Castleton Health Care Center

Based on observation, interview and record review, the facility failed to ensure an infection control program that consisted of surveillance and tracking of infections for 6 out of 12 months reviewed, failed to ensure infection control was maintained by a resident's central catheter/PICC (a tube inserted into a vein near the heart) missing the needless connector for 1 of 1 random observation of a resident's central catheter, and failed to ensure linen was properly stored on a hallway linen cart with the potential to affect 18 of 71 residents residing at the facility. (Resident W)Findings include: 1. The infection control binder was reviewed on 9/18/25 at 11:21 a.m. The Infection Preventionist was listed as the Assistant Director of Nursing (ADON). The monthly tracking logs consisted of the following months: April of 2025, May of 2025, June of 2025, July of 2025, and August of 2025. There were no logs to indicate surveillance and monitoring of trends for infections was conducted prior to April of 2025. An interview conducted with the ADON, on 9/19/25 at 11:24 a.m., indicated 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 ensure staff remained at bedside while administration of a narcotic medication to a resident as ordered for 1 of 1 random observation of a resident receiving his medications. (Resident X) Findings include: The clinical record for Resident X was reviewed on 9/19/25 at 3:20 p.m. The diagnoses included, but were not limited to, heart failure. The 9/5/25 Quarterly Minimum Data Set assessment indicated Resident X was cognitively intact. A behavior care plan, dated 4/5/24, indicated Resident X had been witnessed holding pain medication in his hand after observation of placing pill in his mouth and drinking water. The interventions included but were not limited to, nurse to observe resident swallowing medication and not pocketing. A physician's order, dated 4/4/24, indicated the staff were to observe the resident swallowing medication due to pocketing. A physician's order, dated 5/19/25, indicated the resident was to receive 10-325 milligrams of Percocet every six hours. The staff were to crush the medication 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's call light was within reach for 1 of 2 residents reviewed for call devices in reach. (Resident N)Findings include:The clinical record for Resident N was reviewed on 9/17/25 at 12:30 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis. The ADL (activities of daily living) care plan, revised 8/18/25, indicated he had an ADL self-care performance deficit related to impaired balance, limited mobility, pain, and shortness of breath, and she would refuse to get out of bed. An intervention was to encourage her to use bell to call for assistance. The 8/29/25 Quarterly MDS (Minimum Data Set) assessment indicated she was moderately cognitively impaired. An observation and interview were conducted with Resident N in her room on 9/17/25 at 12:18 p.m. She was lying in bed. Her call light cord was tied around the right side rail, hanging down the right side of her bed, eight inches from the floor. Resident N…

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 residents' preferences were honored for 2 of 2 residents reviewed for choices. (Resident T and Resident V) Findings include: 1. The clinical record for Resident V was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident V included, but were not limited to, kidney disease. An Annual 7/18/25 Minimum Data Set (MDS) assessment indicated Resident V was cognitively intact. An interview was conducted with Resident V on 9/18/25 at 10:03 a.m. She indicated the staff have poor communication with the residents. The staff does not know anything about the residents' preferences with care. Resident V had to tell staff how she prefers to be bathed, and how to transfer her in her wheelchair. She reminds them to remove the dirty clothes from her hamper. They just throw wet linen and trash in the hamper with her clothes. Since they do not remove the dirty clothes from the hamper it delays her clothing to be sent to the laundry to be cleaned. She has…

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 was able to receive personal funds when requested for 1 of 2 residents reviewed for personal funds. (Resident Z)Findings include: The clinical record for Resident Z was reviewed on 9/17/25 at 11:00 a.m. The diagnoses for Resident Z included, but were not limited to, anxiety. The 8/4/25 Quarterly Minimum Data Set (MDS) assessment indicated Resident Z was cognitively intact. An interview was conducted with Resident Z on 9/17/25 at 11:48 a.m. He indicated he was unable to receive his personal funds from the Business Office when he requested $50.00 a couple of weeks ago. The Business Office Manager (BOM) had indicated she was unable to give him any money. An interview was conducted with the BOM on 9/22/25 at 3:07 p.m. She indicated there was a week, or two, the residents were unable to receive their personal funds. The former Executive Director (ED) had abruptly left employment at the facility. The ED was the signer to the checks for the residents' personal funds. Resident Z requested $50.00 a week or two…

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 homelike environment for 2 of 4 residents reviewed for homelike environment. (Resident BB and Resident 44)Findings include: 1. An observation was conducted of Resident 44's room on 9/18/25 at 9:25 a.m. There was brown splatter along both closet doors. On 9/19/25 at 10:55 a.m., there continued to be brown splatter along both of Resident 44's closet doors. On 9/22/25 at 3:30 p.m., there continued to be brown splatter along both of Resident 44's closet doors. On 9/22/25 at 3:35 p.m., the Assistant Director of Nursing (ADON) went into Resident 44's room and acknowledged the splatter on Resident 44's closet doors. 2. An observation and interview were conducted with Resident BB in his room on 9/22/25 at 10:50 a.m. He indicated his television doesn't work. He could turn the television on but there was no volume. Resident BB took the remote and demonstrated he was able to turn the television on and off and attempted to increase the volume, but the television remained with no sound. Resident BB 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 interview and record review, the facility failed to timely complete a Significant Change of Status Minimum Data Set (MDS) assessment for a resident who discontinued dialysis services for 1 of 2 residents reviewed for dialysis (Resident 2). Findings include: The clinical record for Resident 2 was reviewed on 9/18/25 at 10:15 a.m. The resident's diagnosis included, but were not limited to, diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure. A Quarterly MDS assessment, completed 7/26/25, indicated Resident C was cognitively intact and had received dialysis. A physician's order, dated 7/28/25, indicated she was to receive hemodialysis on Monday, Wednesday, and Friday weekly. During an interview on 9/19/25 at 10:32 a.m., Resident 2 indicated she did not receive dialysis anymore. The doctor stopped her dialysis a couple of months ago. During an interview on 9/19/25 at 11:05 a.m., the Transportation Director indicated she had not taken Resident 2 to or from dialysis since she started working at the facility. The Transportation Director…

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

Based on interview and record review, the facility failed to ensure care plan meetings were held timely for 1 of 1 resident reviewed for care plan meetings. (Resident N)Findings include:The clinical record for Resident N was reviewed on 9/17/25 at 12:30 p.m. Her diagnoses included, but were not limited to, chronic kidney disease and heart failure. Resident N had the following MDS (Minimum Data Set) Assessments completed: 9/19/24 Admission, 12/27/24 Quarterly, 3/14/25 Quarterly, 6/9/25 Quarterly, and 8/20/25 Quarterly. An interview was conducted with Resident N on 9/17/25 at 12:34 p.m. She indicated she was not having care plan meetings at the facility and was unsure what they were. There were no care plan meeting notes documented in the Miscellaneous or Assessments section of the electronic health record. An interview was conducted with the ED (Executive Director) on 9/22/25 at 1:57 p.m. She indicated they only had verification for two care plan meetings since Resident N's 9/13/24 admission. The last one was held in January of 2025. On 9/22/25 at 1:57 p.m., the ED provided 2 care…

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 facial hair trimming and nail care was provided for 2 of 6 residents reviewed for Activities of Daily Living. (Residents Q and W) Findings include: 1. The clinical record for Resident W was reviewed on 9/17/25 at 1:00 p.m. The diagnoses included, but were not limited to, heart failure. An Annual Minimum Data Set (MDS) assessment, dated 9/2/25, indicated Resident W was moderately cognitively impaired. An Activity of Daily Living (ADLs) care plan for Resident W, dated 12/14/24, indicated the staff was to during “BATHING: Check nail length and trim and clean on bath day and as necessary.” An observation was conducted of Resident W on 9/17/25 at 2:16 p.m. The resident was sitting in her wheelchair in the dining room. The resident's nails were observed to be long in length and a black substance underneath them. The resident indicated at that time; she would like them trimmed. An observation was conducted of Resident W in bed on 9/18/25 at 9:32 a.m. Resident W's nails were observed long in length. August 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 catheter care was provided and urine outputs were recorded every shift for 2 of 3 residents reviewed for catheter care. (Resident T and Resident 1) Findings include:1. The clinical record for Resident 1 was reviewed on 9/17/25 at 2:30 p.m. The diagnoses for Resident 1 included, but were not limited to, acute kidney failure and sepsis.An admission Minimum Data Set (MDS) assessment, dated 8/21/25, indicated Resident 1 was cognitively intact. A care plan, dated 8/6/25, indicated Resident 1 had an indwelling catheter due to neurogenic bladder. A physician's order, dated 8/6/25, indicated the resident was to have a 16 French Foley (indwelling) catheter. A physician's order, dated 8/6/25, indicated the resident was to have catheter care completed every shift and as needed.The September 2025 Medication and Treatment Administration Records (MAR/TAR) indicated the resident had received catheter care every shift. An interview was conducted with Resident 1 on 9/17/25 at 2:26 p.m. He indicated the staff does 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 oxygen therapy was delivered to a resident, as ordered by the physician, and to ensure a resident who was receiving oxygen therapy had a physician's order for oxygen for 2 of 5 residents reviewed for oxygen therapy. (Resident 2 and Resident 55)Findings include: 1. The clinical record for Resident 2 was reviewed on 9/18/25 at 10:15 a.m. The resident's diagnoses included, but were not limited to, diabetes, anxiety disorder, chronic kidney disease, and respiratory failure. A physician's order, dated 12/20/24, indicated she was to receive oxygen at one liter a minute via nasal cannula each shift. A Quarterly Minimum Data Set (MDS) assessment, completed 7/26/25, indicated Resident C was cognitively intact and received oxygen therapy. During an interview on 9/19/25 at 10:32 a.m., Resident 2 indicated she did not use her oxygen all the time. She wore it mostly at night when she needed it. She hasn't utilized oxygen at all times for a while. She was not wearing oxygen at the time of the interview. On 9/22/25…

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

Based on interview and record review, the facility failed to ensure a resident with chronic pain and polyosteoarthritis had a care plan to address her pain; administer as needed pain medication timely; and document vital signs and non-pharmacological interventions for as needed pain medication administrations, as ordered, for 2 of 2 residents reviewed for pain. (Resident N and Resident BB)Findings include:1. The clinical record for Resident N was reviewed on 9/17/25 at 12:30 p.m. Her diagnoses included, but were not limited to, chronic pain, polyosteoarthritis, chronic obstructive pulmonary disease, chronic kidney disease, and heart failure. There was no care plan to address Resident N's chronic pain. An interview was conducted with Resident N on 9/17/25 at 12:18 p.m. She indicated she had arthritis in her legs. It hurt to sit in her wheelchair. She wasn't currently in pain, only if she moved. The physician's orders indicated to administer one 25 milligram (mg) tablet of tramadol every eight hours as needed for chronic pain. They indicated, Pain assessment Before and After PRN [as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident on dialysis received pre/post assessments that included vital signs and obtaining weights that were consistent and documentation of dialysis refusals and confirmed dialysis appointments were included in the electronic health record (EHR) for 1 of 1 resident reviewed for death. (Resident P)Findings include: The clinical record for Resident P was reviewed on 9/22/25 at 9:43 a.m. The diagnoses included, but were not limited to, end stage renal disease, type one diabetes mellitus, epilepsy (seizure disorder), congestive heart failure, noncompliance with other medical treatment, and muscle weakness. A Quarterly Minimum Data Set (MDS) assessment, dated 6/10/25, indicated Resident P received dialysis and was cognitively intact. An Annual MDS assessment, dated 8/27/25, indicated Resident P was cognitively intact and experienced rejection of care behavior. A care plan for dialysis, initiated on 8/28/24 and revised on 9/16/25, 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 interview and record review, the facility failed to ensure ancillary services were consented to and provided timely for 2 of 2 residents reviewed for dental services and 1 of 2 residents reviewed for vision services (Resident T and Resident R). Findings include: 1. The clinical record for Resident T was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident T included, but were not limited to, obstructive and reflux uropathy (any condition that affects urinary tract, kidneys and bladder). Resident T was admitted to the facility on [DATE]. An 8/20/25 Quarterly Minimum Data Set (MDS) assessment indicated Resident T was cognitively intact. An interview was conducted with Resident T on 9/18/25 at 9:37 a.m. She indicated she would like to see an eye doctor and a dentist. She has been asking to see the eye doctor but still had not heard anything. A resident's ancillary consent was provided by the Executive Director on 9/22/25 at 11:26 a.m. It indicated the resident filled out in September she would like…

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 record review, the facility failed to ensure a system of records for facility staff signing-on and signing-off regarding controlled medications being accounted for was maintained regarding 3 of 5 narcotic logs reviewed. (Facility)Findings include: An observation was conducted of three medication carts that contained a narcotic log/binder. Two medication carts were located on Sunset and Shoreline hallways, and the third log was located on the medication cart on the rehabilitation hallway. The following was noted: One cart had a count sheet form dated 9/16/25 to 9/22/25. There were three instances where staff did not sign-in or sign-out from their shift to indicate if there were cards of narcotics added, removed, and/or the total number of narcotic medication cards in the narcotic box of the medication cart. One cart had a count sheet form dated 9/1/25 to 9/22/25. There were seven instances where staff did not sign-in or sign-out from their shift to indicate there were cards of narcotics added, removed, and/or the total number of narcotic medication cards 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician included rationales for declining pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. (Resident 2)Findings include: The clinical record for Resident 2 was reviewed on [DATE] at 10:15 a.m. The resident's diagnoses included, but were not limited to, diabetes, anxiety disorder, chronic kidney disease, and acute and chronic respiratory failure. Physician's orders, dated [DATE], indicated she was to receive atorvastatin calcium 20 milligram (mg); one tablet daily by mouth at bedtime, dicyclomine hydrochloride (antispasmodic) 20 mg by mouth twice daily, and pantoprazole sodium (gastric acid reducer) 20 mg by mouth each morning. A physician's order, dated [DATE], indicated she was to receive trazodone (anti-depressant) 50 mg by mouth at bedtime for insomnia. A physician's order, dated [DATE], indicated she was to receive hydrocodone- acetaminophen (narcotic pain medication) 7.5- 325 mg; one tablet by mouth…

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 administer a resident's medication as ordered that resulted in a resident receiving their medication in an excessive dosage for 1 of 5 residents reviewed for unnecessary medications. (Resident 68) Findings include: The clinical record for Resident 68 was reviewed on 9/23/25 at 9:49 a.m. Her diagnoses included, but were not limited to, insomnia.The physician's orders indicated to administer one 3 mg tablet of melatonin by mouth in the evening for insomnia, effective 1/6/25. There was another order to administer one 3 mg tablet of melatonin by mouth at bedtime for sleep, effective 7/28/24.The September 2025 MAR (medication administration record) indicated she received the 3 mg tablet of Melatonin at 8:00 p.m. and 9:00 p.m. daily, for a total of 6 mg per day. The Assessment/Plan sections of the 8/13/25 and 9/19/25 psychiatry progress notes indicated to continue melatonin 3 mg every evening for sleep disorder.The 8/19/25 pharmacy note to the facility indicated there were two orders for melatonin and to please discontinue 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 tube feeding was stopped prior and after an anticonvulsant medication was administered as ordered for 1 of 1 resident reviewed for tube feeding. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 9/23/25 at 11:00 a.m. The diagnoses for Resident 4 included, but were not limited to, seizures. A physician's order, dated 5/4/25, indicated the resident was to receive two tablets of 100 milligrams of phenytoin sodium (Dilantin) at 8:00 p.m. A physician's order, dated 7/29/25, indicated the resident was to receive 1.5 Jevity enteral feeding at 75 milliliters an hour for 10 hours a day with 55 milliliters of water flushes. The feeding was scheduled to start at 6:00 p.m. and stopped at 4:00 a.m. The staff were to hold the feeding for two hours before and two hours after the administration of the Dilantin. The order was changed on 9/16/25. A physician's order, dated 9/16/25, indicated the resident was to receive 1.5 Jevity enteral feeding at 65 milliliters an hour for 10 hours a day with 55…

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 medical records were accurately documented for 2 of 5 residents reviewed for unnecessary medications. (Resident V and Resident 2) Findings include: 1. The clinical record for Resident V was reviewed on 9/18/25 at 9:30 a.m. The diagnoses for Resident V included, but were not limited to, kidney disease. A physician's order, dated 7/17/25, indicated Resident V was to receive 150 milligrams of bupropion (antidepressant) in the evenings. The medication was changed on 8/6/25. A physician's order, dated 8/6/25, indicated Resident V was to receive 1.5 tablets, total dosage of 225 milligrams, of bupropion daily. A physician's order, dated 8/25/25, indicated Resident V was to receive 300 milligrams of bupropion daily. The August 2025 Medication Administration Record (MAR) indicated the following days Resident V did receive 1.5 tablets that equaled 225 milligrams of bupropion: 8/10/25, 8/12/25, 8/13/25, 8/15/25, 8/19/25, 8/23/25, and 8/24/25. An interview was conducted with the Executive Director (ED), the Nurse…

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 influenza and pneumococcal immunizations were offered and administered upon consent for approval for 3 of 5 residents reviewed for immunizations. (Resident 7, Resident 9, and Resident 35)Findings include: 1. The clinical record for Resident 35 was reviewed on 9/19/25 at 10:30 a.m. A current physician's order, dated 6/25/24, indicated Resident 35 could receive the pneumonia vaccination unless contraindicated. An immunization informed consent document, dated 4/13/25, indicated Resident 35 consented to receive the pneumococcal immunization. The immunization tab within the electronic health record (EHR) indicated the last pneumococcal immunization was historical and last administered on 10/8/1999 as Pneumovax Dose 1. 2. The clinical record for Resident 7 was reviewed on 9/19/25 at 10:40 a.m. The diagnoses included, but were not limited to, asthma. A current physician's order, dated 8/28/25, indicated Resident 7 could receive the pneumonia vaccination and influenza vaccination unless contraindicated. An immunization…

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 floors were clean as evidenced by spillage of unknown substances on the floors for 1 of 5 units and 14 of 14 residents reviewed for environment. (Shoreline Unit, Resident B, Resident C, Resident E, Resident J, Resident M, Resident N, Resident O, Resident P, Resident Q, Resident R, Resident S, Resident T, Resident U, and Resident V). Findings include: An observation was conducted, on 8/4/25 at 10:01 a.m., of the flooring by the nurse's station and Shoreline hallway. Dirt and spots of spillage of an unknown black substance were observed on the flooring in the hallway and adjacent nurse's station. During an interview on 8/4/25 at 10:35 a.m. with Resident G's Representative, he indicated the housekeeping was bad at the facility and the building was dirty. An observation was conducted, on 8/4/25 at 12:23 p.m., of the flooring by the nurse's station and the Shoreline hallway. The flooring appeared dirty with spillage of an unknown black substance.The Director of Nursing (DON) provided documentation of 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 protect the residents' right to be free from physical abuse by a resident-to-resident altercation for 2 of 2 residents reviewed for abuse. (Residents CC and Resident J) Findings include: The clinical record for Resident CC was reviewed on 8/5/25 at 10:00 a.m. The diagnoses included, but were not limited to, paranoid schizophrenia. A care plan, dated 3/30/25, indicated Resident CC had a behavior of being obsessive compulsive. The interventions included, but were not limited to, Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.A care plan, dated 4/3/25, indicated the resident had difficulties with changes. The clinical record for Resident J was reviewed on 8/5/25 at 10:15 a.m. The diagnoses included, but were not limited to, schizoaffective disorder and bipolar disorder.A care plan, dated 7/9/25 with revision date 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 timely report an allegation of missing funds to the Indiana Department of Health for 1 of 4 residents reviewed for misappropriation. (Resident C)Findings include: The clinical record for Resident C was reviewed on 8/4/25 at 10:00 a.m. The diagnoses included, but were not limited to, cognitive communication deficit. A Quarterly Minimum Data Set assessment, dated 7/4/25, indicated Resident C was moderately cognitively impaired. A list of grievances for the month of June and July of 2025 was provided by the Executive Director (ED) on 8/4/25 at 10:15 a.m. Resident C was not listed on the list for missing items or funds.During an interview on 8/4/25 at 2:40 p.m., Resident C's Representative indicated he brought $80.00 into the facility and gave it to the previous Business Office Manager (BOM) over Easter weekend in April, and the money was put into a safe. He indicated the current BOM did not know where the funds were after he inquired about them later in April and was not aware of any money being held in the safe.On 8/4/25 at…

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 disposition of a resident's Percocet (oxycodone-acetaminophen) medication was handled securely; which included ensuring staff were implementing accurate monitoring, tracking and timely destroying a not needed narcotic medication. This resulted in the facility missing 44 white tablets of 10-325 milligram tablets of Percocet medication for 1 of 4 residents reviewed for narcotic medications. (Resident L) Findings include: The clinical record for Resident L was reviewed on 8/4/25 at 1:00 p.m. The diagnoses included, but were not limited to, osteoarthritis. A physician's order, dated 5/19/25, indicated Resident L was to receive 10-325 milligrams of Percocet every six hours. A pharmacy delivery form, dated 7/14/25, indicated delivery of 56 tablets of 10-325 milligrams of Percocet for Resident L. There was a written note on the form indicated, resending yellow. A reportable incident to the Indiana Department of Health, dated 7/21/25, indicated the…

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

Based on observation, interview, and record review, the facility failed to perform post fall assessments timely, obtain blood sugar readings and administer insulin as ordered by the physician, and timely update physician's orders for a diabetic foot ulcer for 1 of 3 residents reviewed for falls and 2 of 3 residents reviewed for medication administration. (Resident B, Resident F, and Resident H)Findings include: 1. The clinical record for Resident B was reviewed on 7/16/25 at 11:00 a.m. The diagnoses included, but were not limited to, encephalopathy (brain dysfunction) and heart failure. An Annual Minimum Data Set (MDS) assessment, completed 3/14/25, indicated Resident B was cognitively impaired. A nursing progress note, dated 3/11/25 at 11:44 p.m., indicated Resident B had sustained a fall. “Resident had a fall this shift in bedroom, CNA [Certified Nurse Aide] was doing her rounds when resident was found laying on his belly with right foot tangled in sheet. When asked [what happened] resident stated he was trying to get something off the floor. Floor was clear. CNA had last seen…

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 obtain laboratory services timely for 1 of 3 residents reviewed for falls. (Resident B)Findings include: The clinical record for Resident B was reviewed on 7/16/25 at 11:00 a.m. The diagnoses included, but were not limited to, encephalopathy (brain dysfunction) and heart failure. An Annual Minimum Data Set (MDS) assessment, completed 3/14/25, indicated Resident B was cognitively impaired. A progress note, dated 3/16/25 at 5:53 a.m., indicated Resident B was experiencing signs and symptoms of confusion and restlessness. A progress note, dated 3/16/25 at 6:31 a.m., indicated nursing staff had received new orders for STAT (immediate) laboratory testing from the on-call Nurse Practitioner/Physician. Laboratory testing ordered included a complete blood count (CBC) and complete metabolic panel (CMP). A physician's order, initiated on 3/16/25, indicated to obtain a CBC and CMP STAT for altered mental status. The clinical record for Resident B did not contain laboratory results for the CBC and CMP ordered on 3/16/25. 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 interview and record review, the facility failed to ensure a resident's fall, notification of physician of the fall, and notification of the responsible party of the fall were documented in the clinical record for 1 of 3 residents reviewed for falls (Resident H).Findings include: The clinical record for Resident H was reviewed on 7/16/25 at 2:10 p.m. The diagnoses included, but were not limited to, diabetes with foot ulcer, repeated falls, and dementia.An admission Minimum Data Set (MDS) assessment, completed 5/8/25, indicated he was severely cognitively impaired. He required substantial assistance with bathing, lower body dressing, and donning and doffing footwear. A care plan, last revised 7/1/25, indicated Resident H had an actual fall with minor injury due to poor balance. The goal was for him to resume usual activities without further incident. The interventions included, but were not limited to, monitor, document and report as needed for 72-hours to the physician regarding signs and symptoms of pain, bruises, and changes in mental status. On 7/17/25 at 1:50 p.m., the…

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

Based on interview and record review, the facility failed to ensure the disposition of a resident's oxycodone-acetaminophen medication that had been delivered by pharmacy was handled and stored securely; resulting in missing 60 tablets of a resident's narcotic medication for 1 of 4 residents reviewed for medication reconciliation. (Resident B) Findings include: The clinical record for Resident B was reviewed on 6/11/25 at 2:00 p.m. The diagnoses included, but were not limited to, stroke, heart disease, and kidney disease. A physician's order, dated 1/1/25, indicated Resident B was to receive oxycodone-acetaminophen (narcotic pain medication; also known as Percocet) 10-325 milligrams (mg) every four hours as needed for pain. A pharmacy control drug record, dated 1/17/25, indicated, on 2/18/25 at 4:32 p.m., Resident B had 29 tablets remaining in a medication bubble card of the 10-325 milligrams of oxycodone-acetaminophen. A pharmacy delivery form, dated 2/19/25 at 10:15 a.m., indicated Registered Nurse (RN) 2 had received the pharmacy delivery that morning of 60 tablets of 10-325…

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 ensure the kitchen was maintained clean and in good repair; the food was stored with a label and dated; the water temperatures were monitored for the dishwasher; and the kitchen staff did not store personal drinks in the walk-in-refrigerator. This had a potential to affect 52 of 53 residents that consume food from the kitchen. Findings include: An observation was made of the kitchen on 9/9/24 at 7:18 p.m. The dishwasher area and the dry storage area flooring tiles were observed cracked and broken. The wall behind the dishwasher and in the back of the oven had a yellow substance dripping down the wall. During the tour, Dietary Aide (DA) 2 was observed running the dishwasher. The dishwasher was running three times, and each time the rinse cycle had reached 165 degrees Fahrenheit (F). A manufacture plate on the dishwasher indicated the wash cycle should reach 150 degrees F, and the rinse cycle should reach 180 degrees F. DA 2 indicated he doesn't look at the gauges while he was running the dishwasher. After, 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 interview and record review, the facility failed to implement an antibiotic stewardship program to ensure infections involving antibiotic usage in the facility were tracked and monitored. This had a potential to affect 53 of 53 residents that reside in the facility. Findings include: The antibiotic stewardship binder was provided by the Director of Nursing (DON) on 9/13/24 at 9:00 a.m. It included the facility's monthly tracking and monitoring of residents' infections that had utilized antibiotics. The binder did not include monthly tracking from January 2024 through May 2024 to indicate the facility was tracking or monitoring the residents' antibiotic usage. The months of June 2024, July 2024, and August 2024's antibiotic tracking sheets did not include the infection the resident had nor a method of tracking locations where the residents' with an infection were located throughout the facility. An interview was conducted with the Regional Nurse Consultant (RNC) on 9/13/24 at 10:00 a.m. He indicated the building had changed corporations in March of 2024. Unfortunately, he…

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

Based on observation, interview, and record review, the facility failed to ensure an insulin flex pen was primed prior to administration of an insulin dosage for 1 of 3 residents observed for medication administration. (Resident 104) Findings include: The clinical record for Resident 104 was reviewed on 9/10/24 at 11:00 a.m. The diagnoses included, but were not limited to, type 1 diabetes mellitus. A physician order, dated 8/24/24, indicated the resident was to receive 8 units of Humulin N insulin (intermediate acting insulin) twice a day. An observation was made of Resident 104's medication administration with Licensed Practical Nurse (LPN) 3 on 9/9/24 at 8:27 p.m. LPN 3 was observed preparing the resident's 8 units of Humulin N insulin utilizing an insulin flex pen. LPN 3 used the dosage knob on the flex pen to dial up 8 units of insulin. LPN 3 entered the resident's room and administered the 8 units of insulin to the resident. There was no observation of priming the flex pen prior to dialing up the 8 unit dosage the resident was to receive. An interview was conducted with LPN 3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely develop and implement an individualized behavior plan of care for 1 of 1 resident reviewed for behaviors (Resident 15). Findings include: The clinical record for Resident 15 was reviewed on 9/10/24 at 1:52 p.m. The diagnoses included, but were not limited to, dementia, stroke, aphasia (decreased ability to express and understand language), major depressive disorder with psychotic symptoms. He was admitted to the facility from a psychiatric hospital on 8/5/24. A physician's order, dated 8/5/24, indicated he was to receive quetiapine (anti-psychotic medication) 100 milligrams (mg) three times daily. A physician's order, dated 8/5/24, indicated he was to receive divalproex sodium (seizure medication and mood stabilizer) delayed release tablet 500 mg twice daily. A physician's order, dated 8/5/24, indicated Resident 15 exhibited a target behavior. Each shift was to chart the number of episodes the targeted behavior had occurred,…

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 blood pressure was within the parameter to administer midodrine (a medication to treat low blood pressure) for 1 of 5 residents reviewed for unnecessary medications. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 9/12/24 at 11:30 a.m. The diagnoses included, but were not limited to, hypertension (high blood pressure). A physician order, dated 8/28/24, indicated the resident was to receive 5 milligrams of midodrine twice a day for hypotension (low blood pressure). The staff was to hold the medication if the resident's systolic blood pressure (pressure your blood is pushing against your artery walls when the heart beats/first number of blood pressure) was greater than 110. The September 2024 Medication Administration Record (MAR) indicated the resident's midodrine medication was administered in the mornings and nightly, on 9/1/24, through the morning of 9/12/24. The MAR did not include blood pressure readings obtained prior to administration of the midodrine…

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 were implemented during a wound dressing change for 1 of 2 residents observed for pressure ulcers. (Resident 25) Findings include: The clinical record for Resident 25 was reviewed on 9/11/24 at 11:20 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus. A care plan, dated 8/19/24, indicated the resident was in enhanced barrier precautions related to a wound. A care plan, dated 5/9/24, indicated the resident's right ankle had a diabetic ulcer. A physician order, dated 8/14/24, indicated the resident's right ankle wound was to be cleansed with Dakins (antiseptic solution), apply Santyl (ointment that removes dead tissue from wounds) and calcium alginate (dressing for wounds), and cover with a gauze dressing twice a day. An observation was conducted of a wound dressing change to Resident 25 with the Director of Nursing (DON) and License Practical Nurse (LPN) 1 on 9/11/24 at 2:11 p.m. LPN 1 and the DON utilized hand hygiene and donned gloves prior 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 treatment changes for a pressure ulcer were implemented for Residents B and C and ensure a treatment for an identified pressure ulcer was initiated for Resident C. Findings include: 1. The clinical record for Resident B was reviewed on 2/10/24 at 7:15 p.m. The diagnoses included, but were not limited to, malnutrition, congestive heart failure, asthma, seizures, and atrial fibrillation. A physician order, dated 1/18/24, indicated to cleanse coccyx with wound cleanser, pat dry, apply medihoney and cover with bordered foam daily. A wound progress note, dated 1/24/24, indicated a stage 3 pressure ulcer to the coccyx that was identified on 12/20/23. The plan was to cleanse the coccyx with 1/4 strength Dakins solution, apply medihoney to promote autolytic debridement, cover with a foam dressing daily and as needed. The additional instructions included, but were not limited to, .Ensure dressing changed per RX [physician orders] to promote maximum efficacy The electronic treatment administration record (ETAR), January 2024,…

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 foods in the kitchen. This affected 38 of 41 residents in the facility who eat food from the kitchen. Findings include: A tour of the kitchen and interview was conducted with the Dietician on 9/26/23 at 11:00 a.m. During the tour, the clean dish racks were observed. There was an open, half bottle of water and an open sandwich bag containing small candies and suckers on one of the shelves next to clean dishes. The dietician indicated the bag of candy and water bottle were not supposed to be there. The dietician removed the bag of candy and water bottle from the shelf and placed it elsewhere in another part of the kitchen. During the tour the dry storage room was observed. There was an open bottle of lemon juice with 2/3 of the contents remaining on a shelf. The label on the bottle indicated to refrigerate after opening. The dietician indicated there was some lemon juice missing, so it needed tossed out. The dietician removed the lemon juice from the shelf. During the tour, a counter near 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 grievances were addressed and followed up timely for 1 of 1 residents reviewed for grievances and 12 of 12 residents attended in a resident council meeting. (Residents' 3, 7, 8, 9, 14, 18, 19, 23, 25, 31, 32, 39) Findings include: 1. The clinical record for Resident 39 was reviewed on 9/27/23 at 11:00 a.m. The resident's diagnosis included, but was not limited to, stroke. Resident 39 was admitted to facility on 7/21/23. An interview was conducted with Resident 39 and Family Friend 22 on 9/27/23 at 11:06 a.m. They indicated Resident 39 was missing 2 blankets since admission on [DATE]. The first blanket that had been brought in on admission was sent to laundry and never has returned. A second blanket was brought in and sent to laundry and it also has not been returned. The resident was on his third blanket. After discussion with the former Administrator about the missing blankets he reported the laundry supervisor was on medical leave, 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 interview and record review, the facility failed to maintain documentation of a thorough investigation for 1 of 1 resident reviewed for abuse. (Resident 41) Findings include: The clinical record for Resident 41 was reviewed on 9/27/23 at 3:07 p.m. Her diagnoses included, but were not limited to, chronic obstructive pulmonary disease, fibromyalgia, and major depressive disorder. She discharged from the facility on 6/27/23. On 9/27/23 at 11:40 a.m., the DON (Director of Nursing) provided the 5/26/23 reportable incident report for Resident 41. It read, Brief Description of Incident .[Name of Resident 41] stated that a staff member was tired the other day. And that we were all tired the other day. [Name of Resident 41] stated that they all looked a little tired. This morning [name of Resident 41] was asleep in her room. A female entered her room. [Name of Resident 41] was not able to identify her, and this person was verbally coming at [name of Resident 41.] [Name of Resident 41] stated that she has a history of being abused while she is asleep. [Name of Resident 41] stated 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 record review and interview, the facility failed to ensure a care plan was initiated for a resident who was totally dependent on the assistance of others for ADL (Activities of Daily Living) care for 1 of 16 care plans reviewed. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 9/28/23 at 11:31 a.m. Resident 12's diagnoses included, but not limited to, hemiplegia (paralysis of one side of body), diabetes type II, anxiety, and aphasia (loss of ability to understand or express speech) Resident 12's quarterly MDS (Minimum Data Set) dated 8/6/23 indicated, she required extensive assistance of two persons for bed mobility; totally dependent on assistance of two persons for transfers, toileting, and bathing; and totally dependent on assistance of one person for personal hygiene. Resident 12's Care Plan initiated on 5/4/23 and last revised on 8/17/23 did not contain a care plan related to her total dependence for ADL care nor any interventions with the specific care and services that would be implemented. An interview with MDSC (Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care plan meetings were conducted for 1 of 1 residents reviewed for care plan meetings. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 9/26/23 at 12:00 p.m. The resident's diagnosis included, but was not limited to, Autistic disorder. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 26 was moderately cognitively impaired. A care plan meeting dated 4/13/23 indicated the social worker and family attended the care plan meeting that day. An interview was conducted with Resident 26 on 9/26/23 at 12:03 p.m. He indicated he has not had a care plan meeting in a long time. An interview was conducted with the Social Services Director on 9/28/23 at 11:06 a.m. She indicated the resident's last care plan meeting was conducted in April 2023. He should have had a care plan meeting after the quarterly July 2023 MDS. 3.1-35(d)(2)(B)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for a resident who was unable to carry out activities of daily living by not ensuring twice weekly showers/complete bed baths for 2 of 3 residents and at least weekly hair washing for 1 of 3 residents reviewed for activities of daily living (ADLs). (Residents 12 and 26 ) Findings include: 1. The clinical record for Resident 12 was reviewed on 9/28/23 at 11:31 a.m. Resident 12's diagnoses included, but not limited to, hemiplegia (paralysis of one side of body), diabetes type II, anxiety, and aphasia (loss of ability to understand or express speech) Resident 12's quarterly MDS (Minimum Data Set) dated 8/6/23 indicated, she required extensive assistance of two persons for bed mobility; totally dependent on assistance of two persons for transfers, toileting, and bathing; and totally dependent on assistance of one person for personal hygiene. An interview with Resident 12'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure accurate documentation of a resident's MAR (medication administration record) for 1 of 1 resident reviewed for hospice (Resident D) and 2 of 6 residents reveiwed for unnecessary medications (Resident 23 and Resident 32). Findings include: 1. The clinical record for Resident D was reviewed on 9/26/23 at 12:20 p.m. His diagnoses included, but were not limited to, delusional disorder and dyskinesia. He was admitted to the facility on [DATE] and to hospice services on 3/10/23. An interview was conducted with Family Member 6 on 9/28/23 at 5:48 p.m. He indicated he was Resident D's Medical POA (power of attorney.) Hospice Nurse 7 called him to inform him a nurse from the facility had contacted her about discontinuing one of his medications. He had a meeting with Hospice Nurse 7 and the facility's Wound Nurse at the facility on Monday, 9/25/23, to discuss it. Family Member 6 questioned why the discontinuation of the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to coordinate the provision of a medication with hospice to ensure administration, as ordered, for 1 of 1 resident reviewed for hospice. (Resident D) Findings include: The clinical record for Resident D was reviewed on 9/26/23 at 12:20 p.m. His diagnoses included, but were not limited to, delusional disorder and dyskinesia. He was admitted to the facility on [DATE] and to hospice services on 3/10/23. The 3/22/23 hospice care plan, revised 9/8/23, indicated the goal was for resident's comfort to be maintained through the review date. An interview was conducted with Family Member 6 on 9/28/23 at 5:48 p.m. He indicated he was Resident D's Medical POA (power of attorney.) Hospice Nurse 7 called him to inform him a nurse from the facility had contacted her about discontinuing one of his medications. He had a meeting with Hospice Nurse 7 and the facility's Wound Nurse at the facility on Monday, 9/25/23, to discuss it. Family Member 6 questioned why…

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

Based on observation, interview and record review, the facility failed to ensure infection control was maintained during tracheostomy care for 1 of 1 residents reviewed for tracheostomy (artificial airway in neck) (Resident 14); and maintain an infection prevention and control program by staff touching the insides of medication cups, not performing hand hygiene at appropriate times, mixing contents of a medication cup with a gloved finger for 1 of 4 reviewed for medication administration (Resident 12). Findings include: 1. The clinical record for Resident 14 was reviewed on 9/26/23 at 11:55 a.m. The resident's diagnosis included, but was not limited to, tracheostomy. An observation was made with Registered Nurse (RN) 2 and License Practical Nurse (LPN) 1 providing tracheostomy care for Resident 14 on 9/29/23 at 11:09 a.m. During the care, RN 2 was observed donning sterile gloves. She indicated her left hand would be non-sterile and her right hand would be sterile during the procedure. Using her left sterile hand, RN 2 removed the resident's inner cannula of her tracheostomy 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 provide a safe comfortable environment for 2 of 4 resident rooms reviewed for environment and 1 of 2 facility dryers reviewed for environment. (Resident 5 and 26). Findings include: On 9/26/23 at 11:38 a.m., Resident 5's room was observed. The wall by the Resident 5's bed was marred and the paint was chipped. Resident 5 indicated the wall had been that way for a while. On 9/26/23 at 12:07 p.m., Resident 26's room was observed. The walls of the room had multiple areas of chipped paint. On 9/29/23 at 1:50 p.m., environmental tour of the facility was conducted the DM (Director of Maintenance). Resident 5's room was observed with the DM who indicated the wall by Resident 5's bed was scrapped and had missing paint due to the bed scrapping against the wall and should be repainted. Resident 26's room was observed with the DM, who indicated that Resident 26's room did have multiple areas of chipped pain and should be repainted. During the environmental round the laundry area of the facility was observed. The DM 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.