident was moderately impaired for daily decision making. Interview with the Social Service Director on 11/1/23 at 9:44 a.m., indicated that he would put the resident on the list for the dentist. He indicated the dentist usually came to the facility every three months. Interview with the Administrator on 11/1/23 at 2:10 p.m.,…

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

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to monitoring food consumption for 1 of 1 residents reviewed for nutrition. (Resident 76) Finding includes: The record for Resident 76 was reviewed on 11/1/23 at 11:01 a.m. Diagnoses included, but were not limited to, type 2 diabetes and end stage renal disease. The Significant Change Minimum Data Set (MDS) assessment, dated 8/1/23, indicated the resident was cognitively intact. The resident required supervision with eating and he received a mechanically altered, therapeutic diet. He had no weight issues during the assessment reference period. The current Care Plan, indicated the resident was at risk for impaired nutritional status due to a therapeutic diet, mechanically altered diet, and was at risk for malnutrition. Interventions included, but were not limited to, offer a substitute if less than 50% of his meal was consumed. The October 2023 Food Consumption record indicated there was no documentation of the resident's food consumption on 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 and interview, the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections related to disinfecting a mattress for 1 of 4 treatments observed and the storage of wash basins on 1 of 5 units. The facility also failed to ensure hand hygiene was completed after direct resident contact for 1 of 6 residents observed for medication administration. (Residents 34, 56, and Apple Lane) Findings include: 1. On 11/1/23 at 10:00 a.m., the pressure ulcer treatment for Resident 34 was observed with the Wound Nurse. The resident's left heel boot was removed. The Wound Nurse hand sanitized, donned gloves, and removed the dressing to the resident's left heel. Once the dressing was removed, the resident's heel started bleeding and blood was dripping onto the resident's low air loss mattress. The Wound Nurse removed her gloves, hand sanitized, and donned new gloves. The area was cleansed with normal saline 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.