Robin Run Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure grievance resolutions were provided, or effectively addressed ongoing concerns related to call lights response times and staffing availability to meet the resident's needs and preferences for 1 of 15 residents reviewed for grievances (Residents H) and for 6 of 6 residents who participated in a resident council meeting. Findings include: On 9/16/25 at 11:11 a.m., Resident H was observed. She wore shorts and had a thin sheet over her lap as a blanket. Resident H's husband arrived and indicated to Certified Nursing Aide, (CNA) 11, he was upset to keep finding her dressed in shorts because she got cold easily and preferred long pants and long sleeve shirts. Resident H's husband indicated he had complained about it on several occasions and just went to check her closet and found no long pants. He apologized to CNA 11 and indicated it was not her fault, but he was frustrated that he had to keep reminding staff to put her in long pants.…

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

Based on observation, interview, and record review, the facility failed to ensure residents who resided in the secured memory care unit received necessary care and services for activities of daily living (ADL) including eating, toileting, and grooming for 10 of 15 residents reviewed for ADLS (Residents E, F, G, H, J, K, L, M, N and P). Findings include:During a continuous observation on 9/16/25 from 10:10 a.m. until 1:00 p.m., in the secured memory care unit (MCU), the following was observed: Resident N was asleep on a couch in the TV lounge area and there was a strong odor of urine from him. Resident E was provided a small plastic cup of a supplemental chocolate shake but had fallen asleep and spilled the shake on his lap. LPN 12 took the empty cup from him but did not wipe off his lap. Residents F, G, H, J, and M's hair were observed to be unbrushed. Resident G's hair appeared greasy, Resident M's hair was falling out of a loose ponytail, and Resident F's hair was unbrushed and fell over her face. Resident G's fingernails were observed to be long and had debris under them. 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.

Based on observations, interviews, and record review, the facility failed to provide sufficient nursing staff to meet the needs of residents in the secured memory care unit as evidence by unmet or untimely assistance with activities of daily living (ADL) care for 10 of 15 residents reviewed for ADLs (Residents E, F, G, H, J, K, L, M, N and P), failed to ensure the appropriate assistance was available for the transfer of a resident in a hoyer lift which tipped and caused the resident to receive a skin tear for 1 of 4 resident reviewed for accidents (Resident P), and failed to ensure enough staff to timely answer call lights and assist residents for 4 of 7 months of grievances reviewed. Findings include:1. During a continuous observation on 9/16/25 from 10:10 a.m. until 1:00 p.m., in the secured memory care unit (MCU), the following was observed: There was only Certified Nursing Aide (CNA )11 on the unit and Licensed Practical Nurse (LPN) 12 on the unit. Resident N was asleep on a couch in the TV lounge area and there was a strong odor of urine from him. Resident E was provided a…

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

Based on observations and interviews, the facility failed to ensure medications stored in medication carts were appropriately stored, labeled, and dated. This deficient practice had the potential to affect 9 of 57 residents receiving medication from the facility (Residents 24, 59, 9, 57, 4, 36, 7, 32, and 8). Findings include:On 9/16/25 at 10:45 a.m. medication cart one was reviewed with Qualified Medication Aide (QMA) 21. The medications reviewed were as follows:1. Resident 24 had three Atrovent inhalers with no open date or expiration date.2. Resident 59 had a Dorzolamide eye drop (a prescription eye drop medication used to treat elevated pressure in the eye) with no open date and no expiration date. Three open Lantanoprost eye drop (an eye drop used to lower elevated pressure in the eye) containers with no open date or expiration date and a sticker on them that said refrigerate. A Fluticasone nasal spray (a steroid nasal spray used to treat symptoms of allergies and other conditions by reducing inflammation in the nose) with no cap covering the applicator and had no open date or…

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

Based on observations, interview, and record review, the facility failed to ensure appropriate infection prevention measures were taken during wound treatments for 2 of 2 residents reviewed for wounds (Residents G and 55). Based on interview and record review, the facility failed to ensure an effective infection surveillance tracking and trending procedure was in place for 4 of 9 months of infection surveillance reviewed. Findings include:1. On 9/16/25 at 11:08 a.m., Resident 55 was observed. She was seated in a recliner chair in the main TV lounge with an over-bed table in front of her with the remainder of her breakfast meal. An unidentified Hospice nurse arrived and removed her breakfast tray. Without wiping off the surface of the table, the Nurse set down supplies for a dressing change and put on gloves without hand hygiene. She pulled a chair up beside Resident 55, and proceeded to remove an old bandage from the Resident's right forearm, and completed a wound treatment on top of the bedside table, and did not perform hand hygiene between gloves changes. On 9/16/25 at 2:41 p.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 observations, interviews, and record reviews, the facility failed to ensure residents had clear orders for code status to reflect the resident's/family's choices for 2 of 2 residents reviewed for code status (Residents B and K), and failed to adhere to a resident's physician order for Do Not Resuscitate (DNR) for 1 of 2 residents reviewed for code status (Resident B). Findings include:1. On 9/18/25 at 1:29 p.m., a record review was completed for Resident B. He had the following diagnoses which included but were not limited to constipation, insomnia, Parkinson's disease (a progressive neurological disorder that affects movement), and urinary retention. A Physician's Orders for Scope of Treatment (POST) form in his electronic health record (EHR), dated 7/17/25, indicated Resident B desired Do Not Resuscitate (DNR) comfort measures only. A physician order, dated 7/31/25, indicated Resident B desired a code status of Do Not Intubate (DNI)/intubate/shock. He had an order for a hospice referral on 7/31/25. Resident B's baseline care plan did not discuss his desire for his code…

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 follow up with a pharmacy recommendation for psychotropic medications for 1 of 5 resident reviewed for pharmacy recommendations (Resident 5). Findings include: On 0/18/25 at 10:46 a.m., a record review was completed for Resident 5. She had the following diagnoses which included but were not limited to fracture of left lower leg, type 2 diabetes, hypertension, multiple fractures of ribs left side, major depressive disorder, and difficulty in walking.Resident 5 had current pharmacy orders for aripiprazole (an antipsychotic drug used to treat bi-polar and schizophrenia) 10 milligrams (mg) daily. She also had an order for Prozac (an antipsychotic drug used to treat depression) 40 mg daily.She had a pharmacy recommendation on June 30, 2025. It was recommended she get CMS (Centers for Medicare and Medicaid Services) diagnoses or titrate the aripiprazole off. This recommendation was not followed up with. She had a care plan that indicated she used psychotropic medications dated 6/16/25.On 9/19/25 at 1:32 p.m., during an interview…

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 documentation and interview, the facility failed to adequately investigate an allegation of misappropriation for an unidentified resident for 1 of 1 abuse allegation investigation reviewed. Findings include: An Indiana Department of Health incident report, dated 8/18/25, indicated the incident occurred on 6/30/25 at 12:10 p.m. A Qualified Nurse Aide (QMA) had been accused of stealing an unknown resident's credit card and used it to pay the QMA's cell phone bill. The report indicated a family member of the QMA called the facility on 8/18/25 to inform them that the QMA had told them on 8/17/25, she had taken the resident's credit care information and their social security number and used it to pay her cell phone bill. The family member provided a picture of the piece of paper with the information, but it did not have the resident's name, and the social security number was cut off. The incident report indicated witnesses were interviewed, staff were educated, and the police were notified. The report lacked explanation of why the incident report indicated the incident date 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 record review and interview, the facility failed to develop a baseline care plan (a care plan that is developed at the time of admission through 48 hours of admission) for 1 of 7 residents reviewed for baseline care plans (Resident 66). Findings include: Findings include:On 9/18/25 at 1:06 p.m., a record review was completed for Resident 66. She had the following diagnoses which included but were not limited to hypertension, heart disease, pacemaker, chronic kidney disease, and dizziness. She admitted on [DATE].Her record lacked a baseline care plan as of 9/18/25.On 9/19/25 at 9:52 a.m., Resident 66's record had a baseline care plan. During an interview, the Minimum Data Set (MDS) Coordinator indicated she had added the care plan.A policy titled Care Plans-Baseline dated March 2022, was provided by the Regional Nurse Consultant (RNC) on 9/19/25 at 2:09 p.m. It indicated, The baseline care plan includes instruction needed to provide effective, person-centered care of the resident that meet professional…

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 implement a care plan for residents' desired advanced directives for 2 of 7 residents reviewed for care plans (Residents 5 and 21) and failed to implement a care plan for a resident's behaviors for 1 of 7 residents reviewed for care plans (Resident 7) reviewed for care plans. Findings include:1. On 9/18/25 at 10:46 a.m., a record review was completed for Resident 5. She had the following diagnoses which included but were not limited to fracture of left lower leg, type 2 diabetes, hypertension, multiple fractures of ribs left side, major depressive disorder, and difficulty in walking. Resident 5's record lacked a care plan containing advanced directives. On 9/18/25 at 1:50 p.m., the Minimum Data Set (MDS) nurse indicated she added a care plan for resident's advanced directives, and a full code status. 2. On 9/17/25 at 2:21 p.m. Resident 21's medical record was reviewed. She was a long-term care resident who was residing in the facility for rehabilitation from a wound. Resident 21 had an active order for a full code status.…

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, interviews and record reviews, the facility failed to update care plans related to wounds for a resident (Resident 5) and new fall interventions for a resident (Resident 7) for 2 of 5 residents reviewed for care plan concerns. Findings include: 1. On 9/19/25 at 11:12 a.m. Resident 7's medical record was reviewed. He was a long-term resident whose diagnoses included but were not limited to myocardial infarction (heart attack), dementia, and bipolar disease. An Interdisciplinary Team (IDT) note, dated 9/11/24, indicated Resident 7 had a fall on 9/9/24. The note indicated the new fall interventions were to put antiroll backs and extended brakes on the resident's wheelchair and put nonskid strips next to the resident's bed. The note indicated the care plan had been updated. An Interdisciplinary Team (IDT) note, dated 9/13/24, indicated Resident 7 had a fall on 9/13/24. The note indicated the new fall interventions were to put brightly colored tape on the resident's call light and add a bolster mattress to the resident's bed. The note indicated the care plan 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.

Based on observation, interview, and record review, the facility failed to prevent the potential for the development of pressure ulcers when a resident's socks were too tight and left abrasions around his calf, and failed to ensure a resident had a pressure reducing cushion added to her wheelchair as ordered by her physician for 2 of 5 residents reviewed for pressure (Residents K and F). Findings include:1. On 9/17/25 at 10:24 a.m., Resident K was observed. He was seated in a wheelchair in the doorway of his bedroom. A plastic brace was in place on his left ankle that pressed to the skin on the back of his calf as his sock did not come above his calf. There was a red abrasion that encircled his right calf. The sock on his right foot was observed to be tight around his lower leg. During an interview on 9/18/25 at 9:57 a.m., Resident K indicated the abrasion around his right leg was from his socks being too tight, and the brace on his left foot was part of a specialized shoe to help his foot alignment. He indicated sometimes the brace pressed into the back of his leg and hurt, because…

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 A. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when a resident was assisted with only one CNA and the Hoyer lift tipped over for 1 of 4 residents reviewed for accidents (Resident L). B. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when a resident on the secured memory care unit was observed wandering and asking to go home, had access to the locked door codes, and the facility failed to maintain an Elopement Binder in case of an elopement for 1 of 4 residents reviewed for accidents (Resident 39). C. Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place for 1 of 4 residents reviewed for accidents (Resident 7), and failed to ensure fall risk assessments were completed quarterly for 1 of 4 residents reviewed for accidents (Resident 19). Findings include:A. On 9/19/25 at 9:08 a.m., Resident L's record was reviewed. She was 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 maintain a system for management of resident funds, and return personal funds within 30 days of discharge, for 8 of 11 residents reviewed for misappropriation of property (Residents F, G, H, J, K, L, M, and N). Findings include:Anonymous concerns during the survey process indicated that residents' personal money was being mismanaged by management. Residents had not been reimbursed 30 days after discharge, and some non-return of funds dated back to residents who discharged in December 2023. Eleven (11) resident accounts were reviewed for reimbursement. a. On 4/16/25, Resident F's account was closed, and a refund of $2940.97 was still due. b. On 6/22/23, Resident G's account was closed, and a refund of $839.00 was still due. c. On 4/16/24, Resident H's account was closed, and a refund of $73.40 was still due. d. On 9/24/24, Resident J was discharged from the facility, and a refund of $100.00 was still due. e. On 11/12/24, Resident K's account was closed, and a refund of $16.18 was still due. f. On 5/28/24, Resident L'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.

Based on observation, interview, and record review, the facility failed to ensure residents who were dependent on staff for bathing and showering assistance received those services for 4 of 15 residents reviewed for Activities of Daily Living (ADL) assistance (Residents C, P, Q, and R). Findings include:A confidential concern during the survey indicated there were residents that had not received a showerer for over a month.1. On 8/15/25 at 12:45 p.m., Resident C was observed sitting in a manual wheelchair (WC) at bedside with his feet propped on a bed, his hair was combed but looked greasy. The resident indicated that he had only received 1 shower since his admission to the facility a few weeks prior. An aide had been assisting him to bed one evening and offered to help him with a shower, and at the time he was pleased as his hair was gummy and slimy, and he had a doctor's appointment the next day and wanted to look presentable. Point of Care (POC - an electronic documentation system) documentation indicated, Resident C was scheduled to have a shower weekly on Tuesday and Friday.…

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 identification, assessment, documentation, and notification of skin issues for 1 of 4 residents reviewed for wound care (Resident E). Findings include: A confidential concern during the survey indicated a resident was found to have an unexplained bruise and red area to her forehead that was never reported to the family.On 8/18/25 at 10:15 a.m., Resident E was observed sitting with her eyes closed in a lounge among peers who were watching TV. The resident was sitting in a Broda chair (a reclining geriatric care) and made a small noise, but did not move or open her eyes when the chair was moved by staff. Resident E's skin was observed to have an area of dark discoloration measuring approximately 2 (inches) by (x) 3 on the left side of her face on the temple area, extending onto the ear, and a circular area of red discoloration measuring approximate 1 1/2 on the lower forehead above the dark discoloration. Qualified Medication Aide (QMA) 14 indicated the resident rarely opened her eyes and did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to prevent the development of a unstageable (full-thickness skin and tissue loss wound where the depth of the injury cannot be determined because the wound bed is obscured by slough or eschar) sacral wound that resulted in wound debridement and the wound increased to a Stage 3 (Full thickness tissue loss with subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed) pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident C). Findings include:A confidential concern during the survey indicated a resident was found to have an open wound by a Certified Nursing Assistant (CNA) more than 24 hours after admission, after 3 nurses had completed skin assessments and not identified the wound.On 8/15/25 at 12:45 p.m., Resident C was observed sitting at bedside in a manual wheelchair (WC) with his feet propped on a bed, watching TV. The resident indicated he had a sore on his bottom that was a result of being left sitting on a…

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

Based on observation, record review, and interview, the facility failed to ensure respiratory treatments were provided with professional standards of practice for 2 of 4 residents reviewed for medication administration (Residents C and E). Findings include: During a medication administration observation on 4/25/25 at 8:22 a.m., QMA 10 prepared a nebulizer treatment for Resident E. QMA 10 poured liquids into a nebulizer medication chamber, handed the handheld mouthpiece to the resident, turned on the nebulizer machine, and informed Resident E she would be back in eight (8) minutes to shut off the machine. QMA 10 then left the room. Resident E was not observed having her respiratory status assessed before or after the nebulizer treatment, nor was she monitored during the treatment. 1. Resident C's record was reviewed on 4/24/25 at 3:15 p.m. Diagnoses on Resident C's profile included sepsis of an unspecified organism (condition when the body's dysregulated response to an infection cannot be identified), and gastroesophageal reflux disorder (GERD - when acid reflux and heartburn occurs…

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 manage pain for a resident with a history of falls, who was experiencing pain related to a fall with a fracture of her left hip for 1 of 4 residents reviewed for falls (Resident B). Findings include: A record review was conducted on 12/20/24 at 2:10 p.m. Resident B had the following diagnoses which included, but not limited to, osteoarthritis of the knee, malignant neoplasm of head of pancreas (pancreatic cancer), adult failure to thrive, Alzheimer's disease (degenerative brain disorder), major depressive disorder, and insomnia. Resident B had a care plan, dated 2/25/24, which indicated she was at risk for falls related to confusion, diagnosis of dementia (degenerative brain disorder), left femur (thigh bone) fracture with impaired safety awareness, unsteady gait (walk) at times, diagnosis of pancreatic cancer, and possible side effects from medications. Resident B's illness has progressed, and she had become weaker and needed more assistance. She continued to attempt to self-ambulate due to impaired safety awareness. 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 initiate a Minimum Data Set (MDS) significant change assessment after a change in condition for 3 of 3 residents reviewed for hospice change in condition (Residents 14 and 49). Findings include: 1. On 8/20/24 at 1:35 p.m., Resident 14's record was reviewed. A physician order, dated 6/22/24, indicated for her to be admitted to a local hospice. Her Minimum Data Set (MDS) assessments were reviewed. A significant change was not completed after her admission to hospice. Her diagnoses included, but were not limited to, malignant neoplasm of the pancreas (cancer of the pancreas), Alzheimer's disease (brain disorder), and a history of breast cancer. Her hospice care plan, dated 5/8/24, indicated she was on hospice and would enjoy small group activities. Her cancer care plan, dated 6/24/24, indicated she had a terminal prognosis related to pancreatic cancer and was on hospice. 2. On 8/20/24 at 11:23 a.m., Resident 49's medical record was reviewed. He was a long-term care resident who resided on the secured memory care unit with a…

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

Based on observation, interview, and record review, the facility failed to ensure the food in the kitchens were dated according to policy for 1 of 1 observation and the refrigerator and freezer temperature logs were completed for 2 of 3 kitchen and pantry observations. Findings include: 1. On 8/18/24 at 9:55 a.m., during a tour of the main kitchen with the Dietary Manager (DM) and Chef 12. At 10:04 a.m., the walk-in refrigerator had 3 large bags of fresh thyme, one bag of fresh cilantro, one bag of fresh mint, one bag of fresh dill with no date of arrival or expiration. A large bag of pepperoni was observed not sealed, the expiration date was 8/9/24. A plastic bag of whipped cream was not dated. The feta cheese had no expiration date. At 10:10 a.m., the walk-in freezer had undated items; a plastic bag of crumbled sausage, package of impossible burgers, and a lemon meringue pie. 2. On 8/18/24 at 9:45 a.m., during a tour of the satellite kitchenette with the Dietary Manager (DM) the August refrigerator temperature log-in document was observed incomplete. a. No temperatures were logged…

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, interview, and record review, the facility failed to appropriately code the Minimum Data Set (MDS) with accurate information for 3 of 5 residents reviewed (Resident 11, 1, and 211). Findings include: 1. On 8/18/24 at 12:59 p.m., a record review was conducted for Resident 11. She had the following diagnoses which included schizoaffective disorder, diabetes mellitus type 2 (high blood sugar), anxiety disorder, and chronic kidney disease. She had a level II completed on October 28, 2021 due to having schizoaffective disorder. Her MDS, dated [DATE], indicated she did not require a level II assessment. 2. On 8/20/24 at 11:01 a.m., a record review was conducted for Resident 1. She had the following diagnoses but not limited to paranoid schizophrenia, major depression, heart failure, insomnia, and unspecified dementia. She had a level II, completed on January 22, 2024, due to having paranoid schizophrenia. Her MDS, dated [DATE] indicated she did not require a level II assessment. 3. On 8/20/24…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a fall care plan for a resident with a history of falls for 1 of 5 residents reviewed (Resident 60). Findings include: On 8/20/24 at 10:37 a.m., a record review was conducted for Resident 60. He had the following diagnoses which included, but were not limited to, myocardial infarction (MI) (heart attack), hypertension, and vitamin D deficiency. He was admitted to the facility on [DATE] with a history of falls. His medical record lacked documentation of a care plan to address his risk for falls and interventions included to prevent falls from occurring. During an interview with the Director of Nursing (DON) on 8/23/24 at 10:28 a.m., she indicated she could not find the fall care plan and he was only at facility for a short time. A policy dated March 2022 titled, Care Plans, Comprehensive Person-Centered was provided by the Executive Director (ED) on 8/22/24 at 9:17 a.m. It indicated, The interdisciplinary team (IDT) in conjunction with 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.

2. On 8/18/24 at 11:54 a.m., a record review was conducted for Resident 53. He had the following diagnoses which included but were not limited to cerebral infarction (CI) (stroke), anemia, dysphagia (difficulty swallowing) and muscle weakness. Resident 53's April 2024 weight was 150.0 pounds. His weight on 8/16/24 was 133.4 pounds. He had a weight loss of 16.6 pounds over a 4-month period. This was a significant weight loss at 11.07%. Resident 53's record indicated he was unable to have oral nutrition related to dysphagia. He had an order, dated 7/25/24, for Osmolite 1.2 cal oral liquid give 75 ml (milliliter)/hr (hour) via g-tube (gastrostomy) every shift for continuous feeding, flush 30 ml every hour, turn off from 2:00 p.m. until 6:00 p.m. Resident 53 had a care plan, dated 5/29/24, that indicated he was nothing by mouth (NPO) due to dysphagia from CVA (stroke). He was at risk for aspiration. The goal, dated 5/29/24, indicated Resident 53 would receive nutrition and fluids through g-tube (gastrostomy). A nutrition/dietary note, dated 8/14/24 at 2:58 p.m., indicated Resident 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 record review and interview, the facility failed to reconcile medications upon discharge for 2 of 5 residents reviewed for medication disposition (Residents 60 and 58). Findings include: 1. On 8/20/24 at 10:37 a.m., a record review was conducted for Resident 60. He had the following diagnoses which included but were not limited to myocardial infarction (MI) (heart attack), falls, hypertension, type 2 diabetes mellitus (high blood sugar), and vitamin D deficiency. Resident 60 discharged to home on 5/20/24. There was no record of the following medications reconciled at the time of discharge. a. Asprin (ASA) 81mg (milligrams) by mouth daily b. Atorvastion (used for high cholesterol) 40 mg by mouth daily c. Crestor (used for high cholesterol) 20 mg by mouth daily d. Dorzolamide HCL Timolol Mal Ophthalmic Solution 2-0.5% both eyes daily e. Eliquis (blood thinner) 20 mg by mouth daily f. Plavix (blood thinner) 75 mg by mouth daily g. Metoprolol tartrate (blood pressure) 25 mg by mouth two times daily h. Gabapentin (nerve pain) 100 mg 2 capsules by mouth three times daily i.…

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 label tuberculin serum appropriately for 1 of 1 medication room reviewed. Findings include: On 8/19/24 at 10:17 a.m., the north nurse's station was observed in the presence of the Assistant Director of Nursing (ADON). Observed a vial of tuberculin serum that lacked a date to indicate when it was opened. During an interview with the Director of Nursing (DON) on 8/22/24 at 10:30 a.m., she indicated tuberculin serum needed to be dated when it was opened and in the refrigerator when not in use. A policy dated April 2019, was provided by the Executive Director (ED) on 8/21/24 at 11:37 a.m. It indicated, Labels for stock medications include all necessary information, such as: the name and strength of the drug, the lot or control number, the expiration date when applicable, appropriate accessory and cautionary statements and directions for use . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review and interviews, the facility failed to document resident's blood sugars and insulin administration on the Medication Administration Record (MAR) for 2 of 5 residents reviewed (Resident 20 and 11). Findings include: 1. A record review was conducted for Resident 20. He had the following diagnoses which included but were not limited to hypertension, type 2 diabetes mellitus (high blood sugar), unspecified dementia, and chronic kidney disease. His MAR included an order, dated 7/3/24, which indicated Humalog KwikPen subcutaneous (SC) (under the skin) pen injector 100 unit/ml (milliliter) (insulin lispro) inject as sliding scale if blood sugar was 150-200 give 2 units of insulin, 201-250 give 4 units of insulin, 251-300 give 6 units of insulin, 301-350 give 8 units of insulin and if blood sugar is 351 or higher call provider, SC before meals and at bedtime for diabetes type 2. On the following dates and times his insulin documentation was omitted. a. 8/6/24 at 6:30 a.m. b. 8/11/24 at 6:30 a.m. c. 8/12/24 at 6:30 a.m. d. 8/9/24 at 11:30 a.m. e. 8/3/24 at 4:30 p.m. f.…

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

Based on observation, and interview, the facility failed to ensure dietary staff covered facial hair during food preparation, maintained clean and sanitary conditions in the kitchen, pantry, and pantry refrigerator, and food was stored at proper temperature for 3 of 3 food storage and food preparation areas observations. This deficient practice had the potential to affect 79 residents who received food from the kitchen. Findings include: A grievance documented from the resident council, dated 3/28/24, indicated dietary issues, and menu food options. A resident requested for dietary to provide peanut butter and jelly. During a random observation of the satellite kitchen, on 4/29/24 at 9:15 a.m., the satellite kitchen manager indicated food was usually kept approximately 30 minutes after meals for residents who requested leftovers. Indicated the satellite kitchen was locked after dietary staff left for the evening, so pitchers of juice and peanut butter sandwiches were left in the pantry on the nursing unit to be used for evening snacks, nursing staff had no access to ice cream cups,…

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 care for a resident in a manner that preserved the resident's dignity and rights for 1 of 3 residents reviewed for quality of care (Resident K). Findings include: During an interview on 4/24/24 at 3:31 p.m., a family member indicated the family would get upset when they visited and Resident K did not out of bed every day in the morning. The family had requested the resident be out of bed in the morning and be laid down in the afternoon, therefore being up approximately 4 hours daily which would accommodate him being taken to activities. The family was also unhappy when the resident was in bed and dressed only in a T-shirt or gown and adult brief. The resident tended to be cold and family members had provided thermal tops and pajama bottoms so he would stay warm. During the last care plan meeting the family had been promised the staff would get the resident out of bed daily from around 11:00 a.m., - 3:00 p.m. daily, he loved to attend…

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 call lights were within reach for 3 of 3 dependent residents observed for call light placement (Residents M, P, and Q). Findings include: 1. During a random observation on 4/25/24 at 10:57 a.m., Resident M was observed sitting in a wheelchair (wc) at the end of her bed, the call light cord was pulled out of the wall and laying on the bed out of the resident's sight. The resident indicated that she could not see and was transferred out of the bed and propelled around in her wc by the staff. On 4/25/24 at 11:23 a.m., a 2nd observation of Resident M sitting in a wc at end of her bed, the call light remained unplugged from the wall and lying on the bed. Observation of 2 unidentified Certified Nursing Assistants (CNA's), Registered Nurse (RN) 6, and the Director of Nursing (DON) walking by the resident room on the hallway, no one addressed the call light which was visible from the hallway. On 4/25/24 at 12:30 p.m., a 3rd observation of Resident M sitting in a wc at the end of her bed conversing with a…

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

Based on observation, interview, and record review, the facility failed to address resident grievances regarding missing clothing and hearing aids (Residents C, J, and Q). Findings include: Confidential interviews were conducted during the survey: a. Patient laundry was frequently missing and there had been multiple complaints by family members looking for their loved one's clothes. b. Concerns about resident care and the quality of resident care were reported to the nursing staff multiple times, and the receptionist. There was no response from management regarding the concerns. Grievance logs, dated January - April, 2024, indicated 2 resident requests to return to Assisted Living, and 1 concern from resident council regarding dietary issues, menu food items, and a resident request for peanut butter and jelly. 1. During an interview on 4/23/24 at 12:44 p.m., a family member indicated after Resident C was admitted the family noticed the resident's clothing was missing. Upon questioning the staff multiple times, they just kept saying they knew nothing about her clothes. Resident C'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 provide personalized activities to a dependent resident incapable of self-initiated activities (Resident K) and failed to consistently provide activities to a resident with dementia (Resident J) 2 of 3 residents reviewed for quality of care (Residents K and J). Findings include: During an interview on 4/24/24 at 3:31 p.m., a family member indicated the family would get upset when they visited and Resident K was out of bed every day in the morning. The family had requested the resident be out of bed in the morning and be laid down in the afternoon, therefore being up approximately 4 hours daily which would accommodate him being taken to activities. The family was also unhappy when the resident was in bed and dressed only in a T-shirt or gown and adult brief. The resident tended to be cold and family members had provided thermal tops and pajama bottoms so he would stay warm. During the last care plan meeting the family had been promised 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 fall follow up was completed to include neurological (neuro) checks, 72 hour follow up documentation, interventions were initiated, and care plans were updated, for 2 of 2 residents reviewed for falls (Residents C, and K). Findings include: Confidential interview was conducted during the survey, indicated falls and minor injuries were not always being reported and monitored especially on residents who fell frequently or were confused. 1. During an interview on 4/23/24 at 12:44 p.m., Resident C's family member indicated the resident had several falls in the facility due to being so weak. The family received a call from the physician stating the resident was in the hospital after passing out on the toilet, but when the facility was called for follow up questions, the family was told the resident passed out in the main dining room. Resident C's record was reviewed on 4/24/24 at 9:55 a.m. Diagnoses on Resident C's profile included, but not limited to, muscle weakness, difficulty walking, and lack 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 observation, interview, and record review, the facility failed to properly elevate the head of the bed for a resident receiving nutrients via a gastroscopy tube (g-tube) with a known history of aspiration pneumonia (when food or liquid is breathed into the airways or lungs instead of being swallowed), and put a label on infusing bags of tube feeding formula for 1 of 1 resident observed for tube feeding (Resident K). Findings include: During a random observation on 4/24/24 at 3:23 p.m., Resident K was observed lying on his back in the bed with eyes open, and tube feed formula infusing per pump at 70 ml/hr (milliliters per hour). Neither the bag of formula or bag of water hanging next to the formula had a label to indicate the date or time the formula was hung, name of the nurse who hung the formula, or name and physician's order for the formula, or physician's order for the water. During an interview on 4/24/24 at 3:31 p.m., a family member indicated, the family had gotten upset when they visited and Resident K was lying flat in bed without the HOB elevated, it was dangerous…

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 necessary treatments and services to promote the healing of non-pressure ulcers for 1 of 3 residents reviewed for skin impairment (Resident E). The deficient practice was corrected on 1/3/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: A confidential statement indicated, on 1/1/24 a resident advocate was in the facility to visit Resident E and smelled a foul odor around the resident. A dressing on the resident's foot was dated as last changed on 12/24/23, and it was supposed to have been changed daily. The dressing was stuck to the wounds on Resident E's foot, and a nurse had to soak the dressings to remove and change them. The resident was sent to a local hospital related to the wounds and was kept overnight. On 1/23/24 at 10:59 a.m., Resident E was observed sitting in a bariatric wheelchair in his room watching television (TV) while feeding himself breakfast with a spoon that had a built-up handle. The resident was observed to be wearing blown up boots…

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 comprehensive care plans were revised to update person-centered interventions for 7 of 15 residents reviewed for care plan revision and timing, (Residents 14, 3, 26, 46, 47, 59 and 1). Findings include: 1. On 6/5/23 at 11:00 a.m., Resident 14's medical record was reviewed and indicated she had been transferred to the hospital on 3/24/23. She returned 3/29/23 after surgery to repair a fractured femur. On 6/7/23 at 8:47 a.m., Resident 14 was observed in a seated position in her bed with a tray table and breakfast plate. When asked if she had any recent falls, Resident 14 indicated yes. When asked if that was how she fractured her femur, Resident 14 indicated, well that's a mystery. She indicated she did not fall, and although she did not remember the day it happened she was told by her daughter and staff that she had been acting out of her ordinary and was in her wheelchair going up and down the halls, which she never did. Resident 14 indicated she had a very routine schedule and preferred to stay in 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 a soft touch call light (an assistive device used to summon staff for residents with limited mobility) was in reach for a resident for 1 of 15 residents reviewed for call light use (Resident 57). Findings include: On the following dates and times Resident 57's soft touch call light was observed on the upper right corner of the bed on his non-functional side of his body where he was unable to reach it: 6/5/23 at 12:08 p.m., 6/6/23 at 10:10 a.m., 6/7/23 at 12:10 p.m., 6/8/23 at 11:50 a.m., and 6/9/23 at 1:26 p.m. On 6/7/23 at 1:25 p.m., Resident 57's record was reviewed. He had diagnoses which included, but were not limited to, incomplete quadriplegia (the paralysis of all four limbs blocks some, but not all signals from getting through, the person might still have some ability to move), displaced fracture of the second cervical vertebra (neck spinal bones), fracture of T7-8 vertebra (chest spinal bones), Parkinson's disease (progressive disease of the nervous system), and muscle weakness. 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, interviews and record review, the facility failed to ensure comprehensive care plans were created and implemented for 1 of 15 residents reviewed for care plan implementation (Resident 59). Findings include: During an observation on [DATE] at 9:49 a.m., Resident 59 had 2 cups of water on her overbed table. The cups had lids on them with no straws to access the water without taking the lids off. The water was warm. She indicated she liked cold water with ice. During an observation on [DATE] at 9:40 a.m., Resident 59 had a cup of water on her overbed table. The cup had a lid with a straw inserted into the lid. The straw contained half of the wrapper still on it. The water was warm. On [DATE] at 10:05 a.m., Resident 59's medical record was reviewed. She had diagnoses which included, but were not limited to, cerebral palsy (a disorder that affects the ability to maintain posture), muscle weakness, dysphagia (difficulty swallowing), altered mental status, and age-related physical debility. 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 appropriate nail care was completed for residents' who could not do nail care for themselves for 3 of 3 residents reviewed for nail care (Residents 59, 21, and 23). Findings include: 1. During an observation on 6/6/23 at 9:49 a.m., Resident 59 had a dark brown substance under her fingernails, along with facial hair on her chin. She indicated she would like to have the hair removed from her chin. During an observation on 6/7/23 at 10:36 a.m., Resident 59 had a dark brown substance under her fingernails. During an observation on 6/8/23 at 9:37 a.m., Resident 59 had a dark brown substance under her fingernails. A record review was completed on 6/8/23 at 10:05 a.m. Resident 59 had the following diagnoses, but not limited to cerebral palsy, muscle weakness, dysphagia, altered mental status, hypothyroidism, hyperlipidemia, major depression, essential hypertension, gastro-esophageal reflux disease, and age-related physical debility. Resident 59's care plan, dated 3/24/23, indicated she had an ADL (Activities…

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

Based on observation, interview, and record review, the facility failed to ensure resident dressing changes were completed appropriately for 1 of 2 residents reviewed for dressing changes, a resident's skin assessments were completed and accurate for 1 of 3 residents reviewed for skin assessments, and failed to float a resident's heels according to a physician's order for 1 of 3 residents observed for skin assessments (Resident 23). Findings include: On 6/6/23 at 3:10 p.m., Resident 23's record was reviewed. Her diagnoses included but were not limited to, diabetes mellitus (DM), heart failure, anxiety disorder, dementia (progressive brain disorder), history of malignant neoplasm (cancer) of the bladder, and an artificial open of urinary tract (urostomy). 1. Resident 23's Weekly Skin Integrity Reviews were reviewed. a. On 5/5/23, a pressure ulcer on the coccyx was noted with no measurements. b. On 5/12/23, incontinent associated dermatitis on the coccyx was noted with no measurements. c. On 5/19/23, incontinent associate dermatitis on the coccyx was noted to be red, an abrasion 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 identify the potential for accidents when a mobility aid was removed from a bed, leaving the open attachment bar exposed next to the mattress for 1 of 6 residents reviewed for accidents (Resident 20). Findings include: During an observation on 6/5/23 at 11:03 a.m., Resident 20 was observed sitting in her wheelchair next to her bed. A circular grab bar (called a Halo device) was observed installed on the open side of her bed. She indicated she had falls in the past and a Halo bar was placed to both sides of her bed. She indicated the Halos on both sides had been helpful, but some lady came in and took the right Halo off her bed. Resident 20 indicated this had made bed mobility more difficult for her. She was less mobile in bed and her sense of security on the right side of the bed was no longer present. During an observation on 6/6/23 at 9:45 a.m., Resident 20 was observed sitting in her room. She had a Halo on the left side of her bed. During an observation on 6/7/23 at 1:13 p.m., Resident 20's bed had a halo…

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 monitor a resident, who experienced a change of condition due to weight loss, and failed to ensure interventions were implemented to prevent further weight loss and decline for 1 of 2 residents reviewed for weight loss (Resident 47). Findings include: During an observation and interview on 6/8/23, Resident 47 was sitting in her recliner. The leg rest was up. She was attempted to demonstrate how to lower her legs but was unable to as she was observed to press the cloth side of the chair, and not the retract button. When asked about the food, Resident 47 indicated it was horrible and she did not like it. During an observation on 6//8/23 at 2:35 p.m., Resident 47 was sitting in her wheelchair in her room. During an observation on 6/9/23 at 1:02 p.m., Resident 47 was sitting in the dining room. She was eating a turkey wrap sandwich. She was able to feed herself. A record review was completed on 6/9/23 at 9:35 a.m. She had diagnoses which…

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 received person-centered trauma informed care after she sustained severe burns to her extremities from an apartment fire. This deficient practice had the potential to effect 1 of 2 residents reviewed for Trauma informed care. accurate baseline care plan was put in place for a resident (Resident 173) to address immediate care concerns related to her skin integrity and medications. This deficient practice had the potential to affect 1 of 2 residents reviewed for new admission baseline care plans. Findings include: On 6/6/23 at 9:46 a.m., Resident 173 was initially observed. She was seated in a regular wheelchair in her room. She wore an oversize dress gown so that her bare legs and thighs were observed. She had intact, neat, clean odor free bandages to her bilateral thighs. Large portions of her bilateral shines were observed to be covered with scar tissue or scarred skin. During an interview on 6/7/23 at 8:41 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 and interview, the facility failed to properly store medications that were over the counter medications brought in by family members for 2 of 13 residents reviewed for medication storage (Residents 21 and 51). Finding include: 1. During a review of medication storage with RN 8 on 6/5/23 at 10:45 a.m., the 20-hall cart contained medications belonging to Resident 21. The medication bottles had her last name on them only. There were no pharmacy labels with directions on how to administer the medications. The medications included aspirin, folic acid, vitamin d3, and calcium. 2. Resident 51 had a bottle of multivitamin on the 20-hall cart with only his name on the bottle. There was no pharmacy label to indicate the directions for use. RN 8 indicated she thought the bottles only required the resident's name. During a medication pass on 6/8/23 at 12:13 p.m., Resident 20 and 51's medication bottles contained a piece of tape with the resident's name, dose and directions on each bottle. A policy titled, Storage of Medication, was provided by the VPCO (Vice President 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 observations, interviews and record review, the facility failed to ensure a gradual dose reduction (GDR) was attempted and/or a clinically contraindication was documented for a resident, (Resident 3) for 1 of 5 residents reviewed for unnecessary medications. Findings include: On 6/5/23 at 2:37 p.m., Resident 3 was observed in the main dining room during program planning activity. Here eyes were closed, and her head was bowed. She did not engage in the activity. On 6/6/23 at 8:57 a.m., was observed in her room. She was laying on her bed, diagonally rather than horizontally. On 6/7/23 at 10:08 a.m., Resident 3 was observed. She appeared to be asleep in her bed. On 6/7/23 at 10:37 a.m., Resident 3 was observed. During a conversation, her voice was flat, and her face was expressionless. On 6/8/23 at 11:57 a.m., Resident 3 was observed up in the main dining room for a book reading activity. Her eyes were closed and her head nodded off, she did not participate. On 6/7/23 at 10:13 a.m., Resident 3's medical record was reviewed. She was a long-term care resident with diagnoses…

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 staff used appropriate hand hygiene while assisting residents with eating for 3 of 3 residents observed being assisted with dining (Resident 9, 21, and 24). Findings include: On 6/5/23 at 12:21 p.m., Certified Nursing Aide (CNA) 12 was assisting Resident 24 with eating. She provided her a bite of pasta. At 12:24 p.m., without washing her hands or hand gelling, she used Resident 21's utensils with her bare hands and cut up more of her food. She went back to assisting Resident 24 with eating. On 6/5/23 at 12:23 p.m., CNA 9 moved a chair with her bare hands near Resident 24, she did not hand wash or sanitize before assisting her with eating. On 6/5/23 at 12:26 p.m., CNA 9 stopped assisting Res 24, she did not hand washing or sanitize and assisted Resident 21 with [NAME] her food using her fork with her bare hands and helping it into Resident 21's hand. CNA 9 indicated Resident 21 did not want help, but she needed it. Then, with hand…

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.