Westside Retirement Village

Based on interview and record review, the facility failed to ensure behavior monitoring and documentation in the medical record to support rationales for denying gradual dose reductions (GDR) for antipsychotic and antidepressant medications for 2 of 5 residents reviewed for unnecessary medications (Resident 81 and 2). Findings include:1. On 3/3/26 at 10:37 a.m. Resident 81's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, dementia, major depressive disorder, and psychotic disorder. A pharmacy review was done on 7/14/25 indicating Resident 81 had Zyprexa (an atypical antipsychotic medication) 2.5 milligrams (mg) at bedtime ordered. The recommendation was to Gradual Dose Reduction (GDR) (a required process in nursing homes to taper psychotropic or antipsychotic medications to the lowest effective dose, thereby minimizing side effects.) the medication with the goal being to discontinue the medication. The recommendation was denied. The Nurse Practitioner (NP)'s reason for denying the recommendation was, Resident 81 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.

Based on observation, record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 3 of 19 residents' MDS assessments reviewed (Residents 15, 12, and 3). Findings include:1. During an observation, on 3/2/26 at 12:17 p.m., Resident 15 was observed with no natural teeth (edentulous). Resident 15's record was reviewed on 3/4/26 at 1:40 p.m. An annual MDS assessment, dated 1/16/26, indicated the resident had no oral/dental issues, including being edentulous. During an interview, on 3/5/26 at 3:17 p.m., the Corporate Nurse indicated Resident 15 was edentulous, and the MDS assessment should have been coded accordingly. The facility used the Resident Assessment Instrument (RAI) manual and did not have a separate policy for MDS assessments. The Centers for Medicare and Medicaid Services (CMS) MDS RAI Manual, version 3.0, dated October 2025, indicated, .Section L: Oral/Dental Status. Intent: This item is intended to record any dental problems present in the 7-day look-back period. Check L0200B, no natural teeth or tooth fragment(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 interviews and record reviews, the facility failed to ensure a new Preadmission Screening and Resident Review (PASRR) level one was completed after a new major mental illness diagnoses was added to the diagnoses lists for 2 of 2 residents reviewed for PASRR compliance (Resident 81 and 2). Findings include:1. On 3/3/26 at 10:37 a.m. Resident 81's medical record was reviewed. She was a long-term care resident whose diagnoses included, but were not limited to, dementia, major depressive disorder, and psychotic disorder. On 5/12/25 Resident 81's medical chart was updated to add psychotic disorder as a new diagnosis. The record lacked documentation of the facility submitting a new level one PASRR to include the new diagnosis added to her medical record. On 3/4/26 at 12:13 p.m. the Executive Director (ED) indicated the most current PASRR level 1 was completed on 3/19/25, so the new psychotic disorder diagnosis added on 5/12/25 would not have been on that level one. 2. On 3/3/26 at 10:37 a.m. Resident 2's medical record was reviewed. She was a long-term care resident whose…

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 activities of daily living (ADL) care was provided to residents who required assistance to maintain their personal hygiene for 2 of 28 residents reviewed for ADLs (Residents 6 and 15). Findings include:1. During an observation, on 3/2/26 at 10:45 a.m., Resident 6 was lying in bed. Resident 6 had untrimmed facial hair around her mouth, and the fingernails on her left hand were long and untrimmed with dark debris underneath them. During an observation, on 3/3/26 at 11:28 a.m., Resident 6 was lying in bed. The resident had untrimmed facial hair around her mouth. The resident's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. During an observation, on 3/3/26 at 2:05 p.m., Resident 6 was lying in bed. The resident had untrimmed facial hair around her mouth. The resident's fingernails, on both hands, were long and untrimmed, with dark debris underneath them. During an observation, on 3/4/26 at 1:17 p.m., Resident 6 was lying in bed. The resident had untrimmed facial hair…

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 maintain a functional resident call system for 1 of 1 resident reviewed for call light concerns (Resident 7). Findings include:On at 3/2/26 at 10:11 a.m., Resident 7 called out repeatedly for help. Her call light was not illuminated. During an interview on 3/2/26 at 10:13 a.m., Resident 7 indicated her call light had not been working for months. Resident 7 pressed her call button, but the light did not illuminate outside of her room. On 3/2/26 10:32 a.m., the Maintenance Director began to work on repairing her call light. In the meantime, Resident 7 was provided a small hand-held bell. Additional observations throughout the survey period revealed missing hallway call light covers for multiple rooms which included, but were not limited to: 118, 117, 115, 114, 112, and 121, making call lights difficult to see if they were on or not. On 3/4/26 at 10:00 a.m., Resident 7's call light was illuminated and the alarm sounded. An unidentified passing nurse indicated, someone was in the room with Resident 7, but 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a physician's order by documenting fluid intakes for a resident on restricted fluid intake for 1 of 4 residents reviewed for quality of care. (Resident E) Findings include:The clinical record for Resident E was reviewed on 7/22/24 at 10:43 a.m. Diagnoses included cirrhosis of the liver, diastolic congestive heart failure, and obesity. The resident was admitted [DATE].An acute care hospital physician's discharge note, dated 3/27/25, indicated the resident had hepatic cirrhosis and chronic diastolic heart failure and to continue plan of fluid restriction. A current physician's order, dated 3/27/25, indicated the resident was to have a regular diet with thin liquids with a 1500 ml (milliliter) fluid restriction. A review of the residents clinical record lacked fluid intake documentation or a care plan regarding the fluid restriction. During an interview on 7/22/25 at 1:34 p.m., the ADON indicated the fluid restriction was viewed as a dietary…

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 keep a resident's call light in reach and to apply ordered oxygen for 1 of 4 residents reviewed for neglect. (Resident D)Findings include:During an interview on 7/21/25 at 11:33 a.m., Resident D was observed seated on the side of her bed. An oxygen concentrator was observed on the opposite side of the bed, out of reach of the resident. The resident indicated she had recently gotten dressed with the assistance of staff and had forgotten to put her oxygen back on. She reached for her call light to get staff assistance and the light was observed coiled on the floor next to the bed, out of reach of the resident. During an observation on 7/21/25 at 11:46 a.m., accompanied by the Administrator, the oxygen concentrator with the resident's nasal cannula was observed out of reach on the opposite side of the bed where the resident was seated. The Administrator handed the tubing to the resident who applied the oxygen and indicated staff should have reapplied the oxygen following care. The call light tubing was observed…

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 a clean, orderly shower room for resident use on 1 of 3 shower rooms observed for cleanliness. (100 hall) Findings include:During an observation of the 100 Hall shower room on 7/22/25 at 2:10 p.m., accompanied by the Assistant Director of Nursing (ADON), the following was observed: the floor had feces on the floor in three different areas outside the shower area. A used plastic bag, wet paper towels and a used nicotine patch were on the floor. The floor was visibly dirty throughout the room. There was a used nicotine patch stuck to the shower wall. Around the base of the shower area, where the wall and floor meet, there was a black substance. During an interview at the time of the observation, the ADON indicated the shower rooms should not be in this condition and was an unacceptable way to leave the shower room. During an interview on 7/22/25 at 2:21 p.m., the Lead Housekeeper indicated the room was unclean. The floors should be swept and mopped and all debris thrown away. The dark substance between the tiles on…

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 temperature and palatability of food served for 5 of 6 residents reviewed for food temperature (Residents C, D, E, F, and M). This had the potential to affect 89 of 89 residents who received food from the kitchen. Findings include: On 5/19/25 at 10:30 a.m., Resident E was observed lying in bed with a breakfast tray on an over the bed table in front of her with half a biscuit and a sausage patty left. The resident indicated, food served in her room was often cold, and staff would not reheat the food, citing no microwave as the reason. On 5/19/25 at 10:56 a.m., Resident F was observed lying in bed speaking with a visitor who was at bedside. The resident indicated he usually had no concern with the temperature of his food, but he did not always get the food he ordered. Resident F gestured to his menu selections from the day prior, and indicated he did not get the roasted chicken and broccoli, and the nursing staff would not contact the kitchen for a replacement. On 5/19/25 at 11:25 a.m., Resident D…

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 a safe, clean, and sanitary environment on 1 of 2 units (100) observed for cleanliness. Findings include: On 5/19/25 at 2:41 p.m., Resident C indicated his bathroom was not stocked with toilet paper or paper towels, the bathroom sink was loose and about to fall off the wall, the carpet had not been vacuumed or shampooed and was stained with unidentified dried substances, and his room surfaces had not been dusted leaving an accumulation of dust. He indicated he spilled his urinal almost daily on his bed or the carpet which made his room stink, but staff did not see his room concerns as a priority. Resident C gestured to paper debris and food on the floor throughout the room, to include nuts and a blue colored chocolate coated candy along the wall near the entry and indicated the mess had been on the floor for at least 2 weeks. On 5/19/25 at 4:00 p.m., Housekeeper 19 was observed sweeping and mopping on the front 100 unit hallway during the day. There were no other housekeepers observed on the remaining two 100 unit…

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 or document showers for 1 of 3 residents reviewed for bathing preferences (Resident D). Findings include: On 5/19/25 at 11:25 a.m., Resident D was observed sitting in a chair at bedside looking through shopping bags of new clothing her daughter had delivered. The resident indicated she was concerned that she had not had a shower since her admission to the facility on 4/27/25. Resident D indicated before her admission to the facility, she would cover the dialysis port on her right upper chest with a product she picked up from a local pharmacy, and she showered without problems. Now nursing staff made the excuse every Tuesday and Thursday that they were working on getting her a physician's order for a dressing to cover her port, but that had not happened. Resident D indicated that she was supposed to be discharged within days so she supposedly would have to wait until she got home to shower herself. Resident D indicated that she had voiced to staff saying she could not take a shower without first…

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 grievances were followed up, an investigation completed, and grievances resolved for 3 of 3 residents reviewed for grievances (Residents B, C, and M), and 3 of 3 months reviewed for Resident Council (March, April, and May 2025). Findings include: Grievance logs, included: a. On 4/5/25, Resident M indicated the lunch and supper meals were cold, and the breakfast meals on the past two occasions of being cold had seemed frozen. The resolution was for audit and temperature checks, and to look into opening the 300-hallway kitchen. b. On 4/21/25, Resident B complained about having only one shower since her admission to the facility. The resolution was for staff to continue to offer showers and therapy to work on a lift with the resident. c. On 5/6/25, Resident C complained about his room not being cleaned, his bathroom floor having not been mopped, the trash emptied, or his urinal emptied. The resolution was for the housekeeping staff to go into the room twice daily for cleaning and restocking needs. On 5/14/25, 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 residents who wanted to register to vote were registered and the residents who were registered to vote were able to vote for 5 of 5 residents who wanted to vote in the 2024 Presidential Election (Residents B, C, D, E, and F). Findings include: During an interview, on 1/10/25 at 9:28 a.m., Resident B indicated his democratic right was violated because he was not registered and wanted to vote. During an interview, on 1/10/25 at 8:47 a.m., Resident E indicated he wanted to vote but did not get his absentee ballot. During an interview, on 1/10/25 at 8:56 a.m., Resident F indicated she wanted to vote, but no one got her up. During an interview, on 1/10/25 at 9:00 a.m., Resident D indicated she wanted to vote. They were supposed to come to the facility and did not. During an interview, on 1/10/25 at 9:01 a.m., Resident C indicated he wanted to vote. He signed the papers, but they did not come back or provide an absentee ballot. During an interview, on 1/10/25 at 9:02 a.m., the Activity Director (AD)…

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 reviews, the facility failed to ensure a timely and appropriate response to grievances related to answering call lights in a timely manner. This deficient practice had the potential to affect 11 of 11 residents who spoke on behalf of the facility during a resident council meeting. Findings include: On 1/13/25 at 11:05 a.m., copies of the resident council meeting minutes from July 2024 to November 2024 were reviewed. A resident council meeting minutes form, dated 7/24/24 at 2:00 p.m., indicated residents had to wait 1 to 2 hours sometimes for their call light to be answered and it was worse at night. A resident council follow-up form, dated 7/25/24, indicated all staff were reeducated on the call light policy and procedure. A resident council meeting minutes form, dated 10/18/24 at 1:30 p.m., indicated call light response times were getting better but sometimes call lights were still not answered within a reasonable time frame especially on night shift and weekend shifts. A resident council follow-up form, dated 10/18/24, indicated all…

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 clean and homelike environment was maintained in the main dining room of the memory care unit when remnants of feces were not cleaned up after a resident's incontinent episode, which had the potential to effect 22 of 22 residents who resided on the memory care unit , and the facility failed to ensure the floors for 2 of 22 residents' rooms (Residents 193 and 6) were free from large areas of staining due to resident incontinent episodes. Findings include: 1. During an initial tour of the memory care unit on 1/8/25 at 10:26 a.m., an irregular shaped dried clump of brown debris was observed in the corner of the dining room near the double glass door to the patio. There was a small brown streak on the baseboard near the stain as well. There was a large irregular puddle-shaped stain on the floor in the same corner, it was a yellow color. On 1/10/25 at 9:41 a.m., the Floor Tech entered the unit with an industrial carpet cleaner and began to clean the dining room carpet. On 1/14/25 at 11:37 a.m., stains and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on observation, interview, and record review, the facility failed to ensure a resident, (Resident H) who had a history of falls received interventions to prevent a fall in which he sustained a nasal fracture for 1 of 8 residents reviewed for accidents. B. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when a resident, (Resident 193) who had exhibited behaviors of intrusive wandering, continued to intrusively wander into other residents' rooms and upset them for 1 of 8 residents reviewed for accidents. C. Based on observation, interview, and record review, the facility failed to ensure the Elopement binder was up to date that included four current residents (Residents 193, 89, 74 and 73) who were at risk for elopement for 4 of 8 residents reviewed for accidents. D. Based on observation, interview, and record review, the facility failed to prevent the potential for accidents when medications were left at bedside for two residents (Residents 1…

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 provide hand hygiene between residents and wear gloves when administering an ear drop to a resident (Resident 19) for 1 of 1 Qualified Medication Aide (QMA 21) observed. Findings include: On 1/14/25 at 8:25 a.m., medication administration observation was completed with QMA 21. She had already had a resident's medications in a cup and ready to administer. She went to administer the medications and came back to her medication cart. She did not perform hand hygiene before going to the next resident (Resident 20). She prepared his medications and administered his medications to him, came back to the medication cart and did not perform hand hygiene. She went to the next resident, Resident 25 and prepared his medications. She administered his medications and returned to the cart. She did not perform hand hygiene after administering his medications. Lastly, she prepared Resident 19's medications. She went to resident's room and administered the medications. She had ear drops to administer to the resident's left ear. She pushed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity when a Certified Nurse Aide (CNA) spoke harshly to a resident and the resident's room had pictures with insturctions hanging in public view (Resident 1) and when a resident (Resident 40) was not assisted to the restroom in a timely manner by two staff members who were available for 2 of 2 residents reviewed for dignity. Findings include: 1. During a continuous observation on 1/14/25 at 9:11 a.m. until 10:47 a.m., the following was observed. At 9:11 a.m., Resident 40 was observed as she sat at a table and finished her breakfast. She drank all of her juice, a cup of coffee and requested a second cup of coffee. When she finished her breakfast, she was not offered an opportunity to toilet after the meal and was assisted to an activity. At 10:00 a.m., Activity Assistant 29 began to gather residents for an activity and assisted Resident 40 to another table. At 10:08 a.m., Resident 40 said out loud, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had advanced directives or code statuses for 3 of 4 reviewed for advanced directives (Residents 250, 45, and B) . Findings include: 1. A record review was completed on [DATE] at 1:45 p.m. Resident 250 admitted to the facility on [DATE]. She had the following diagnosis which included but not limited to gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), age-related osteoporosis, and schizoaffective disorder. Upon initial review, her medical record lacked an order and a care plan to address her advanced directive wishes. Later, the Director of Nursing (DON) provided a copy of the resident's care plan indicating she had a care plan, and an order were entered for her advanced directive. The care plan was dated [DATE]. The DON indicated the advanced directive was not present until the documents were requested. The care plan, dated [DATE], indicated Resident had advanced directives cardio-pulmonary…

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 the Minimum Data Set (MDS) assessments were coded accurately for 2 of 18 residents reviewed for MDS (Residents 193 and 81). Findings include: 1. On 1/9/25 at 1:13 p.m., Resident 193 was observed on the secured memory care unit. She paced and wandered without purpose throughout the unit. She entered several other rooms that were not hers but walked back out. Staff attempted to redirect her, but Resident 193 continued to wander through the unit. On 1/10/25 at 9:07 a.m., Resident 193 was observed as she wandered, unnoticed, into another resident's room. The resident in her room, chased Resident 193 out and yelled, get out of my room! This is not your room, you don't belong in here! She raised her arm with a magazine in hand with a shooing gesture. Resident 193 walked back to the dining room and sat at a table. She indicated to a tablemate, she got mad at me. On 1/13/25 at 2:35 p.m., Resident 193 was observed as she wandered, without…

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 that accurate information was submitted on a Pre-admission Screen and Record Review (PASRR) Level I for 1 of 6 residents reviewed for PASRR, (Resident 68), and the facility failed to complete a new level I for a resident who admitted to the facility on a 30 day exclusion for pre-admission screening and resident review (PASARR) for 1 of 2 residents reviewed for PASARR (Resident 90). Findings include: 1. On [DATE] at 10:00 a.m., Resident 68 was observed in the secured memory care unit. She was pleasantly confused and engaged in a table activity. On [DATE] at 1:08 p.m., Resident 68's medical record was reviewed. She was a long-term care resident who resided on the secured memory care unit and had diagnoses which included, but were not limited to, psychotic disorder with delusions and unspecified dementia. A PASRR Level I, dated [DATE], indicated Resident 68 did not require a level II screen because she did not have a major mental…

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 reviewed and revised as needed with resident's updated interventions for 1 of 18 residents reviewed for care plan revisions, (Resident 14). Findings include: On 1/9/25 at 10:17 a.m., Resident 14's room was observed. There was a picture hung to the wall above her bed, which depicted the resident's left arms with a black splint in place. The picture had instructions to keep brace on at all times. Throughout the survey week, Resident 14 was not observed to wear any brace or splint. On 1/9/25 at 2:04 p.m., Resident 14's medical record was reviewed. She was a long-term care resident who resided on the secured memory care unit with a diagnosis of dementia. She had a comprehensive care plan 1/2/24 which indicated, she had an activities of daily living (ADL) self-care performance deficit related to her diagnoses. Interventions for her plan of care included but were not limited to, wear L [left] edema glove and L wrist orthotic at all times. Cover with bandage during bathing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's activities of daily living were completed for 1 of 8 residents reviewed for completed ADLs (Resident B). Findings include: On 1/9/25 at 11:38 p.m., Resident B's medical record was reviewed. He was admitted on [DATE]. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) (lung disease), diabetes mellitus (blood sugar disorder) with chronic kidney disease, acute and chronic respiratory failure with hypoxia (low oxygen levels), and obstructive sleep apnea (causes breathing to stop or be reduced during sleep). A care plan, dated 6/6/24, indicated Resident B was dependent on staff for meeting emotional, intellectual, physical, and social needs. A care plan, dated 5/24/24, indicated Resident B needed assistance with mobility and activities of daily living (ADL)s. On 1/08/25 at 12:10 p.m., Resident B's toenails were observed outside of his blanket. They were extremely long; the left…

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 with a gastrointestional tube had appropriate services and documentation for medications and nutrition for 1 of 1 residents reviewed for gastrointestinal tube (G-tube) (Resident 295). Findings include: On 1/9/25 at 9:35 a.m., Resident 295 was observed to have a G-tube, but the Resident indicated that the nurses do not use it for anything. During an interview on 1/9/25 at 10:16 a.m., Licensed Practical Nurse (LPN) 8 indicated nursing staff did not use Resident 295's G-tube for medications or feeding supplements. During an interview on 1/10/25 at 10:46 a.m., LPN 17 indicated she did not care for the Resident often, but she knew nursing staff did not use the G-tube for anything, and only followed orders to flush it. During an interview on 1/10/25 at 11:55 a.m., LPN 15 indicated she was newer to that hall but she had never had to use the Resident's G-tube for medications or feeding supplements. LPN 15 indicated nursing staff…

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

Based on observation, interview, and record review, the facility failed to ensure oxygen (O2) levels were set correctly for 2 of 2 residents using nasal cannulas (NC) (Resident Z and B), and the facility failed to ensure humidifier bottles for oxygen administration were changed at 7 day interval, and a bipap mask and tubing were protected from contamination for 1 of 2 residents reviewed for contamination of bipap masks and tubing when not in use (Resident B). Findings include: 1. On 1/10/25 at 12:33 p.m., Resident Z's record was reviewed. Her diagnoses included, but were not limited to, idiopathic peripheral autonomic neuropathy (nerve pain), diabetes mellitus (blood sugar disorder), edema (swelling) in both lower extremities, and another diagnosis, dated 1/7/25, of pneumonia. A new physician's order, dated 1/10/25, indicated 2 liters of oxygen per minute (lpm) as needed for shortness of breath. Staff may titrate (change) to keep oxygen saturations above 90%. A respiratory care plan, dated 12/19/24, indicated Resident Z would have no signs or symptoms of poor oxygen absorption. 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 record review and interview, the facility failed to obtain a blood pressure as indicated in an order prior to administration of a blood pressure medication for 1 of 4 residents reviewed (Resident 250). Findings include: On 1/10/25 at 12:36 p.m., a record review was completed for Resident 250. She had the following diagnosis which included but not limited to gastro-esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), age-related osteoporosis, and schizoaffective disorder. She had an order for prazosin HCL capsule 1 milligram (mg) by mouth at bedtime for prophylaxis. Hold if systolic blood pressure (SBP) was less than 100 or pulse less than 60. The order lacked instructions to obtain a blood pressure prior to administering the medication. During an interview with the Director of Nursing (DON) on 1/14/25 at 1:45 p.m., she indicated there should have been a blood pressure added to the order. A policy titled Administration of Medications was provided by the Regional Director of Clinical Services (RDCS) on 1/14/25 at 2:03 p.m. It indicated, .Right…

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 and interview, the facility failed to remove expired drugs from the population for 2 of 2 medication rooms observed (medication rooms [ROOM NUMBERS]). Findings include: On 1/13/25 at 9:52 a.m., medication room [ROOM NUMBER] was observed to have a bottle of lorazepam belonging to Resident 28 in the refrigerator. The bottle had his name written on it. The bottle was opened and there was no date to indicate when it was opened. In the 100-medication room, an opened bottle of aplisol (used to test for tuberculosis) was in the refrigerator. It had a date opened of 12/26/24. It had expired. In the 300-medication room, an opened bottle of chlorpactin 2mg/liter belonging to Resident 27. It was sent by the pharmacy on 12/26/24. In the expiration space 12/30/24 was written in. RN 5 brought the bottle in and stated the date opened was 12/30/24 and that it was not expired. The medication was good for 10 days in the refrigerator. That time had expired. A policy titled Storage and Expiration Dating 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 ensure a resident's wheelchair (WC) (Resident 14) was maintained in a safe operating condition with a broken brake and brake handle and a resident's WC's left arm did not slide inappropriately forward and back (Resident 1) for 2 of 16 wheelchair reviewed for proper working order Findings include: 1. On 1/8/25 at 11:02 a.m., Resident 1's wheelchair's left arm was observed to be broken. It was freely moving forward and backward. On 1/8/25 at 11:02 a.m., Resident 1 indicated the staff knew the wheelchair was broken. On 1/14/25 at 1216 p.m., Resident 1's wheelchair was observed to still be broken with the left arm moving too freely forward and backward. During an interview, on 1/14/25 at 12:16 p.m., the Regional Director of Clinical Services (RDCS) indicated Resident 1's wheelchair was already fixed. During an interview, on 1/14/25 at 12:17 p.m., Certified Occupational Therapy Assistant (COTA) 38 indicated the bolt under her wheelchair was completely broken in half. She indicated she emailed the wheelchair…

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

Based on record review and interview, the facility failed to ensure adequate supervision, monitoring, and interventions were implemented for a resident who had a diagnosis of dementia (chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life) and a history of aggressive behaviors for 1 of 6 residents reviewed for dementia (Resident BB), resulting in verbal and physical threats, and resident to resident altercations against his dementia diagnosed peers (Residents CC, F, DD, EE, and U). Findings include: The facility reported on the Indiana State Department of Health (ISDH) Survey Report System Resident BB being involved in 6 incidents: on 4/16/24 with Resident CC, on 5/4/24 with Resident F, on 5/30/24 with Resident CC, on 7/16/24 with Resident DD, on 9/8/24 with Resident EE, and on 11/4/24 with Resident U. Resident BB's medical record was reviewed on 11/6/24 at 1:06 p.m. The resident was admitted to the facility's memory care unit, on 11/10/23, with aggressive behaviors. Diagnoses included, but were…

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 and biologicals were labeled, stored, and destroyed properly for 4 of 5 medication carts utilized for medication storage on the 100 and 300 hallways. Findings include: On 1/4/24 at 12:03 p.m., during an observation of the 100 hallway medication cart 3 with Registered Nurse (RN) 5, the following was observed, a. Resident J had an opened bottle of Alphagan P eye drops (used to treat glaucoma) labeled 1 drop in both eyes twice daily, and no opened date. b. Resident J had an opened bottle of Dorzolamide -Timolol eye drops (used to treat glaucoma) labeled 1 drop in both eyes twice daily, and no opened date. c. Resident J had an opened bottle of Rocklatan 0.02% - 0.005% eye drops (used to treat glaucoma) labeled 1 drop in both eyes at bedtime, and no opened date. d. Resident L an opened bottle of Geri-Tuss (used to treat cough and chest congestion)100 milligram (mg) per 5 milliliter (ml) labeled to give 20 ml as needed (prn) for cough, and no opened date. e. Resident K had an opened bottle 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 ensure a resident was provided showers per the resident's choice for 1 of 3 residents reviewed for activities of daily living and showers (Resident (B). Findings include: During observation and interview on 8/15/24 at 10:00 a.m., Resident B was not receiving showers as scheduled. He was to have a shower on Mondays and Thursdays. On 8/16/24 at 9:30 a.m., the medical record for Resident B was reviewed. admission diagnosis included but were not limited to paraplegia (paralysis that occurs in the lower half of the body), complete acute neurologic 7/22/2023, dysphagia oropharyngeal phase (difficulty swallowing) 4/1/2024, muscle weakness 7/27/2023, dysphagia (difficulty speaking) 9/26/2023, neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles of the urinary system don't work together properly) 7/24/2023, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems) 4/3/2024. A quarterly Minimum Data Set (MDS) assessment,…

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 followed when providing catheter care to 1 of 2 residents reviewed for catheter care (Resident D). Findings include: During observation and interview on 8/15/24 at 11:25 a.m., Resident D was lying down in bed. He indicated he had a suprapubic catheter (a thin flexible tube that drains urine from the bladder by inserting it through a small incision in the lower abdomen and into the bladder), that was attached to a urinary drainage leg bag (a bag used to collect urine) attached to a catheter tube (a thin flexible tube that is inside the bladder to collect urine). The bag was attached to the leg with straps to hold it into place. The resident indicated the staff had disconnected it from the drainage bag and placed a leg bag on. The catheter bag was hanging onto the trash can next to the bed. The uncapped tubing was inside of the trash can. The resident indicated he had placed it there. He indicated the staff did not clean the bag tip with alcohol pad prior to connecting…

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 address grievances in a manner which could be tracked for 5 of 5 months reviewed for grievance resolutions for the Resident Council meetings and the facility's grievance log for 4 of 4 residents reviewed for grievances (Residents E, K, Q, and R). Findings include: 1. On 6/20/24 at 2:50 p.m., the Resident Council minutes were provided by the Director of Nursing (DON) and she indicated if the Resident Council brought up a concern in the meeting, staff had advised the Activity Director (AD) to complete a blue grievance card for each concern brought up in the meeting and distribute the blue cards to the appropriate department manager and Executive Director (ED). When the blue card was filled out, the department manager completed the investigation steps to follow up on the concern and a copy was submitted to the ED. The Resident Council minutes indicated the following concerns by the Resident Council without a response from the facility of grievance resolutions: a. Residents not receiving scheduled showers b. Call lights taking…

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, record review, and interview, the facility failed to revise care plans for 2 of 6 residents reviewed for care plan revision (Residents GG and H). Findings include: 1. On 4/16/24 at 3:00 p.m., Resident GG was observed for wound care. The wound care nurse and wound care physician were completing wound rounds with the resident. Resident GG was observed to have an unstageable (full thickness tissue loss where the depth of the wound is completely obscured by eschar or dead tissue in the wound bed) pressure ulcer to her right ischium, a brief rash to her left buttock, and unstageable deep tissue injury (DTI -purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue) to her left and right heel. The left and right heel was observed for the first time during the wound rounds on 4/16/24. On 4/17/24 at 10:30 a.m., a comprehensive record review was completed for Resident GG. She had the following diagnoses which included but were not limited to heart failure,…

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, record review, and interview, the facility failed to ensure effective wound management for a resident admitted with an open area on the coccyx that worsened resulting in a stage 3 pressure ulcer (full thickness tissue loss - subcutaneous fat may be visible, and slough may be present) to the coccyx for 1 of 3 residents reviewed for pressure ulcers (Resident H). Findings include: On 4/15/24 at 11:45 a.m., Resident H's responsible party indicated they were not happy with the care and services the resident was receiving after having recently been admitted to the facility for rehabilitative services related to a fall before admission at another facility. There had been a delay in starting rehabilitative services, Resident H was being left in the bed, and at times the resident's room smelled of urine. Last evening when the family arrived around 5:00 p.m., they found the resident still in a gown and lying flat in bed, and questioned how was she going to get better if left in bed. The 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 observation, interview, and record review, the facility failed to ensure timely meal service, failed to maintain food temperatures before serving meals to residents, and failed to provide appealing meals per resident preference and repeated complaints. This deficient practice had the potential to effect 102 of 102 residents who were served from the kitchen. Findings include: 1. During the initial pool sample selection of the survey, the majority of residents interviewed complained about the food. The residents' general consensus was that meals were served late, the food was cold, they were not allowed to be warmed up, and the food looked and tasted awful. On 11/27/23 at 12:23 p.m., a lunch observation was conducted. An uncovered, uninsulated metal rolling rack was pushed from the service hall into the lobby. The Business Office Manager was noted to hold the door open as [NAME] 4 went to get a second tray. A cold breeze was felt as it drafted from the service hall and past the rack of food. At 12:30 p.m., the lunch rack was delivered to Memory Care. Four lunch trays were…

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

A. Based on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a general state of cleanliness, failed to ensure proper label/dating of foods, failed to remove expired items from rotation, failed to ensure hair restraints were in use during food preparation and failed to cover foods during meal preparation to prevent the potential for contamination. This deficient practice had the potential to effect 102 of 102 residents who were served from the kitchen. B. Based on observations and interviews, the facility failed to ensure staff utilized hand hygiene during meal service for 2 of 2 dining observations observed in Memory Care (Residents G, MM, NN, U, and P) Findings include: A1. On 11/27/23 at 9:46 a.m., in initial kitchen tour was delayed when the Executive Director (ED) requested the tour not to be conducted until the cook arrived. The ED indicated there was no kitchen manager but [NAME] 4 was filling in and on his way. She indicated [NAME] 55 could assist until [NAME] 4 arrived. Cook 55 arrived back from delivering breakfast…

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 essential kitchen equipment was maintained in good and working condition to prevent the potential for accidents. This deficient practice had the potential to effect 102 of 102 residents who were served from the kitchen. Findings include: 1. On 11/27/23 [NAME] 55 arrived back from delivering breakfast trays at 9:55 a.m., and an initial kitchen tour was conducted. There was a two-compartment standing Hot-Box next to the stove. The box was observed on, and leaking water from the back. The water dripped down over electrical cords and coils and created a standing puddle of water in front and under the stove. [NAME] 55 indicated it been in use but broke over the weekend and she was not sure why it was leaking. On 11/27/23 at 10:10 a.m., [NAME] 4 arrived. When asked about the puddle of water underneath the stove, [NAME] 4 indicated it was from the leaking hot box. The hot box broke over the weekend and it needed to be fixed and he had put a maintenance request in the day before. A copy of the maintenance…

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 that Resident Council Grievances were followed up on and failed to ensure effective resolutions were achieved for 12 of 102 residents who attended a resident council meeting (Residents D, E, F, AA, BB, CC, DD, EE, FF, GG, HH and JJ). Findings include: 1. On 11/30/23 at 9:00 a.m., the Resident Council Minutes and Responses were reviewed and revealed the following: On 1/17/23- 12 residents were present. The minutes from the previous meeting were read, but not accepted. New business included, but was not limited to: Nursing- Night shift will not change you when you need them to, turn off light, don't come back. Night shift will not answer call lights. Dietary- Food is cold. Housekeeping: lots of clothes still missing. There were not Grievance Responses for this resident council meeting. On 3/14/23- 13 residents were present. New business included, but was not limited to: Nursing: CNAs will not change us when we need it and come in and turned light off. Dietary: The food is always cold and served the same…

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 Memory Care (MC) resident rooms and bathrooms were kept clean, toilets were safe to use without risk of falling, and failed to ensure all walls were intact for 18 of 24 MC resident rooms (Resident B, G, H, J, K, L, M, N, O, P, Q, R, S, T, U, V, and W). Based on observation, interview, the facility failed to keep the 100 Hall shower area warm enough for residents to use and the 300 Hall shower area was in disrepair, cluttered, and dirty for 2 of 3 hallway showers observed (Residents D, E, F, AA, CC, DD, EE, FF, GG, HH, and JJ). Findings include: 1a. On 11/27/23 at 10:01 a.m., Resident G's and Resident H's toilet was observed to be loose. The bathroom floor was not swept, had ground in dirt around the perimeter of the floor, and the bathroom floor was cracked. It was not homelike. 1b. On 11/28/23 09:40 a.m., Resident G's and Resident H's toilet was observed to be loose. The bathroom floor was not swept, had ground in dirt around the perimeter of the floor, and the bathroom floor was cracked. It was 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 code the Minimum Data Set (MDS) with accurate information pertaining to PASRR (Pre-admission Screening and Resident Review) (an assessment for screening for possible serious mental illness or intellectual disabilities) (Resident 2, E, 38, 21, EE and FF) and failed to accurately code a resident (Resident O) for a hospital discharge for 7 of 7 residents reviewed. Findings include: 1. A comprehensive record review was completed for Resident 2 on 11/27/23 at 2:45 p.m. She had the following diagnoses which included but were not limited to paranoid schizophrenia, intellectual disability, unspecified dementia, asthma and muscle weakness. She had a level II (indicating there is mental illness and/or intellectual disability) dated 8/10/18. Her MDS, dated [DATE], section A1500 was coded with a 0 indicating she did not have a level II. 2. A comprehensive record review was completed for Resident E on 11/28/23 at 4:22 p.m. She had the following 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 record review and interview, the facility failed to care plan advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for 13 of 15 residents reviewed for care plans (Resident B, 83, L, Z, 38, 18, 43, P, 4, 87, 48, 256 and 74), end of life care/hospice services for 1 of 15 residents reviewed for care plans (Resident 13), and failed to address a resident's care plan for unnecessary medications for Resident P for 15 of 15 residents reviewed for comprehensive care planning. Findings include: 1 a. A record review was completed for Resident 38 on 11/28/23 at 2:24 p.m. She had the following diagnoses which included but were not limited to bipolar disease, anxiety disorder, obstructive sleep apnea, difficulty breathing, hypertension, and heart failure. Her comprehensive care plan lacked addressing her wish for do not resuscitate (DNR). b. 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 provide range of motion to maintain a resident's range of motion for 3 of 4 residents reviewed (Resident 18, 73 and FF). Findings include: 1. A comprehensive record review was completed on 11/28/23 at 1:45 p.m. Resident 18 had the following diagnoses which included but were not limited to hypertension, benign prostatic hyperplasia, constipation, hyperlipidemia, cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit. His care plan lacked to address passive or active range of motion to prevent further decline in mobility and functioning. During multiple observations of Resident 18, he was always in bed. During an interview on 12/1/23 at 4:00 p.m., he indicated he preferred to stay in bed. He did not get out of bed to take showers. He preferred bed baths. 2. A comprehensive record review was completed for Resident 73 on 11/29/23 at 2:00 p.m. He had the following diagnoses which included but were not limited to paraplegia, constipation, GERD (gastro-esophageal reflux…

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 sufficient staff were available to meet the needs and wants of the residents and failed to ensure call lights were answered in a timely manner for 6 of 6 days of observation and for 14 of 14 residents interviewed (Residents OO, PP, Z, AA, DD, D, E, BB, CC, EE, FF, GG, HH, and JJ). Findings include: During an interview on 11/27/23 at 11:38 a.m., Resident OO was observed in bed. She indicated, she hoped she would be assisted out of bed so she could go play bingo, but since she required the use a Hoyer lift and two staff members, she would probably not be able to get up since the aides would not have time to get to her. Resident OO indicated she had put her call light on earlier and was still waiting for help to get her brief changed. A smell of urine was noted, and she indicated she had not been changed since the night before. She thought her call light was still on, but upon observation it was not. She put her call light on and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure effective supervision and monitoring of residents with dementia (Residents 4 and 52) for 2 of 3 residents who were reviewed for Dementia care and services, and the facility failed to prevent intrusive wandering into peers' rooms by a resident with dementia for 1 of 3 residents who were reviewed for Dementia care and services (Resident 52). Findings include: 1. On 11/29/23 at 3:40 p.m., Resident 4's medical record was reviewed. He was a long-term care resident and had diagnoses which included but not limited to dementia (a progressive and degenerative brain disease which effects memory), heart disease, and muscle weakness. Resident 4 admitted to the facility on [DATE], into room on the 200 hall on the Memory Care Unit. He was subsequently moved four times until his discharge on [DATE]. A late nursing progress note created on 10/30/23 at 8:15 a.m., but made effective for 10/26/23 at 12:30 p.m., indicated Resident 4 had 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 observation and record review, the facility failed to date eye drops and insulin pens and failed to remove expired eye drops from the medication carts for 2 of 3 medication carts observed (Resident 11 and 22). Findings include: 1. On [DATE] at 1:27 p.m. the 100 hall medication cart 3 was observed to have eye drops belonging to Resident 11. There were 3 eye drops of his with no dates on the medications. a.) Refresh was undated. b.) Dorazalamide-Timolol was undated. c.) Alphagan 0.1% was undated. 2. On [DATE] at 1:45 p.m., the 100 hall medication cart 2 was observed to have eye drops belonging to Resident 11. The eye drops were expired. Rocklatan 0.05% were dated [DATE]. The manufacturers recommendation was to keep eye drops in the refrigerator at a temperature of 36 degrees Fahrenheit to 46 degrees Fahrenheit until the bottle was open. Once the bottle had been opened, the drug could be kept at room temperature for up to 6 weeks. There was a pen of Lantus insulin on the cart belonging to Resident 22. 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 glucometers (machines to take blood sugars) were cleaned between residents and in a manner to ensure the machines were disinfected for 4 of 5 observations of Accuchecks (Residents 62, 67, 80, and 94). Findings include: 1. During an observation on 11/30/23 at 11:55 a.m. Qualified Medication Aide (QMA) 16 collected supplies for Accuchecks (test to check blood sugar levels in blood) and placed them in a cardboard box. The glucometer was not observed to be cleaned prior to use. QMA 16 used the glucometer to perform an Accuchecks on Resident 62. All supplies were placed back into the cardboard box and QMA 16 left the resident's room. The glucometer was not cleaned after use. On 11/30/23 at 12:01 p.m., QMA 16 entered Resident 67's room with the Accuchecks supplies and glucometer. The glucometer was not cleaned prior to use. QMA 16 cleaned the resident's finger with an alcohol swab and fanned her finger with his hand to dry it. Then took the resident's Accuchecks. The glucometer was not cleaned after use. On…

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

Based on interview and record review, the facility failed to ensure residents had the opportunity to received influenza, pneumonia, and COVID-19 vaccinations for 5 of 5 residents reviewed for vaccinations (Resident Q, W, M, R, and N). Findings include: On 12/04/23 at 3:06 p.m., five residents were reviewed for their immunization status based on infection control standards. a. Resident Q's electronic chart indicated for her influenza vaccination; the immunization was requested. Her pneumonia vaccination showed an undated refusal. Her Covid-19 indicated a consent was required. b. Resident W's electronic chart indicated for his influenza vaccination; the immunization was requested. c. Resident M's electronic chart indicated for her influenza vaccination; the immunization was requested. Her pneumonia vaccination showed an undated refusal. Her Covid-19 indicated a consent was required. d. Resident R's electronic chart indicated for her influenza vaccination; the immunization was requested. Her pneumonia vaccination showed an undated refusal. Her Covid-19 indicated a consent was required.…

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 had the right to be treated with dignity for 4 of 5 residents reviewed for dignity (Residents 79, MM, 83, and R). Findings include: 1. On 11/27/23 on 12:47 p.m., Resident MM was heard requesting milk from the MC activity Assistant (MC AA) and was given water. On 11/27/23 at 12:50 p.m., Resident MM requested milk again, Licensed Practical Nurse (LPN) 5 told her he didn't know if they had milk. On 11/27/23 at 12:51 p.m., Resident MM raised her voice and requested milk again. LPN 5 and Certified Nursing Aide (CNA) 7 were in the MC dining room. They did not respond to her statement. On 11/27/23 at 12:52 p.m., CNA 7 asked Resident MM if she was ok, the resident indicated she wanted milk. CNA 7 did not provide milk, instead she began clearing lunch trays. On 11/27/23 at 12:54 p.m., Resident MM raised her voice and asked for milk again. LPN 5, CNA 7, and CNA 8 were observed in the dining room. No one addressed her or provided her milk. On 11/27/23 at 12:56 p.m., Resident MM asked CNA 7 for milk…

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 provide a resident shower twice a week for 1 of 1 resident reviewed for showers (Resident Y). Finding include: During a record review on 11/29/23 at 4:00 p.m., Resident Y had the following diagnoses which included but were not limited to hypertension, presence of a pacemaker, hypothyroidism, hyperlipidemia, GERD (gastro-esophageal reflux disease), anemia, osteoarthritis, and constipation. Resident had a BIMS (brief interview of mental status) of 15/15 which indicated she was cognitively intact. On 11/28/23 at 11:03 a.m., Resident Y was observed sitting in her chair in her room. She indicated she had not had a shower for 9 days. Prior to that it was 11 days. If the facility could provide her showers two times per week, she would be happy. Resident indicated her buttocks was hurting during the interview. On 11/30/23 at 3:27 p.m., Resident Y was observed sitting up in her chair in her room. She indicated she had a shower on 11/28/23. She had waited 9 days for a shower. On 12/1/23 at 9:39 a.m., Resident Y was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident's wound treatment was done as ordered and expired solution was not used on the resident's wound for 1 of 4 wounds reviewed (Resident Q). Findings include: On [DATE] at 1:33 p.m., Resident Q's record was reviewed. She was admitted on [DATE] with severe cognitive impairment. Her diagnoses included, but were not limited to, dementia (progressive, degenerative brain disorder), squamous cell carcinoma of the skin (disease caused by uncontrolled growth of abnormal cells), and diabetes mellitus (blood sugar disorder). On [DATE] at 1:33 p.m., a physician's order indicated to cleanse the bridge of the nose with normal saline, pat dry, then apply Betadine (antiseptic for skin disinfection) paint every day shift for wound healing. A skin care plan, revised on [DATE], indicated she was at risk for skin impairment related to squamous cell carcinoma (cancer that occurs on the outer most part of the skin) of the skin. The intervention…

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 reviews, observations and interviews, the facility failed to provide services to intervene and promote skin integrity for 1 of 3 residents reviewed for pressure ulcers (Resident 18). Findings include: A comprehensive record review was completed on 11/28/23 at 1:45 p.m. Resident 18 had the following diagnoses which included but not limited to hypertension, benign prostatic hyperplasia, constipation, hyperlipidemia, cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit. Resident 18 had a stage IV (full thickness tissue loss with muscle and/or bone visible) pressure ulcer to his sacrum and a stage 2 (partial thickness tissue loss) pressure ulcer to his right heel. Interventions included but were not limited to a low air loss mattress, heel protectors to both heels, turn every 2 hours, use a wedge to prop him to his side, and nutritional support. On a wall in Resident 18's room was a picture of the control panel of his low air loss mattress. The picture demonstrated the therapy mode set to alternating and comfort level set to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident, (Resident 4) received sufficient monitoring and interventions to prevent falls, failed to ensure a resident (Resident 256) was free from the potential for accidents related to his specialized diet orders, failed to ensure a resident (Resident 78) was free from the potential for accidents related to her fall interventions, and failed to prevent the potential for accidents for a Memory Care resident (Resident 86) who was found to have medication in her room for 4 of 4 residents reviewed for accidents. Findings include: 1. On 11/27/23 at 10:55 a.m., Resident 4 was initially observed in his room. He complained of pain in his side and back from a fall he sustained the previous day. No call before you fall, or other reminder signs to ask for assistance were noted in his room. During an interview on 11/29/23 at 1:52 p.m., Resident 4's family member indicated he had finally been sent to the hospital but had to be transferred to…

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

Based on interview and observation, the facility failed to ensure a resident's indwelling catheter bag and tubing did not contact the floor and failed to ensure residents were free from constipation for 2 of 5 residents reviewed for bowel and bladder (Resident Y and 18). Findings include: 1. A comprehensive record review was completed on 11/28/23 at 1:45 p.m. Resident 18 had the following diagnoses which included but not limited to hypertension, benign prostatic hyperplasia, constipation, hyperlipidemia, cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit. Resident 18 had an order, dated 7/21/23, for an indwelling catheter (suprapubic catheter). Resident 18 had an order, dated 7/21/23, for Miralax 17grams (used for constipation). Add 4-8 ounces of fluid and administer every 24 hours as needed for constipation. During an observation and interview on 11/28/23 at 11:00 a.m., Resident 17 indicated the powder they mix in water did not help him have bowel movements (BM). He indicated he did not get out of bed and would have bowel movements in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure resident's did not have significant weight loss and interventions were implemented to prevent further weight loss for 2 of 4 resident's reviewed for weight loss (Resident 34 and 53). Findings include: 1. A comprehensive record review was completed on 11/30/23 at 9:15 a.m. for Resident 34. She had the following diagnoses which included but were not limited to moderate protein-calorie malnutrition, right sided weakness, chronic kidney disease, hypothyroidism, type 2 diabetes mellitus, insomnia, gastro-esophageal reflux disease (GERD), osteoarthritis, generalized anxiety disorder, and insomnia. Resident 34 had the following weights: a.) 11/13/23: 117.0 b.) 10/9/23: 122.2 c.) 9/1/23: 130.0 d.) 8/3/23: 132.1 e.) 7/5/23: 134.0 f.) 6/6/23: 134.3 g.) 5/2/23: 135.0 Resident 34 lost 18 pounds in a 6-month period. She lost 13% of her body weight in 6 months. On 9/29/23 at 4:22 p.m., the Interdisciplinary Team met to discuss resident's care…

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

Based on observation, interview, and record review, the facility failed to date a peripherally inserted central catheter (PICC) dressing and failed to date intravenous (IV) tubing for 1 of 1 resident reviewed for IVs (Resident 18). Findings include: A record review was completed on 11/28/23 at 1:45 p.m. Resident 18 had the following diagnoses which included but not limited to hypertension, benign prostatic hyperplasia, constipation, hyperlipidemia, cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit. Resident 18 had an order, dated 11/22/23, to change his PICC dressing every Sunday and to measure his arm circumference (10cm above the antecubital), measure external catheter length, and notify the physician if length changed since last measurement. He had an order, dated 11/22/23, to change the dressing as needed for concern of line movement or infection. He had an order, dated 11/22/23, to change the IV administration tubing every 24 hours. During an observation on 11/27/23 at 11:00 a.m., Resident 18 had a PICC line to his right upper arm.…

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 (Resident 4) was treated for pain after a fall from which he sustained several rib fractures and the facility failed to ensure a resident (Resident P) was given effective interventions for pain after a fall from which she sustained a fractured wrist for 2 of 3 residents reviewed for pain. Findings include: 1. On 11/27/23 at 10:55 a.m., Resident 4 was initially observed in his room. He complained of pain in his side and back from a fall he sustained the previous day. He grimaced with movement and indicated it hurt very bad. A family member was in the room to check on him and indicated he had fallen out of his wheelchair the day before and has complained of pain ever since. On 11/28/23 at 9:30 a.m., Resident 4 was observed a second time. He continued to complain of pain on his right side and said it was worse than the day before and rated his pain a 9 out of 10. He complained of pain with any movement and was unable to eat…

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

Based on record review and interview, the facility failed to ensure blood glucose monitoring was obtained for a resident with diabetes mellitus with insulin to manage (Resident FF), failed to ensure a resident's medications had an appropriate diagnoses for use and an indication for medication use (Resident X), and failed to provide documentation pharmacy review of medications (Resident 4) for 3 of 5 residents reviewed for unnecessary medications. Findings include: 1.A comprehensive record review was completed for Resident FF on 11/27/23 at 2:45 p.m. He had the following diagnoses which included but were not limited to heart disease, type 2 diabetes mellitus, hypertension, bipolar disorder, neuropathy, contracture of left and right wrist, contracture of right knee, contracture of left and right ankle, and hyperlipidemia. Resident FF had an order, dated 6/10/23, for Basaglar Kwikpen subcutaneous solution pen-injector 100 unit/ml (insulin glargine) inject 12 units subcutaneously at bedtime related to type 2 diabetes mellitus without complications. Staff were to call the physician if…

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 provide diets and fluids according to residents' orders for 2 of 2 residents reviewed for diet orders (Residents 40 and 91). Findings include: 1. A comprehensive record review was completed for Resident 40 on 11/29/23 at 10:15 a.m. He had the following diagnoses which included but were not limited to hypertension, chronic pain, obstructive uropathy, peripheral vascular disease, and malignant neoplasm of prostate. Resident 40 had a diet order, dated 11/1/23, for a regular diet, mechanically altered texture, nectar mild consistency. During an observation on 11/27/23 at 1:30 p.m., Resident 40 was served a lunch tray with regular fluids. Staff removed the fluids from his tray and did not replace his fluids with nectar thickened liquids. Resident 40 was yelling out that he was choking and needed fluids. RN 17 was made aware that Resident 40 had no fluids. While waiting for fluids, Resident 40 attempted to take a spray bottle of water and squirt into his mouth. During an observation on 11/28/23 at 3:07 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 observation, interview, and record review, the facility failed to report allegations of abuse for 1 of 3 residents reviewed for abuse (Resident B). Findings include: During a confidential interview it was indicated that Resident B had been mishandled and mistreated by several nursing staff members. She often complained that staff were too rough with her and when family reviewed video footage of her care, they were shocked to see how rough and unkind the staff treated and spoke to her. A complaint was made to the Executive Director (ED), on 5/17/23, when a family member came into the building to formally request copies of the resident's medical record. At that time, the ED was shown screen shot pictures from the video footage of different staff members who had been seen mistreating Resident B, but the ED dismissed the concerns. The family member did not feel that the matter had been taken seriously. On 10/11/23 at 9:52 a.m., Resident B's family indicated Resident B would indicate, They [staff] would talk rudely, yell at her, thrust her legs on the bed after resident asked…

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 revise and follow care plans for 1 of 2 residents reviewed for care planning (Resident F). Findings include: On 10/10/23 at 10:30 a.m., Resident F was observed lying on her back in bed. She was alert and responded to questions asked of her. On 10/10/23 at 1:00 p.m., Resident F was observed lying on her back in bed. On 10/10/23 at 2:00 p.m., Resident F was observed lying on back in bed. On 10/10/23 at 2:15 p.m., Physician 10 and RN 11 entered room to provided wound care for Resident F. RN 11 indicated the mattress that Resident F was on alternates the pressure on resident's buttocks, therefore, she did not need to be turned side to side. When RN 11 questioned about signage in the resident's room hang on a cabinet referring to a turn schedule for Resident F, she indicated Resident F was not turned due to the type of mattress she was on, and she was unsure why the signage was hanging up in the room. RN 11 indicated Resident F did not to lie on her sides and she will cry out when turned to her side. RN 11…

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 accidents when the secured memory care doors were not adequately monitored during a malfunction which unlocked the secured door, and a resident was able to exit two separate doors and was later found walking in the parking lot for 1 of 3 residents reviewed for elopement (Resident D). Findings include: On 10/4/23 the facility reported, Resident D had been able to exit the secured memory care unit. Upon their investigation it was discovered that the magnetic lock door had malfunctioned and been unlocked for an unspecified amount of time. On 10/11/23 at 10:05 a.m., Resident D was observed in the secured memory care unit, in his room. He sat on the edge of the bed and worked on a large coloring picture. On 10/11/23 from 11:35 a.m. until 12:15 p.m., Resident D was observed. He independently walked from his room into the main dining room where he retrieved a broom and dustpan. He returned to his room and swept up colored-pencil shavings. He returned the broom and dustpan. He returned 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 and interviews the facility failed to ensure a resident had their call light within reach for 1 of 1 resident reviewed (Resident F). Findings include: On 10/10/23 at 10:30 a.m., Resident F was observed lying on her back in bed. She was alert and responded to questions asked of her. She was unable to move her arms. When asked if she could reach the tube, she nodded her head in a side-to-side motion indicating no. She had a mouthpiece call light. This type of call light worked by the resident blowing air into a tube. The call light was on her left side and out of reach of her mouth. On 10/10/23 at 1:00 p.m., Resident F was observed lying on her back in bed. Her mouthpiece call light was on the left side of her bed and out of reach of her mouth. On 10/10/23 at 2:00 p.m., Resident F was observed lying on back in bed. Her mouthpiece call light was on the left side of her bed and out of reach of her mouth. On 10/10/23 at 2:00 p.m. during an interview with a family member, she indicated Resident F never had her call light within reach. On 10/11/23 at 10:00 a.m., 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.