Brickyard Healthcare - Laporte Care Center

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had physician's orders to self-administer for 4 of 4 residents reviewed for self-administration of medication. (Residents 44, 52, 20 and 8) Findings include: 1. On 4/1/25 at 9:44 a.m., 1:09 p.m. and 3:50 p.m., a bag of Mucinex throat lozenges was observed in a plastic bin on Resident 44's overbed table. On 4/2/25 at 1:50 p.m., the bag of throat lozenges remained on the resident's overbed table. The record for Resident 44 was reviewed on 4/3/25 at 2:05 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The 3/12/25 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact. The April 2025 Physician's Order Summary (POS) indicated the resident may self-administer her nebulizer treatment and oral medications once prepared by the licensed nurse/QMA. Medications may be left with me to self-administer as long as I am in the room. There…

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 maintain a resident's dignity related to wearing a hospital gown during the day and not consistently offering pleasure food for 1 of 1 resident reviewed for dignity. (Resident 17) Finding includes: During a random observation on 3/31/25 at 11:21 a.m., Resident 17 was observed in bed wearing a hospital gown. At that time, an enteral tube feeding was infusing into the peg tube (a tube inserted directly into the stomach for nutrition). The resident's roommate was seated in a chair in the room as well. At 11:25 a.m., the roommate received her lunch meal and proceeded to eat in the room. Resident 17 did not receive a tray and was not offered anything to eat. On 3/31/23 at 3:22 p.m., the resident was observed in bed still wearing a hospital gown. During an interview at that time, the resident indicated she did not receive anything to eat for lunch, and sometimes they would bring a pudding for me to eat. During random observations on 4/1/25 at…

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

Based on record review and interview, the facility failed to file a grievance form, thoroughly investigate, and resolve grievances related to a resident representative's complaints for 1 of 1 resident reviewed for grievances. (Resident B) Finding includes: The closed record for Resident B was reviewed on 4/3/25 at 10:43 a.m. Diagnoses included but were not limited to, diabetes, sacral (tailbone area) pressure ulcer, cancer of the large intestine, and dementia. The 1/29/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making, and required maximum assistance with ADLs (activities of daily living) and transfers. A Social Services Note, dated 3/3/25, indicated during a meeting with the SSD (Social Services Director), nursing, wound care, and the Administrator, the resident's representative had concerns about the resident's care and made multiple accusations. There was no documentation of the specific concerns, investigation or resolution. A grievance form was not initiated. A Social Services Note, dated 3/6/25, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure activities of daily living (ADLs) were completed for dependent residents related to shaving and washing hair for 3 of 8 residents reviewed for ADLs. (Residents 17, 37, and 63) Findings include: 1. During random observations on 3/31/25 at 11:21 a.m. and 3:22 p.m., Resident 17 was observed in bed wearing a hospital gown. At that time, she had a moderate amount of facial hair on her chin. During random observations on 4/1/25 at 8:58 a.m., 1:10 p.m. and 2:30 p.m., the resident was observed in bed wearing a hospital gown and had a moderate amount of facial hair on her chin. During random observations on 4/2/25 at 10:20 a.m., 11:26 a.m., 1:30 p.m. and 5:14 p.m., the resident was observed in bed wearing a hospital gown and had a moderate amount of facial hair on her chin. The record for Resident 17 was reviewed on 4/2/25 at 10:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, stroke,…

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 a resident with signs and symptoms of constipation was treated for 1 of 1 resident reviewed for constipation, and areas of discoloration, and edema were assessed and monitored for 1 of 2 residents reviewed for skin conditions non-pressure related and for 1 of 1 resident reviewed for edema. (Residents 63, 57, and 122) Findings include: 1. The record for Resident 63 was reviewed on 4/2/25 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory failure, anxiety, heart disease, osteoarthritis, and heart failure. The 12/24/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was never/rarely understood and was severely impaired for decision making. The resident was dependent on staff for ADL care and was always incontinent of bowel. A Care Plan, revised on 1/19/25, indicated the resident was at risk for constipation related to decreased…

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 a resident's toenails were cut, kept trimmed and podiatry care was provided for 1 of 1 resident reviewed for foot care. (Resident 63) Finding includes: During random observations on 3/31/25 at 11:25 a.m. and 4/1/25 at 8:59 a.m., Resident 63 was sitting up in a Broda chair. On 4/2/25 at 10:20 a.m., 11:30 a.m., and 5:20 p.m., the resident was observed reclined in a Broda chair. At those times, the resident was observed with very long toenails. On 4/3/25 at 9:32 a.m., QMA 1 and the Wound Nurse were in the room. At that time, they were both shown the resident's long toenails. During an interview on 4/3/25 at 9:55 a.m., the Wound Nurse indicated the resident received hospice care, so they would have to let hospice know the toenails needed to be trimmed. The record for Resident 63 was reviewed on 4/2/25 at 11:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute respiratory…

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 assistive devices were in place for a resident with a limited range of motion for 1 of 1 resident reviewed for positioning. (Resident 50) Finding includes: During random observations on 3/31/25 at 11:34 a.m. and 12:15 p.m., and on 4/1/125 at 11:32 a.m. and 1:12 p.m., Resident 50 was observed sitting in her wheelchair. At that time, her right arm was elevated on a small bed pillow. There was no arm tray observed on the wheelchair. The record for Resident 50 was reviewed on 4/1/125 at 2:10 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, stroke, right side hemiplegia (weakness or paralysis of one side of the body), vascular dementia, anxiety, high blood pressure, and osteoarthritis. The 2/10/25 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and had a limited range of motion impairment to one side for the upper extremity. A Care Plan, dated 12/13/24, indicated the resident had an ADL self-care performance deficit…

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 residents with a history of falls had preventions in place to prevent more falls/injuries related to a floor mat beside the bed and keeping the bed in the lowest position for 2 of 3 residents reviewed for falls. (Residents 37 and 63) Findings include: 1. During random observations on 4/1/25 at 9:00 a.m. and 2:30 p.m., and on 4/2/25 at 3:00 p.m., Resident 37 was observed in bed. At those times, the resident's bed was not in the lowest position. The record for Resident 37 was reviewed on 4/1/25 at 2:50 p.m. Diagnoses included, but were not limited to, Parkinson's disease, Alzheimer's disease, high blood pressure, delusions, osteoarthritis, depression, and acute kidney failure. The 3/3/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not alert and oriented and was dependent on staff transfers and bed mobility. The resident had no falls since the last assessment. A Care Plan, revised on 9/20/24, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 3 of 4 residents reviewed for nutrition. (Residents 14, 39, and 52) Findings include: 1. On 3/31/25 at 11:54 a.m., Resident 14 was seated in her room in her wheelchair. The resident was served noodles, meatballs, peas, and a fruit cup. The resident indicated she wanted nothing to eat. On 4/2/25 at 11:38 a.m., the resident was served grilled cheese and soup for lunch. She was not eating any of her meal. At 11:55 a.m., the resident was observed drinking her milk but not eating any food. The record for Resident 14 was reviewed on 4/1/25 at 1:12 p.m. Diagnoses included, but were not limited to, mild cognitive impairment, adult failure to thrive, and dysphagia (difficulty swallowing). The Significant Change Minimum Data Set (MDS) assessment, dated 1/13/25, indicated the resident had moderate cognitive impairment. The resident had sustained a weight loss…

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 the head of the bed was elevated to at least 45 degrees while a resident's enteral feeding was infusing into the peg tube (a tube inserted directly into the stomach for nutrition) for 1 of 1 resident reviewed for tube feeding. (Resident 17) Finding includes: During a random observation on 4/2/25 at 5:14 p.m., Resident 17 was observed lying completely flat in bed. The head of the bed was flat and not elevated to at least 45 degrees. At that time, the resident had an enteral tube feeding infusing at 55 cubic centimeters (cc) per hour. CNA 2 and RN 1 were immediately notified and asked to reposition the resident in bed. During an interview at that time, CNA 2 and RN 2 both indicated the resident played with the remote control and would lower the head of the bed all the time by herself. RN 1 indicated she had administered her medication at 4:10 p.m., and the head of the bed was elevated at that time. The record for Resident 17 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 assess and document a resident's pain in accordance with their care plan for 1 of 1 resident reviewed for pain management. (Resident 20) Finding includes: During an observation on 3/31/25 at 10:36 a.m., Resident 20 winced in pain when moving in bed. He indicated he had pain in his shoulder and hip daily rating 5-8 out of 10. He indicated all the facility was doing for his pain was giving him Tylenol and he did not know why. The resident's record was reviewed on 4/1/25 at 3:30 p.m. Diagnoses included but were not limited to, amputation of the left leg, COPD (chronic obstructive pulmonary disease), and acute respiratory failure with hypoxia (low oxygen levels). The 2/5/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily incision making, required partial assistance with ADLs (activities of daily living) and was independent with transfers. A Physician's Order, dated 12/22/24, indicated Biofreeze External Gel 4 % (a topical pain medication) to the left hip every 3…

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 a dialysis access site was assessed and monitored as ordered for 1 of 1 resident reviewed for dialysis. (Resident 39) Finding includes: The record for Resident 39 was reviewed on 4/2/25 at 9:57 a.m. Diagnoses included, but were not limited to, stroke, congestive heart failure, and dependence on renal dialysis. The Quarterly Minimum Data Set (MDS) assessment, dated 3/4/25, indicated the resident was moderately impaired for daily decision making and he was receiving dialysis. A Care Plan, dated 12/12/24 and reviewed on 2/14/25, indicated the resident had an alteration in kidney function evidenced by hemodialysis for end stage renal disease (ESRD). Interventions included, but were not limited to, monitor, document, and report as needed (PRN) signs and symptoms of infection to access site: redness, swelling, warmth or drainage. A Physician's Order, dated 5/31/24 and listed as current on the April 2025 Physician's Order Summary (POS), indicated the resident's arteriovenous (AV) fistula (a dialysis access site) to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure medications were not used for an excessive duration and an excessive dose for 1 of 1 resident reviewed for antibiotics and 1 of 5 residents reviewed for unnecessary medications. (Residents 44 and 63) Findings include: 1. The record for Resident 44 was reviewed on 4/3/25 at 2:05 p.m. Diagnoses included, but were not limited to, ESBL (extended-spectrum beta-lactamase), neurogenic bladder, sepsis, and urinary tract infection (UTI). The Significant Change Minimum Data Set (MDS) assessment, dated 3/12/25, indicated the resident was cognitively intact. She was dependent with toileting hygiene, always incontinent of bladder, and had received an antibiotic during the last 7 days. A Care Plan, dated 10/17/24 and reviewed on 3/26/25, indicated the resident was on antibiotic therapy related to a history of frequent UTI's. A Physician's Order, dated 10/15/24 and listed as current on the April 2025 Physician's Order Summary (POS), indicated the resident 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 medications were stored correctly for 1 of 7 residents observed during medication administration and 1 of 4 residents reviewed for self-administration of medications. (Residents 23 and 20) Findings include: 1. On 4/2/25 at 4:32 p.m., LPN 1 was observed preparing medications for Resident 23. When the LPN entered the resident's room, a medication cup containing two pills was left on top of the medication cart as well as a Tamsulosin (a medication used to relax the muscles of the bladder and prostate) tablet which was in it's original package. Upon entering the room, the LPN closed the door and the medication cart was out of her view. During an interview on 4/3/25 at 2:00 p.m., the Director of Nursing indicated the pills should not have been left on top of the medication cart. The current facility Medication Storage policy was provided by the Director of Nursing on 4/4/25 at 9:45 a.m. The policy indicated all drugs and biologicals would be stored in locked compartments (i.e., medication carts, cabinets,…

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 infection control practices were in place and implemented related to not donning personal protective equipment (PPE) for residents in enhanced barrier precautions (EBP) and not cleaning multi-use equipment during wound care for 1 of 1 resident with a tube feeding and for 1 of 1 resident with a pressure ulcer. (Residents 17 and 63 ) Findings include: 1. During a random observation on 4/2/25 at 5:14 p.m., Resident 17 was observed lying completely flat in bed. The head of the bed was flat and not elevated to at least 45 degrees. At that time, the resident had an enteral tube feeding infusing at 55 cubic centimeters (cc) per hour. CNA 2 and RN 1 were immediately notified and asked to reposition the resident in bed. CNA 2 and RN 1 both donned clean gloves to both hands and proceeded to reposition the resident in bed. The RN turned the tube feeding off and lifted up the resident's gown and disconnected the tube. At that time, 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 food was prepared and stored under sanitary conditions related to a greasy deep fryer, improper labeling of food, and dried spillage in refrigerators in 1 of 1 kitchens and 2 of 3 pantries throughout the facility. (The Main Kitchen, A and C wing pantries) Findings includes: 1. During the Brief Kitchen Sanitation Tour on 5/8/24 at 9:12 a.m. with the Dietary Food Manager, (DFM) the following was observed: a. The deep fryer was noted with many food crumbs and was greasy on both sides, with the grease extending to the side of the convection oven. During an interview at that time, the DFM indicated the deep fryer was cleaned weekly. 2. During an observation of the A-Wing pantry refrigerator on 5/9/24 at 9:10 a.m., there was a heavy accumulation of dried pink, orange, and red beverage spillage. The refrigerator housed the resident's food and other beverages. During an interview at that time, LPN 3 had no comment regarding the spillage. 3. During an observation of the C-Wing pantry refrigerator on 5/14/24 at…

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

Based on observation, record review, and interview, the facility failed to maintain an infection control program related to incomplete documentation of the infection control program, incomplete mapping of infections and lack of glove use during insulin administration during a medication pass for 1 of 8 residents observed during medication pass. (Resident 51 and LPN 1) Findings include: 1. The Infection Control Program was reviewed on 5/9/24 at 9:00 a.m. The January, February, March and April 2024 Infection Surveillance Data Collection Forms included the following: - resident's name and room number - infection type - infection onset date - antibiotic name - antibiotic start and stop date - comments The Infection Control Logs lacked any documentation of diagnostic lab or x-ray results or if criteria for a true infection were met. Five residents in March and ten residents in April lacked documentation of signs or symptoms associated with the infection. During an interview on 5/9/24 at 9:30 a.m. with the Infection Preventionist (IP), she indicated she did not include the infection…

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

Based on observation and interview, the facility failed to ensure a resident who required staff assistance for activities of daily living (ADLs) received necessary services related to having the ability to reach the call light when ADL care was needed, for 1 of 1 resident reviewed for accommodation of needs. (Resident 32) Finding includes: During an interview on 5/8/24 at 10:12 a.m., Resident 32 indicated he had waited over 30 minutes to get help off the stool and he could not reach the call light to get help. On 5/8/24 at 10:20 a.m., Resident 32 was observed having attempted to reach for the call light from his wheel chair, but the call light was not within reach. The resident smelled of feces and had attempted to get help from staff. On 5/8/24 at 10:28 a.m., the resident was observed with the Director of Nursing (DON). The resident was seated in his wheelchair and had attempted to reach the call light. The DON witnessed his attempt and realized the call light was not within reach. She then moved the resident's bed several inches, which allowed the resident to pass through 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 protect the residents' right to be free from misappropriation of medication related to a staff nurse using a resident's insulin pen for her personal use, for 1 of 1 resident reviewed for misappropriation of medication. (Resident 25) The deficient practice was corrected by 10/31/23, prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the misappropriation of medication, notified the police, placed the nurse on suspension while the investigation took place, the resident's insulin pen was removed from the medication cart and discarded, a new insulin pen was reordered for the resident to use, the facility provided inservices to the entire staff regarding the misappropriation of medication, and completed random observations on all shifts to ensure compliance of the policy was implemented correctly. The random observations were completed 5 times a week for 4 weeks, weekly for 4 weeks, and then weekly for 4 months. LPN 4 was guilty of misappropriation of medication and 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 provide ADL (activities of daily living) assistance to dependent residents related to nail care and the removal of facial hair, for 3 of 6 residents reviewed for ADL care. (Residents 23, 45, and 11) Findings include: 1. During random observations on 5/8/24 at 10:01 a.m. and 1:17 p.m., on 5/9/24 at 9:25 a.m., 11:55 a.m., and 1:08 p.m., and on 5/10/24 at 12:20 p.m., Resident 23 was observed in bed. At those times, the resident was unshaven. The record for Resident 23 was reviewed on 5/9/24 at 2:35 p.m., Diagnoses included, but were not limited to, dementia with behaviors, high blood pressure, heart disease, major depressive disorder, and anxiety. The 2/13/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and needed substantial/maximal assist with personal hygiene. A Care Plan, revised on 1/18/24, indicated the resident had a physical functioning /self care deficit related to weakness, impaired mobility, and impaired cognition. 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, record review, and interview, the facility failed to ensure an assessment was completed and devices were in place for a resident with limited range of motion for 1 of 1 resident reviewed for range of motion. (Resident 45) Finding includes: During random observations on 5/8/24 at 9:27 a.m. and 1:10 p.m., on 5/9/24 at 9:28 a.m., 11:55 a.m., and 1:06 p.m., and on 5/10/24 at 12:30 p.m., Resident 45 was observed sitting in a wheelchair. At those times, the resident was observed with her left hand clenched and lying against her chest. On 5/13/24 at 11:00 a.m., the Director of nursing assessed the resident's left hand and indicated with passive range of motion, the ring finger could be straightened out, however, the middle finger would only extend up to 75 degrees. She indicated at the time, Occupational Therapy would be completing an assessment of the hand. The record for Resident 45 was reviewed on 5/13/24 9:53 a.m. Diagnoses included, but were not limited to, Alzheimer's dementia, high blood pressure, depression , psychotic disorder, and traumatic subdural…

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 meal consumption was monitored for a resident with a history of weight loss and/or were at nutritional risk for 1 of 2 residents reviewed for nutrition. (Resident 51) Finding includes: The record for Resident 51 was reviewed on 5/9/24 at 11:00 a.m. Diagnoses included, but were not limited to, pneumonia, diabetes, anemia, acute pancreatitis, and anxiety. The 2/26/24 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making, had no oral problems and weighed 222 pounds with no significant weight loss. The resident needed setup or clean up assistance with eating. A Care Plan, dated 2/24/24, indicated the resident was at nutritional risk related to obesity, diabetes, and anemia. The approaches were to observe meal intakes. The resident weighed 204 pounds on 2/20/24 and 206 pounds on 3/6/24. A weight obtained on 4/12/24 indicated the resident weighed 189 pounds, which was an 8.25% weight loss in 30 days. Physician's Orders on the current 5/2024 Physician Order…

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

Based on record review and interview, the facility failed to ensure a newly hired CNA was certified past 120 days of employment for 1 of 44 employees reviewed for licensure and certification. (Employee 1) Finding includes: Review of the employee records was completed on 5/14/24 at 10:02 a.m. Employee 1 was hired on 1/10/24. Employee 1's 120th day of employment was on 5/8/24. The employee's time card was reviewed and indicated she had worked on the following days as a CNA after her 120 days of employment without certification: 5/9/24, 5/13/24, and 5/14/24. During an interview on 5/14/24 at 10:47 a.m., the Payroll Coordinator indicated she was unaware they had only 120 days to work, she thought it was 120 shifts. Employee 1 was working the floor as a CNA today on 5/14/24. 3.1-14(e)

Based on observation, record review, and interview, the facility failed to ensure clinical records were accurately documented related to weekly skin assessments and nutritional supplements for 1 of 1 residents reviewed for skin conditions and 1 of 2 residents reviewed for nutrition. (Residents 16 and 51) Findings include: 1. During a random observation on 5/8/24 at 9:36 a.m., Resident 16 was observed with many bloody and dried scabs all over his upper body including his arms and trunk. The record for Resident 16 was reviewed on 5/10/24 at 12:42 p.m. Diagnoses included, but were not limited to, pulmonary disease and fibrosis, type 1 diabetes, major depressive disorder, high blood pressure, heart disease, anxiety, and stroke. The Quarterly Minimum Data Set (MDS) assessment, dated 4/1/24, indicated the resident was cognitively intact for daily decision making and did receive applications of ointment other than the feet. The Care Plan, revised on 3/25/24, indicated the resident had altered skin integrity, non-pressure related to a rash to bilateral upper and lower extremities including…

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.