Harcourt Terrace Nursing And Rehabilitation

Based on observation, interview and record review, the facility failed to document a resident's behaviors or distress which required the increase or addition of a psychotropic medication or the non-pharmaceutical interventions used to treat the behaviors for 1 of 5 residents reviewed for unnecessary medications. (Resident 72)Findings include:During an observation, on 1/5/26 at 10:57 a.m., Resident 72 was in bed with her eyes closed and her arm hanging off the bed. During an observation, on 1/5/26 at 2:47 p.m., Resident 72 was in bed with a flat effect and was speaking very slowly. During an observation, on 1/6/26 at 10:05 a.m. and 1:57 p.m., Resident 72 was in her bed with her eyes closed. During an observation, on 1/7/26 at 11:01 a.m. and 2:20 p.m., Resident 72 was asleep in her bed. During an observation, on 1/8/26 at 10:59 a.m., Resident 72 was lying on her side asleep in her bed. During an observation, on 1/9/26 at 10:38 a.m., Resident 72 was slowly ambulating to the bathroom without assistance. The clinical record for Resident 72 was reviewed on 1/7/25 at 12:01 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Ombudsman was notified of residents' discharge for 2 of 4 residents reviewed for hospitalization. (Resident 21 and Resident 73)Findings include:The clinical record for Resident 73 was reviewed on 1/6/26 at 9:42 a.m. The diagnoses included, but were not limited to, hypertension, Alzheimer's dementia, and major depressive disorder. The clinical record indicated Resident 73 was discharged to a psychiatric facility on 10/29/25. There was no documentation to indicate the Ombudsman was notified of the transfer/discharge in the clinical record. The list of residents on the transfer/discharge notification to the Ombudsman, for October, November and December 2025, was reviewed on 1/6/26 at 3:50 p.m. Resident 73 was not found to be listed on the documents. 2. The clinical record for Resident 21 was reviewed on 1/7/26 at 11:47 a.m. The diagnoses included, but were not limited to, dementia, syncope and collapse, and hypertension. The clinical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) tracking assessment was transmitted as required for 1 of 1 resident reviewed for MDS. (Resident 12)Findings include:The clinical record for Resident 12 was reviewed on [DATE] at 1:56 p.m. The diagnoses included, but were not limited to, dementia, heart failure, and generalized anxiety.A nursing progress note, dated [DATE], indicated Resident 12 had expired with his family at the bedside.The MDS tracking assessment for the death in the facility was not located in the medical record. During an interview, on [DATE] at 2:18 p.m., MDS Coordinator 1 indicated the assessment for death in the facility needed to be completed in seven days. If the assessment was not completed in seven days, it would be late. The resident should have had the MDS completed by [DATE].During an interview, on [DATE] at 12:18 p.m., the Director of Nursing indicated the facility did not have a policy for MDS. During an interview, on [DATE] at 9:36 a.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.

Based on observation, interview and record review, the facility failed to ensure oxygen was set on the correct liter flow according to the physician's order for 1 of 4 residents reviewed for respiratory care. (Resident 62)Findings include:During an observation, on 1/6/26 at 10:10 a.m., Resident 62 was receiving oxygen, and it was set between 3 and 3.5 liters. During an observation, on 1/7/26 at 9:07 a.m., Resident 62 was receiving oxygen, and it was set on 3 liters. During an interview, on 1/7/26 at 9:10 a.m., Licensed Practical Nurse (LPN) 11 indicated she changed the setting from 3 liters of oxygen to 2 liters of oxygen. It was supposed to be on 2 liters of oxygen according to the physician's order.The clinical record for Resident 62 was reviewed on 1/6/26 at 12:15 p.m. The diagnoses included, but were not limited to, chronic respiratory failure and sleep apnea. A physician's order, dated 10/22/20, indicated to administer 2 liters of oxygen continuously when the resident was not wearing a BiPAP (Bilevel Positive Airway Pressure) machine. A care plan, dated 10/22/20, 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 ensure medication carts were free from loose pills, medications contained pharmacy labels, opened medications were labeled with the date the medication was opened, unopened medications which required refrigeration were stored properly, expired medications were not stored in the medication cart, and damaged medication packaging was not secured with tape for 2 of 2 medication carts reviewed for medication labeling and storage. (Willow Bend 2/Moving Forward cart and Augustes Cottage CB cart)Findings include:1. During an observation, on 1/8/26 at 10:03 a.m., the [NAME] Bend 2/Moving Forward medication cart had the following:a. Breztri Aerosphere inhalation (an aerosol respiratory inhaler) with 25 of 28 administrations remaining did not contain a pharmacy label, was not in the medication packaging, and was missing an open date.b. Latanoprost eye drops with instructions to keep the medication refrigerated until it was opened did not have an open date and the sealed medication cap was still present on the bottle.c.…

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 furnishings remained in a safe and homelike condition in 1 of 1 dining room observed for environment. (Men's Memory Care Unit)Findings include:During an observation, on 1/5/26 at 11:58 a.m., a dining table placed in front of the nursing station and close to the window was observed to have approximately one quarter of the laminate coating torn off which exposed a composite board surface. A male resident was seated at the spot where the cover was missing and was running his hand on the loose material. There was no debris around the resident to indicate he had removed the table laminate.During an observation, on 1/6/26 at 12:11 p.m., the table was observed in use and in the same condition.During an interview, on 1/7/26 at 8:26 a.m., LPN 9 indicated she was not sure if the table had been reported to maintenance.During an interview, on 1/7/26 at 8:27 a.m., LPN 19 indicated she would put another maintenance request in for the table and the tabletop was peeled off last night (1/6/26).During an observation and…

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

Based on interview and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed for resident rights. (Resident B)Findings include:A facility reported incident, dated 9/22/25, indicated a staff member had a concern regarding a female resident who was treated roughly by a QMA (Qualified Medication Aide) during care on 9/15/25 at 8:01 p.m. The clinical record for Resident B was reviewed on 9/23/25 at 1:45 p.m. The diagnoses included, but were not limited to, dementia with other behavioral disturbances, Alzheimer's disease, generalized anxiety disorder, pain, difficulty in walking, and cognitive communication deficit.A care plan, dated 10/19/23, indicated Resident B refused medications and ancillary services. The interventions included, but were not limited to, offer other staff as needed, provide Resident B with safety and redirect the resident as needed.A care plan, dated 10/19/23, indicated Resident B had a hearing loss. The interventions included, but were not limited to, facing the resident when speaking, obtain 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 Activity of Daily Living (ADL) care was provided in a safe and comfortable manner for 2 of 3 residents reviewed for ADL care. (Resident B and C)Findings include:A facility reported incident, dated 9/22/25, indicated a staff member had a concern regarding a resident who was treated roughly by a QMA (Qualified Medication Aide).1. The clinical record for Resident B was reviewed on 9/23/25 at 1:45 p.m. The diagnoses included, but were not limited to, dementia with other behavioral disturbances, Alzheimer's disease, generalized anxiety disorder, pain, difficulty in walking, and cognitive communication deficit.A care plan, dated 11/8/22, indicated Resident B required assistance with ADLs including bed mobility and transfers. The interventions included, but were not limited to, assist with bed mobility, transfers, and locomotion/ambulation as needed.A facility document, titled Employee Communication Form, dated 9/19/25, indicated QMA 1 was terminated from the facility for a violation of resident rights related 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a clean, sanitary, and homelike environment was provided for 1 of 12 rooms reviewed for environment. (room [ROOM NUMBER]) Findings include: During an observation, on 7/2/25 at 9:18 a.m., room [ROOM NUMBER] had an old urine smell to it. There were approximately 7 different flies in the room. 2 flies were crawling on top of Resident B as he was sleeping. There were also 2 flies in his cup of juice and a sock on his bedside table. The bedside commode had a very small amount of dark yellow urine in the basin. In room [ROOM NUMBER]'s bathroom, there was a dried, dark drown substance smeared on the toilet with 2 flies crawling on the substance. There was also a puddle of liquid on the floor with dark yellow liquid on the trash can liner. Resident B and C resided in room [ROOM NUMBER]. The clinical record for Resident B was reviewed on 7/2/25 at 10:15 a.m. The diagnoses included, but were not limited to, dementia, osteoarthritis, 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 right to privacy was provided during personal care for 1 of 3 residents reviewed for resident rights. (Resident 376) Findings include: During an observation, on 1/27/25 at 10:54 a.m., LPN 5 entered Resident 376's room to administer a gastrostomy tube (a feeding tube inserted into the abdomen directly into the stomach) bolus (a method of administering liquid food directly into the stomach) of Jevity 1.5 (a nutrition supplement). The resident's door was left open. LPN 5 pulled the resident's cover back and lifted his gown exposing his abdomen. The privacy curtain in the resident's room was not closed and three people walked by the resident's room. The clinical record for Resident 376 was reviewed on 1/23/25 at 3:42 p.m. The diagnoses included, but were not limited to, acute respiratory failure with hypoxia (low levels of oxygen in your body tissue), convulsions, congestive heart failure, dysphagia (difficulty swallowing), and atrial fibrillation. During an interview, on 1/27/25 at 11:35 a.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.

Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed for a resident with a hand splint for 1 of 4 residents reviewed for care plans. (Resident 33) Findings include: During an observation, on 1/22/25 at 12:10 p.m., Resident 33 was sitting in the dining room. Unit Manager 4 entered the dining room and placed a blue hand splint on the resident's right hand. During an observation, on 1/23/25 at 11:00 a.m., the resident was sitting in the activity room, and a hand splint was on her right hand. During an observation, on 1/27/25 at 10:27 a.m., the resident was sitting in the activity room, and a hand splint was on her right hand. The clinical record for Resident 33 was reviewed on 1/23/25 at 3:19 p.m. The diagnoses included, but were not limited to, transient ischemic attack (temporary disruption in the blood supply to a part of the brain), hypertension, anxiety disorder, and major depressive disorder. The electronic medical record did not include a physician's order or a care plan for a right-hand splint. 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 pharmaceutical services were obtained timely to support a resident's healthcare needs for 1 of 1 resident reviewed for pharmacy services. (Resident 376) Findings include: The clinical record for Resident 376 was reviewed on 1/23/25 at 3:42 p.m. The diagnoses included, but were not limited to, convulsions, congestive heart failure, emphysema, and encephalopathy (a change in your brain function due to injury or disease). A care plan, dated 3/8/24, indicated the resident was at risk for injury related to seizure activity. Interventions included, but were not limited to, administer medications as ordered. A physician's order, dated 1/9/25, indicated to give Lacosamide (an anticonvulsant medication) 10 milligrams (mg)/ 1 milliliter (ml) solution twice a day. The physician's order for Lacosamide 10 mg/1 ml solution was ordered on 1/9/25 and was not available until 1/22/25. The resident received his first dose on 1/22/25 at 11:05 a.m. The resident missed 26 doses of the medication. During an interview, on 1/27/25 at 9:53…

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 were assessed for side effects of antipsychotic medications with the Abnormal Involuntary Movement Scale (AIMS) according to the policy and procedure for 2 of 5 residents reviewed for unnecessary medications. (Resident 37 and 45) Findings include: 1. The clinical record for Resident 37 was reviewed on 1/27/25 at 10:44 a.m. The diagnoses included, but were not limited to, Alzheimer's disease with early onset, type 2 diabetes mellitus with diabetic polyneuropathy, dementia with other behavioral disturbance and agitation, bipolar disorder, mood disorder, generalized anxiety disorder, and moderate recurrent major depressive disorder. A care plan, dated 10/10/23, indicated the resident was at risk for adverse side effects related to the use of psychotropic medication, antipsychotic, antidepressant and antianxiety medication. A physician's order, dated 1/1/24, indicated to give risperidone (an atypical antipsychotic medication) 0.5 milligrams (mg) twice a day. A physician's order, dated 5/2/24, indicated to give…

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

Based on interview and record review, the facility failed to ensure documentation was complete and accurately reflected the care provided for 2 of 2 residents reviewed for accurate documentation. (Resident 55 and 18) Findings include: 1. The clinical record for Resident 55 was reviewed on 1/27/24 2:52 p.m. The diagnoses included, but were not limited to, diabetes mellitus, dementia, and hypertension. A care plan, dated 7/25/23, indicated the resident was at risk for altered nutritional status related to dementia, hypertension, and schizophrenia. Interventions included, but were not limited to, offer bedtime snacks. A physician's order, dated 11/7/23, indicated to administer a bedtime snack to the resident. The January 2025 Medication/Treatment record indicated snacks were not administered because they were not available on January 6th, 13th, 15th and 20th. The documentation indicated that the resident was given 0 (zero) bedtime snacks on those days. 2. The clinical record for Resident 18 was reviewed on 1/28/25 at 3:03 p.m. The diagnoses included, but were not limited to,…

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

Based on observation, interview and record review, the facility failed to ensure a resident had been assessed to self-administer medications for 1 of 1 resident reviewed for medication administration. (Resident B) Finding includes: During an interview and observation, on 10/23/24 at 9:16 a.m., Resident B was up in her room. A clear plastic cup was noted on the table with approximately eight pills in the cup. Resident B indicated the nurse brought the medications to her when she was bathing or dressing and she was to take the medications when she ate, so the nurse left the pills in the room. The resident's breakfast tray was noted to be on the table and untouched. The clinical record for Resident B was reviewed on 10/23/24 at 10:27 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, end stage renal disease, and chronic systolic heart failure. There was no physician's order, care plan or assessment to indicate the resident was able to self-administer medications found in the record. During an interview, on 10/23/24 at 9:45 a.m., RN 1 indicated she went to…

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

Based on observation, interview and record review, the facility failed to ensure cups were free of film/build up from hard water prior to using the cups to serve drinks to residents for 1 of 1 dishwasher reviewed. Finding includes: During an observation of the kitchen, on 10/23/24 at 8:59 a.m., clean cups were found to be stored in the dishwasher room. They were stored bottom up in large plastic dishwasher crates in a shallow square container with wheels that set up off the floor approximately six inches. There were 18 of 29 cups found to have a white film in the bottom, inside of the cups. The film could be scrapped off the bottom of the cup. There were also an additional 9 of 9 cups with handles, found stored in a separate dishwasher crate, also containing a film at the bottom. During an interview, on 10/23/24 at 9:01 a.m., Dietary Staff 2 indicated the cups were used to serve fluids. The Kitchen Manager supplied the salt, and they were out of salt. All the cups had been washed. During a random observation, on 10/23/24 at 9:09 a.m., Resident B was observed to move his bedside…

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 weights and physician notification were completed as ordered for residents with congestive heart failure (CHF), to document accu checks (finger stick blood sugars) and insulin administration and failed to ensure a resident with routine orders for Ativan and morphine received the medication as ordered for 4 of 4 residents reviewed for quality of care. (Resident 8, 10, 75 and 81) Findings include: 1. The record for Resident 8 was reviewed on 12/07/23 at 9:39 a.m. Diagnoses included, but were not limited to, chronic (congestive) systolic heart failure and chronic kidney disease stage 3. A physician's order, dated to 10/19/23, indicated to obtain daily weights for congestive heart failure and to notify the physician for a weight gain of 3 pounds in a day or 5 pounds in a week. A Medication Administration Record (MAR), dated 10/1/23 to 10/31/23, indicated 4 missing weights for 10/14, 10/15, 10/16, and 10/19/2023. There was incomplete information on 10/3, 10/4, 10/5, and 10/6/23. A MAR, dated 11/1/23 to 11/30/23,…

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

Based on observation, interview and record review, the facility failed to ensure medications administered orally were separated from topical medications, to store cleaning supplies separately from medications, medication carts were clean and free of loose medications, medications were not relabeled for use for another resident, opened medications were dated, medications were stored in the refrigerator until opened, discontinued and expired medications were disposed of routinely and medication storage refrigerators were clean for 3 of 3 medication carts reviewed and 1 of 1 medication storage rooms reviewed. (The women's memory care medication cart, the men's memory care medication cart, the [NAME] Bend medication cart #2 and the women's memory care medication storage room). Findings include: 1. During a medication cart observation with the Assistant Director of Nursing (ADON), on 12/7/23 at 11:03 a.m., the women's memory care unit cart was observed to have the following: a. The top left drawer had bisacodyl (a stool softener) suppositories sitting next to one bottle of eye drops 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 record review and interview, the facility failed to ensure there was documentation to show the resident/representative made the choice about the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and to ensure the resident's financial representative was notified of the SNF ABN for 2 of 3 residents reviewed for beneficiary notification. (Resident 6 and 56) Findings include: 1. The SNF ABN for Resident 6 indicated the resident no longer required skilled nursing care and did not need skilled rehabilitation on a daily basis. Beginning on 11/19/23, the resident's stay would not be covered under Medicare. The options indicated the resident/representative was to check only one box and the facility could not choose a box for the resident/representative. Option 2 was checked to indicate the resident/representative wanted the care listed above and did not want Medicare billed. The resident/representative understood they may be billed now because they were responsible for the payment of the care. They could not appeal because Medicare would not be billed.…

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 initiate a new PASARR (Preadmission Screening and Resident Review) level I when a resident was started on a new psychotropic medication for 2 of 2 residents reviewed for PASARR. (Resident 44 and 38) Findings include: 1. The record for Resident 44 was reviewed on 12/8/23 at 10:25 a.m. Diagnoses included, but were not limited to, dementia, major depression with agitation, bipolar disorder, and other personality and behavioral disorder. A PASARR level I, dated 4/18/2019, indicated the resident had one mental health diagnoses of personality change and was not taking any antipsychotic medications. A PASARR level II, dated 8/11/22, indicated the resident was added a bipolar diagnosis and was not taking any antipsychotic medications. A physician's order, with a start date of 9/2/22 and an end date of 9/21/23, indicated the resident took Olanzapine (an antipsychotic medication) 5 milligrams (mg) at bedtime. There was no new PASARR done after the resident was started on an antipsychotic medication. During an interview, on 12/8/23…

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

Based on interview and record review, the facility failed to ensure there was documentation in the Electronic Health Record to include if the resident went to the scheduled dialysis treatments for 1 of 2 residents reviewed for dialysis. Resident 39) Finding includes: The record for Resident 39 was reviewed on 12/7/23 at 10:38 a.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes mellitus, congestive heart failure, generalized anxiety disorder, and chronic embolism and thrombosis of the right jugular vein. A physician's order, dated 6/20/23, indicated dialysis days on Monday, Wednesdays, and Fridays with a chair time of 9:15 a.m. The was no documentation in the Electronic Health Record (EHR) for 11/15/23, 11/22/23, 11/24/23 and 11/29/23 to indicate if the resident went to dialysis or did not go to dialysis. There were no progress notes, no dialysis events, and no dialysis communication form. There was no event for dialysis on 10/30/23, 11/6/23, 11/8/23, 11/10/23, 11/13/23, 11/27/23, 11/29/23 or 12/4/23 for the dialysis treatment. The facility…

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

Based on observation, record review and interview, the facility failed to ensure the narcotic count sheets were signed by two nurses to verify the correct count of controlled substances between shifts for 2 of 3 medication carts reviewed. (the women's memory care medication cart and the [NAME] bend #2 medication cart) Findings include: 1. During an observation, on 12/7/23 beginning at 11:03 a.m., the following was observed on the Shift Change Verification of Controlled Substances form, dated December 2023, for the women's memory care unit: a. The form was labeled the Cedar Bay unit for December 2023. a. The same nurse signed the on-coming nurse space and the off-going nurse space for the night shift on December 2. b. There were no nurse signatures on the day shift and evening shift for December 5. c. The same nurse signed as the on-coming and off-going nurse for the evening shift on December 6. d. There was only one nurse signature on the on-coming nurse space and no signature for the off-going nurse for the day shift on December 7. e. There was only one nurse signature on 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 provide an environment free of odors on the south hall and around the nursing station on the skilled unit for 1 of 3 units reviewed for environment. (Willow Bend Unit) Findings include: During a walk through of the facility, on 10/23/23 at 9:27 a.m., a very strong smell of urine was noted in the south hall of the skilled care unit (Willow Bend Unit). The smell was strongest between rooms 15-18. During an interview, on 10/23/23 at 9:32 a.m., RN 5 indicated staff was changing residents at the time and then walked down the hall. She returned at 9:33 a.m., and indicated she would call housekeeping and locate the source of the urine smell and have it cleaned if needed. She then walked down the hall towards the end to a room on the left and knocked on the door, and again returned and indicated the smell was coming from that room, the resident refused care and was care planned for refusing care. During a random walk through of the [NAME] Bend Unit, on 10/24/23 at 8:33 a.m., a smell of urine was noted at the nursing…

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 protect a resident from abuse when the resident was reported to have been hit in the back of the head/neck by a staff member for 1 of 3 residents reviewed for abuse. The deficient practice was corrected on 10/13/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: An Incident Report to the Indiana Department of Health, dated 10/8/23, indicated the Executive Director was notified by staff another resident made contact with a resident in the TV room. They type of injury was redness to the back of the neck. The action taken by facility included ensuring resident safety, the Executive Director was notified, the employee was immediately suspended pending an investigation. The investigation was to include staff and resident interviews and skin assessments for residents who were unable to be interviewed. During an observation, on 10/23/23 at 3:49 p.m., Resident B was up in a recliner in the television room (also referred to as Man Cave and Theater Room) on the men's memory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were stored safely in the original containers until the time of administration for 12 of 17 residents on the [NAME] Cottage Memory Care Unit. (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13) Finding includes: During an observation, on 10/25/23 at 8:42 a.m., QMA 3 was observed to remove a clear plastic medication cup of medications from the top drawer of the medication cart. She was not observed to set up the medications individually using the computer or medication cards to prep the medications. The drawer of the medication cart contained multiple cups of medications with names written on each cup. QMA 3 indicated there were 10 cups of medications in the drawer. Before the QMA could answer any questions, LPN 4, who had been standing approximately three feet behind the QMA approached the medication cart and indicated to the QMA medications could not be set up in cups, they needed to be prepped one at a time. The QMA…

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.