Waters Of Huntingburg, The

Based on observation, interview, and record review, the facility failed to ensure implementation of care plan interventions for 2 of 3 residents reviewed for falls. A call light was observed out of reach, nonslip material was not placed under furniture, and a resident was not taken to the common area or toileted after a meal as indicated in risk for falls care plans. (Resident 6, Resident 35)Findings include:1. On 9/8/25 at 11:46 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, renal failure, dementia, anxiety, and psychotic disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/15/25, indicated a severe cognitive impairment and no behaviors. Resident 6 required substantial to maximum assist (helper does more than half the effort) with eating, toileting, bed mobility, showers and transfers. Resident 6 had one fall with no injury. A current risk for falls care plan, initiated 6/15/21 and last revised 5/22/25, included, but was not limited to, the following interventions:Resident to be brought to common area…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to revise care plans with new interventions to prevent falls for 3 of 3 residents reviewed for falls. (Resident 17, Resident 6, Resident 35)Findings include:1. On 9/8/25 at 11:05 A.M., Resident 17's clinical record was reviewed. Resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia and psychotic disorder. The most recent significant change Minimum Data Set (MDS) assessment, dated 8/13/25, indicated a severe cognitive impairment and no behaviors. Resident 17 required partial to moderate assist (helper does half the effort) with toileting, and substantial to maximum assist (helper does more than half the effort) with showers. The MDS assessment indicated one fall since the prior assessment on 7/29/25 with no major injury. A current falls care plan, dated 7/29/25, indicated the following interventions: Attempt to keep areas free of clutter, dated 7/29/25. Keep call light in reach, dated 7/29/25. Notify and…

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

Based on observation, interview, and record review, the facility failed to ensure physicians orders were followed for insulin administration and blood glucose monitoring (blood sugar testing) for 1 of 9 residents randomly observed during medication administration. Resident 2 was observed to receive the wrong dose of insulin and Resident 2 and Resident 8's medications were left blank on the Medication Administration Record (MAR). (Resident 8, Resident 2)Findings include:1. On 9/8/25 at 11:40 A.M., Registered Nurse 16 was observed administering insulin to Resident 2. His blood sugar was 537. She indicated for a blood sugar (BS) of 501-600, the resident should get 9.5 units. After obtaining the resident's Humalog insulin pen, she applied the needle, primed the pen with two units of insulin, used anti-bacterial hand rub (ABHR), and put on her gloves. Once she entered the resident's room, she dialed the pen to 9.0 units and administered the dose into the resident's abdomen. At that time, she indicated you can't give 9.5 units because the pen only allows one unit increments. The nurse did…

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 staff provided a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinence care and 4 of 9 residents observed during medication passes. Multiple items were touched with gloved hands and the same gloves were used to perform care, hand hygiene was not done between dirty to clean tasks, a resident was left with a brown substance on his bottom, staff washed hands with less then 15 second lather, and staff did not sanitize hands between residents during medication passes. (Resident 5, Resident 14, Resident 33, Resident 36, Resident 27)Findings include: 1.On 9/7/25 at 11:02 A.M., Licensed Practical Nurse (LPN) 22 was observed prepping medications for Resident 14 and did not sanitize hands before or after the medication pass. On 9/7/25 at 11:10 A.M., LPN 22 was observed prepping medications for Resident 33 and washed hands with a seven second lather after administering the medications. On 9/7/25 at 11:21 A.M.,…

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

Based on interview and record review, the facility failed to ensure accurate receiving of routine medications for 1 of 3 residents reviewed for unnecessary medications. A physician's order was entered incorrectly which led to an interruption of a resident's routine medication and an unprescribed dosage reduction. (Resident B)Finding includes:A record review on 7/22/25 at 10:30 A.M., Resident B's diagnoses included, but were not limited to, unspecified polyneuropathy.Resident B's most recent quarterly Minimum Data Set (MDS) assessment, dated 4/15/25, indicated the resident had moderate cognitive impairment and received routine pain medication. Resident B's physician's orders included, but were not limited to; Lyrica Oral Capsule 100 milligrams (mg) give one (1) capsule two times a day for pain (started 5/10/24 and discontinued 6/24/25), Lyrica Oral Capsule 100 milligrams (mg) give two (2) capsules at bedtime related to polyneuropathy (started 11/5/24 and discontinued 6/24/25), Lyrica Oral Capsule 100 mg give one (1) capsule every morning and at bedtime for pain (started 6/24/25 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate staff was available on a locked dementia unit. A licensed nurse was not stationed on the unit during 2 of 2 days during the survey, monitoring and documenting of behaviors was not being completed during a 30-day review period, and staffing patterns did not meet the facility's Alzheimer's/Dementia Special Care Unit staffing specifications. (Memory Springs unit, Resident C, Resident D) Findings include: 1. During an observation and interview 2/4/25 at 9:50 A.M., LPN 2 entered Memory Springs (locked dementia unit). LPN 2 checked in and then exited then unit. One Certified Nurse Aide (CNA) 5 and one activity assistant (AA) 3 were on the Memory Springs unit. CNA 5 indicated that the Memory Springs unit nurse floated from the front hall located at the front of the building. The nurse or other staff come on the unit periodically to check in, administer medications, or will come to the unit if needed and contacted by the CNA.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide necessary treatment and services for 2 of 3 residents reviewed for dementia care. Resident behaviors were not monitored and known behaviors were not documented by nursing staff. (Resident C, Resident D) Findings include: 1. During an interview on 2/4/25 at 9:55 A.M. CNA 5 indicated that she had to watch Resident C because he liked to joke around on the dementia unit and the other residents did not realize he was joking. Resident C's diagnoses included, but were not limited to, Alzheimer's disease, vascular dementia with mood disturbance, cognitive communication deficit, and anxiety. Resident C's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive impairment, and wandered daily. Resident C's physician orders included, but were not limited to, behavioral monitoring every shift for depression, withdrawn, anxiety, pacing (started 8/23/24), reside on secure unit due to Alzheimer's dementia…

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

Based on interview and record review, the facility failed to ensure accurate documentation of resident records for 3 of 3 records reviewed. Staff members that initialed they were completing assessments were not on the schedule as worked at the time of the assessments. (Resident B, Resident C, Resident D) Findings include: 1. On 12/17/24 at 9:30 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, depression, and psychotic disorder. The most recent Annual MDS (Minimum Data Set) Assessment, dated 11/18/24, indicated a severe cognitive impairment, partial or moderate assist required with toileting, and supervision or touching assist with all other ADLs (activities of daily living). A progress note, dated 11/30/24 at 6:43 A.M. indicated Resident B had experienced an unwitnessed fall in the dining room. A neurological (neuro) evaluation flow sheet, dated 11/30/24, indicated neuro checks were completed from 11/30/24 at 5:00 A.M. through 12/3/24 during the 7:00 A.M. to 3:00 P.M. day shift. The form lacked initials to indicate what…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the physician in regard to a need to alter treatment for 2 of 5 residents reviewed for unnecessary medications. The physician was not notified of resident's elevated blood sugar readings and elevated weights. (Resident 30, Resident L, Resident J, Resident F) Findings include: 1. On 9/25/24 at 3:13 P.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, atherosclerotic heart disease, hypertension (HTN), and edema. Resident 30 was admitted on [DATE]. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/13/24, indicated Resident 30 was cognitively intact and supervision of staff with set up for bed mobility, transfers, toileting, was on a therapeutic diet, had a significant weight gain, and was given insulin. Physician's Orders included, but were not limited to, the following: Weekly Weight in the morning…

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

Based on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection during 1 of 4 observations of care. The facility failed to track all infections for 3 of 5 residents reviewed for infections. Staff lathered hands for 6 seconds, touched items with gloved hands before care was performed, wiped the residents buttock's first, failed to perform hand hygiene when gloves were changed, and touched multiple items with soiled gloves after care. (Resident G, Resident J, Resident K, Resident M) Findings include: 1. On 10/1/24 at 9:15 A.M., the facility tracking binder was reviewed for July 2024, August 2024, and September 2024. The facility tracking lacked the following UTI's (urinary tract infections): Resident K had a UTI in July 2024. The facility tracking map lacked documentation of the UTI. Resident J had a UTI in August 2024. The facility tracking map lacked documentation of the UTI. Resident G had a UTI in August and September 2024. The facility tracking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 5 residents reviewed for unnecessary medications. A resident's clinical record lacked an antianxiety, antipsychotic, antiplatelet, and diabetes care plans. A resident's clinical record lacked a care plan for smoking and an order to add NAS (no added salt) to a resident's diet was not implemented. (Resident 18, Resident 30) Findings include: 1. On 9/26/24 at 2:57 P.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, other arterial embolism and thrombosis of abdominal aorta, generalized anxiety disorder, borderline personality disorder, and bipolar disorder. Resident 18 was admitted [DATE]. The most recent admission MDS (Minimum Data Set), dated 7/22/24, indicated Resident 18 was cognitively intact, an extensive assist of 2 staff for bed mobility, transfers, toileting, and was administered antianxiety,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan for 1 of 1 residents reviewed for bowel and bladder incontinence. Physician orders were not followed, physician was not notified related to change in condition, treatments were being done without an order, care plans were not updated, and wound assessments were not completed. (Resident J) Findings include: On 10/1/24 at 10:05 A.M., Resident J's clinical record was reviewed. Diagnosis included, but were not limited to, cellulitis of the right lower limb. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 9/23/24, indicated no cognitive impairment, always incontinent of urine, frequently incontinent of bowel, and required extensive assistance of two with toileting. Physician orders included, but were not limited to: Stool occult with culture and sensitivity if indicated, 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 interview and record review, the facility failed to ensure measures to heal existing pressure ulcers and prevention of additional pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. Care plan interventions were not followed, orders were not placed, pressure ulcers were not staged correctly, and dressings were not completed as ordered for a resident with chronic pressure ulcers. (Resident D) Findings include: On 9/26/24 at 11:48 A.M., Resident D's clinical record was reviewed. Diagnosis included, but were not limited to, paraplegia, diabetes mellitus, anxiety, and depression. The most recent Annual and State Optional MDS (Minimum Data Set) Assessment, dated 8/23/24, indicated no cognitive impairment, extensive assistance of one with bed mobility, extensive assistance of two with toileting, total dependence of two with transfers, and two stage 4 pressure ulcers. Current physician orders included, but were not limited to: Dakins (1/4 strength) External Solution (Sodium Hydrochloride), apply to right and left ischium topically one time a day for wound healing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision and prevent falls for 1 of 2 residents reviewed for accidents. Fall risk assessments and neuro (neurological) assessments were not completed after a resident fell. The care plan was not updated after a fall. (Resident L) Findings include: On 9/25/24 at 1:46 P.M., Resident L's clinical record was reviewed. Diagnoses included, but was not limited to, unsteadiness on feet, anxiety disorder, and diabetes mellitus. The most recent State Optional and Quarterly MDS (Minimum Data Set) Assessment, dated 7/23/24, indicated Resident L had severe cognitive impairment and required supervision of 1 staff member for bed mobility, and supervision and setup help for transfer and toileting. Current Physicians Orders included, but was not limited to, OLANZapine [psychotropic] Oral Tablet Disintegrating 5 MG (Olanzapine). Give 5 mg by mouth at bedtime related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED…

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

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice and a comprehensive person-centered care plan for 1 of 2 residents reviewed for respiratory care. The resident was receiving oxygen without monitoring oxygen saturation (O2 sat) levels (level of oxygen in the blood) or monitoring how often and what LPM (Liter Per Minute) of oxygen was being used by the resident. The order lacked perimeters for the staff to determine accurate LPM needed and a care plan was not developed for oxygen use. (Resident 30) Finding includes: On 9/26/24 at 11:15 A.M., Resident 30 was observed asleep in her bed wearing O2 per nasal cannula at 3 LPM. On 9/27/24 at 7:22 A.M., Resident 30 was observed eating breakfast wearing oxygen (O2) per nasal cannula at 3 LPM with the right nasal cannula on the outside of her nose. At that time, the resident indicated she wore her oxygen all the time. On 9/27/24 at 7:51 A.M., Resident 30 was observed laying in bed wearing her O2 per nasal cannula at 3 LPM and the nasal cannula…

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

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for Urinary Tract Infections (UTI). A resident with a UTI missed 4 of 28 ordered doses of an intravenous (IV) antibiotic. (Resident F) Finding includes: On 9/27/24 at 10:47 A.M., Resident F's clinical record was reviewed. Diagnosis included, but were not limited to, obstructive uropathy. The most recent Discharge MDS (Minimum Data Set) Assessment, dated 9/14/24, indicated an indwelling catheter and frequent bowel incontinence. Cognition status was not assessed. Physician orders included, but were not limited to: Cefepime HCl Infection Solution Reconstituted 1 GM (gram), use 50 ml (milliliter) intravenously every 6 hours for UTI for 7 days, reconstituted with 50 ml normal saline, dated 9/19/24 through 9/25/24. Resident F's Medication Administration Record (MAR) for September 2024 indicated Cefepime was not administered as ordered on the following dates/times: 9/19/24 at 12:00 A.M. (indicated other/see nurse notes) 9/19/24 at 6:00…

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

Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 2 medication carts observed. A narcotic box was unlocked. (100/200 Hall) Findings include: During an observation on 9/24/24 at 9:38 A.M., the medication cart on the 100/200 hall was reviewed. The narcotic lock box was observed unlocked. At that time, the ADON (Assistant Director of Nursing) indicated it should have been locked. On 9/30/24 at 12:30 P.M., the DON (Director of Nursing) provided a current Medication Storage in the Facility policy, dated February 2017 that indicated, .All drugs classified as Schedule II of the Controlled Substances Act will be stored under double locks . This Federal Tag relates to Complaint IN00442764. 3.1-25(n)

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety for 1 of 1 observations of the kitchen. The food temperature log lacked food temperatures for food served 12 of 19 days reviewed. Finding includes: On 9/24/24 at 9:38 A.M., the food temperature logs from 9/5/24 through 9/23/24 were reviewed. The following dates had no temperatures documented for the food served at dinner: 9/6/24 9/8/24 9/10/24--no temperatures for breakfast, lunch, or dinner 9/13/24--no temperatures for breakfast, lunch, or dinner 9/15/24 9/16/24 9/17/24 9/18/24 9/20/24 9/21/24 9/22/24 9/23/24 On 9/24/24 at 9:40 A.M., the Dietary Manager indicated if there was nothing written for food served at dinner on those days, staff probably didn't do them. If they were taken, they should be documented there. At that time, he indicated they do have some newer staff at that time and they may need to re-educate them about getting food temperatures before serving it. On 9/30/24 at 12:30 P.M., a current non dated Monitoring Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer or properly document the pneumococcal immunization for 3 of 5 residents reviewed for immunizations. Clinical records lacked documentation that the resident received or refused a pneumococcal vaccine when a consent was signed to receive the vaccine. (Resident 20, Resident 5, Resident 4) Findings include: 1. On 9/30/24 at 9:17 A.M., Resident 20's clinical record was reviewed. Diagnosis included, but was not limited to schizoaffective disorder, hypertension, diabetes mellitus, hyperlipidemia, aphasia, non-Alzheimer's dementia, depression, and schizophrenia. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 9/13/24, indicated Resident 20 was severely cognitively impaired and his pneumococcal vaccine was not up to date. Resident 20 was [AGE] years old and was admitted on [DATE]. Resident 20's immunization record was reviewed for pneumococcal vaccine. Resident 20 received Prevnar-13 on 12/20/2022. The clinical record lacked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to monitor a resident's behaviors, as needed psychotropic medications were given beyond 14 days without a rational to continue, orders were not followed, for 1 of 3 residents reviewed for behaviors. (Resident B) Findings include: On [DATE] at 11:34 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, vascular dementia, unspecified severity, with other behavioral disturbance, depression, unspecified insomnia, unsteadiness on feet, other abnormalities of gait and mobility, cerebrovascular disease. A significant change MDS (Minimum Date Set) assessment, dated [DATE], indicated Resident B's cognition was severely impaired, physical behavioral symptoms directed towards others 1-3 days, verbal behavioral symptoms directed towards others 1-3 days, wandering 1-3 days. Resident B's initial admission to the facility was [DATE], expired at the…

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

Based on interview, and record review, the facility failed to provide necessary treatment and services for 1 of 3 residents reviewed for dementia care. A resident's plan of care was not updated, and physician orders were not implemented following an incident of new and escalated inappropriate sexual behaviors with a resident that resulted in an additional similar incident with another resident in a locked dementia unit. (Resident B, Resident C, Resident D) Finding includes: During a review of facility reported incidents on 4/24/24 at 1:15 P.M., an incident dated 4/2/24 at 6:32 A.M., indicated that Resident B was sitting in the dining room on the locked dementia unit next to Resident C. Resident B kissed Resident C two times on the lips. Resident B then made contact with Resident C's breast. An incident dated 4/8/24 at 7:01 P.M., indicated that a staff member may have witnessed inappropriate touching between Resident B and Resident D. A follow up to the incident, dated 4/17/24, indicated Resident B was started on a Climara patch and was put on one-to-one observation until he…

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

Based on observation, interview and record review, the facility failed to provide proper treatment and care to maintain mobility and good foot health for 5 of 5 residents reviewed for foot care. Four residents had long, thick toe nails curling over the end of their toes. One resident had long nails and ingrown toenails. (Resident B, Resident C, Resident D, Resident E, Resident F) Findings include: 1. During an observation on 1/31/24 at 9:50 A.M., Resident B was lying in bed getting a bed bath. She indicated to CNA 2 to be careful when she washed her right foot because her right great toe was sore. She indicated she had been trying to see the podiatrist for 3 months but was told due to a glitch in her insurance, the podiatrist would not see her. She indicated her nails need trimmed and both of her great toes were ingrown. CNA 2 agreed with the resident that her toenails needed trimmed. All of the nails on both feet stuck above the end of toes. On 1/30/24 at 11:00 A.M., Resident B's clinical records were reviewed. Diagnosis included, but were not limited to, morbid obesity, asthma,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable environment for residents, staff and the public. Resident room floors were sticky in 11 of 29 rooms observed. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: On 1/30/24 at 10:50 A.M., resident council meeting minutes were reviewed. On 8/2/23, a note indicated floors sticky after mopping On 2/1/24 from 10:00 A.M. through 10:24 A.M., the following rooms were observed with sticky floors: room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] room [ROOM NUMBER] On 1/31/24 at 9:00 A.M., the Housekeeping Supervisor indicated the floors were sometimes sticky after cleaning, and could be due 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 dependent residents received the necessary services to maintain good grooming, and personal hygiene for 2 of 3 residents observed for care. A CNA continued to wipe a resident during perineal care after the resident complained of pain. A CNA did not wipe appropriately for one resident. (Resident B, Resident E) Findings include: 1. During an observation on 1/31/24 at 9:50 A.M., Resident B indicated to CNA 2 while getting a bed bath to be careful in the perineal area because she was still tender. CNA 2 used fingers to spread labia and washed area gently with a soapy wet wash cloth from top to bottom. CNA 2 used a clean, wet wash cloth to rinse the area. On 1/30/24 at 11:00 A.M., Resident B's clinical records were reviewed. Diagnosis included, but were not limited to, morbid obesity, asthma, depression, spinal stenosis, lumbar region with neurogenic claudication and hypertension. The most current quarterly MDS (Minimum Data Set) Assessment, dated 11/3/23, indicated Resident B is cognitively intact and needs…

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 followed for 3 of 3 residents during observation of perineal care and a bed bath. Staff failed to wash hands or sanitize and gloves were not changed between dirty and clean tasks during peri care. (Resident B, Resident D, Resident E) Findings include: 1. On 1/31/24 at 9:13 A.M., CNA 2 and CNA 4 were observed to provide incontinence care for Resident E. CNA 2 washed hands with a four second lather, and CNA 4 washed hands with a nine second lather. Both aides pulled the blanket down off the resident, and both put on gloves. CNA 4 asked CNA 2 to raise the bed, and CNA 2 indicated I just put my gloves on, yeah, then touched the bed controller with gloved hands to raise the bed. Without changing gloves, CNA 2 pulled wipes out of a package, and one fell onto the resident's foot. CNA 2 took the wipe and placed that one plus two others on the clean brief that was lying by the resident's head. CNA 2 then used all three wipes, one at a time, to clean the front of the resident'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 interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a current certified Infection Preventionist for 5 of 5 days of the survey. Finding includes: On 7/10/23 at 8:15 A.M., the Administrator indicated the ADON (Assistant Director of Nursing) was the Infection Preventionist and provided a certificate that indicated the ADON had successfully completed CDC (Centers for Diesease Control and Prevention) Train Module 1 Infection Prevention and Control Program from the Nursing Home Infection Preventionist Training Course, dated 3/28/23. During an interview on 7/13/23 at 11:26 A.M., the ADON indicated she was the Infection Preventionist and started that role in April of 2023. At that time, she indicated she wasn't sure if she had to be certified but thought completing Module 1 of the CDC training meant her certification was complete. She was unaware there were 23 other modules needed to complete her certification. On 7/13/23 at 3:50 P.M., a current…

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

Based on interview and record review, the facility failed to deliver mail to the residents on Saturdays for 4 of 9 residents interviewed about mail service. During a resident council meeting, residents indicated they failed to get mail every Saturday. (Resident 10, Resident 20, Resident 27, Resident 32) Findings include: On 7/11/23 at 12:58 P.M., during a resident council meeting, Resident 10, Resident 20, Resident 27, and Resident 32 indicated if the assistant activity person was not working on Saturday the mail sat in the business office until Monday. During an interview on 7/12/23 at 11:28 A.M., the activity assistant indicated she worked every other weekend. When she worked, she sorted and delivered the mail. If the activity director or herself were not working, there was no one to deliver the mail on the weekend. During an interview on 7/12/23 at 1:35 P.M., the Administrator indicated it was the manager on duty's responsibility to get the mail and distribute it on the weekends. On 7/13/23 at 12:10 P.M. a current undated Postal Services (Mail) policy provided by the…

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

Based on observation, interview, and record review, the facility failed to provide an ongoing activity program for 1 of 4 units observed and 1 of 1 resident council meetings. (Hope Springs Dementia Unit, Resident 13, Resident 38, Resident 42, Resident 36, Resident 37, Resident 97, Resident 35, Resident 10) Finding includes: 1. The following were observations and interviews regarding Hope Springs: During a continuous observation on 7/9/23 from 9:45 A.M. through 12:07 P.M., no activities were observed on the Hope Springs Dementia Unit. During an observation on 7/10/23 at 9:18 A.M., Qualified Medication Aid (QMA) 3 was observed eating a snack while sitting at a dining room table talking to Resident 13. During a continuous observation on 7/10/23 from 10:48 A.M. through 11:30 A.M., four residents were observed sitting in the dining room. There were crayons sitting on a table, but no one was using them. Resident 13 was observed eating a cookie with a copy of the Daily Chronicle sitting in front of her. During that time, there were no activities observed on the unit. During a continuous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards, and ensure residents received adequate supervision and assistive devices to prevent accidents for 3 of 4 residents reviewed for accidents, and 1 of 4 units reviewed for hot water. The water temperature in resident areas exceeded 120 degrees Fahrenheit, care plans were not updated with new interventions following falls, neurological checks were not completed following falls, and interventions were observed out of place. (Hope Springs Dementia Unite, Resident 35, Resident 13, Resident 38) Findings include: 1. On 7/9/23 between 10:38 A.M. and 11:27 A.M., the following water temperatures were obtained on the Hope Springs Dementia Unit: Shower room [ROOM NUMBER].5 degrees Fahrenheit room [ROOM NUMBER] (private bathroom) 124.1 degrees Fahrenheit room [ROOM NUMBER] (private bathroom) 123.7 degrees Fahrenheit room [ROOM NUMBER] (shared with room [ROOM NUMBER]) 121.8 degrees Fahrenheit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide accommodations for a resident in a timely manner for 1 of 1 resident reviewed for accommodation of needs. The facility failed to provide a bariatric air mattress for a resident, or an appropriate lift for transfers. (Resident 34) Findings include: During an interview on 7/10/23 at 9:52 A.M., Resident 34 indicated he had been waiting six months for an air mattress. He indicated the facility had ordered one, but it did not fit his bed. He indicated the facility staff kept telling him another one had been ordered. On 7/10/23 at 2:05 P.M., Resident 34 was observed lying in bed on a pressure reducing mattress. At that time, Resident 34 indicated a man came in his room earlier to measure his mattress so he could get an air mattress. On 7/11/23 at 10:28 A.M., Resident 34 was observed lying in bed. At that time, he indicated a couple weeks ago the staff tried getting him up with a lift. They didn't think he was back in the seat far…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was completed and given to residents or resident representatives for 2 of 3 residents reviewed for hospitalizations. The clinical records lacked documentation of the residents or representatives receiving a completed notice of transfer or discharge at the time they were transferred from the facility. (Resident 5, Resident 32) Findings include: 1. On 7/11/23 at 10:28 A.M., Resident 5's clinical record was reviewed. Progress notes indicated the resident was transferred out of the facility to the emergency room (ER) on 12/17/22, admitted , and returned on 12/17/22. Resident 5 was again transferred out of the facility to the ER on [DATE], admitted , and returned on 3/6/23. Resident 5's clinical record lacked documentation that a notice of transfer or discharge was completed and given to the resident or a representative at the time of both transfers. On 7/11/23 at 1:30 P.M., a copy of the completed notice of transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold policy was provided to residents or resident representatives for 2 of 3 residents reviewed for hospitalizations. The clinical records lacked documentation of the resident or family representatives receiving a bed hold policy at the time they were transferred from the facility. (Resident 5, Resident 32) Findings include: 1. On 7/11/23 at 10:28 A.M., Resident 5's clinical record was reviewed. Progress notes indicated the resident was transferred out of the facility to the emergency room (ER) on 12/17/22, admitted , and returned on 12/17/22. Resident 5 was again transferred out of the facility to the ER on [DATE], admitted , and returned on 3/6/23. Resident 5's clinical record lacked documentation that a bed hold policy was given to the resident or a representative at the time of both transfers. On 7/11/23 at 1:30 P.M., a copy of the bed hold policies given were requested and not made available during the survey. 2. On 7/10/23 at 2:32…

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

Based on interview and record review, the facility failed to ensure MDS (Minimum Data Set) Assessments were accurate for 2 of 5 residents reviewed for unnecessary medications. (Resident 5, Resident 16) Findings include: 1. On 7/11/23 at 10:28 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, post traumatic stress disorder (PTSD). The most recent annual MDS Assessment, dated 6/27/23, indicated Resident 5 was moderately cognitively impaired, not a tobacco user, did not have PTSD, and received an anti-anxiety, opiod, and antibiotic for 7 of 7 days during the lookback period. Current physician's orders included, but were not limited to, the following: The resident may smoke in accordance with the facility smoking policy, ordered on 4/14/2023 Effexor XR capsule give 3 capsules by mouth in the morning for PTSD, ordered on 3/7/23 Resident 5's MAR (Medication Administration Record) for June 2023 indicated Resident 5 was not on an anti-anxiety, opiod, or antibiotic during that month. During an interview on 7/12/23 at 10:22 A.M., the MDS Coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide care plan conferences quarterly for 2 of 6 residents reviewed for care plan conferences. (Resident 26, Resident 5) Findings include: 1. On 7/11/23 at 8:48 A.M., Resident 26's clinical record was reviewed. Diagnosis included, but were not limited to, dementia and anxiety. The most recent quarterly MDS (minimum data set) assessment dated [DATE], indicated a severe cognitive impairment. The most recent care plan conference was documented on 2/21/23. On 7/12/23 at 9:58 A.M., the Social Services Director (SSD) indicated Resident 26 had a conference scheduled for 5/9/23, and the family called and wished to reschedule. At that time, a handwritten care conference schedule was provided, and indicated a care conference was scheduled for Resident 26 on 7/19/23. 2. On 7/11/23 at 10:28 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, stroke with hemiplegia affecting left dominant side,…

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 proper storage of medications in 1 of 2 medication storage rooms. Discontinued/expired medications were stored in the storage room and not appropriately disposed. (100 Hall Medication Storage Room) Findings include: On 7/12/23 at 10:00 A.M., a plastic container was observed sitting on the counter in the Medication Storage Room on the 100 Hall with the following medications for residents no longer residing in the facility: Resident discharged on 7/3/23 ducosate sodium 100 mg (milligrams)-9 capsules ibuprofen 600 mg-30 pills epinephrine 0.3 mg-3 pens chloraseptic lozenges-18 lozenges Hospice resident, passed on 6/2/23 acetaminophen 650 mg suppositories in a prescription bottle-3 suppositories Hospice resident, passed on 6/20/23 haloperidol 5 mg in a prescription bottle-9 pills Hospice resident, passed on 7/3/23 saline enema-4 boxes A tied plastic bag of expired medications from the Emergency Medication System contained the following medications: diltiazem 30 mg-15 unit dose packages amoxicillin/clavulanic acid 875/125…

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 food items were properly labled and not expired during 1 of 2 kitchen observations. Findings include: During the initial tour of the kitchen on 7/9/23 at 9:23 A.M., the following was observed: Dry storage: An undated plastic 22 quart container with 4 quarts of cereal. Refrigerator: An undated block of cheese. A bag of cheddar shredded cheese, dated 6/27/23 and 7/6/23. A bag of mozzarella shredded cheese, dated 7/4/23 and 7/5/23. A container of chicken base, dated 7/2/23 3 bags filled with ham. 2 bags dated 7/6/23 and 1 bag was unreadable. A container of tomato soup, dated 7/2/23. A container of garlic gin oil, dated 6/28/23. Freezer: A bag of mixed vegetables, dated 6/1/23. A container of tomato sauce, dated 4/20. The label lacked a year. 2 apple pies, 1 was dated 2/26/23 with a use by date of 3/1/23, and the other pie was dated 4/23/23 and did not have an expiration date on it. During an interview on 7/9/23 at 9:28 A.M., cook 5 indicated food items are are dated when they are opened and discarded 3…

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.