Eagle Valley Meadows

Based on observation, interview, and record review, the facility failed to ensure medication was not left at bedside without a self-medication assessment for 1 of 1 resident reviewed for medication self-administration (Resident B). Findings include: On 10/10/24 at 10:16 a.m., Ventolin (albuterol) and Symbicort inhalers were observed on Resident B's over the bed table. On 10/10/24 at 11:24 a.m., Resident B's self-administration assessment was reviewed. It indicated on 9/5/24, she was approved to self-administer bacitracin (topical antibiotic) to her nose. No other medications were listed to self-administer. A current policy, titled, General Dose Preparation and Medication Administration, dated 4/30/24, was provided by the DON, on 10/10/24 at 11:30 a.m., a review of the policy indicated, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident This citation relates to Complaint IN00443579. 3.1-11

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident B) was comprehensively assessed for her nutritional status and person centered interventions were implemented for 1 of 3 residents reviewed for nutrition. Findings include: During an interview on 10/9/24 at 11:36 a.m., Resident B indicated, she did not like the food and was tired of only being able to receive hamburgers as food substitutes. She was supposed to be on a low sodium diet, but did not feel like she had been provided with a variety of options or healthier options. Resident B indicated when she asked for alternative food options, staff told her the alterative menu would also be a hamburger. Resident B indicated she had never been visited by the Registered Dietician (RD). She wanted the RD to see her, review her new low sodium diet, and give more options than just a hamburger. On 10/9/24 at 1:11 p.m., Resident B's lunch tray was observed, and the meal had been consumed. Resident B pointed to her…

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 were competent with medication administration for 2 of 2 residents observed for medication administration (Residents B and E) Findings include: On 10/10 24 at 10:09 a.m., LPN 8 was observed at the B Hall Medication Cart. During a medication administration for Resident B, LPN 8 provided a Symbicort inhaler (treats asthma and COPD-chronic obstructive pulmonary disease), the resident took a puff of the inhaler. Immediately after, LPN 8 provided albuterol (treats asthma and COPD) and Spirva (dilates bronchial passage ways) with no delay between puffs. He provided water for the resident to rinse her mouth. She swallowed the water. On 10/10/24 at 10:35 a.m., LPN 8 was observed preparing medication for Resident E. He was observed pouring 15 mL (milliliters) Robitussin (cough suppressant) into a medication cup. He was observed lifting the round cardboard from the touch of the bottle with his bare fingers. He double checked the level of medication at eye-level and indicated 15 mL. The physician's order…

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 provided according to the physician's order (Resident B) for 1 of 2 residents reviewed for medication administration. Findings include: On 10/10/24 at 9:45 a.m., Resident B expressed concern about missing some of her medications. She indicated she missed her clonazepam (antianxiety) four times this week. On 10/10/24 at 11:24 a.m., Resident B's October Medication Administration Record (MAR) was reviewed for missing medications. According to the MAR: a. Her clonazepam 1 mg, a scheduled IV tablet (controlled substance), was not given on 10/3/24 at 10:00 p.m., 10/4/24 at 2:00 p.m. and 10:00 p.m., 10/7/24 at 2:00 p.m. and 10:00 p.m., 10/8/24 at 10:00 p.m., and 10/9/24 at 10:00 p.m. b. Her dicyclomine tablet (for irritable bowel), 20 mg was not given on 10/3/24 at 10:00 p.m., 10/4/24 at 10:00 p.m., 10/7/24 at 10:00 p.m., 10/8/24 at 10:00 p.m., 10/9/24 at 10:00 p.m., and 10/10/24 at 8:00 a.m. c. Her dorzolamide-timolol 2-0.5 % (treat glaucoma) was not given at 7:00 p.m. on 10/3/24, 10/4/24,…

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 prevent the potential for the spread of a highly contagious virus when staff failed to perform hand hygiene and don personal protective equipment (PPE) in a COVID-19 positive isolation room for 2 of 2 days of observation. This deficient practice had the potential to effect 22 of 78 residents who resided on the D-hall of the facility. Findings include: During an interview on 10/9/24 at 11:36 a.m., Resident B indicated she was worried about catching COVID-19 because she knew staff were not using the appropriate PPE to enter isolation rooms. She indicated she often sat at the nurses station and watched as staff entered COVID-19 positive rooms and they did not put on a gown, gloves or new masks. On 10/9/24 at 1:30 p.m., Resident C's room was observed from the hallway. The door was open, but there was a bright red sign which indicated PPE was required to enter the room due to droplet isolation precautions. On 10/9/24 at 1:48 p.m., Certified Nursing Assistant (CNA) 6 entered Resident C's room. She did not perform…

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

Based on observation, interview, and record review, the facility failed to maintain the dignity and the right to refuse services of 1 of 5 residents reviewed for resident rights (Resident S). Findings include: On 8/20/24 at 11:43 a.m., during an initial observation and interview, Resident S was observed the resident lying in bed. The call light was within reach on the right side of her bed attached to her bed rail. She was on a low air loss mattress to facilitate comfort and prevent skin breakdown. The resident was cognitively intact, alert, and pleasant. The resident indicated she was able to stand and transfer to her wheelchair with assistance from the staff. She preferred to have meals in her room, but she was able to go to the dining room. The resident indicated on 8/17/24 (she was unsure of the time), she was in the lobby with her daughter, and she removed her oxygen tubing from her nose because she did not feel any air in the tube. She indicated Licensed Practical Nurse (LPN) 5 was sitting at the nurse's desk and she asked the nurse three times for help. She indicated LPN 5…

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 reviews, the facility failed to provide a safe, clean, comfortable environment to ensure pest control interventions were effective for 5 of 5 months of recommendations reviewed. This deficiency had the potential to affect 75 of 75 residents residing in the facility. Findings include: 1. During a kitchen tour, on 6/2/24 at 10:47 a.m., several dozen flying insects were observed alighting from clean dishes when the clean dish shelf was slightly wiggled. On 6/2/24 at 10:48 a.m., [NAME] 16 indicated she had seen flying insects all around the kitchen. On 6/2/24 at 10:49 a.m., the Dietary Manager (DM) indicated she had seen the Maintenance Man (MM) using a vacuum device to remove the flying insects. On 6/2/24 at 10:57 a.m., the DM indicated the large tub under the 3 compartment sink was there because the sink leaked. The tub was observed with standing water. On 6/2/24 at 11:00 a.m., a wet blanket was observed around the bottom of the ice machine in the kitchen. The DM…

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

Based on observations, the facility failed to label and date medications when opened and remove expired medications from use for 2 of 4 medication carts and 1 of 1 refrigerator. Findings include: 1. A hall medication cart a. Resident 64 had a vial of Haldol in the medication cart. The vial was a one time use only and lacked a date when opened. b. Resident 2 had breo in the medication cart. It lacked a date when opened. 2. B hall medication cart a. A bottle of Systane eye drops was in the medication cart. It did not have a label on the bottle. b. Resident 226 had a bottle of Systane eye drops in the medication cart with no date to indicate when it was opened. 3. Refrigerator had the following: a. Resident 54 had 2 bottles of lorazepam in the refrigerator. One bottle lacked a date to indicate when it was opened. The other bottle was opened on 2/22/24 that had expired. b. Resident 6 had a bottle of lorazepam in the refrigerator. It lacked a date to indicate when it was opened. c. There was a bottle of lorazepam in the refrigerator. It lacked a label on the bottle. A medication storage…

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 linens were not contaminated for 4 of 12 residents during dining service (Resident 3, 9, 7, 21, and 46) and failed to ensure kitchen temperature logs were completed. Findings include: 1 On 6/2/24 at 12:18 p.m., the Social Services Director (SSD) was observed bringing tablecloths and clothing protectors into the dining room. She was holding them up against her body and sleeve. She indicated she was just making sure everyone had tablecloths and clothing protectors. On 6/2/24 at 12:20 p.m., the SSD was observed putting a table cloths on a table while Resident 9 was sitting at the table, then she provided him with a clothing protector. On 6/2/24 at 12:23 p.m., the SSD was observed to pick up trash from the dining room floor and threw it away. She did not do any hand hygiene and put a table cloth on Resident 21's table and provided clothing protectors for Resident 21, Resident 46, Resident 7, and Resident 3. A current policy, titled, Laundry/Linen dated 12/2021, was provided by the Executive Director (ED),…

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 designate an Infection Preventionist (IP) who was available for a minimum of 20 hours a week and did not share the duties/responsibilities of other departments, to ensure daily monitoring and implementation of the Infection Control and Prevention program for 5 of 5 months reviewed. This deficient practice had the potential to affect 75 of 75 residents who resided in the facility: Findings include: Upon survey entrance, name and certification of the facilities IP was requested and provided. The Executive Director (ED) indicated the facility's IP was Licensed Practical Nurse, (LPN) 4, who also served as the full time Minimum Data Set (MDS) Coordinator. On 6/4/24 at 10:24 a.m., the Regional IP Consultant (RIPC) indicated the facility had been without a full-time IP for a couple of months, but he came to the building about 1-2 times a month in order to update the infection tracking binder, complete the infection mapping and antibiotic stewardship reports. The RIPC indicated, his time in the building was less than…

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 had a bariatric bed with mobility bars and her call light was in reach for 1 of 5 resident reviewed for accommodation of needs (Resident 43). Findings include: On 6/2/24 at 11:23 a.m., Resident 43 was observed lying on her left side on the edge of her mattress. The upper portion of her mattress was outside of the bed frame. Her call light was observed on the floor. On 6/3/24 at 2:18 p.m., Resident 43's was in her room, in her wheelchair, and her call light was observed on the floor. On 6/4/24 at 10:04 a.m., Resident 43 was in her room, in her wheelchair, and her call light was observed on the floor. On 6/5/24 at 9:39 a.m., Resident 43 was observed sitting on the edge of her bed with her feet on the floor. Her mattress was observed to be askew, the top portion of the mattress was outside of the bed frame. She indicated she wanted mobility bars to be able to move easier in bed. On 6/5/24 at 10:27 a.m., Resident 43's record was reviewed. On 5/1/23 her weight was recorded as 382 pounds. Her…

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 assess 1 of 4 residents for coordination of preadmission screening and resident review (PASARR) who required a referral for a level II assessment based on medical diagnoses and medication usage (Residents 64). Findings include: On 6/5/24 at 9:49 a.m., a record review was completed for Resident 64. He had the following diagnoses which included, but were not limited to, metabolic encephalopathy (a chemical imbalance in the brain), psychotic disorder with delusions due to known physiological condition, anxiety disorder, and depression. Resident 64 had a level I. The level I lacked information to include resident's mental illness diagnosis and use of Haldol (a psychotropic medication used to treat mental and mood disorders). This information would have triggered a level II to be completed if, not omitted. A policy titled, PASRR Policy, was provided by the Director of Nursing Services (DNS) on 6/5/24 R 11:55 a.m. It indicated, .Any resident with an intellectual, mental disability or related condition will be referred to the…

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

Based on observation and interview, the facility failed to provide nail care for a resident who was unable to care for his own nail care for 1 of 4 residents (Resident 67) reviewed for activities of daily living (ADLS). Findings include: During an observation on 6/3/24 at 9:40 a.m., Resident 67's nails were long and dirty. When asked if he wanted his nails that long, he indicated he called his daughter to have her cut them, but she was too busy working. During an observation on 6/4/24 at 3:25 p.m., Resident 67's nails were still long and dirty. During an observation on 6/5/24 at 9:41 a.m., Resident 67's nails were long and dirty. A record review was completed on 6/5/24 at 10:30 a.m. He had the following diagnoses which included but were not limited to malignant neoplasm of the prostate (cancer), anemia, hypertension, and age-related physical debility. During an interview with the DNS on 6/5/24 at 9:41 a.m., she was informed of resident's nails being long and dirty. She indicated she would inform the nurse to trim his nails or she would trim them herself. Resident 67 had a care plan,…

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 residents who needed respiratory equipment had the equipment they needed and the equipment was covered when not in use for 2 of 2 residents reviewed for respiratory equipment (Resident 43 and 106). Findings include: 1. On 6/2/24 at 11:23 a.m., Resident 43's respiratory equipment was observed. She was observed to be on 4 liters of oxygen per minute by nasal cannula and had a BIPAP machine (non-invasive ventilator to assist with breathing) on her bedside table. Respiratory tubing was observed leading into a plastic bag, there was no BIPAP mask in the plastic bag. Resident 43 indicated a CNA (Certified Nursing Aide) threw it away and she was unable to use her BIPAP machine at night. On 6/3/24 at 2:19 p.m., the BIPAP mask was observed to be missing. The resident indicated she asked for another BIPAP mask. On 6/4/24 at 10:04 a.m., Resident 43 did not have a BIPAP mask in the plastic bag with the BIPAP tubing. She was unable to use it.…

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 appropriate personal protective equipment (PPE) was utilized during high contact resident care, to prevent the potential for the spread of infection for a resident for (Resident 62) who had an open wound with recurrent infections for 1 of 2 residents reviewed for enhanced barrier precautions (EBP). Findings include: During a random observation on 6/4/24 at 9:43 a.m., Resident 62 was observed in the spa room on the secured memory care unit, where she received a shower from an unidentified nursing assistant (CNA). The CNA did not have an isolation gown or gloves on as she conducted Resident 62's shower. Resident 62 was seated on a shower chair, and evidence of stool incontinence was present by smell and stool was observed on the shower floor near the drain. When asked where the Resident's wound was, the CNA gently asked the resident to lean forward, and with her bare hand lifted the skin of her right buttock to reveal the wound. The wound dressing was not in place and the open wound was in direct contact…

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 failed to ensure fall interventions were personalized, implemented, and care planned for 1 of 3 residents reviewed for accidents (Resident B). Findings include, An Indiana State Department of Health Survey Report System report, dated 3/6/24 at 8:26 a.m., indicated Resident B had an unwitnessed fall with injury, and was unable to explain how incident happened. Resident B had an acute oblique distal clavicle fracture and was sent to the emergency room (ER) once results received. All interventions were in place prior to fall to include call light in reach and non-skid footwear, call before you fall signage, and body pillow. On 3/11/24 a follow up indicated the root cause of the fall was determined to be resident attempting to go to work. An anonymous interview indicated Resident B had fallen 3 times while in the care of the facility where she had resided less than 3 weeks. On Sunday 3/3/24 the family was informed 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 observation, interview, and record review, the facility failed to ensure a resident did not have significant weight loss for 1 of 8 residents reviewed for weight loss (Resident L). Findings include: On 3/7/24 at 11:29 a.m., Resident L was observed as Activity Assistance (AA) 9 assisted Resident L to a dining room chair. Resident L was observed walking on her own with a walker. AA 9 gave her a coloring page and crayons. She indicated lunch would be arriving soon. On 3/7/24 at 12:20 p.m., Resident L was observed to receive a regular lunch of three large sweet and sour meatballs, a deep fried eggroll, sugar snap peas, steamed rice, mandarin oranges, and vanilla ice cream. No one cut-up her food for her. No staff member directed, cued, or assisted her with eating. During a limited interview during lunch, on 3/7/24 at 12:35 p.m., Resident L indicated she was having trouble chewing her food and she did not like it. She had been observed taking very few and small bites from the eggroll and chewed for a long…

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

A. Based on observation, interview, and record review, the facility failed to ensure all resident rooms were adequately cleaned for 19 of 20 residents reviewed for cleanliness and home-like environment (Resident B, C, D, E, G, H, J, L, N, O, P, Q, R, S, T, U, V, W, and X). B. Based on observation, interview, and record review, the facility failed to ensure a memory care (MC) resident's refrigerator did not contain spoiled, undated food for 1 of 1 MC refrigerators reviewed for spoiled, undated food (Resident D) and failed to ensure other resident refrigerators had completed refrigerator temperature sheets for 4 of 4 residents' refrigerator observed (Resident F, J, and L). C. Based on observation, interview, and record review, the facility failed to keep a hall clear of open soiled bags of linen and trash outside a resident's room for 1 of 15 resident rooms observed (Resident M). Findings include: A. On 8/17/23 at 9:35 a.m., during a general observation of the building, only one housekeeping cart was observed by a resident's room on the B Wing. On 8/17/23, during a continuous…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to reconcile and document the disposition of medications for 4 of 5 discharged residents reviewed for discharge (Residents 64, 67, 68, and 69). Findings include: 1. On [DATE] at 10:51 a.m., Resident 64's medical record was reviewed. He had the following diagnoses, which included, but were not limited to, diabetes type II, congestive heart failure, essential hypertension, major depression, anxiety bi-polar disorder, osteoarthritis of the knee, and reduced mobility. Resident 64's medication regimen included acetaminophen, atorvastatin, biofreeze, clopidogrel, cyclobenzaprine, doxycycline, escitalopram oxalate, ferrous sulfate, gabapentin, insulin lispro, Levemir insulin, melatonin, metformin, metoprolol tartrate, nitroglycerin, pantoprazole, quetiapine, ranolazine, tamsulosin, thera-M vitamin, tramadol, and zinc. 2. On [DATE] at 10:35 a.m., Resident 67's medical record was reviewed. She had the following diagnoses, but not limited to Alzheimer's disease,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident's, (Resident 31) comprehensive care plan was updated to reflect the change of his Advance Directive status and wishes, and failed to ensure a physician's order was obtained for a resident (Resident 66) who received hospice care and had an Out of Hospital Do Not Resuscitate (DNR) form for 1 of 3 residents reviewed for Advance Directives. Findings include: 1. On [DATE] at 11:52 a.m., Resident 31 was initially observed. He sat upright on the edge of his bed; he was alert and oriented. During the interview he was asked if he had advance directive plans and he indicated that there was a recent meeting where he decided to change his status like his brother to a Do Not Resuscitate (DNR). On [DATE] at 12:00 p.m., Resident 31's medical record was reviewed for advance directive status. He had a Physician Order for Scope of Treatment (POST) which indicated he was a DNR status, while his comprehensive care plan indicated Resident 31…

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 care plan was updated after removal of a nephrostomy tube for 1 of 1 residents reviewed for urinary catheters (Resident 21). Findings include: On 3/13/23 at 11:28 a.m., during a random interview and observation, Resident 21 was seated in a wheelchair, in her room. She wore a hospital gown and a blue sweater. A small catheter bag, which contained clear yellow liquid, was observed on the resident's lap. A larger urinary catheter bag, which was covered for dignity, was attached underneath her wheelchair. Resident 21 indicated she had a suprapubic (catheter inserted through the abdomen to the bladder) fastened under her chair, the smaller bag was a drain to her kidney. She did have two drains, one to each kidney but the urologist was able to remove one. On 3/16/23 at 10:14 a.m., Resident 21's medical record was reviewed. The diagnoses included but were not limited to sepsis (severe systemic infection), chronic kidney disease, neuromuscular dysfunction of bladder, and adult failure to thrive. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to identify change in condition and ensure timely transfer to the hospital after residents experienced change of condition for 2 of 3 residents reviewed for hospitalizations (Residents 16 and 26). Findings include: 1. On 3/14/23 at 10:22 a.m., Resident 16 was initially observed. He laid in his bed which was in a raised position, slightly higher than regular height. Although the head of his bed was elevated, he asked that it be raised higher to make it easier for him to speak. There was a long flexible arm device attached to the left side bedrail and positioned directly near his mouth. He was observed to be overweight, and indicated he was unable to move due to being quadriplegic. He wore a nasal cannula (NC) which was hooked up to a concentrator beside his bed set at 4 liters (L). He indicated he had gotten an infection in his spine which gradually paralyzed him, most recently he had lost even more control of his hands and arms. He was soft…

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 implement interventions to prevent the potential for falls for a resident who had a history of falls with fracture for 1 of 4 residents reviewed for accidents (Resident 34). Findings include: During an observation on 3/17/23 at 1:12 p.m., Resident 34 was observed lying in bed. She had a low air mattress, regular size with grab bars. The mattress did not have bolsters (build up edges for boundaries) on it. During an observation on 3/20/23 at 12:57 p.m., Resident 34 was observed lying in bed. She had a regular low air loss mattress without bolsters. A comprehensive record review was completed for Resident 34 on 3/20/23 at 9:32 a.m. She had diagnoses which included, but were not limited to, senile degeneration of the brain, fracture of the right femur, protein-calorie malnutrition, dementia, osteoporosis, and muscle weakness. On 8/8/22, Resident had a fall and was sent to the hospital for surgical repair of her right femur. Resident 34 returned to the facility on 8/12/22. An Interdisciplinary Team (IDT) progress…

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 treatments/services for a resident who had a diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 1 residents reviewed for PTSD (Resident 56) Findings include: On 3/14/23 at 9:36 a.m., Resident 56 was observed sitting up in a standard chair with bright tape on the arms of the chair in her room. The door to the room was shut. On 3/15/23 at 10:32 a.m., Resident 56 was observed lying in bed on her right side. Her eyes were closed. On 3/15/23 at 2:34 p.m., Resident 56 was observed sitting up in a chair in her room. The door to her room was shut. On 3/16/23 at 9:23 a.m., Resident 56 was observed sitting up in a chair in her room. The door to the room was shut. On 3/16/23 at 12:16 p.m., Resident 56 was observed sitting up in her wheelchair in the dining room. She was alert and did not display any behaviors. On 3/20/23 at 9:51 a.m., Resident 56 was observed sitting in the lounge area with other residents. She was alert and did not display any behaviors. On 3/15/23 at 2:02 p.m., a comprehensive record…

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

Based on observation and interview, the facility failed to properly label medications for 2 of 2 residents randomly observed during a medication storage observation (Residents 21 and Resident 4) . Findings include: 1. During an observation on 3/15/23 at 8:55 a.m., Resident 21 had an order for thera-M 9mg/400mcg by mouth daily. RN 9 removed the bottle of medication from the cart. The bottle lacked a prescription label. It had her name on it. 2. During an observation on 3/16/23 at 11:43 a.m., Resident 4 had a box with her name on it. LPN 5 indicated these medications were stored in the narcotic box. She had two boxes. One was 1:3 releaf oil. The other was social CBD. LPN 5 indicated one goes on her skin and the other was oral. The medications lacked a prescription label. On 3/17/23 at 10:20 a.m., a policy titled, General Dose Preparation and Medication Administration, was provided by the DNS (Director of Nursing Services). The policy indicated, .Facility staff should not administer a medication if the medication or prescription label is missing or illegible. 3.1-25(j) 3.1-25(m)…

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