Allison Pointe Healthcare Center

Based on interview and record review, the facility failed to ensure 1 of 7 residents reviewed for resident rights had their resident's rights honored related to personal property request by a facility staff member. (Resident B) Findings include:In an interview with Resident B on 12-29-25 at 1:45 p.m., she indicated on 12-9-25 between 8:00 p.m. and 10:00 p.m., LPN 3 came to her and told me that she had heard I had a vehicle I might be interested in selling because she had heard that I might not be needing it anymore. For starters, why would she or any of the staff be discussing me or my business amongst themselves? Plus, with my diagnosis of breast cancer, that kind of makes me think they know something that I don't know. How is that appropriate in any manner? Resident B indicated LPN 3 told her that her family member was needing to buy a car to use for college. In an interview on 12-29-25 at 3:45 p.m., with the Executive Director (ED) she indicated she received a phone call from LPN 3 on the evening of 12-9-25, in which LPN 3 notified her she had inadvertently got a resident worked…

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

Based on interview and record review, the facility failed to ensure a controlled substance medication received from the contracted pharmacy was properly processed and safely stored in the facility for 1 of 3 residents reviewed for pharmacy services. (Resident E) Findings include:A facility reported incident was received by the Indiana Department of Health's (IDOH) Long Term Care Division on 11-18-25 at 7:14 p.m. The report indicated the facility had received a delivery of a controlled medication, oxycodone, for Resident E on 11-15-25, but the medication was unable to be accounted for. It indicated notifications were made to the resident, resident representative, the Executive Director, the Director of Nursing, the attending physician, and the local law enforcement agency and an investigation was launched immediately. It indicated the nurse on duty for Resident E on the date of 11-15-25, was immediately suspended, pending results of the investigation. A medication reconciliation was initiated. Pain and skin assessments were initiated. Staff and resident interviews were initiated. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document controlled medications in sufficient detail to ensure an accurate reconciliation of the narcotic count for 4 of 5 residents reviewed for pain and ensure an intravenous (IV) antibiotic was administered timely for a newly admitted resident and completely for 2 of 4 residents reviewed for IV medications (Resident B, Resident L, Resident H, and Resident D). Findings include: 1. The clinical record for Resident L was reviewed on 6/12/25 at 3:10 p.m. The diagnoses included, but were not limited to, end stage renal disease, opioid dependence, low back pain, muscle weakness, and lumbago with sciatica (lower back pain accompanied by sciatic nerve pain). A care plan, revised 5/15/25, indicated Resident L was at risk for pain related to end stage renal disease. The goal was for Resident L to be able to verbalize relief of pain. The interventions included, but were not limited to, providing medication per physician's orders. A physician's order, 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 2. The clinical record for Resident M was reviewed on 6/12/25 at 2:20 p.m. The diagnoses included, but were not limited to, anxiety disorder, fracture of the right upper humerus (arm bone). He was admitted to the facility on [DATE]. The acute care hospital discharge instructions, dated [DATE], indicated Resident M was to receive the following medications upon admission to the facility: 1. Aspirin 81 milligram (mg) two times daily, 2. gabapentin (anti-seizure medication) 400 mg three times daily, 3. levetiracetam (anti-seizure medication) 500 mg two times daily, 4. lorazepam (anti-anxiety medication) one mg once daily, 5. methocarbamol (muscle relaxer) 500 mg, two tablets every six hours, 6. oxycodone-acetaminophen (narcotic pain medication) 10 mg - 325 mg, two tablets every four hours as needed for pain, 7. clonazepam (anti-anxiety medication) one mg tablet two times daily, 8. losartan (high blood pressure medication) 50 mg once daily, and 9. paroxetine (anti-depressant) 40 mg once daily. The June 2025…

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 timely obtain Total Parenteral Nutrition (TPN) for 1 of 4 residents reviewed for medication availability. (Resident H) Findings include: The clinical record for Resident H was reviewed on 6/12/25 at 10:30 a.m. The diagnoses included, but were not limited to, perforation of intestine and peritoneal abscess. She was admitted to the facility on [DATE]. The on-boarding clinical evaluation provided by the discharging facility indicated Resident H's diagnoses/reasons for admission included, but were not limited to, TPN (artificial nutrition to be administered intravenously). It also indicated Resident H was alert and oriented. An order for Clinimix (a variation of TPN) 8/14, and Clinolipid (fat emulsion supplement) were entered on 6/6/25. The Clinimix was to run intravenously at a continuous rate of 65 milliliters (mL)/hour, and the Clinolipid was to run intravenously at a rate of 21 mL/hour on the evenings of Monday, Wednesday, Friday, and Saturday. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely address a resident's pain for 1 of 5 residents reviewed for pain management. (Resident H) Findings include: The clinical record for Resident H was reviewed on 6/12/25 at 10:30 a.m. The diagnoses included, but were not limited to, perforation of intestine and peritoneal abscess. She was admitted to the facility on [DATE]. The on-boarding clinical evaluation provided by the discharging facility indicated Resident H was alert and oriented. An order was entered, on 6/6/25, for oxycodone immediate release (IR) 10 mg, one tablet as needed every six hours for moderate to severe pain. On 6/12/25 at 1:07 p.m., an interview was conducted with Resident H. She indicated on the day she arrived she asked staff several times about when she was going to get her medications and they kept telling her the pharmacy is on their way. Resident H indicated she was in pain and was vomiting and crying. She indicated Registered Nurse (RN) 3 had given her oxycodone 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 ensure a resident remained free from significant medication errors by receiving the incorrect narcotic pain medication on multiple occasions for 1 of 4 residents reviewed for medication administration. (Resident L) Findings include: The clinical record for Resident L was reviewed on 6/12/25 at 3:10 p.m. The diagnoses included, but were not limited to, end stage renal disease, opioid dependence, low back pain, muscle weakness, and lumbago with sciatica (lower back pain accompanied by sciatic nerve pain). A care plan, revised 5/15/25, indicated Resident L was at risk for pain related to end stage renal disease. The goal was for Resident L to be able to verbalize relief of pain. The interventions included, but were not limited to, providing medication per physician's orders. A physician order, dated 5/19/25 to 5/28/25, indicated the use of oxycodone 5 milligrams (mg); administer one tablet every four hours for pain. A physician order, dated 5/28/25 to 6/6/25, indicated the use of oxycodone-acetaminophen (narcotic pain…

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 attempt non- pharmacological interventions for pain, to assess pain levels prior to administering an as needed pain medication, and to assess the effectiveness of as needed pain medication for 1 of 3 residents reviewed for pain (Resident C). Findings include: The clinical record for Resident C was reviewed on 4/3/25 at 11:00 a.m. The diagnoses included, but were not limited to, cerebral infarction (disrupted blood flow to the brain), aphasia (inability to swallow), and hemiplegia (inability to move one side of the body). He was admitted to the facility on [DATE]. A physician's order, dated 2/10/25, indicated to monitor pain every shift. A physician's order, dated 2/10/25, indicated to administer oxycodone (narcotic pain medication) immediate release (IR) 5 milligram (mg); give one tablet every six hours as needed for moderate to severe pain. A care plan, last revised on 2/11/25, indicated he was at risk for pain related to stroke,…

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 infection control by staff not donning a gown when providing personal care for a resident in enhanced barrier precautions (EBP) and not ensuring soiled linen was not placed directly on the floor for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). (Resident C) Findings include: The clinical record for Resident C was reviewed on 4/3/25 at 11:00 a.m. The diagnoses included, but were not limited to, cerebral infarction (disrupted blood flow to the brain), aphasia (inability to swallow), and hemiplegia (inability to move one side of the body), and tracheostomy. A physician's order, dated 2/12/25, indicated Resident C was receiving enhanced barrier precautions related to having a tracheostomy, gastric tube, and wounds. It was to occur when dressing, bathing, showering, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting. An admission Minimum Data Set (MDS) assessment, completed 2/17/25, indicated Resident C was non- verbal and could not make his…

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 address grievances that were reported in resident council meetings for 9 of 9 residents that attended a resident council meeting. (Residents' 1, 8, 12, 28, 39, 63, 67, 71, and 73) Findings include: The November 2024, December 2024, and January 2025 resident council minutes did not indicate any concerns that were discussed with the following departments: nursing, housekeeping, laundry, business office, activities, and maintenance. A resident council meeting was conducted on 1/29/25 at 2:00 p.m. The resident attendees were Residents' 1, 8, 12, 28, 39, 63, 67, 71, and 73. During the meeting, the resident council indicated the staff do not answer the call lights timely. This had been ongoing for a while and had not improved. It was not discussed at previous resident council meetings. An interview was conducted with the Activities Director on 2/3/25 at 8:58 a.m. She indicated grievances discussed in the resident council meetings were only recorded in the meeting minutes if the entire group had reported a concern. The facility…

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

Based on observation, interview, and record review, the facility failed to serve food at palatable temperatures for 4 of 4 residents reviewed for food (Resident 24, Resident 14, Resident C, and Resident 44). Findings include: 1 a. The clinical record for Resident 24 was reviewed on 1/30/25. The diagnoses included, but were not limited to, heart failure. A Quarterly Minimum Data Set (MDS) assessment, completed 11/1/24, indicated he was cognitively intact. During an interview on 1/30/25 at 10:04 a.m., Resident 24 indicated his food was not always hot when he received it. 1 b. The clinical record for Resident 14 was reviewed on 1/29/25 at 10:20 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease. A Quarterly MDS assessment, completed 11/06/24, indicated he was cognitively intact. During an interview on 1/29/25 at 10:29 a.m., Resident 14 indicated when food was delivered the hot items were not hot and the cold items were not cold. 1 c. The clinical record for Resident 44 was reviewed on 1/29/25 at 10:00 a.m. The diagnoses included, but were not…

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

Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident's ability to communicate and regarding Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for communication and 1 of 1 resident reviewed for PASRR (Resident E and Resident 28). Findings include: 1. The clinical record for Resident E was reviewed on 1/29/25 at 11:27 a.m. The diagnoses included, but were not limited to, diabetes and malnutrition. An Annual MDS assessment, completed 1/2/25, indicated Resident E had clear speech. He was rarely or never able to understand what was said to him or to make himself understood. During an interview on 1/31/25 at 11:37 a.m., Unit Manager 4 indicated Resident E was able to speak and understand English enough to communicate his needs. During an interview on 2/3/25 at 11:20 a.m., Resident E indicated the facility staff treated him well. During an interview on 2/3/25 at 11:31 a.m., the Social Service Assistant indicated Resident E could make his needs known, but at times…

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 nail care was provided and to ensure lotion was applied with personal hygiene for 2 of 6 residents reviewed for activities of daily living (ADLs). (Resident B and Resident E) Findings include: 1. The clinical record for Resident B was reviewed on 1/28/25 at 3:30 p.m. The diagnoses included, but were not limited to, respiratory failure. An 11/25/24 Quarterly Minimum Data Set (MDS) assessment indicated Resident B was cognitively impaired. The staff was to provide substantial/maximal assistance with bathing. An ADL care plan, dated 10/10/24, indicated .offer shower evening shift, Tuesday and Friday . Observations were conducted of Resident B on 1/28/25 at 3:32 p.m., 1/31/25 at 10:52 a.m., and 2/3/25 at 11:25 a.m. Resident B's nails were observed long in length. An interview was conducted with Resident B's Representative on 1/30/25 at 3:48 p.m. She indicated Resident B was not provided with good hygiene care. An interview was conducted with Licensed Practical Nurse (LPN) 1 on 2/3/25 at 11:34 a.m. She…

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 timely provide foot care to 1 of 2 residents reviewed for skin conditions. (Resident 7) Findings include: The clinical record for Resident 7 was reviewed on 1/30/25 at 10:33 a.m. His diagnoses included, but were not limited to, traumatic brain injury, dementia, chronic pain, and chronic obstructive pulmonary disease. The 12/12/24 Quarterly MDS (Minimum Data Set) assessment indicated he required substantial/maximal assistance for putting on and taking off footwear. The ADL (activities of daily living) self-care performance deficit care plan, revised 5/28/24, indicated he required assistance with ADLs, due to a functional deficit related to traumatic brain injury. The physician's orders indicated podiatry, as needed, effective 4/1/24. The 5/11/23 podiatry consent form indicated he requested to be seen for podiatry services, and to please have the podiatrist examine him for thickened, dystrophic (deformed, discolored, or thickened,) and/or painful nails with increased risk of infection. An observation 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 care planned fall interventions were implemented timely for 1 of 2 residents reviewed for positioning (Resident 63). Findings include: The clinical record for Resident 63 was reviewed on 01/28/25 at 1:50 p.m. The diagnoses included, but were not limited to, personal history of transient ischemic attack, muscle weakness, and abnormal posture. A care plan, dated 04/04/24, indicated Resident 63 was at risk for falls. The goal was for the resident not to sustain major injury related to falls. The interventions included, but were not limited to, a mat to be placed on the floor at bedside, bed in lowest position, and ensure that bed locks are engaged, initiated on 07/25/22. On 01/28/25 at 11:43 a.m., Resident 63 was observed lying in bed with no mat on the floor at bedside. On 01/31/25 at 09:27 a.m., Resident 63 was observed lying in bed eating breakfast with no mat on the floor at bedside. On 02/03/25 02:09 p.m., Resident 63 was observed lying in bed with no mat on the floor at bedside. On 02/03/25 02:11…

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 infection control by not donning on personal protective equipment (PPE) while providing respiratory care for 1 of 2 random observations of respiratory care. (Resident 75) Findings include: The clinical record for Resident 75 was reviewed on 1/28/25 at 11:00 a.m. The diagnoses included, but were not limited to, acute respiratory distress syndrome, tracheostomy, and acute respiratory failure. A physician order, dated 10/22/24, indicated the resident was in enhanced barrier precautions every shift. An observation was made of Resident 75 in his room with Respiratory Therapist (RT) 2 on 1/28/25 at 11:49 a.m. RT 2 was observed at Resident 75's bedside providing respiratory care to the resident. At that time, RT 2 was not observed wearing a gown while providing respiratory care. An interview was conducted with the Regional [NAME] President of Risk Management on 1/28/25 at 3:42 p.m. She indicated RT 2 should have been wearing PPE while providing respiratory care. An Enhanced Barrier Precaution policy was…

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

Based on observation, interview, and record review, the facility failed to maintain residents' room in a clean manner and good repair for 2 of 10 residents reviewed for environmental concerns. (Resident 47 and 60) Findings include: 1. An observation of Resident 60's room was made on 1/29/25 at 1:34 p.m. The restroom floor had no tile or flooring. There were a significant number of small, brownish spots on the ceiling above her bed. The ceiling vent cover between her bed and restroom was pulling away from the ceiling. An environmental tour was conducted with the Maintenance Director and Administrator on 2/4/25 at 2:40 p.m. During the tour, Resident 60's room was observed. An interview was conducted with Resident 60 at that time. The small, brownish spots on the ceiling above her bed remained, and the ceiling vent cover between her bed and restroom remained pulled away from the ceiling. There was a screw on one side of the vent that was no longer affixed to the drywall above it. The restroom flooring was now placed, but there was a puddle of water built up in the back left corner 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 interview and record review, the facility failed to ensure monitoring was completed of a resident on anticoagulant medications for 1 of 3 residents reviewed for medications. (Resident B) Findings include: The clinical record for Resident B was reviewed on 9/20/24 at 1:00 p.m. The diagnoses included, but was not limited to, lung cancer and pulmonary embolism (blood clot in the lungs). The resident was admitted to the facility on [DATE]. A hospital discharge medication list, dated 9/13/24, indicated Resident B was to receive 0.7 milliliters (ml) enoxaparin injection medication (anticoagulant medication) twice a day while receiving 5 milligrams (mg) of warfarin (anticoagulant medication) daily. The staff was to obtain daily international normalized ratio (INR) test (blood test measures how long it takes the blood to clot) until he becomes therapeutic with INR levels within a 2-3 range; then discontinue the enoxaparin and continue with the daily warfarin. A physician order, dated 9/13/24, 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 interview and record review, the facility failed to record urine outputs for residents utilizing a urinary catheter for 2 of 3 residents reviewed for urinary catheters. (Resident F and Resident G) Findings include: 1. The clinical record for Resident G was reviewed on 9/20/24 at 1:30 p.m. The diagnoses included, but was not limited to, paraplegia and neuromuscular dysfunction of bladder (bladder problems due to nerve/spinal cord damage). A care plan, dated 8/16/24, indicated Resident G had an indwelling and suprapubic (tube that drains urine from the bladder through a small incision in the lower abdomen) urinary catheters. A physician order, dated 8/15/24, indicated the resident had an 18 French (size of catheter) Foley Catheter (type of urinary catheter) to be changed every 30 days. A physician order, dated 8/15/24, indicated the staff was to measure and record the urine output every shift. A physician order, dated 8/15/24, indicated the staff was to empty the urostomy bag (an opening in the abdominal wall to redirect urine away from the bladder) every shift. The September…

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

Based on interview and record review, the facility failed to ensure a resident's dignity was maintained for 1 of 3 residents reviewed for abuse. (Resident F) Finding include: The clinical record for Resident F was reviewed on 7/31/24 at 9:00 a.m. The diagnosis included, but was not limited to, below the knee amputation (BKA). The admission Minimum Data Set (MDS) assessment, dated 5/13/24, indicated Resident F was cognitively intact. An interview was conducted with Resident F on 7/31/24 at 9:39 a.m. He indicated a night shift nurse, Licensed Practical Nurse (LPN) 3, does not like him. He can't remember for sure what day, but believed, on 7/24/24, he had requested some pain medication from LPN 3. LPN 3 had responded to him and how she had just given him his medications and he was f p her off. During that time, LPN 3 had called him a drug addict. The resident indicated he and LPN 3 were cussing at each other. She then left his room. The only other person in the room was his roommate, Resident V, and he does not hear very well. An interview was conducted with Resident V 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 interview and record review, the facility failed to ensure a resident's physician was notified of elevated blood glucose readings per physician's order for 1 of 3 residents reviewed for medication administration. (Resident C) Findings include: The clinical record for Resident C was reviewed on 7/30/24 at 11:30 a.m. The diagnoses included, but was not limited to, diabetes type I, end stage renal disease (ESRD), major depressive disorder, and neuropathy (weakness, numbness, and pain from nerve damage). An interview with Resident C conducted, on 7/30/24 at 12:17 p.m., indicated, there were numerous times the facility did not administer her insulin, and she had given herself her own insulin from her personal supply she had prior to her admission to the facility. A physician's order, dated 6/21/24, indicated Resident C was to give 10 units of Glargine insulin (long acting insulin) twice daily for diabetes. A physician's order, dated 6/21/24, indicated Resident C was to inject Humalog insulin (short-acting insulin) subcutaneously as per the sliding scale: If blood glucose was…

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

Based on interview and record review, the facility failed to ensure the timely reporting of a resident's unusual swelling of his left thigh/leg, which was identified as a left hip fracture, to the State Survey Agency for 1 of 4 residents reviewed for abuse/neglect. (Resident P) Findings include: The clinical record for Resident P was reviewed on 7/31/24 at 11:30 a.m. The diagnosis included, but was not limited to, paraplegia (chronic condition that affects the lower half of the body, causing loss of muscle function and sensory or motor impairment). A quarterly Minimum Data Set (MDS) assessment, dated 1/19/24, indicated Resident P was cognitively intact and required partial/moderate assistance to transfer from bed to chair and to get in/out of a tub/shower. A Facility Reported Incident, dated 2/2/24 at 8:30 p.m., indicated Resident P had a self-reported fall. The report indicated the type of injury sustained was a left hip fracture. The immediate action taken was Resident P had a self-reported fall to the Nurse Practitioner and his left hip was noted to be swollen. Resident P…

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 thoroughly investigate an allegation of abuse for 1 of 3 reportable incidents reviewed. (Resident N) Findings include: The clinical record for Resident N was reviewed on 8/01/24 at 10:00 a.m. The diagnoses included, but were not limited to, fracture of mandible, fracture of fourth metatarsal bone to right foot, and pain. The resident was admitted on [DATE]. The resident discharged on 6/11/24. The admission Minimum Data Set (MDS) assessment, dated 5/29/24, indicated Resident N was cognitively intact. A reportable incident, dated 5/22/24, indicated the following, .Resident [N] reported that he walked to his door entry and yelled that he was in pain. He stated that the nurse [[License Practical Nurse [LPN] 3]] allegedly told him to get back in bed. Resident stated that later the nurse came to his room and allegedly stated that she would not give him his medication . The complete investigation file for Resident N, dated 5/22/24, was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered as ordered and an Orthopedic appointment and DEXA scan (a bone density test) were scheduled in a timely manner for a resident who had an acute distal tibial and fibula fracture for 1 of 4 residents reviewed for abuse and/or neglect and for 1 of 3 residents reviewed for medications. (Resident F and Resident P) Findings include: 1. The clinical record for Resident F was reviewed on 7/31/24 at 9:00 a.m. The diagnosis included, but was not limited to, below the knee amputation (BKA). The admission Minimum Data Set (MDS) assessment, dated 5/13/24, indicated Resident F was cognitively intact. A care plan, dated 5/7/24, indicated Resident F has complaints of acute/chronic pain or at risk for pain .Follow physician orders for complaint of pain . A care plan, dated 5/7/24, indicated Resident F has impaired skin integrity, or at risk for altered skin integrity r/t [related to] left BKA and opened wound to right shin . 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess or address a resident's pain for 1 of 3 residents reviewed for pain. (Resident N) Findings include: The clinical record for Resident N was reviewed on 8/01/24 at 10:00 a.m. The diagnoses included, but were not limited to, fracture of mandible, fracture of fourth metatarsal bone to right foot, and pain. The resident was admitted on [DATE]. The resident discharged on 6/11/24. The admission Minimum Data Set (MDS) assessment, dated 5/29/24, indicated Resident N was cognitively intact. An admission evaluation for Resident N, dated 5/22/24, indicated the following, .Does the resident complain of pain? yes, Date of pain onset, if known .5/20/24. How frequent does the pain occur? every 4 hours. location of pain - right hip fracture and 4th and 5th toe fractures. Times when pain is worse: morning, night. Feeling of pain: acute .Based on assessment, enter residents severity level of pain (0-10) .8. Resident is to explain what their pain feels like .acute…

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 reconciliation of narcotic medications and assure names and signatures of dispensing nurses were present on the narcotic control record for 1 of 3 residents reviewed for medication administration. (Resident F) Findings include: The clinical record for Resident F was reviewed on 7/31/24 at 9:00 a.m. The diagnosis included, but was not limited to, below the knee amputation (BKA). The admission Minimum Data Set (MDS) assessment, dated 5/13/24, indicated Resident F was cognitively intact. A physician's order, dated 6/26/24, indicated Resident F was to receive 15 milligrams of oxycodone every 4 hours for pain. The medication was discontinued on 7/20/24. Resident F's controlled drug administration record for 15 milligrams of oxycodone indicated a count of 10 tablets. The record indicated the following documented recordings: On 7/20/24 at 12:00 p.m., a total amount of tablets was 3, 1 tablet was removed with a remaining total of 2 tablets. On 7/20/24 at 4:00 p.m., a total amount of tablets was 2, 1 tablet was…

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

Based on interview and record review, the facility failed to ensure residents' clinical records were complete and accurate for 1 of 3 residents reviewed for tube feeding and 1 of 3 residents reviewed for medication administration. (Resident C and Resident E) Findings include: 1. The clinical record for Resident E was reviewed on 7/30/24 at 1:00 p.m. The diagnosis included but was not limited to: tracheostomy. A physician order, dated 4/1/24, indicated Resident E was to receive enteral feeding every shift. Staff were to check and record residuals every 8 hours. If residuals were greater than 100 milliliters (ml), hold feeding and notify medical provider. A physician order, dated 4/1/24, indicated Resident E was to receive enteral feeding every shift. The staff was to document the total formula and water intake every shift. The May 2024 Medication Administration Record (MAR), indicated the residuals for Resident E's enteral feeding was recorded on day, evening, and night shift as the following: - day shift: 5/1/24 - NA (nonapplicable), 5/3/24 - 200 ml, 5/6/24 - 480 ml, 5/8/24 - 200…

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 timely obtain medications from the pharmacy, to accurately document administration of medications, and to timely obtain pain medication from the emergency drug supply for 3 of 4 residents reviewed for medication availability. (Resident B, D, and H). Findings include: 1. The clinical record for Resident B was reviewed on 2/19/24 at 11:15 a.m. The Resident's diagnosis included, but were not limited to, quadriplegia (loss of movement of all 4 limbs) and anoxic (lack of oxygen) brain injury. A care plan, initiated 5/5/22, indicated Resident B had impaired cognitive function due to a head injury. The goal was for all areas of care to be met by staff. The interventions included, but were not limited to, administer medications as ordered, initiated 5/5/22, communicate with resident, family, and caregivers regarding his capabilities and needs, initiated 5/5/22. A Quarterly MDS (Minimum Data Set) Assessment, completed 12/13/23, indicated 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 and interview, the facility failed to maintain the tile walls in a cleanly manner in the kitchen. This had the potential to affect all 117 residents in the facility. Findings include: An observation was conducted of the kitchen with the District Dietary Manager (DDM), on 12/5/23 at 10:50 a.m. There was a dark substance that appeared liked caked dirt, debris, and/or grease located on the tile behind the double oven along the top part of the preparation area adjacent to the double oven. The DDM indicated they had rented a pressure washer to clean parts of the kitchen but that had not be utilized for the wall tile. They have attempted to scrub parts of the tile wall but not all of such. An observation was conducted of the kitchen with the DDM, on 12/5/23 at 12:05 p.m. There was a dark substance that appeared like caked dirt, debris, and/or grease located on the tile behind the double oven, the top part of the preparation area adjacent to the double oven, and along the tile located behind the pre rinse area in the dish room towards the floor. An interview conducted…

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 physicians' order was in place for the use of total parenteral nutrition (TPN) and clarify physicians; order upon readmission for the utilization of TPN for 1 of 3 residents reviewed for intravenous (IV) therapy. (Resident H) Findings include: The clinical record for Resident H was reviewed on 12/6/23 at 1:38 p.m. The diagnoses included, but were not limited to, tracheostomy status, diabetes mellitus, muscle weakness, and history of infectious and parasitic diseases. Resident H was readmitted to the facility from the hospital on [DATE]. An observation conducted on 12/5/23 at 12:52 p.m. of Resident H lying in her bed with an IV device to her right chest. It was connected to a bag that contained TPN running at 75 milliliters (mL) an hour. Licensed Practical Nurse (LPN) 2 was present and indicated the TPN was connected by night shift, and she monitors the site and administration of TPN during her shift. Upon review of Resident H'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 the trash compactor did not have trash items located outside of the unit for 1 of 2 trash disposal items observed. Findings include: An observation was conducted, on 12/5/23 at 10:50 a.m., of the outside of the kitchen to where a trash compactor and a trash receptacle adjacent to the trash compactor. The trash compactor had bags of trash and other numerous items of trash located on the ground, beside the trash compactor. Another observation was conducted, on 12/5/23 at 12:10 p.m., of the trash compactor. It contained 2 trash bags and other random items of trash located right outside of the trash compactor. An interview conducted with the District Dietary Manager, on 12/5/23 at 2:05 p.m., indicated she noticed writer was observing the outside trash receptacles. She then noticed the trash located outside of the trash compactor. She went to get staff assistance and they proceeded to clean up the trash that was located outside of the trash compactor. She wasn't sure how often the trash is picked up but sometimes, if 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 interview and record review, the facility failed to ensure licensed nurses were able to demonstrate competency in skills and techniques necessary to input physicians orders into the electronic medical record, recognize a change in condition, and follow-up with a change in condition. This had the potential to affect all 108 residents that reside in the facility. Findings include: Resident B did not have admission orders entered into the electronic medical record accurately, timely, and that such orders were administered as ordered by the physician for a resident who later experienced a change in condition that was not documented in the medical record. Cross reference F684. During an interview on [DATE] at 2:21p.m., LPN 26 indicated she had worked on [DATE] from 6:00 p.m. until [DATE] at 6:00 a.m. To LPN 26's knowledge, Resident B's admission orders had been taken care of by UM 22. LPN 26 was a fairly new employee to the facility. She had not received report from the previous shift. LPN 26 had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure sufficient staff to carry out timely meal service at the facility for 96 of 108 residents who are served food from the kitchen. Findings include: The ED provided the Meal Service Schedule for the facility on 10/26/23 at 11:00 a.m. It indicated breakfast started at 7:00 a.m. The Cambridge Unit was served at 7:30 a.m. The Main Dining Room was served at 7:45 a.m. The [NAME] Unit was served at 8:15 a.m. It indicated lunch started at 12:00 p.m. The Cambridge Unit was served at 12:30 p.m. The Main Dining room was served at 12:45 p.m. The [NAME] Unit was served 1:15 p.m. It indicated dinner started 5:00 p.m. The Cambridge Unit was served at 5:30 p.m. The Main Dining Room was served at 5:45 p.m. The [NAME] Unit was served at 6:15 p.m. An interview was conducted with Resident 24, who resided on the [NAME] Unit, on 10/27/23 at 10:10 a.m. She indicated the food just sat on the food cart was never served hot. An interview was conducted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 96 of 108 residents who eat food from the kitchen. (Residents 8, 24, 225, 226, and 228) Findings include: An interview was conducted with Resident 8 on 10/27/23 at 10:56 a.m. They indicated the food sucks, and you wouldn't serve it to an animal. The quality was horrible and didn't have the right nutrients. Resident 8 ate a lot of peanut butter and jelly, because the food was so bad. An interview was conducted with Resident 24 on 10/27/23 at 10:10 a.m. She indicated the food was never served hot, sat on the food cart for a long time, and was not quality food. The oatmeal served at breakfast was so sticky, you could wad it up, throw it on the wall, and it would stick. The kitchen served out of date milk and food you wouldn't feed to a dog. She never got a hot plate. The only thing the kitchen could trick you with is a boiled egg. Everything they served was low…

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 properly store clean dishes, bread in the dry storage area, and refrigerated foods and maintain kitchen equipment in a clean, sanitary condition for 96 of 108 residents in the facility. Findings include: A tour of the kitchen was conducted with the District Dietary Manager (DDM) on 10/26/23 at 11:30 a.m. An interview was conducted with the DDM during this tour. During the initial tour, the preparation refrigerator was observed. There was an opened box of orange juice for the orange juice dispenser with an open bag containing the orange juice contents. the open bag was sticking out of the front of the box. There was orange juice contents on the open bag and box, exposed to air. The DDM indicated the orange juice bag was typically contained within the box. During the initial tour, the stove hood was observed. There was a missing vent cover with exposed pipes. There was a cobweb hanging between 2 front sprinkler pipes directly over the stove. There was a heavy amount of dried splash on the stove and ovens. The…

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

Based on observation, interview, and record review, the facility failed to maintain the floors in a cleanly manner in the kitchen for 96 of 108 residents in the facility. Findings include: A tour of the kitchen was conducted with the DDM (District Dietary Manager) on 10/26/23 at 11:30 a.m. During the tour, the stove and oven area was observed. There was a significant amount of dark gunky looking debris and food particles stuck to the floor underneath the stove area. The DDM indicated the floors should be swept and mopped nightly, but it did not look like it was done last night. During the tour, thee walk in refrigerator was observed. There was dark, gunky debris built up around thee baseboards of the floor in the refrigerator. The DDM indicated mopping should be done daily and deep cleaning monthly. During the tour, the dishwasher area was observed. There was a significant amount of gunky debris and mineral scale build up underneath the dishwasher machine. The Environment policy was provided by the ED (Executive Director) on 10/31/23 at 12:07 p.m. It read, The Dining Services…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain an effective training program for all new and exisiting staff by determining the amount and types of training necessary based on the facility assessment that included, but were not limited to, inputting physician orders, clarifying physician orders, identification of a change in a residents' condition, follow-up with a change in condition, notification of the physician, and documentation in the medical record. The facility failed to ensure newly hired staff received orientation that was based on the training topics that aligned with the facility assessment. This had the potential to affect all 108 residents that reside in the facility. Findings include: Resident B did not have admission orders entered into the electronic medical record accurately, timely, and that such orders were administered as ordered by the physician for a resident who later experienced a change in condition that was not documented in the medical record. Cross reference…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment for 7 of 12 resident rooms observed. (Residents 7, 32, 43, 62, 228, 226, and 69) Findings include: 1. An observation conducted of Resident 7's room on 10/26/23 at 3:39 p.m., noted the wall by the window with missing paint approximately the size of a ruler. The roommate of Resident 7 indicated the area of missing paint has been there for a while. The area of missing paint was still noted on 11/2/23 at 10:31 a.m. 2. An observation conducted of Resident 32's room, on 10/27/23 at 10:17 a.m., noted crumbs on wheelchair and built up dirt located on the legs of the bedside table. The crumbs were still located to the foot rests of the wheelchair along with built up of dirt to the legs of the bedside table on 11/2/23 at 10:33 a.m. 3. An observation conducted of Resident 43's room, on 10/26/23 at 11:33 a.m., noted an area of plastered dry wall beside the bed that was not painted. There was missing paint on the walls by both beds located in the room. The area of…

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

Based on observation and interview, the facility failed to protect and value a resident's private space by not knocking on doors and requesting permission before entering a resident's room for 2 residents during a random observation (Resident 52 and 38) and not taking into account the physical limitations of a resident by not clearly explaining to a resident who is blind what she had placed on his bedside tray table nor where it was placed so that he may find it for 1 of 1 residents observed during a random observation (Resident 52). Findings include: 1. A random observation made on 10/30/23 at 3:14 p.m. observed CNA (Certified Nursing Assistant) 20 passing out lunch trays. CNA 20 failed to knock and wait for permission to enter Resident 52's room when delivering his lunch tray. After exiting his room, she grabbed another tray from the dining cart and proceed to Resident 38's room where she failed again to knock and wait for permission to enter prior to entering the room. An interview with CNA 20 conducted on 10/30/23 at 3:16 p.m. indicated, she was aware she should have knocked…

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 review, record the facility failed to have the Interdisciplinary team (IDT) determine and document a self medication assessment was clinically appropriate for 2 of 2 residents randomly observed with medications at the bedside. (Resident 12 and 83) Findings include: 1. The clinical record for Resident 83 was reviewed on 10/26/23. Resident 83's diagnoses included, but not limited to, bipolar, dysphagia (difficulty swallowing), and anxiety. A random observation conducted on 10/26/23 at 2 p.m. of Resident 83's room found on his bed side table a small white pill. When Resident 83 was asked about the pill, he stated he didn't know what the medication was but, then indicated to give it to him and he would take the pill now. It was explained to Resident 83 that if he was unaware of what the medication was, he probably shouldn't just take it but rather ask his nurse about it. An interview with Resident 83's QMA (Qualified Medication Assistant) 22 was conducted immediately following the random observation. QMA 22 indicated, she was unable to identify the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation,interview, and record review, the facility failed to ensure continued provision of a wheel chair and to ensure a resident's television was positioned for viewing for 1 of 4 residents reviewed for personal property and 1 of 2 residents reviewed for accommodation of needs. (Resident E and Resident 50) . Findings include: 1. The clinical record for Resident E was reviewed on 10/30/23 at 10:46 a.m. His diagnoses included, but were not limited to: type 2 diabetes, hypertension, major depressive disorder. He was discharged from the facility to the hospital on 4/30/23, readmitted to the facility on [DATE], discharged to the hospital on 8/11/23, readmitted to the facility on [DATE], discharged to the hospital on 8/31/23, readmitted to the facility on [DATE], and discharged to the hospital on 9/13/23. Resident E discharged to another facility when he left the hospital. The ADL (activities of daily living) self care performance deficit care plan, initiated 10/19/23, indicated he required assistance…

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 timely address a resident's guardian's grievances and to promptly resolve an oral grievance from a resident regarding missing clothing items for 2 of 4 residents reviewed for personal property. (Resident E and Resident 32) Findings include: 1. The clinical record for Resident E was reviewed on 10/30/23 at 10:46 a.m. His diagnoses included, but were not limited to: type 2 diabetes, hypertension, major depressive disorder. He was discharged to the hospital on 8/11/23, readmitted to the facility on [DATE], discharged to the hospital on 8/31/23, readmitted to the facility on [DATE], and discharged to the hospital on 9/13/23. Resident E discharged to another facility when he left the hospital. The ADL (activities of daily living) self care performance deficit care plan, initiated 10/19/23, indicated he required assistance with ADLs. An intervention was that he required extensive assistance with transfers, bed mobility, and toileting. The impaired cognitive…

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 accuracy of a resident's MDS (Minimum Data Set) assessment for 1 of 1 resident reviewed for PASRR (Pre admission Screening Resident Review) and 2 of 3 residents reviewed for MDS accuracy. (Resident 26, 83, and 69) Findings include: 1. The clinical record for Resident 26 was reviewed on 10/26/23 at 3:35 p.m. His diagnoses included, but were not limited to: bipolar disorder, major depressive disorder, anxiety disorder, and mild vascular dementia. Resident 26's 6/25/18 Summary of Preliminary Findings and Recommendations of PASRR/MI [Pre admission screening resident review/mental illness] Level II Mental Health Assessment indicated he was mentally ill and to continue current mental health services, medication monitoring, and medication administration. It indicated diagnoses of bipolar disorder, major depression, and anxiety disorder. Section A1500 of Resident 26's 4/12/23 Annual MDS assessment, completed by SS (Social Services) 26, indicated he was not considered by the state level II PASRR process to have…

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 timely update an ADL (Activities of Daily Living) care plan to reflect the resident's refusal of care and to ensure a resident's dialysis care plan was updated for 1 of 4 residents reviewed for ADL care and 1 of 2 residents reviewed for Dialysis. (Resident 69 and Resident C) Findings include: 1. The clinical record for Resident 69 was reviewed on 10/26/23 at 12:13 p.m. The Resident's diagnosis included, but was not limited to, hypertension and anemia. A care plan, last revised on 8/1/23, indicated Resident 12 had an ADL self care performance deficit and required assistance with ADL care. The goals were for her to no have further declines in range of motion and to exhibit improved function. The interventions included, but were not limited to, Resident 12 required extensive assistance of 2 staff members for transfers. A Quarterly MDS (Minimum Data Set) Assessment, completed 9/27/23, indicated she was cognitively intact and was dependent on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide showers that included shaving and by not ensuring twice weekly showers/complete bed baths were provided for 2 of 4 residents reviewed for Activities of Daily Living. (Resident 225 and Resident F) Findings include: 1. The clinical record for Resident 225 was reviewed on 10/26/23 at 2:30 p.m. The diagnoses included but were not limited to: major depressive disorder, anxiety disorder and blindness. The resident was admitted on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 225 was cognitively intact. The resident was needing partial/moderate assistance with bathing and supervision that included verbal cues and touching assistance for personal hygiene and dressing. An ADL care plan for Resident 225 indicated the resident was needing assistance with ADL's due to blindness. An observation was made of Resident 225 on 10/26/23 at 2:24 p.m. The resident was observed wearing blue jeans and a black…

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 services to prevent a resident's range of motion from declining and failed to ensure a resident with limited range of motion received appropriate treatment, equipment, and services to prevent further decrease in range of motion for 2 of 3 residents reviewed for range of motion ( Resident 34 and 61). Findings include: 1. The clinical record for Resident 61 was reviewed on 10/27/23 at 2:26 p.m. The Resident's diagnosis included, but were not limited to, chronic respiratory failure and age-related debility. An Occupational Therapy Discharge summary, dated [DATE], indicated that on 7/17/23, Resident 61's bilateral upper body strength was 4-/5 (part movement through full range against gravity and slight to moderate resistance). She was able to grasp and hold items with minimal assistance. She had been discharged from Occupational Therapy due to hospitalization. A Quarterly MDS (Minimum Data Set) Assessment, completed 8/12/23, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow physician orders for the administration of gastrostomy tube (g-tube) bolus feedings for a random observation during medication administration. (Resident 95) Findings include: The clinical record for Resident 95 was reviewed on 11/2/23 at 10:00 a.m. The diagnoses included, but were not limited to, gastostomy status, congestive heart failure, and acute kidney failure. A current physician order was noted for [NAME] Farms tube feeding of 375 milliliters (mL) with 140 mL water flush every 4 hours. This order was on the computer screen for Licensed Practical Nurse (LPN) 5 to observe, on the electronic medication administration record (EMAR), prior to administration for Resident 95. A feeding tube care plan, revised 4/3/23, indicated to provide tube feeding per providers' orders. An observation conducted on 10/30/23 at 12:35 p.m., with Licensed Practical Nurse (LPN) 5 administering a carton of [NAME] Farms tube feeding that contained 325…

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 assure a resident had an inner canula present in her tracheostomy, as ordered by a physician, for 1 of 1 resident reviewed for tracheostomy care (Resident 61). Findings include: The clinical record for Resident 61 was reviewed on 10/27/23 at 2:26 p.m. The Resident's diagnosis included, but were not limited to, tracheostomy and chronic respiratory failure. A physician's order, dated 7/29/23, indicated to replace inner cannula during trach care daily and as needed. A physician's order, dated 7/29/23, indicated to provide trach care every shift and as needed. A care plan, last revised on 7/31/23, indicated Resident 61 was receiving tracheostomy care due to respiratory failure. The goal was for her to be free of signs and symptoms of complications from tracheostomy. The interventions included, but were not limited to, administer treatments per medical provider's order, initiated 5/16/21, and to provide trach care and suctioning per order, initiated 5/16/21. During an interview on 11/2/23 at 10:20 a.m., RT…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident receiving dialysis services had physician orders for dialysis services and monitoring of the site for 1 of 2 residents reviewed for dialysis. (Resident C) Findings include: The clinical record for Resident C was reviewed on 10/26/23 at 2:00 p.m. The diagnoses included but were not limited to: chronic kidney disease and type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident C was cognitively intact. A care plan dated 10/6/23 indicated Resident C received dialysis services in the facility on Mondays, Wednesdays and Fridays. The resident's access site was in her right chest. The resident's physician orders did not include dialysis orders or monitoring the resident's site. An interview was conducted with Resident C on 10/26/23 at 1:59 p.m. She indicated she received dialysis services in the facility on Tuesdays, Thursdays and Saturdays. The resident's port was located on her left thigh. The…

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

Based on interview and record review, the facility failed to accurately monitor, document, and track behaviors for 1 of 5 residents reviewed for unnecessary medications, 1 of 4 residents reviewed for dignity, and 1 of 1 resident reviewed for abuse.(Resident 34, Resident F, and Resident 8). Findings include: 1. The clinical record for Resident F was reviewed on 10/31/23 at 10:18 a.m. Resident F's diagnoses included, but not limited to, hemiplegia (paralysis of one side of the body) affecting the right, dominant side, bipolar disorder, major depressive disorder, aphasia (difficulty with speaking), and anxiety disorder. A Psychiatry progress note dated 8/10/23 indicated, Resident F was seen for a follow-up visit for psychiatric medication management. He was taking Zoloft (anti-depressant) and melatonin (sleep aide). Resident F is frequently agitated and cursing at staff. Refuses po[sic, per os, by mouth] meds. Will start Risperadal Consta (an anti-psychotic medication). Resident F's presenting symptoms included, but not limited to, agitation, uncooperative with nursing care, delusions,…

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 the resident was provided clothing for 1 of 4 residents reviewed for Activities of Daily Living. (Resident 225) Findings include: The clinical record for Resident 225 was reviewed on 10/26/23 at 2:30 p.m. The diagnoses included but were not limited to: major depressive disorder, anxiety disorder and blindness. The resident was admitted on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 225 was cognitively intact. The resident was needing partial/moderate assistance with bathing and supervision that included verbal cues and touching assistance for personal hygiene and dressing. An ADL care for Resident 225 indicated the resident was needing assistance with ADL's due to blindness. The resident's inventory sheet dated 10/11/23 indicated Resident 225 does not have any clothes. An observation was made of Resident 225 on 10/26/23 at 2:24 p.m. The resident was observed wearing blue jeans and a black…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medication carts did not contain expired medications along with loose pills located in 2 out of 4 medication carts observed. Findings include: An observation was conducted of [NAME] cart 3 with Licensed Practical Nurse (LPN) 6 on 10/30/23 at 1:50 p.m. There was a vial of Humalog for Resident 43 with a use by date of 10/15/23. There was also a vial of Novolog for Resident 70 with a use by date of 10/17/23. The second drawer contained 9 loose pills in the center compartment and other loose pills in the right compartment of that same drawer. An observation was conducted of [NAME] cart 1 with Unit Manager 24 on 10/30/23 at 1:55 p.m. There were loose pills scattered in the second and third drawers of the medication cart. There was a packet that contained a 4 milligram tablet of Zofran (anti nausea medication) in the top drawer that didn't have a resident name, instructions, or date. A policy titled Storage of Medications, revised…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was provided milk as preferenced and failed to ensure a resident's preference for an alternative food item, which was on the always available menu, was always available for 2 of 6 residents reviewed for food. (Resident 225 and Resident 52) Findings include: 1. The clinical record for Resident 225 was reviewed on 10/26/23 at 2:30 p.m. The diagnoses included but were not limited to: major depressive disorder, anxiety disorder and blindness. The resident was admitted on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 225 was cognitively intact. The resident was needing partial/moderate assistance with bathing and supervision that included verbal cues and touching assistance for personal hygiene and dressing. An ADL care for Resident 225 indicated the resident was needing assistance with ADL's due to blindness. An interview was conducted with Resident 225 on 10/31/23 at 10:00 a.m. He indicated he 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 hand hygiene was performed prior to staff touching pills with their bare hands and ensure personal protective equipment (PPE) was donned prior and during administration of a aerosol generating procedure (AGP) for 2 of 14 residents observed for medication administration. (Resident 100 and Resident 85) Findings include: 1. An observation was conducted of medication administration with Resident 100 by Licensed Practical Nurse (LPN) 5 on 10/30/23 at 1:00 p.m. LPN 5 proceeded to administer a nebulizer treatment to Resident 100 after she listened to their lung sounds along with obtaining a full set of vital signs. No PPE was donned prior to entering Resident 100's room before or during the administration of such nebulizer treatment. LPN 5 went to the nurses station to take a phone call while the Assistant Director of Nursing (ADON) entered the room to remove the nebulizer treatment mask from Resident 100 and obtained post treatment vital signs without donning PPE prior to entering Resident 100's room. 2. 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 interview and record review, the facility failed to prepare a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of all pre and post discharge medications, and a discharge plan of care for 3 of 3 residents reviewed for discharge. (Resident B, Resident F and Resident G) Findings include: 1. The clinical record for Resident F was reviewed on 9/19/23 at 1:00 p.m. The diagnosis included but was not limited to: type 2 diabetes mellitus. A nursing note dated 6/30/23 indicated resident requested to be transferred to another long term care facility. A nursing progress note dated 7/6/23 indicated the resident discharged that day to another long term care facility. The resident was discharged with medications and personal items. 2. The clinical record for Resident G was reviewed on 9/19/23 at 1:15 p.m. The diagnosis included but was not limited to: tracheostomy. A nursing progress note dated 9/5/23 indicated Resident G was discharged to another long term care facility with medications. The clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure identified skin impairments were assessed after admission/readmission to the facility and ensure treatments were initiated timely after identification of skin impairments for 2 of 3 residents reviewed for pressure ulcers. (Resident C and Resident D) Findings include: 1. The clinical record for Resident C was reviewed on 8/29/23 at 12:09 p.m. The diagnoses included, but were not limited to, encephalopathy, tracheostomy status, stage 3 pressure ulcer, and gastrostomy status. A care plan for pressure ulcer, revised 6/21/23, indicated Resident C had impaired skin integrity related to right buttock wound. The interventions listed to administer treatments as ordered by the physician. A wound care provider note, dated 8/8/23, indicated a deep tissue injury (DTI) located to Resident C's left heel and a DTI located to the sacrum. Resident C was hospitalized from [DATE] to 8/18/23. A readmission assessment, dated 8/18/23, indicated an identified skin…

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 gastrostomy (g-tube/feeding tube) feedings and flushes were consistent with physician orders for 3 of 4 residents reviewed for feeding tubes. (Resident C, Resident D, and Resident E) Findings include: 1. The clinical record for Resident C was reviewed on 8/29/23 at 12:09 p.m. The diagnoses included, but were not limited to, encephalopathy, tracheostomy status, gastrostomy (g-tube) status, and congestive heart failure. A care plan for nutrition, revised 4/3/23, indicated Resident C had a feeding tube and the intervention was listed to provide supplements per physician orders. A physician order, dated 8/24/23, was noted to flush feeding tube with 25 mL of water every hour. A physician order, dated 8/24/23, was noted for tube feeding at 70 mL every hour. An observation conducted on 8/29/23 at 1:18 p.m., of Resident C lying in bed and the g-tube was connected to the feeding pump. There was a container of feeding and a container with water present for water flushes to the g-tube. The feeding pump had…

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