Alpha Home - A Waters Community

Based on observation, interview, and record review, the facility failed to ensure there was consistent communication between the facility and the dialysis center regarding the residents' care for 2 of 2 residents (Residents 24 and 6) reviewed for dialysis services. Findings include:1. On 12/2/25 at 2:41 p.m. Resident 24 was observed in his room as he sat in his wheelchair speaking with another resident. Resident 24 indicated the staff did not do any type of assessment or vitals when he got back from dialysis treatments, they only welcomed him back and helped him get settled when needed. On 12/3/25 at 9:18 a.m. Resident 24's medical record was reviewed. He was a long-term care Resident whose diagnoses included but were not limited to end stage renal disease (kidney disease). Resident 24 had an active order initiated on 4/10/24 that indicated he would receive dialysis treatment every Monday, Wednesday, and Friday. The medical record lacked documentation of communication between the facility and the dialysis center. 2. On 12/3/25 at 9:50 a.m., a record review was completed for Resident…

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

Based on record review and interview, the facility failed to obtain a urine culture and sensitivity after a resident was found on the floor next to her bed for 1 of 3 residents reviewed (Resident 2).Findings include: On 12/4/25 at 11:48 a.m., a record review was completed for Resident 2. She had the following diagnoses which included but were not limited to history of cardiac arrest, type 2 diabetes, neuropathy (nerve pain), hypertension, generalized anxiety, and muscle weakness.On 7/25/25 at 6:56 p.m., Resident 2 was found on the floor next to her bed. She was not injured. The Interdisciplinary team recommended labs, a complete blood count (CBC), basic metabolic profile (BMP), a urinalysis (UA), and a culture and sensitivity (C&S). The facility completed the STAT (as soon as possible) CBC, BMP, and urine. It was recommended to obtain another C&S. On 7/25/25 the labs were complete, and a culture was indicated with results to follow. The culture was not completed. On 12/4/25 at 2:01 p.m., during an interview with the Regional Nurse Consultant (RCS), she indicated the lab was unable…

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 fall prevention interventions were individualized and implemented, and fall follow-up assessments and interventions were completed for 1 of 3 residents reviewed for falls (Residents B). Findings include, A confidential concern during the survey indicated Resident B had fallen out of bed while an aide was providing care on an unknown date, and there were questions concerning whether the staff member had been qualified to provide care. Resident B's clinical record was reviewed on 5/27/25 at 2:15 p.m. The diagnoses included, nontraumatic intracerebral hemorrhage (stroke), aphasia (difficulty in communicating and understanding verbal and written language), dysphagia (difficulty swallowing), and pressure ulcer. An admission physician's note, dated 3/17/25, indicated Resident B had been hospitalized with right sided weakness and aphasia following a large left-sided intercranial hemorrhage. The resident was unsteady on his feet, and staff were to utilize fall precautions per facility policy. A Fall Risk…

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 medication and biologicals were stored according to facility policy for 1 of 1 treatment carts observed for medication and biological storage. Findings include: During a random observation on 5/28/25 at 12:31 p.m., an unlocked treatment cart containing tubes and bottles of biological (medications used to treat skin conditions and wounds) was positioned near the nurse's station, outside the main dining room, and near the entry to the 100 hallway. The top drawer of the treatment cart was opened exposing insulin and blood glucose testing supplies to include a box of exposed lancets (small disposable needles), bottles of blood glucose strips, packaged dressings, and alcohol pads. There was a plastic medication cup with unidentified pills and capsules sitting unsecured on top of the treatment cart. There were 8 residents observed sitting in the main dining room within view of the treatment cart, and Resident H was standing beside the treatment cart. Licensed Practical Nurse (LPN) 7 was observed sitting down inside 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 interviews and record review, the facility failed to ensure Resident Council grievances were followed up on and reported back to the Resident Council for review and approval. This deficient practice had the potential to effect 4 of 54 residents who attended the Resident Council meeting. Findings include: On 9/24/24 at 10:00 a.m., the Resident Council minutes were reviewed. A meeting was held on 2/22/24 with new and old business which indicated, Residents want to go out for outings like eating/shopping. There was no documentation of a response to the Resident Council's request. A meeting was held on 3/21/24 which indicated, old business was not discussed and they requested more outing again. Two separate grievances were hand written on behalf of two residents related to wanting to go on more outings and general nursing care concerns. There was no documentation of a response to the Resident Councils requests, and/or the individual grievances. The next meetings were held on 6/20/24, 7/18/24, and 8/15/24 which discussed general care concerns which included, but were not limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 5 of 5 residents reviewed for MDS accuracy (Resident 9, 47, 12, 11, and 33). Findings include: 1. On 9/26/24 at 10:00 a.m., a record review was completed for Resident 9. She had the following diagnoses which included, but were not limited to, hypertension (high blood pressure) (HTN), diabetes mellitus type 2 (blood sugar disorder) (DM), and weakness. She had a physician's order for aspirin 81mg (antiplatelet) by mouth daily. Her Minimum Data Set (MDS) assessment, dated 8/20/24, indicated she took an anticoagulant (blood thinner). She did not have an order for an anticoagulant. Her aspirin should have been coded as an antiplatelet on the MDS. She had a care plan, dated 9/8/22, that indicated she was at risk for abnormal bleeding related to the daily use of aspirin with an increased risk for bruising and/or bleeding. 2. On 9/25/24 at 11:21 a.m., a record review was completed for Resident 47. He had the…

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

Based on observation and interview, the facility failed to date medications when opened for 1 of 3 medication carts reviewed (medication cart 300) and 1 of 3 treatment carts (treatment cart 3). Findings include: 1. On 9/23/24 at 10:21 a.m., the 300-hall treatment cart was observed with Qualified Medication Assistant (QMA) 13. Resident 5 had a Lantus pen (insulin, used to treat diabetes) in the treatment cart. It lacked a date to indicate when it was opened. Resident 36 had a Humalog pen (insulin) in the treatment cart. It lacked a date to indicate when it was opened. 2. On 9/23/24 at 10:32 a.m., the 300-hall medication was observed with QMA 13. It contained Resident 5's flonase (used for allergies) in the cart with no date to indicate when it was opened. Resident 21 had a bottle of ear drops in the cart. It lacked a date to indicate when it was opened. A policy titled; Medication Storage in the Facility was provided by the Regional Nurse Consultant (RCS) on 9/26/24 at 9:53 a.m. It lacked information regarding the dating of medications when opened. The RCS indicated this was the only…

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 dignity for a female resident with long facial hair for 1 of 1 resident reviewed for dignity (Resident 33). Findings include: During an interview, on 9/23/24 at 11:10 a.m., Resident 33 indicated she did not like the long hair on her face and would prefer to be shaved. She indicated she was unable to do it alone and needed assistance with this task. The hair on her face was observed to be long. During an interview, on 9/24/24 at 11:42 a.m., Resident 33 indicated she talked with the facility staff yesterday about wanting to have the facial hair removed, but nothing had happened yet. Her long facial hair was still intact. On 9/24/24 at 1:47 p.m., Resident 33's record was reviewed. Her diagnoses included, but were not limited to, supraventricular tachycardia (irregularly fast or erratic heartbeat), chronic respiratory failure (long-term condition that occurs when the body's respiratory system can't effective function), and age-related debility (physiological decline). A care plan, dated 11/6/23, 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.

Based on record review and interview, the facility failed to add comprehensive care plans for 2 of 2 residents reviewed for comprehensive care plans (Residents 47 and 12). Findings include: 1. On 9/25/24 at 11:13 a.m., a record review was completed for Resident 47. He had the following diagnoses which included but were not limited to end stage renal disease (ESRD), dementia, hypertension (HTN), and age-related physical debility. His medical record lacked a care plan addressing his nutritional needs related to ESRD with dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are unable to do so). A care plan, dated 4/10/24, was provided by the Director of Nursing (DON) on 9/25/24 at 1:48 p.m. It indicated Resident 47 was at risk for potential complications related to dialysis, ESRD. 2. On 9/25/24 at 10:58 a.m., a record review was completed for Resident 12. She had the following diagnoses which included but were not limited to dementia, chronic kidney disease, major depressive disorder, and anxiety. She was ordered to take melatonin 3 milligrams (mg)…

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

Based on record reviews and interviews, the facility failed to update care plans with changes in resident care for 2 of 3 residents reviewed for care plan revision (Resident 25 and 12). Findings include: 1. On 9/25/24 at 10:45 a.m., a record review was completed for Resident 25. She had the following diagnoses which included but not limited to depressive disorder, generalized anxiety disorder, and a history of opioid abuse. She had a care plan to address the use of medications to treat behaviors, Buspar (an antianxiety), trazodone (an antidepressant), duloxetine (an antidepressant), and mirtazapine (an antidepressant). The care plan failed to address Resident 25 refused to have gradual dose reductions (GDR) per her preference. 2. On 9/25/24 at 10:58 a.m., a record review was completed for Resident 12. She had the following diagnoses which included dementia, major depressive disorder, and insomnia. She had a care plan that indicated, at risk for decline in mood related to diagnosis of major depression single episode diagnosis and she is on an antidepressant. Her medication regimen…

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

Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 11) who experienced a fall was not moved until after a medical assessment was completed to prevent the potential for worsening any known or unknown injuries for 1of 1 of residents reviewed for accidents. Findings include: On 9/24/24 at 11:18 a.m., Resident 11's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, history of a stroke, weakness/paralysis of his left side, vascular dementia, muscle wasting and atrophy, chronic pain syndrome and wedge compression fracture of the L1 vertebra. An Interdisciplinary team (IDT) progress note, dated 1/18/24 at 12:22 p.m., indicated Resident 11 had been in transit on the facility bus to a dental appointment when he slid out of his wheelchair and landed on his butt, on the floor of the bus. At the time of his fall, he complained of pain in his left shoulder/elbow and stated he hit his head on the wheelchair. Resident 11 was assisted back into his wheelchair on the bus 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 a resident, (Resident 35) received treatments and services to prevent the worsening of contracture in her hand and wrist for 1 of 1 residents reviewed for range of motion. Findings include: On 9/23/24 at11:32 a.m., Resident 35 was initially observed. The fingers of her right hand were contracted into a fist, and her wrist was contracted upward at a slight angle. There was no splint or palm protector observed in her room at that time. On 9/24/24 at 9:36 a.m., Resident 35 was observed. She did not have a palm protector in place. On 9/24/24 at 2:03 p.m., Resident 35 was observed. She did not have a palm protector in place. On 9/24/24 at 2:10 p.m., Resident 35's medical record was reviewed. She was a long-term care resident who resided on the secured memory care unit and had diagnoses which included, but were not limited to, dementia, muscle weakness, and contracture of her left hand. An Occupational Therapy (OT) referral summary, dated 5/9/24, indicated, Resident 35 had been referred for therapy 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.

Based on record review and interview, the facility failed to obtain a resident's blood pressure and pulse prior to administering metoprolol (an antihypertensive medication) as ordered for 1 of 6 residents reviewed for medications(Resident 14). Findings include: On 9/24/24 at 2:19 p.m., a record review was completed for Resident 14. She had the following diagnoses which included but were not limited to hypertension (HTN). She was prescribed a medication, metoprolol (a medication used to treat hypertension). The order was to take 25 milligrams (mg), give 1 tablet by mouth two times daily for HTN, hold for systolic blood pressure less than 100 or pulse less than 60. The medication administration record (MAR) for August 2024 and September 2024 were reviewed and they lacked documentation of a blood pressure and pulse prior to administering the medication, metoprolol. Resident 14 had a care plan that indicated she had HTN dated 7/12/24. The goal, dated 10/30/24, indicated her blood pressure would remain stable through the next review. An intervention, dated 11/7/22, indicated to…

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 pharmacy recommendations to reduce an psychotropic medications were declined with adequate documentation of symptoms for 2 of 5 residents reviewed for unnecessary medications (Residents 34 and 9). Findings include: 1. On 9/24/24 at 1:20 p.m., Resident 34's medical record was reviewed. She was a long-term care resident who resided on the secured memory care with diagnoses which included, but were not limited to, dementia, schizoaffective disorder, bipolar type and anxiety. A pharmacy recommendation, dated 1/3/24, indicated Resident 34 was scheduled for a trail reduction of an antianxiety medication. The doctor declined the recommendation and indicated Resident 34 was symptomatic. Resident 34's December 2023 and January 2024 behavior monitoring was reviewed. There were not documented days of symptoms. Resident 34's nursing progress notes lacked documentation of symptoms. Resident 34's record lacked documentation of symptoms. During an interview on 9/26/24 at 11:40 a.m., the Director of Nursing (DON) indicated that…

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

Based on observation, interview, and record review the facility failed to ensure an x-ray was completed for 1 of 1 resident reviewed for x-rays (Resident 33). Findings include: On 9/24/24 at 1:47 p.m., Resident 33's record was reviewed. Her diagnoses included, but were not limited to, supraventricular tachycardia (irregularly fast or erratic heartbeat), chronic respiratory failure (long-term condition that occurs when the body's respiratory system can't effective function), and age-related debility (physiological decline). A Nurse Practitioner (NP) progress note, dated 9/21/24 at 12:00 p.m., indicated Resident 33 complained of left (L) mid-foot pain. She believed it got tangled in the Hoyer lift pad. He ordered 3 view x-ray of her left foot to rule out acute injury, reduced mobility, and acetaminophen extra strength 500 mg. Staff to administer 2 capsules by mouth every 6 hours for pain. Resident 33 indicated the pain was 10 out of 10 when pressure was applied. At other times, the pain was 2-3. A further review of Resident 33's record showed no x-ray results for her left foot. During…

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 properly sanitize a blood glucometer meter for 1 of 5 glucometer meter (Resident 103) stored on the treatment cart. Findings include: On 9/25/24 at 11:34 a.m., LPN 12 performed a blood sugar for Resident 103. The machine was on top of the cart before the procedure. LPN 12 indicated the machine was clean from the use before. She proceeded to complete the blood sugar for Resident 103 as ordered. Upon completion, she took a Sani-wipe and wiped the monitor and sat on a Kleenex for it to dry. When she was asked about how long the machine needs to sit to dry, she responded that it would sit for 5 minutes before she put the machine back into its box. A policy titled Policy and Procedure, Cleaning/Disinfecting/Maintaining Glucose Meters was provided by the Director of Nursing (DON) on 9/25/24 at 12:01 p.m. It indicated, .3. Open the towelette or package and remove one towelette, 4. Wipe the entire surface or the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids, 5. Dispose 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 interview and record review, the facility failed to ensure the influenza vaccination was offered and the pneumonia and COVID-19 vaccinations were completed for a resident who requested them for 1 of 5 residents reviewed for vaccinations (Resident 102). Findings include: On 9/26/24 at 11:15 a.m., Resident 102's record was reviewed. His diagnoses included, but were not limited to, diabetes mellitus (DM) (blood sugar disorder), chronic kidney disease (long-term kidney disease), and chronic hepatitis (long-term liver infection). His immunizations were reviewed in his electronic medical record. The areas for influenza, pneumonia, and COVID-19 immunizations were blank. On 9/25/24 at 1:41 p.m., Resident 102's influenza, pneumonia, and COVID-19 immunization records were requested from the Infection Preventionist (IP) /Assistant director of Nursing (ADON). On 9/25/24 at 2:56 p.m., Resident 102's influenza, pneumonia, and COVID-19 immunization records were requested from the IP/ADON. The DON provided Resident 102's signed consent to receive the pneumococcal vaccination and the…

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

Based on record review and interview, the facility failed to ensure a resident with a tracheostomy (trach) (an opening surgically created through the neck into the trachea to allow air to fill the lungs with a tube) had physician's orders for tracheostomy care, oxygen, oxygen humidity, suctioning, and to keep oxygen saturation (sats) greater than (>) 90% for 1 of 2 residents reviewed with a tracheostomy (Resident B). Findings include: Resident B's record was reviewed on 9/13/24 at 9:54 a.m. Resident B was admitted to the facility, on 6/26/24, with the diagnoses included, but were not limited to, acute respiratory failure with hypoxia (occurs when the respiratory system is unable to provide enough oxygen to the body's tissues), pulmonary embolism (PE) (blood clot blocks an artery in the lungs), chronic atrial fibrillation (type of irregular heart beat that causes the top chamber of the heart, atria, to quiver and beat irregularly lasting longer than one week), coronary artery aneurysm (clinical entity defined by a focal enlargement of the coronary artery exceeding the 1.5-fold…

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

Based on observation, interview, and record review, the facility failed to ensure a resident debit card was protected from diversion, resulting in $15,179.18 being spent by an employee without the resident's knowledge for 1 of 4 residents reviewed for misappropriation of property (Resident B). The deficient practice was corrected on 9/28/23, prior to the start of the survey, and was therefore past noncompliance. Findings include: An Indiana State Department of Health Survey Report System report, dated 9/5/23, indicated Resident B stated he was missing money. The facility Administrator (ADM) 12 was suspended pending investigation and the facility immediately commenced investigation. An Indiana State Department of Health Survey Report System follow up report, dated 9/13/23, indicated on 9/5/23 the RDO was notified by the BOM 13 regarding suspicious activity on Resident B's personal bank account. BOM 13 stated while assisting Resident B with his mail she had detected multiple ATM cash withdrawals over the course of the previous two months that the resident did not recognize. The RDO…

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 observations, interviews and record reviews, the facility failed to ensure residents did not keep smoking materials independently against facility policy and without appropriate assessment or monitoring, and failed to ensure person-centered assessments and care plans revisions were implemented for 9 of 9 residents reviewed for accidents, (Residents 21, 29, 106, 43, 108, 34, 41, 6 and 105). Findings include: 1. On 8/7/23 at 10:14 a.m., Resident 21 was observed in her room on Hope Springs Hall, a secured memory care unit (SMC). She was reclined in her bed with the head of her bed (HOB) elevated. She wore a nasal canula connected to a concentrator which ran on 4 liters (L). There was a rolling bedside table next to her cluttered with several items which included, but was not limited to, a black lockbox with a key in the lock. The key had a green covering and a tag with her name. When asked about her box, Resident 21 indicated she kept her money, cigarettes, lighter and other valuable items such as some 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.

A. Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was properly replaced, stored and placed on a residents for 3 of 4 residents reviewed for respiratory care (Residents 21, 34, and 2). B. Based on observation, interview, and record review, facility failed to clean the filter of a specialized oxygen concentrator and ensure an ambu-bag was readily accessible at bedside for a resident, who was dependent on respiratory and tracheostomy for 1 of 1 resident reviewed for tracheostomy care (Resident 26). Findings include: A1. On 8/7/23 at 10:14 a.m., Resident 21 was observed in her room on Hope Springs Hall, a secured memory care unit. She was reclined in her bed with the head of her bed (HOB) elevated. She wore a nasal canula connected to a concentrator which ran on 4 liters (L). There was a rolling bedside table next to her. The table was cluttered with several items which included, but was not limited to: a small, personal nebulizer with an attached nebulizer mask. The mask and tubing were dated 5/12/23 and was not bagged. The mask…

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 call light was in reach of a resident who was able to use it for 1 of 9 residents reviewed for call lights within reach (Resident 26). Findings include: On 8/7/23 at 12:24 p.m., Resident 26's call light was observed on the floor, up against the wall. On 8/8/23 at 12:08 p.m., Resident 26's call light was observed on the floor, up against the wall. On 8/10/23 at 9:24 a.m., the Executive Director (ED) indicated Resident 26's was able to move and use her call light independently. On 8/8/23 at 10:12 a.m., Resident 26's record was reviewed. Her diagnoses included, but were not limited to, anoxic brain damage (damage to the brain due to lack of oxygen), tracheostomy status (opening in windpipe to relieve obstruction when breathing), seizures (sudden attack of illness, epileptic fit), altered mental status (this condition causes changes in consciousness), cognitive communication deficit, aphasia (loss of ability to understand or express speech due to brain damage), dyspnea (difficult or labored breathing),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a resident had an order for an advanced directive for 1 of 1 resident (Resident 29). Findings include: On [DATE] at 10:30 a.m., a comprehensive record review was conducted for Resident 29. Her diagnoses included but were not limited to chronic viral hepatitis C, atrial fibrillation (irregular heart rate), dysphagia (difficulty swallowing), generalized anxiety disorder, hearing loss, anemia, muscle weakness, depression, GERD (gastro-esophageal reflux), neuralgia (nerve pain), vitamin deficiency and heart failure. Resident 29's record lacked an order for advance directives. Resident 29 had a care plan dated [DATE] indicating resident requests that CPR (cardiopulmonary resuscitation) measures be attempted when needed. During an interview on [DATE] at 10:21 a.m. with QMA (Qualified Medication Assistant) 10, she indicated she did not see an order for her code status. She indicated if resident coded, she would go and get the charge nurse. During an…

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

Based on observation, interview, and record review, the facility failed to provide a home-like environment for 1 of 9 resident reviewed for home-like environments (Resident 26). Findings include: On 8/7/23 at 12:24 p.m., an observation of Resident 26's room. There was a large bed stored in her room, perpendicular to her bed. It was the main object in her field of vision. The large mattress was askew, the upper corner was on the wall. The bed was unmade and dirty with white flakes on it. The bed controls and a wheelchair foot pedal were on the bed too. On 8/9/23 at 10:52 a.m., an observation of Resident 26's room. There was a large bed stored in her room, perpendicular to her bed. It was the main object in her field of vision. The large mattress was askew, the upper corner was on the wall. The bed was unmade and dirty with white flakes on it. The bed controls and a wheelchair foot pedal were on the bed too. On 8/8/23 at 12:08 p.m., an observation of Resident 26's room. There was a large bed stored in her room, perpendicular to her bed. It was the main object in her field of vision.…

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

Based on record review and interviews, the facility failed to revise a care plan for a resident that did not smoke cigarettes for 1 of 6 residents reviewed for smoking (Resident 31). Findings include: During an interview with Resident 31 on 8/10/23 at 3:05 p.m., he indicated he did not smoke. He indicated the facility told him that for him to leave the building, he needed to have a smoking assessment. On 8/9/23 at 9:45 a.m., a comprehensive record review was conducted. His diagnoses included but were not limited to paraplegia, anemia, essential hypertension, unspecified injury at T2-T6, and pressure ulcers. A smoking assessment was completed on 6/2/23. The assessment indicated he did not smoke. Resident 31 had a care plan dated 1/27/23 indicating he was a smoker. A policy titled Baseline Care Plan Assessment/Comprehensive Care Plan was provided by the RNC (Regional Nurse Consultant) on 8/11/23 at 2:37 p.m., it indicated, .The comprehensive care plan will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in…

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

Based on observations, interview and record review, the facility failed to ensure a resident, (Resident 44) with a history of weight loss, was provided with an upgraded diet as prescribed by his physician, weekly weights were obtained as ordered and failed to provide adaptive or alternative snacks/hydration during the scheduled snack activities for 1 of 2 residents reviewed for hydration/nutrition. Findings include: On 8/7/23 the Hope Spring Memory Care (HSMC) unit activity calendar indicated the activity scheduled for 10:30 a.m. every morning from 8/7/23 - 8/10/23, was Hydration Cart/Snacks. On 8/7/23 at 10:40 a.m., Resident 44 was observed. He paced up and down the hall, and in and out of the dining room. At that time, an Activity Assistant entered the unit with a rolling cart. The cart was observed to have insulated pitchers of coffee and ice pitchers of juice. There were also a variety of individually wrapped snacks. There were no puree and/or mechanical soft options. Resident 44 was not offered a snack or drink. On 8/8/23at 9:32 a.m., Resident 44 was observed as he finished 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis of dementia was provided alternative or adaptive activities for 1 of 2 residents reviewed for dementia care (Resident 40). Findings include: On 8/7/23 the Hope Spring Memory Care (HSMC) unit activity calendar indicated the activity scheduled for 10:30 a.m. was Hydration Cart/Snacks. On 8/7/23 at 10:37 a.m., Resident 40 was observed in her room. She laid in her bed with her eyes closed. There was no music or radio. Her T.V was off and unplugged from the power outlet. At that time, an Activity Assistant entered the unit with a rolling cart. The cart was observed to have insulated pitchers of coffee and ice pitchers of juice. There were also a variety of individually wrapped snacks. On 8/7/23 the HSMC activity calendar indicated the activity scheduled for 11:00 a.m. was Residents Choice. During a continuous observation on 8/7/23 from 11:00 a.m. until 12:25 p.m., no group activities or one-to-one activities…

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 observations, record review and interviews, the facility failed to ensure that a resident received thicken liquids as ordered related to dysphagia for 1 of 7 Residents reviewed to appropriate dietary requirements (Resident 3). Findings include: During an observation on 8/11/23 at 11:23 a.m., a water pitcher was observed on Resident 3's nightstand and out of reach of the resident. It contained regular water. During an observation and interview on 8/11/23 at 11:33 a.m., the RNC (Regional Nurse Consultant) and DON (Director of Nursing) observed the water inside the water pitcher to be regular water. It was not NTL (Nectar Thickened Liquid). On 8/11/23 at 12:00 p.m., Resident 3's record review was conducted. She had the following diagnoses, but not limited to major depression, unsteadiness on feet, dysphagia, cognitive communication deficit, psychotic disorder with hallucinations, generalized anxiety disorder, dementia, essential hypertension, PTSD (Post Traumatic Stress Disorder), schizoaffective disorder bipolar type, and hyperlipidemia. Resident 3 had a diet 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.