Brickyard Healthcare - Willow Springs Care Center

Based on observation, interview and record review, the facility failed to ensure staff followed facility policy and procedure for reconciliation of controlled substances for 2 of 6 medication carts reviewed for controlled medications. (South and Southwest) Findings include: 1. During an observation of medication storage, on 5/5/25 at 1:33 p.m., the South medication cart had the following: a. A document, titled CONTROLLED SUBSTANCE SHIFT CHANGE COUNT RECORD, for February 2025, indicated: On 2/1/25, the form was missing the signature for the off-going nurse from 6:30 a.m. to 6:30 p.m. On 2/6/25, the form was missing the signature for the on-coming nurse from 6:30 a.m. to 6:30 p.m., and the off-going nurse from 6:30 a.m. to 6:30 p.m. On 2/9/25, the form was missing the signature for the on-coming nurse from 6:30 p.m. to 6:30 a.m. On 2/10/25, the form was missing the signature for the off-going nurse from 6:30 p.m. to 6:30 a.m., the on-coming nurse from 6:30 a.m. to 6:30 p.m., and the off-going nurse from 6:30 a.m. to 6:30 p.m. On 2/11/25, the form was missing the signature for the…

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

Based on interview and record review, the facility failed to ensure baseline Abnormal Involuntary Movement Scale (AIMS) assessments were completed for evaluation of adverse reactions related to antipsychotic medication use for 2 of 5 residents reviewed for unnecessary medications. (Resident 4 and 222) Findings include: 1. The clinical record for Resident 4 was reviewed on 5/6/25 at 10:00 a.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia and major depressive disorder. A physician's order, dated 11/14/24, indicated Resident 4 was prescribed Latuda (an antipsychotic medication) 60 milligrams (mg) daily at bedtime. A care plan, dated 11/15/24, indicated Resident 4 used psychotropic medications with an intervention to monitor adverse reactions including, but not limited to, tardive dyskinesia (repetitive involuntary movements). Resident 4's assessments from 11/13/24 to 4/30/25 did not include a baseline AIMS assessment. 2. The clinical record for Resident 222 was reviewed on 5/5/25 at 10:08 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were stored in their original packaging, open dates were placed on medications, and discontinued medications were removed from the cart for 2 of 3 medication carts reviewed for medication storage. (200-unit and 300-unit) Findings include: 1. During an observation, on [DATE] at 1:19 p.m., with RN 8, the 200-unit medication cart had the following: a. one bottle of latanoprost 0.005% eye drops without an open date. b. one bottle of liquid protein 30 ounces opened without a resident's name. c. 19 pills not in a package loose in the drawers. During an interview, on [DATE] at 1:26 p.m., RN 8 indicated the eye drops should have had an opened date, and the liquid protein was for a resident who had discharged . She was supposed to give the liquid protein to the resident at discharge, or it should have been discarded. During an interview, on [DATE] at 1:45 p.m., the Corporate Support Nurse 2 indicated there should not be free…

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 enhanced barrier precautions (EBP) signs were posted, Personal Protective Equipment (PPE) was available and worn, and medications were prepared in a sanitary manner for 3 of 3 residents reviewed for infection control. (Resident 47, 6 and 10) Findings include: 1. During an observation, on 5/2/25 at 10:35 a.m., LPN 6 was observed to provide wound care to the pressure wound on the back of Resident 47's left upper thigh. LPN 6 was observed to clean the wound, starting in the center of the wound bed and moving outward. She was observed to move back into the wound bed using the same gauze dressing to finish cleaning the wound. She was not observed to discard the dressing and use a new gauze dressing when she returned to the wound bed to clean it. After cleaning the wound, LPN 6 was observed to use a towel, which was on the bedside table, to pat dry the wound. She completed the wound care and secured a dressing to the area. LPN 6 was not observed to wear a gown at any time during wound care. The clinical…

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

Based on observation, interview and record review, the facility failed to ensure residents were dressed in their own clothing instead of hospital gowns and to ensure the residents' clothing were located or replaced for 2 of 3 residents reviewed for resident rights. (Resident 46 and 42) Findings include: 1. During an observation and interview, on 6/25/24 at 10:50 a.m., Resident 46 was sitting up in his bed and was wearing a hospital gown. He indicated the only clothing he had now was the hospital gowns. He did not put his name on his clothes, and they were missing from laundry. During an interview, on 6/25/24 at 4:07 p.m., the Social Services Designee (SSD) indicated she was not aware the resident was wearing hospital gowns. The clinical record for Resident 46 was reviewed on 6/26/24 at 1:28 a.m. The diagnoses included, but were not limited to, cerebral infarction due to occlusion or stenosis of small arteries, generalized muscle weakness, generalized anxiety disorder, and major depressive disorder. A personal inventory list for Resident 46, dated 5/20/24, indicated the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's code status was reviewed and updated after returning from an inpatient hospitalization for 1 of 4 residents reviewed for advanced directives. (Resident 39) Finding includes: The clinical record for Resident 39 was reviewed on 6/26/24 at 10:43 a.m. The diagnoses included, but were not limited to, muscle atrophy, type 2 diabetes mellitus, diabetic polyneuropathy, depressive disorder, bipolar disorder, generalized anxiety disorder, and agoraphobia with panic disorder. A hospital Discharge summary, dated [DATE], indicated the resident was a full code. A POST (Physician Orders for Scope of Treatment) form, dated 4/4/23, indicated the resident was a no code. The resident's face sheet showed the resident was a full code During an interview, on 6/26/24 at 10:55 a.m., the Director of Nursing (DON) indicated the resident was listed as a full code when she returned from the inpatient hospitalization. The electronic health record did 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 interview and record review, the facility failed to notify the ombudsman when a resident was hospitalized and discharged for 1 of 3 residents reviewed for hospitalization. (Resident 254) Finding includes: The clinical record for Resident 254 was reviewed on 6/25/24 at 2:44 p.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), unstageable pressure ulcer of sacral region, anxiety disorder, depression, bradycardia (slow heart rate), and anemia. A nursing progress note, dated 6/14/24 at 5:58 a.m., indicated the resident was transferred to the hospital. The Nurse Practitioner (NP) and the Director of Nursing (DON) were notified. The electronic medical record did not include notification or indicate a copy of the notice was sent to the Office of the State Long-Term Care Ombudsman at the time of the transfer to the hospital or later when the resident was discharged . During an interview, on 6/28/24 at 11:52 a.m., the Clinical Support Nurse indicated the facility had provided all the transfer…

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

Based on interview and record review, the facility failed to provide the facility's bed hold policy to 2 of 3 residents reviewed for discharge. (Residents 254 and 154) Findings include: 1. The clinical record for Resident 254 was reviewed on 6/25/24 at 2:44 p.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia (absence of enough oxygen to sustain bodily functions), unstageable pressure ulcer of sacral region, anxiety disorder, depression, bradycardia (slow heart rate), and anemia. A nursing progress note, dated 6/14/24 at 5:58 a.m., indicated the resident was transferred to the hospital. The Nurse Practitioner (NP) and the Director of Nursing (DON) were notified. The electronic medical record did not include the facility's bed hold policy was provided to the resident or resident's representative at the time of the transfer to the hospital or later when the resident was discharged . During an interview, on 6/28/24 at 11:52 a.m., Clinical Support Nurse indicated the facility had provided all the transfer and discharge paperwork, and a facility bed hold…

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 routine blood sugars for an insulin dependent diabetic were obtained for 1 of 2 residents reviewed for quality of care. (Resident 260) Findings include: During an interview, on 6/28/24 at 8:48 a.m., Resident 260 indicated her glucose monitoring system sensor had not been in place for over a week and no staff had been checking her blood sugar. The resident indicated she had been trying to watch what she ate since she did not know what her blood sugar was running. The clinical record for Resident 260 was reviewed on 6/26/24 at 12:41 p.m. The diagnoses included, but were not limited to, periprosthetic fracture around the internal prosthetic right hip joint, stage 4 pressure ulcer of sacral region, and type 2 diabetes mellitus. Physician's orders, dated 6/7/24, included, but were not limited to, the following: a. To apply a Freestyle Libre 2 Reader Device (Continuous Blood Glucose System Receiver) sensor to the upper extremity topically on the day shift every 14 days and as needed for diabetic monitoring, and to call…

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 address the incontinence care of a resident with a colostomy in a timely manner for 1 of 1 resident reviewed for colostomy care. (Resident 42) Finding includes: During an observation, on 6/25/24 at 11:35 a.m., Resident 42 returned from therapy where his colostomy bag had ruptured. The resident was in his wheelchair with a foul smelling, stool-stained shirt. Licensed Practical Nurse (LPN) 8 came into his room and acknowledged the resident's need for a colostomy bag and clothing change, his discomfort, and his need to get back into bed. LPN 8 indicated she would be back as soon as the Certified Nursing Assistant (CNA) was available. The resident indicated to please hurry because he was very uncomfortable with the bowel movement on his abdomen. During an observation, on 6/25/24 at 11:45 a.m., the resident pushed his call light and called out for help. He indicated the smell was bothering him, he was very uncomfortable, and indicated again to please hurry. LPN 8 was at the computer in the nurses' station. CNA 9…

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

Based on observation, record review and interview, the facility failed to ensure a resident received the ordered oxygen flow and the portable oxygen tank contained oxygen for 1 of 2 residents reviewed for respiratory care. (Resident 10) Finding includes: During an observation, on 6/24/24 at 2:46 p.m., the resident was sitting in her wheelchair in her room with her nasal cannula attached to a portable tank. The tank was empty. During an observation, on 6/27/24 at 10:36 a.m., the resident was resting in bed and watching tv. The oxygen tubing was off the resident and on the floor. The clinical record for Resident 10 was reviewed on 6/26/24 at 9:59 a.m. The diagnoses included, but were not limited to, heart failure, atrial septal defect (heart defect) cardiomegaly, hypertension (high blood pressure), chronic respiratory failure with hypoxia, pulmonary embolism (blood clot) without acute cor-pulmonale, chronic pain, and TIA (trans ischemic attack). A physician's order, dated 5/14/24, indicated continuous oxygen at 2 liters per nasal cannula. Call the physician if the oxygen saturations…

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 side rail assessments and consents were completed prior to the use of side rails for 2 of 2 residents reviewed for accident hazards. (Resident 46 and 22) Findings include: 1. During an observation, on 6/25/24 at 10:38 a.m., Resident 46 was sitting up in his bed and indicated he did not use the two upper quarter side rails which were in the raised position. The clinical record for Resident 46 was reviewed on 6/26/24 at 10:28 a.m. The diagnoses included, but were not limited to, generalized anxiety disorder, major depressive disorder, and cerebral infarction due to an occlusion or stenosis of small arteries. The physician's orders did not include an order for side rails. The electronic health record did not include a side rail assessment or consent. During an interview, on 6/28/24 at 11:35 a.m., the Clinical Support Nurse indicated there was no side rail consent or assessment for Resident 46 because he was not supposed to have side rails. She thought maybe the staff switched beds and sometimes 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 clinical rationale was provided for a decline of a gradual dose reduction of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 37) Finding includes: The clinical record for Resident 37 was reviewed on 6/25/24 at 3:45 p.m. The diagnoses included, but were not limited to, malignant neoplasm of prostate, type 2 diabetes with other diabetic kidney complications, dysphagia, dementia in other diseases with anxiety and behavioral disturbances, bilateral osteoarthritis of the hip, and depression. A physician's order, dated 12/5/23, indicated Seroquel (quetiapine) (an antipsychotic medication) 25 mg (milligrams) twice daily. A pharmacist report provided to the Medical Director and DON (Director of Nursing), dated 6/4/24, indicated a dose reduction of quetiapine was recommended. There were 2 choices to complete for the provider to decline or to agree with the dose reduction. If the reduction was declined due to contraindication the clinical rationale was to be provided. A…

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

Based on observation, interview and record review, the facility failed to ensure medications were labeled with an open date, to ensure medication labels were legible, to dispose of expired medications, and to return or dispose of medications after a resident discharged for 3 of 3 medication carts reviewed for medication storage and labeling. (second and third floor carts) Findings include: 1. During an observation, on 6/26/24 at 8:35 a.m., with the Director of Nursing present, one second floor medication cart was found to have an open bottle of amantadine (a medication used for Parkinson's disease) 50 milligrams/milliliter. The bottle had approximately 75 milliliters (ml) of 200 ml left in the bottle. The Director of Nursing was observed to write an open date on the bottle at the time, she dated the bottle as opened 6/1/24. An open bottle of Nystatin (an antifungal) 100000 units was found open without an open date. There was approximately 95 ml of 100 ml left in the bottle. During an interview, on 6/26/24 at 8:35 a.m., the Director of Nursing indicated liquid medications should be…

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 follow up with dental recommendations for oral hygiene and the resident's request to obtain dentures for 1 of 4 residents reviewed for dental services. (Resident 39) Finding includes: During an interview, on 6/25/24 at 11:01 a.m., Resident 39 indicated she was on the list to get her teeth done. She had broken teeth and did not know what the dental plan included. She wanted to get her teeth pulled and have dentures held in place by a few dental implants. The clinical record for Resident 39 was reviewed on 6/26/24 at 10:43 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, depressive disorder, agoraphobia, and diabetic polyneuropathy. A dental note, dated 5/21/24, indicated the resident was missing 19 teeth, had one fractured tooth with an abscess and had two teeth with mobility. The resident had poor oral hygiene and needed assistance to brush her teeth twice daily. The resident wanted a full mouth extraction and dentures retained by implants. The dentist advised against a full mouth extraction.…

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 refrigerator temperatures were monitored and remained below 41 degrees Fahrenheit for 2 of 3 refrigerators in the kitchen. Finding includes: During an observation, on 6/24/24 at 11:09 a.m., the temperature in the refrigerator across from the walk-in refrigerator had a temperature of 48 degrees Fahrenheit. A refrigerator across from the dishwasher area had no internal thermometer and the inside temperature was warm to touch. The refrigerator was storing drinks. The temperature logs on the refrigerators indicated missing temperatures on 6/19/24, 6/20/24, 6/21/24, 6/22/24, 6/23/24, and 6/24/24. During an interview, on 6/26/24 at 10:16 a.m., the Dietary Manager and Dietitian indicated the drinks were removed from the refrigerator. The refrigerator was having issues. A pan under the unit was collecting a clear fluid. A current policy, titled Food Safety Requirements, dated 2024 and received from the Clinical Support Nurse on 6/27/24 at 11:53 a.m., indicated .facility staff shall inspect all food, food…

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

Based on interview and record review, the facility failed to ensure documentation in the Medication and Treatment Administration Record (MAR/TAR) was accurate and correct for 2 of 2 residents reviewed for documentation. (Residents 6 and 45) Findings include: 1. The clinical record for Resident 6 was reviewed on 6/26/24 at 3:24 p.m. The diagnoses included, but were not limited to, personal history of other mental and behavioral disorders, type 2 diabetes, psychotic disturbance, mood disturbance, and anxiety. A physician's order, initiated on 3/29/24, indicated to give 7 units of insulin and it should be given at the start of the nocturnal tube feeding. A physician's order, initiated on 4/1/24, indicated to change the tube feeding administration every night shift. A physician's order, initiated on 4/1/24, indicated to check residual (amount of food/nutrition formula left in the stomach) every shift. A physician's order, initiated on 4/1/24, indicated to check the G-tube placement every day and night shift. A physician's order, initiated on 4/4/24, indicated to flush the G-tube before…

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 staff effectively transcribed a pain medication ordered by the hospice provider and failed to communicate when the resident was found on the floor after a possible fall during end-of-life care for 1 of 1 resident reviewed for hospice. (Resident 53) Finding includes: The clinical record for Resident 53 was reviewed on [DATE] at 12:29 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the esophagus, emphysema, anxiety disorder, and osteoarthritis. A care plan, dated [DATE], indicated the resident was at risk for falls related to deconditioning and gait and balance problems associated with weakness related to the cancer process. The interventions included, but were not limited to, assessing for pain, assessing for medication side effects, keeping personal items available and in easy reach or provide a Reacher, and keep the environment well-lit and free of clutter. A hospice order sheet, dated [DATE], indicated to give…

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 a clean environment for 1 of 4 resident rooms and bathrooms reviewed. (Resident B and C) Findings include: During a telephone interview on 03/12/24 at 9:38 a.m., the family member for former Resident D indicated the resident's bathroom had not been cleaned and smelled of mold. During an observation on 03/12/24 at 10:42 a.m., the room of Residents B and C was found to have food on the floor on Resident C's side, as well as a pillow without a pillow case on the floor propped up by the trash can, a towel on the floor at the foot of the bed, three blue caps from lancets on the floor, a plastic cup, a snack chip bag, a plastic spoon and two Styrofoam cups were found under the bed of Resident C. The shared bathroom smelled of urine, had a brown substance on the outside of the toilet bowl and ties from a dressing were on the floor under the sink. During an interview on 03/12/24 at 10:51 a.m., the Assistant Director of Nursing indicated one housekeeper was in the facility early that day and the second one…

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 physician's order for an X-ray was completed for a resident after a fall for 1 of 3 residents reviewed for quality of care. (Resident B) Finding includes: The record for Resident B was reviewed on 03/12/24 at 11:38 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), heart failure, and a fracture to his right lower extremity. A progress note, dated 12/27/23 at 12:00 a.m., by the Nurse Practitioner (NP) indicated Resident B had fallen and initially did not have complaints of pain. He began to complain of pain in his legs, both shoulders and his back. He rated the pain at 10 out of 10. The NP note indicated .imaging: X-ray of spine, bilateral shoulders, and bilateral lower extremities for post-fall A progress note, dated 12/27/23 at 3:00 p.m., titled, IDT FALL, indicated the resident was to have X-ray imaging of the shoulders and ankle. A progress note, dated 12/27/2023 at 7:01 p.m., indicated Resident B had complained of ankle and shoulder pain due to a fall on 12/26/23.…

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

Based on observation, interview, and record review, the facility failed to properly store nebulizer equipment in a sanitary manner on two separate occasions for 1 of 1 resident observed with respiratory equipment. (Resident B) Finding includes: During an observation on 03/12/24 at 10:36 a.m., a nebulizer machine for Resident B was found on the resident's bed. One end of the tubing was attached to the machine and the other end was noted to be lying on the floor. The mask was not observed to be found. During an observation on 03/14/24 at 10:55 a.m., Resident B's nebulizer machine was observed on the nightstand. The tubing was attached and hanging down the front of the nightstand. The mask was attached to the other end. It was not found to be stored in a bag. During an interview, on 03/12/24 at 10:51 a.m., the Assistant Director of Nursing indicated nebulizer tubing should not be on the floor and it should have been placed in a bag. The record for Resident B was reviewed on 03/12/24 at 11:38 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD),…

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 protect residents from misappropriation of theft of personal property when a housekeeping employee removed a drink from a resident's refrigerator and crackers from a container on top of the resident's refrigerator while the resident was out of the room for 1 of 3 residents reviewed for misappropriation of property. The deficient practice was corrected on 1/30/24, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An Incident Report to the Indiana State Department of Health, dated 1/27/24, indicated Resident 18 voiced, to the CNA, she witnessed the housekeeper take a soda and crackers from her room. The clinical record for Resident 18 was reviewed on 2/13/24 at 1:35 p.m. The diagnoses included, but were not limited to, fracture of tibia or fibula (leg bone) following insertion of orthopedic implant, fracture to the upper and lower end of the right fibula, and methadone dependence. The resident had a Brief Interview for Mental Status (BIMS-an assessment tool used to screen and identify…

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 medication administration when two (2) pills, in a clear cup, were found sitting on a resident's bed for 2 of 2 residents reviewed for accidents hazards. (Resident 4 and 5) Finding includes: During a random observation, on 2/13/24 at 3:51 p.m., two (2) white tablets, with black print L025 on the pills, were found sitting on Resident 4's bed. Resident 4 was not in the room, and his roommate (Resident 5) was alone in the room. The clinical record for Resident 4 was reviewed on 2/13/24 at 4:10 p.m. The diagnoses included, but were not limited to, paraplegia (paralysis of the legs and lower body), gout, and end stage renal disease. Resident 4 did not have an order to self-administer medications. Resident 4 did not have an assessment to self-administer medications. A physician's order, initiated on 2/6/24, indicated to give Sevelamer (controls phosphorus levels for patients with chronic kidney disease and on dialysis) two tablets of 800 milligrams (mg) three times a day. During an interview, 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 ensure the staff notified the physician when the staff were unable to obtain a seal on a wound VAC (Vacuum-Assisted Closure) (a device which decreases air pressure on the wound to help it heal more quickly), of the need to alter treatment, and to get a physician's order when the treatment was changed to a wet-to-dry dressing for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: During an interview, on 01/25/24 at 11:41 a.m., RN 1 indicated she was not able to seal the wound VAC, so she applied a wet to dry dressing. She did not notify the physician. She did not think about asking another nurse to assist her with the wound VAC. At the time, the facility was using contract nurses, and she did not think they were knowledgeable with wound VACs. The clinical record for Resident B was reviewed on 01/26/24 at 10:57 a.m. The diagnoses included, but were not limited to, encounter for surgical aftercare following surgery on the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to contain their trash in the appropriate trash container for 3 of 6 hallways and failed to ensure 1 of 2 shower rooms were not flooding into the hallway when in use during a review of the environment. Findings include: 1. On 8/27/23 at 8:33 p.m., upon entering the third floor, off the elevator, there was a large clear see-through bag filled with smaller clear see-through bags of trash sitting on the floor by the elevator. There were large clear see-through bags filled with smaller clear see-though bags of trash sitting on the floor at the corner of the hallway down from the resident shower room door, at the corner of the hallway next to the door with the name roof access room and next door to room [ROOM NUMBER]. At 8:38 p.m., when the staff on the third floor was picking the trash bags up, they were asked where those trash bags were to be placed after being picked up from each individual room but, none of the staff would answer the question.…

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 smoking paraphernalia (cigarettes, lighters, matches) were stored with facility staff between smoking times for 5 of 9 residents reviewed for accident hazards. (Residents 12, 48, 10, 119, 22) Findings include: 1. During a random observation, on 03/20/23 at 10:41 a.m., Resident 12 was observed to have a pack of cigarettes stored in a stocking on his left leg. During an observation, on 03/20/2023 at 10:15 a.m., Resident 12 was observed propelling himself in a wheelchair towards his room. At the top of his sock, was tucked a red package of cigarettes. The record for Resident 12 was reviewed on 03/24/23. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD), lymphedema (swelling due to lymph build up) and depressive disorder. A Minimum Data Set (MDS) assessment, dated 01/04/23, indicated Resident 12 had a BIMS (Brief Interview for Mental Status) score of 13 which meant he was cognitively intact. A care plan, initiated on 09/26/22, indicated storage of smoking materials…

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 a sanitary homelike environment for 6 of 6 residents observed for environment. (Resident 65, 67, 170, 39, 18 and 58) Findings include: 1. During an observation, on 03/21/23 at 8:41 a.m., Resident 65's room was found to have debris (trash) on the floor. 2. During an observation, on 03/20/23 at 11:32 a.m., Resident 67's room was found to have debris and food on the floor. 3. During an observation, on 03/23/23 at 9:32 a.m., Resident 170's room was found to have used wet towels and wash cloths on the floor by the door. During an interview, on 03/23/23 at 9:33 a.m., License Practical Nurse (LPN) 2 indicated dirty linens were not to be left on the floor. 4. During an observation, on 03/20/23 at 10:03 a.m., Resident 39's room had debris under the bed to include medication cups and burnt popcorn on the floor under the window. 5. During an observation, on 03/22/23 at 1:21 p.m., Resident 18's box fan was noted to have the fan blades covered in a gray dust like substance and a gray dust like substance on the fan…

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 update and revise a care plan for 1 of 18 residents reviewed for comprehensive care plans. (Resident 58) Findings include: During an observation and interview, on 03/21/23 at 11:02 a.m., Resident 58 shook her head back and forth which indicated no when asked if she had a indwelling Foley catheter. The record for Resident 58 was reviewed on 3/27/23 at 9:22 a.m. Diagnoses included, but were not limited to, quadriplegia (inability to move all 4 limbs). A Minimum Data Set (MDS) assessment, dated 2/10/23, indicated no indwelling catheter (Foley catheter) for Resident 58 and the resident had moderately impaired cognition. A care plan, dated 1/13/23, indicated Resident 58 had an alteration in elimination of bowel and bladder, was unaware of voiding sensation, and used of Foley catheter. During an interview, on 03/22/23 at 10:55 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident 58 did not currently have a Foley/indwelling catheter. When Resident 58 returned from the hospital, she did not have a…

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

Based on observation, interview and record review, the facility failed to label and date oxygen tubing and equipment for 2 of 2 residents reviewed for oxygen therapy. (Resident 2 and 58) Findings include: 1. During an observation, on 03/20/23 at 11:00 a.m., Resident 2 was noted to be with a tracheostomy and oxygen mask over the tracheostomy with no date on the tubing or the mask. During an observation, on 03/20/23 at 11:01 a.m., Resident 2 was noted to be with a tracheostomy and oxygen mask over the tracheostomy with no date on the tubing or the mask. During an observation, on 03/21/23 at 2:25 p.m., Resident 2 was noted to be in her wheelchair with a tracheostomy mask over her tracheostomy with no date on the mask. During an observation and interview, on 03/22/23 at 10:10 a.m., Licensed Practical Nurse (LPN) 3 observed Resident 2's oxygen mask and tubing and indicated the oxygen mask or tubing was not dated and the oxygen mask and tubing should be dated when it was changed. The record for Resident 2 was reviewed on 3/24/23 at 3:32 p.m. Diagnoses included, but were not limited 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 observation, interview and record review, the facility failed to measure and record daily temperatures in 1 of 2 medication storage refrigerators. (200-unit refrigerator) Finding includes: During an observation of the 200-unit medication storage refrigerator with the Unit Manager, on 03/23/23 at 8:55 a.m., a posting was observed on the refrigerator indicating the temperature of the refrigerator needed to be between 40-46 degrees Fahrenheit. There was no temperature log to show the temperatures had been checked at least daily. During an interview, on 03/24/23 at 8:48 a.m., the Corporate Support Nurse indicated the staff had not been checking the temperatures. Logs were to be kept for one (1) year. A current policy, titled Storage of Medication Requiring Refrigeration, dated as last reviewed in 2022 and was provided by the Executive Director on 03/23/23 at 12:31 p.m., indicated .The temperature to be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of person performing the check clearly written .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 store food in accordance with professional standards for food service safety regarding unit snack/nutritional refrigerators temperatures and cleanliness for 2 of 2 snack refrigerators reviewed. (3rd floor and 2nd floor) Findings include: During an observation of unit snack/nutritional refrigerators, on 03/23/2023 at 10:41 a.m., with the Director of Maintenance (DOM), the following were observed: 1. In the 3rd floor refrigerator/freezer, multiple bottles of Glucerna were observed in refrigerator portion of the unit, however the temperature of the unit could not be determined due to there was no thermometer in the refrigerator. The freezer portion of the unit was observed to contain a heavy buildup of ice accumulation. During an interview, 3 (three) unidentified nursing staff, present at the nursing station at this time, denied knowledge of who was responsible for monitoring the unit refrigerators or where temperature logs were kept. 2. In the 2nd floor refrigerator/freezer, multiple bottles of Glucerna were…

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