Westminster Village North

Based on observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was worn during a wound treatment and to ensure hand hygiene was performed after doffing disposable gloves for 1 of 3 residents reviewed for wound care (Resident E).Findings include: The clinical record for Resident E was reviewed on 8/18/25 at 11:17 a.m. The diagnoses included, but were not limited to, congestive heart failure. A Quarterly Minimum Data Set assessment, dated 6/9/25, indicated she was severely cognitively impaired. A physician's order, dated 8/12/25, indicated to cleanse the area on the top of the right foot with wound cleanser, apply bacitracin to the wound bed, top with xeroform (petroleum gauze), cover with an ABD pad (type of wound dressing), wrap with kerlix (type of wound dressing) and secure with tape. On 8/19/25 at 10:05 a.m., Registered Nurse (RN) 2 was observed providing wound care to Resident E. RN 2 donned disposable gloves and removed the old dressing from Resident E's right foot. RN 2 went to the bathroom and removed her disposable…

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 Minimum Data Set (MDS) assessment accuracy for behaviors for 1 of 3 residents reviewed for behavior management. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 11:00 a.m. The diagnoses included, but were not limited to, senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. A Significant Change MDS assessment, dated 9/30/24, indicated Resident B exhibited no behaviors. Upon review of the progress notes, the following date(s) were indicative of Resident B exhibiting behaviors: 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/27/24, 9/28/24, & 9/29/24. An interview conducted with the MDS Coordinator, on 12/16/24 at 1:28 p.m., indicated Social Services was responsible for completing the MDS section regarding behaviors.

Based on interview and record review, the facility failed to ensure a resident with dementia and behaviors was care planned for behaviors along with resident specific interventions on approach to care, ensure visits were conducted of a mental health provider, and document approaches to care when Resident B exhibited behaviors for 1 of 3 residents reviewed for behavior management. Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 11:00 a.m. The diagnoses included, but were not limited to, senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. An admission MDS assessment, dated 5/24/24, indicated severe cognitive impairment, physical behaviors directed towards others occurred one to three days, significant risk for injury and interference with care regarding behaviors, and rejection of care every four to six days. A psychiatric visit form, dated 6/27/24, indicated Resident B had multiple behaviors including refusing medications and being combative with care. Treatment goals were for Resident…

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 narcotic pain medication was administered per the physician orders for 1 of 3 residents reviewed for pain management. (Resident B) Findings include: The clinical record for Resident B was reviewed on 12/16/24 at 11:00 a.m. The diagnoses included, but were not limited to, senile degeneration of the brain, dementia with agitation, dementia with psychotic disturbance, and anxiety disorder. A physician order, dated 10/20/24, indicated a fentanyl patch (narcotic pain-relieving patch) 12 mcg (micrograms) was to be applied every three days. This order ended on 11/19/24. A hospice note, dated 11/6/24, indicated an order to increase Resident B's fentanyl patch from 12 mcg to 25 mcg and change the patch every three days. A physician order, dated 11/7/24, indicated to apply a 25 mcg fentanyl patch to Resident B every three days. A controlled drug use record form for Resident B's 25 mcg fentanyl patch indicated one was administered on 11/10/24. A controlled drug use record form for Resident B's 12 mcg fentanyl patch indicated…

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

Based on interview and record review the facility failed to assure residents were treated with dignity and respect for 3 of 9 residents interviewed during Resident Council and 2 of 2 residents reviewed for dignity. (Resident B, P, 52, N, and K) Findings include: 1. The clinical record for Resident N was reviewed on 7/11/24 at 10:04 a.m. The diagnoses included, but were not limited to, unspecified injury of the cervical spinal cord and diabetes. A Significant Change of Status MDS (Minimum Data Set) Assessment, dated 4/8/24, indicated she was cognitively intact. During an interview for Resident Council, on 7/11/24 at 2:30 p.m., Resident N indicated the CNAs (Certified Nurse Aides) would come into her room and turn the call light off, telling her they would be back in a minute, but they never came back. When the staff does not assist with her needs, when her call light was on, she felt neglected and uncared for. She was to the point where she just lets it roll. 2. The clinical record for Resident P was reviewed on 7/10/24 at 10:49 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 promptly act on a resident council grievance about tablecloths in the dining room. This had the potential to affect 9 of 123 residents who attend resident council. Findings include: On 7/11/24 at 1:24 p.m., the ADM (Administrator) provided the resident council minutes for April, May, and June 2024. The Resident Council Minutes, dated April 11, 2024, indicated that Resident 52 did not like the tablecloths removed from the dining rooms and the Administrator (ADM) had encouraged her to give the changes of the dining room experience a chance. A Resident Council meeting was held on 7/11/24 at 2:30 p.m. There were 9 residents in attendance. The council indicated the facility had stopped utilizing tablecloths in the health center dining rooms. The assisted living and the independent living dining rooms had tablecloths. The council had expressed concerns about not utilizing tablecloths in resident council meetings. They had not received any follow-up on the grievance of not having tablecloths, other than the new…

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

Based on interview and record review, the facility failed to timely address resident grievances, provide dates that grievances were resolved, provide dates that follow up was done with the individual who brought forward the grievance, indicate that grievances were confirmed or not confirmed, and to provide a means for residents to file a grievance anonymously for 7 of 7 grievances reviewed. (Residents N, P, and R) Findings include: 1. The clinical record for Resident N was reviewed on 7/11/24 at 10:04 a.m. The diagnoses included, but were not limited to, unspecified injury of the cervical spinal cord and diabetes. A Significant Change of Status MDS (Minimum Data Set) Assessment, dated 4/8/24, indicated she was cognitively intact. A care plan, last revised on 4/23/24, indicated Resident N had a potential for alteration in mood related to depression, flat affect, reports little interest in doing things, tearful episodes, and critical of staff and routine. The goal was for her to demonstrate an improved mood. The interventions included, but were not limited to, encourage and allow open…

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 incident reports were completed after each fall event, post fall assessments were completed on every shift (morning, evening, and night) for 72 hours, and fall interventions were in place for 5 of 8 residents reviewed for accidents. (Residents E, C, F, M, and D) Findings include: 1. The clinical record for Resident E was reviewed on 7/12/24 at 10:30 a.m. The diagnoses included, but was not limited to, dementia and a displaced comminuted (broken in at least two places) fracture of the right femur. A Quarterly Minimum Data Set (MDS) assessment, dated 2/4/24, indicated Resident E required substantial/maximal assistance with transfers to and from bed/chair, toileting, and moving from a sit to stand/stand to sit position. Resident E was not cognitively intact. 1a. A nursing note, dated 12/24/23 at 12:23 p.m., indicated Resident E's Certified Nursing Assistant (CNA) had observed Resident E walking back from her bathroom and witnessed her fall in the bedroom. Resident E complained of a headache and left leg…

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, sanitized, and well maintained kitchen by staff who failed to wear beard restraints to prevent hair from contacting food, ensure proper storage of food products by keeping track of when to discard perishable foods stored in the refrigerator, maintain a minimum washing temperature in 1 of 2 dishwashers in the facility, and failed to sanitize rolling kitchen carts before placing them in the storage room in kitchen 1 of 2 where food products are stored with the potential to affect 97 of 123 residents who receive food from the kitchen. (Facility) Findings include: 1. An observation of the facility kitchens 1 and 2 was conducted, on 7/10/24 at 10:20 a.m., with the Kitchen Manager (KM 2) and the Dining Service Director (DSD). An observation was conducted of kitchen 1, on 7/10/24 at 10:20 a.m., of the walk-in refrigerator. There was an open box containing individual Jello cups with the expiration date, of 6/29/24, and an open box…

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 maintain an effective pest control program so that it remained free of flying insects in a food storage area within 1 of 2 kitchens potentially affecting 97 out of 123 residents. (Facility) Findings include: A tour of kitchen 1 was conducted, on 7/10/24 10:20 a.m., with Kitchen Manager (KM 2) and Dining Service Director (DSD). Tiny flying insects, resembling gnats, were observed flying around in the air and on products in storage area. There were several seen and observation reflected a count of 9 seen in immediate area. An interview was conducted with KM 2 on 7/10/24 at 10:33 a.m. She indicated that there should not be any flying insects in the kitchen or storage area. 3.1-19(f)(4)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely provide a resident with a wheelchair that accommodated his height for 1 of 1 resident reviewed for positioning. (Resident D) Findings include: The clinical record for Resident D was reviewed on 7/10/24 at 2:20 p.m. The diagnoses included, but were not limited to, left sided hemiplegia (paralysis of left side) and dependence on wheelchair. He was admitted to the facility on [DATE]. A care plan, dated 5/9/24, indicated Resident D had a potential for falls related to a history of traumatic brain injury, immobility, non-ambulatory, and abnormal posture due to hemiplegia (unilateral paralysis) affecting his left dominant side. The goal was for him to be free of falls. An admission MDS (Minimum Data Set) Assessment, dated 5/14/24, indicated Resident D was cognitively intact and used a wheelchair for mobility. On 7/10/24 at 2:20 p.m., Resident D was observed in his room sitting in his wheelchair. He would lean back in the wheelchair with…

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

Based on interview and record review, the facility failed to notify a resident's representative of a fall event for 1 of 8 residents reviewed for accidents. (Resident F) Findings include: The clinical record for Resident F was reviewed on 7/10/24 at 2:00 p.m. The diagnosis included, but was not limited to, Alzheimer's disease. An admission Minimum Data Set (MDS) assessment, dated 6/13/24, indicated Resident F was cognitively impaired. A care plan, dated 6/10/24, indicated Resident F had a potential for falls r/t [related to] deconditioning gait/balance problems, unaware of safety needs. fall in the home, down unknown length of time, seen in ER [emergency room] and admit to hospital. Fall in facility impulsive. no injuries . During a Confidential Interview, they indicated Resident F's Representative was not notified the resident had more than one fall at the facility. A nursing progress note for Resident F, dated 6/21/24, indicated the following, .Resident was on the floor in Aspen activity room. She said she got up from her wheel chair and sat on the floor. She denied falling. She…

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

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse or neglect were timely reported to IDOH (Indiana Department of Health) for 1 of 2 residents investigated for dignity. (Resident N) Findings include: The clinical record for Resident N was reviewed on 7/11/24 at 10:04 a.m. The diagnoses included, but were not limited to, unspecified injury of the cervical spinal cord and diabetes. A Significant Change of Status MDS (Minimum Data Set) Assessment, dated 4/8/24, indicated she was cognitively intact. On 7/12/24 at 2:05 p.m., the SSD (Social Services Director) provided Investigation and Follow-up of Grievance/ Complaint forms for Resident N dated 5/21/24. The Follow-up of Grievance/ Complaint form, dated 5/21/24, indicated the following, .Detailed description of complaint: NOC [night] 5/21/24 Res [resident] had complaint related to customer service issues. Department Involved: Nursing. Corrective Measures: Initiated in-service R/T [related to] resident's concern-proper transfers, following CNA [certified nurse aide] assignment…

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 3. The clinical record for Resident F was reviewed on 7/10/24 at 2:00 p.m. The resident's diagnosis included, but was not limited to, Alzheimer's disease. The resident was admitted on [DATE]. An admission MDS assessment, dated 6/13/24, indicated Resident F was cognitively impaired. A hospital Discharge summary, dated [DATE], indicated Resident F was referred for a neurology consultation. The summary provided the neurology contact information. A care plan meeting summary for Resident F, dated 6/10/24, indicated the resident's representatives had requested a neurology consultation, since it had been discussed in the hospital prior to discharge. The resident's clinical record did not include documentation date and time of the neurology consultation nor arrangement of transportation to the appointment. During a Confidential Interview, they indicated Resident F was to be seen by neurology, and the facility had not made arrangements to be seen nor transportation. The facility staff had told Resident F's Representative…

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 who was on continuous oxygen therapy had a physician's order for the oxygen in the electronic health record (EHR) and was provided the necessary care and services by not changing the humidification container as per policy for 1 of 2 residents reviewed for respiratory care. (Resident C) Findings include: An observation of Resident C's oxygen humidification container was conducted on 7/11/24 at 10:03 a.m. The humidification container was dated, 6/1/24, and the water that was left in the container was cloudy. During the observation, Resident C was wearing her nasal cannula and was receiving humidified oxygen from that container however the water in the humidifier container was not bubbling. A review of Resident C's clinical record conducted, on 7/16/24 at 1:49 p.m., indicated Resident C's diagnoses included, but was not limited to, congestive heart failure, dementia, chronic bronchitis, and anxiety disorder. A review of Resident C's hospice binder was conducted on 7/17/24 at 3:09 p.m. The…

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

Based on observation, interview and record review, the facility failed to administer a pain-relieving patch as ordered for 1 of 4 residents reviewed for pain. (Resident K) Findings include: 1. The clinical record for Resident K was reviewed on 7/10/24 at 11:00 a.m. The diagnosis included, but was not limited to, low back pain. A care plan for pain, dated 7/11/24, indicated Resident K was to receive medications as ordered. A physician order, initiated on 7/5/24 and implemented on 7/9/24, indicated the resident was to receive an Aspercreme lidocaine patch for her lower back. The patch was to be applied for 12 hours and removed after 12 hours. The Treatment Administration Record (TAR), dated July 2024, indicated the lidocaine patch was to be applied at 8:00 a.m., and removed at 8:00 p.m. The TAR was documented by the staff the patch was applied, as ordered, from 7/9/24 through 7/17/24. The staff documented the removal of the lidocaine patch, as ordered, from 7/9/24 through 7/16/24. An interview was conducted with Resident K and Resident K's Representative on 7/10/24 at 11:58 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 interview and record review, the facility failed to ensure pre and post assessments were conducted to a resident receiving dialysis for 1 of 1 resident reviewed for dialysis. (Resident 176) Findings include: The clinical record for Resident 176 was reviewed on 7/10/24 at 3:00 p.m. The diagnosis included, but was not limited to, chronic kidney disease. The resident's admission date was 7/5/24. A care plan for Resident 176, dated 7/8/24, indicated the resident needs hemodialysis r/t [related to] renal failure. A physician order, dated 7/10/24, indicated Resident 176 was to receive dialysis every Monday, Wednesday, and Friday. The residents clinical record did not include pre or post assessments on the following dialysis days: 7/12/24 - Friday, and 7/15/24 - Monday An interview was conducted with the Director of Nursing on 7/18/24 at 9:19 a.m. She indicated staff should be conducting pre and post assessments with Resident 176 on dialysis days. A dialysis policy was provided by the Assistant Director of Nursing on 7/18/24 at 10:36 a.m. The policy indicated the following,…

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 stored in the facility's medication carts were not expired for 1 of 6 medication carts observed within the facility. (Facility) Findings include: A review of the facility's medication storage rooms and medication carts was conducted on [DATE] at 10:05 a.m. The following was observed: On the [NAME] hallway with LPN (Licensed Practical Nurse) 3, on [DATE] 10:10 a.m., the medication cart contained a multi-dose vial of Humalog insulin with an open date, of [DATE], for Resident P without an expiration date on vial or prescription medication bottle that housed vial of insulin. An interview conducted with LPN 3, on [DATE] at 10:12 a.m., she indicated all opened insulin vials should have an open date and expiration date. The open insulin vials expire after 28 days from opening. The clinical record for Resident P was reviewed on [DATE] at 1:32 p.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus. 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 interview and record review, the facility failed to provide residents with a palatable grilled cheese sandwich for 2 of 5 residents reviewed for food. (Residents 62 and 93) Findings include: The clinical record for Resident 62 was reviewed on 7/18/24 at 10:40 a.m. An Annual Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Resident 62 was cognitively intact. The clinical record for Resident 93 was reviewed on 7/18/24 at 10:45 a.m. A Quarterly MDS, dated [DATE], indicated Resident 93 was cognitively intact. An interview conducted with Resident 62, on 7/11/24 at 11:08 a.m., indicated she recently had ordered a grilled cheese sandwich from the always available menu and when she received the sandwich, she described it as two pieces of toast with a cold slice of cheese in the middle. Resident 62 indicated the sandwich was not appetizing since the cheese was not even melted on the sandwich nor had it been grilled at all. An interview conducted with Resident 93, on 7/18/24 at 12:05 p.m., indicated,…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during medication administration by picking up dropped pills with bare hands and not cleaning a blood pressure device in-between resident use for 2 of 3 medication administration observations. (Residents 275, 176, 173, 72, and K) Findings include: 1. A medication administration observation was conducted on, 7/11/24 at 8:20 a.m., with Qualified Medication Aide (QMA) 2. QMA 2 was in the process of removing medication cards to prepare morning medications for Resident 275. QMA 2 prepared metoprolol (blood pressure medication) and pressed down on the medication card for Senna (medication used to treat constipation) to where a pill of Senna was dropped on the medication cart. QMA 2 picked up the pill with her bare hands and placed the Senna pill into the medication cup. QMA 2 proceeded to prepare glycopyrrolate (medication for secretions) 2 milligrams by pressing the medication card and one pill fell onto the medication cart. QMA 2 proceeded to pick up the pill…

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 timely notify a cognitively impaired resident's POA (Power of Attorney) of a new medication order for 1 of 3 residents reviewed for change in condition (Resident B). Findings include: The clinical record for Resident B was reviewed on 2/22/24 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia with agitation and obstructive uropathy (retention of urine). He was admitted to the facility on [DATE] and was discharged from the facility on 12/24/23. A care plan, initiated 11/18/23, indicated Resident B had impaired cognition and thought processes related to dementia with severe agitation. The goal was for him to maintain his current level of cognitive function. The interventions included, but were not limited to, administer medications as ordered and to monitor for side effects and effectiveness, initiated 11/18/23, and to communicate with the resident, family, and caregivers regarding resident's capabilities and needs. 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 interview and record review, the facility failed to accurately monitor urinary output and urine characteristics for a resident with a indwelling urinary catheter resulting in hospitalization for acute urinary tract infection and urinary obstruction for 1 of 3 resident reviewed for change in condition. (Resident B). Findings include: The clinical record for Resident B was reviewed on 2/22/24 at 1:30 p.m. The Resident's diagnosis included, but were not limited to, dementia with agitation and obstructive uropathy (retention of urine). He was admitted to the facility on [DATE] and was discharged from the facility on 12/24/23. A care plan, initiated 11/18/23, indicated Resident B had impaired cognition and thought processes related to dementia with severe agitation. The goal was for him to maintain his current level of cognitive function. The interventions included, but were not limited to, administer medications as ordered and to monitor for side effects and effectiveness, initiated 11/18/23, and 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 monitor and assess the condition of a resident's wound, ensure two residents with wounds were provided wound care in accordance with their physician's orders, and to ensure timely application of a resident's geri-sleeves, as ordered, for 4 of 4 residents reviewed for skin conditions and to timely clarify with the medical provider to restart a medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 21, 29, 59, 88 and Resident 178) Findings include: 1. The clinical record for Resident 88 was reviewed on 1/30/23 at 11:40 a.m. Diagnosis included, but was not limited to, Alzheimer's Disease, chronic kidney disease and methicillin resistant staphylococcus (MRSA) infection, and abscess of buttock. A progress note dated 2/5/23 indicated CNA [Certified Nursing Assistant] was putting Res [Resident 88] to bed. Res. sat on the edge of the bed and could not move self back further and could not get his feet under himself. H…

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 carry out activities of daily living (ADLs) for a resident who was unable to perform oral hygiene by not providing the appropriate oral care as prescribed by a dentist and/or dental hygienist for 1 of 3 residents reviewed for ADLs. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 3/22/23 at 3:47 p.m. Resident 11's diagnoses included, but not limited to, Alzheimer's disease, diabetes type II, and chronic obstructive pulmonary disease. Resident 11's quarterly MDS (minimum data set) dated 2/20/23 indicated, Resident 11 required extensive assistance of one person for dressing, toileting, and personal hygiene. Resident 11 had an upper denture with natural teeth lower teeth. An observation of Resident 11's teeth was made on 3/21/23 at 2:45 p.m. Resident 11's lower teeth appeared unbrushed. She had a white substance built up on her lower teeth next to her gums. A physician's order dated 12/13/18 indicated, to assist Resident 11 with daily oral hygiene every day shift. A dental…

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 recognize and address an issue with a resident's fall intervention and to assure fall interventions were implemented for 2 of 2 residents reviewed for accidents. (Resident 51 and 35). Findings include: 1. The clinical record for Resident 51 was reviewed on 3/21/23 at 12:07 p.m. Her diagnoses included, but were not limited to: Alzheimer's disease, anxiety, and major depressive disorder. She resided on the memory care unit of the facility. The 2/13/23 Significant Change MDS (Minimum Data Set) assessment indicated she was severely cognitively impaired and required extensive assistance of 2 persons for bed mobility, transfers, and toilet use. She required extensive assistance of 1 person for dressing and personal hygiene. When moving from a seated to standing position, she was not steady and only able to stabilize with human assistance. The fall care plan, revised 2/20/23, indicated she was at high risk for falls with injuries related to impaired cognition, gait/balance problems, and unaware of safety needs. She…

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

Based on observation, interview, and record review, the facility failed to assure an indwelling urinary catheter bag and tubing were not touching the floor for 1 of 2 residents reviewed for urinary catheters (Resident 12). Findings include: The clinical record for Resident 12 was reviewed on 3/22/23 at 10:35 a.m. The Resident's diagnosis included, but were not limited to, neuromuscular disfunction of the bladder and urinary tract infection. A care plan, last revised 8/9/22, indicated she had an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. The goal was for her to remain free from catheter-related trauma. the interventions included, but were not limited to, position the catheter bag and tubing below the level of the bladder, initiated 8/9/22, and check tubing for kinks during care times each shift, initiated 8/9/22. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/4/2023, indicated she was severely cognitively impaired and had a urinary catheter present. On 03/22/23 10:35 a.m., Resident 12 was observed sitting in her recliner in her room. 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 provide a supplement, as ordered by the physician, for 1 of 1 resident reviewed for nutrition (Resident 35). Findings include: The clinical record for Resident 35 was reviewed on 3/21/23 at 3:19 p.m. The Residents diagnosis included, but were not limited to, osteoporosis and vascular dementia. An Annual MDS (Minimum Data Set) Assessment, completed on 9/25/22, indicated she needed supervision and set up assistance with eating and that she weighed 113 pounds. She had not had weight loss. A Quarterly MDS Assessment, completed on 12/26/22, indicated she needed limited assistance of 1 person with eating and that she weighed 103 pounds. She had lost a significant amount of weight and was not on a physician prescribed weight loss regimen. She was severely cognitively impaired. A care plan, last revised on 12/26/22, indicated Resident 35 had a nutritional problem and had a significant weight loss with a BMI (Body Mass Index) less than 22. The goal was for her to maintain adequate nutritional status as evidenced by…

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 follow the appropriate guidelines for tube feedings per facility policy by not labeling tube feeding bags as required, not capping a tube feeding properly when not in use, and not administering the tube feeding as ordered for 1 of 1 residents with tube feedings. (Resident 20) Findings include: The clinical record for Resident 20 was reviewed on 3/23/23 at 1:57 p.m. Resident 20's diagnoses included, but not limited to, Parkinson's disease, dementia, dysphagia (difficulty with eating/swallowing), stage IV pressure ulcer, and moderate protein-calorie malnutrition. An observation of Resident 20 was made on 3/22/23 at 9:43 a.m. Resident 20 was lying in her bed and had her tube feeding running. The tube feeding bag nor the water flush bag contained a label indicating the contents of each bag, the resident's name, the date and time of administration, nor the initials of the nurse who prepped the feed. A 60 ml (milliliter) syringe was dated 3/21/23 was on the bedside table in its opened package. An observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to assess a location of a resident's pain, and develop and implement non-pharmacological interventions to address a resident's pain for 1 of 3 residents reviewed for pain. (Resident 88) Findings include: The clinical record for Resident 88 was reviewed on 3/21/23 at 11:40 a.m. Diagnosis included, but was not limited to, chronic pain, skin changes, and heart disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 88 was cognitively intact. A physician order dated 1/30/23 indicated Resident 88 was to receive 2 tablets of 325 milligrams of Tylenol every 4 hours for pain as needed. The March 2023 Medication Administration Record indicated Resident 88 had received the two tablets of Tylenol as needed utilizing a pain scale of 1 being the least amount of pain to 10 being the most amount pain on the following days: 3/12/23 - pain level 3 - no documented pain location - documented as follow up pain level of a 2, 3/15/23 - pain…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure location for 1 of 5 medication carts reviewed. Findings include: An observation was conducted of 1 of 2 medication carts on [NAME] Commons on 3/21/23 at 10:35 a.m. There were 4 medication cards containing Coumadin (blood thinning medication) for Resident 73 located within the narcotic log binder on the medication cart. An observation conducted on 3/21/23 at 11:22 a.m., still noted the 4 medication cards within the narcotic log binder for Resident 73. An interview conducted with Unit Coordinator 2, on 3/22/23 at 10:45 a.m., indicated she was organizing the medication cart and realized that Resident 73 no longer took Coumadin and she removed such from the medication cart. A policy titled Medication Storage Policy, revised November 2017, was provided by the Director of Nursing on 3/24/23 at 8:48 a.m. The policy indicated the following, .Policy .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/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 observation, interview, and record review, the facility failed to timely follow up on a dental recommendation for 1 of 1 resident reviewed for dental services (Resident 73). Findings include: The clinical record for Resident 73 was reviewed on 3/21/23 at 3:29 p.m. The Resident's diagnosis included, but were not limited to, cerebrovascular disease and heart failure. A Quarterly MDS (Minimum Data Set) Assessment, completed 1/24/23, indicated she was cognitively intact. During an interview on 3/21/23 at 3:29 p.m., Resident 73 indicated she had a broken tooth and that it had been broken quite a while. She pointed to her right front tooth, which had a chip at the bottom of the tooth. She would like to have it fixed because she did not like how it looked. She had seen the dentist since chipping her tooth, but it had not been fixed yet. On 3/23/23 at 10:43 a.m., the Director of Nursing provided a dental consult report dated 9/30/22, which indicated that Resident 73 had her natural upper and lower teeth. Tooth # 8 presented with a chip which was to be restored. The recommendations…

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.