Creasy Springs Health Campus

Based on interview and record review, the facility failed to ensure medications were transcribed correctly upon admission for 1 of 2 residents reviewed for significant medication errors. (Resident B)Findings include: During an interview, on 9/29/25 at 12:37 p.m., Resident B's family member indicated, on 8/16/25, she witnessed a staff member attempting to administer her husband medication he had never received before. The staff member called the physician and did not administer the medication. A staff member informed her, on 8/18/25, Resident B had received the wrong medications on 8/15/25, 8/16/25, 8/17/25 and 8/18/25. The Director of Health Services (DHS) informed her the facility was monitoring Resident B for reactions related to receiving the wrong medications. Resident B's family was very upset with the nursing staff and was more distressed to see the same nurses still working and administering Resident B's medications. She had told the administration staff about her concerns, and nothing was done. Resident B was at home now and was doing okay. She wanted the facility to prevent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident with a diagnosis of dementia, who resided in the secured locked unit, was not allowed to leave the facility unsupervised for 1 of 1 resident reviewed for elopement. (Resident B) The deficient practice was corrected on 8/25/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:The clinical record for Resident B was reviewed on 9/8/25 at 2:58 p.m. The diagnoses included, but were not limited to, dementia and Alzheimer's disease.Resident B admitted to the facility on [DATE] at 11:21 a.m.An admission assessment, dated 8/22/25 at 11:24 a.m., indicated Resident B was not exit seeking, had no history of elopement, and ambulated without assistive devices. In a facility documented interview, dated 8/22/25, CNA 5 indicated she heard the door alarm and had directed CNA 2 to check the alarm.In a facility documented interview, dated 8/22/25, CNA 2 indicated she heard the door alarm on 8/22/25 at 6:30 p.m. She…

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

Based on observation, interview and record review, the facility failed to ensure a resident was treated with respect and dignity by a staff member during meal service for 1 of 1 resident reviewed for dignity. (Resident 26) Findings include: During an observation, on 1/30/25 at 12:10 p.m., Resident 26 was sitting in his wheelchair in the dining room. Certified Nursing Assistant (CNA) 9 was standing on Resident 26's left side as she assisted him with feeding. CNA 9 remained standing for the entirety of the meal. The clinical record for Resident 26 was reviewed on 2/4/25 at 10:27 a.m. The diagnoses included, but were not limited to, Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. A care plan, dated 12/27/24, indicated the resident had experienced significant weight loss. The interventions included, but were not limited to, offer the resident encouragement and assistance with eating and report difficulties swallowing. During an interview, on 1/30/25 at 12:19 p.m., CNA 2 indicated she would sometime stand up and walk around feeding multiple…

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 promptly implement a do not resuscitate (DNR) order based on a resident's signed advance directive wishes for 2 of 3 residents reviewed for advance directives. (Resident 152 and 160) Findings include: 1. The clinical record for Resident 152 was reviewed on 2/4/25 at 2:31 p.m. The diagnoses included, but were not limited to, cerebral infarction, metabolic encephalopathy, Alzheimer's disease, pneumonia, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, and chronic diastolic (congestive) heart failure. An Indiana advance directive form, signed on 1/13/25, indicated the resident wished to not have life prolonging measures. An Indiana Physician Orders for Scope of Treatment (POST) form, signed on 1/13/25, indicated the resident chose to be a DNR. A physician's order, dated 1/23/25 at 2:32 p.m., indicated full code status. A State of Indiana Out of Hospital Do Not Resuscitate Declaration and Order form, signed on 1/23/25, indicated the resident was to be a DNR upon admission to the facility…

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

Based on interview and record review, the facility failed to ensure a revised Preadmission Screen and Resident Review (PASARR) level I was submitted to reflect a resident's current diagnoses and medications for 1 of 2 residents reviewed for PASARR. (Resident 32) Findings include: The clinical record for Resident 32 was reviewed on 2/4/25 at 11:05 a.m. The diagnoses included, but were not limited to, anxiety, depression, and adjustment disorder with mixed anxiety and depressed mood. A PASARR level I, dated 1/7/25, indicated no mental health diagnoses were known, or suspected and no mental health medications were being prescribed. A physician's order, dated 1/6/25, indicated to give trazodone (an antidepressant medication) 50 milligram (mg) daily. A physician's order, dated 1/7/25, indicated to give sertraline (an antidepressant medication) 25 mg daily. A physician's order, dated 1/7/25, indicated to give buspirone (an anxiety medication) 5 mg daily. There was no PASARR level I completed to reflect the resident's orders for sertraline, trazodone, and buspirone and the resident'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 interview and record review, the facility failed to ensure medications were held according to the physician's ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 4) Findings include: The clinical record for Resident 4 was reviewed on 2/4/25 at 10:31 a.m. The diagnoses included, but were not limited to, essential primary hypertension, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, and type 2 diabetes mellitus. A physician's order, dated 4/11/23, indicated to give lisinopril (a blood pressure medication) 20 milligrams (mg) daily with special instructions to hold the medication for a systolic blood pressure less than 110. A Medication Administration Record (MAR), dated 7/1/24 through 7/31/24, indicated lisinopril was administered on 7/7/24 with a systolic blood pressure of 105 and on 7/14/24 with a systolic blood pressure of 102. A MAR, dated 8/1/24 through 8/31/24, indicated lisinopril was administered on 8/15/24 with a systolic blood pressure of 102 and on 8/26/24 with a systolic blood pressure 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 physician's order was obtained for the administration of oxygen for 2 of 4 residents reviewed for respiratory care. (Resident 150 and 156) Findings include: 1. During an observation, on 1/30/25 at 10:20 a.m., the resident was sitting in the chair in his room wearing 2 liters of oxygen via nasal cannula. He indicated he had been wearing oxygen yesterday and all during the night. The clinical record for Resident 150 was reviewed on 1/31/25 at 2:30 p.m. The diagnoses included, but were not limited to, pulmonary fibrosis, metabolic encephalopathy, chronic obstructive pulmonary disease, atelectasis, hypertensive heart and chronic kidney disease with heart failure, pulmonary hypertension, atrial fibrillation, and peripheral vascular disease. A vital signs report, dated 1/27/25 through 1/31/25, indicated the resident was on 1.5 liters of oxygen on 1/30/25 at 2:51 a.m. and on 2 liters of oxygen at 8:49 a.m. A current care plan, dated 1/28/25, indicated the resident had shortness of breath related to 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.

Based on interview and record review, the facility failed to ensure an order to give Augmentin 500 milligrams (mg) was discontinued when a new order to give Augmentin 875 mg was received which resulted in double doses of the antibiotic for pneumonia for 1 of 2 residents reviewed for antibiotics. (Resident 156) Findings include: During an interview, on 1/31/25 at 10:32 a.m., the resident indicated she had been sick and coughing with pneumonia. The clinical record for Resident 156 was reviewed on 1/31/25 at 2:27 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness, type 2 diabetes mellitus with hyperglycemia, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure, non-ST elevation myocardial (NSTEMI), and asthma. A lab report, dated 1/21/25, indicated the resident's GFR (glomerular filtration rate: a blood test to measure kidney function) was low at 24. The normal range was greater than 60. A physician's order, dated 1/24/25, indicated to give…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure compromised controlled substance medications were disposed of and unopened insulin was stored in the refrigerator for 2 of 2 medication carts (200 hall and 300 hall) and to ensure supplies were not stored under the sink in a medication room for 1 of 2 medication rooms reviewed for medication storage. (the 200-medication room) Findings include: 1. During an observation, on [DATE] at 1:18 p.m., the 200-hall medication cart had a compromised controlled substance card of lorazepam (for anxiety) 0.5 milligrams (mg) for Resident 26 with the 8 and 16 slots taped on the back of the card. The clinical record for Resident 26 was reviewed on [DATE] at 10:27 a.m. The diagnoses included, but were not limited to, Alzheimer's, hypertensive, anxiety disorder, tachycardia, dementia, and acute kidney failure. The medication card indicated the lorazepam 0.5 mg tablets had expired on [DATE]. There was no current order for the lorazepam 0.5 mg tablets…

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 accurately initiate the correct diet orders upon admission and to provide a lunch tray in the correct consistency for 2 of 6 residents reviewed for dining. (Resident 151 and 156). Findings include: 1. During an observation, on 1/30/25 at 11:43 a.m., Resident 151 was sitting at a table in the dining room waiting for her lunch. The Administrator entered the dining room carrying the resident's plate and placed it in front of the resident with the chicken tenders facing her. The meal ticket indicated to serve a regular consistency diet, and the plate had 2 large whole chicken tenders, fries, and a piece of blueberry pie with regular crust. The resident grabbed a fry and began eating it. CNA 2 was assisting the resident with getting her fork when the cook brought out another piece of pie. The Speech Therapist looked over and told them Resident 151 was on a mechanical soft diet. The cook took the extra piece of pie with him and exited the dining…

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 staff wore gloves when touching a resident's medication for 1 of 1 resident randomly observed for infection control. (Resident 31) Findings include: During an observation, on 1/31/25 at 10:40 a.m., QMA 3 brought a pain pill in for the resident along with his morning pills in a small medication cup. The resident indicated he did not want his morning pills until he had food, but he did want to take the pain pill. QMA 3 then picked the pain pill out of the other pills without donning gloves and handed it to Resident 31. The resident attempted to put the pill into his mouth but dropped it onto his shirt. QMA 3 picked the pill up off the resident's shirt and placed it in his mouth without gloves. The clinical record for Resident 31 was reviewed on 2/4/25 at 9:06 a.m. The diagnoses included, but were not limited to, end stage renal disease, chronic diastolic (congestive) heart failure, hypertensive heart and chronic kidney disease, end stage renal disease, and dependence on renal dialysis. A physician'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 interview and record review, the facility failed to ensure the antibiotic stewardship program included a system to monitor duplicate dosing antibiotic use for 1 of 2 residents reviewed for antibiotic stewardship. (Resident 156) Findings include: During an interview, on 1/31/25 at 10:32 a.m., Resident 156 indicated she had been sick and coughing with pneumonia The clinical record for Resident 156 was reviewed on 1/31/25 at 2:27 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, facial weakness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease with heart failure, acute systolic congestive heart failure, chronic kidney disease, non-ST elevation myocardial (NSTEMI), and asthma. A lab report, dated 1/21/25, indicated the resident's GFR (glomerular filtration rate: a blood test to measure kidney function) was low at 24. The normal range was greater than 60. A nursing progress note, dated 1/24/25 at 12:30 p.m., indicated the resident had nausea, vomiting, head…

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 provide an influenza vaccination during the current influenza season when requested with a signed consent form for 1 of 5 residents reviewed for immunizations. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 2/3/25 at 3:40 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, morbid (severe) obesity due to excess calories, Alzheimer's disease, bacterial pneumonia, atrial fibrillation, shortness of breath, dysphagia, and dependence on supplemental oxygen. An influenza vaccination consent form, dated 1/2/24 at 3:50 p.m., was signed by Resident 13 at 3:57 p.m. requesting the influenza immunization. A vaccination record for the resident, received from the Clinical Support Nurse on 2/4/25 at 9:00 a.m., indicated the resident received an influenza vaccine on 10/4/24 at 1:40 a.m. During an interview, on 2/4/25 at 11:00 a.m., the Clinical Support…

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 provide a Covid-19 vaccination when requested with a signed consent form for 1 of 5 residents reviewed for immunizations. (Resident 13) Findings include: The clinical record for Resident 13 was reviewed on 2/3/25 at 3:40 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, morbid (severe) obesity due to excess calories, Alzheimer's disease, bacterial pneumonia, atrial fibrillation, shortness of breath, dysphagia, and dependence on supplemental oxygen. A Covid-19 vaccination consent form, dated 1/2/24 at 3:50 p.m., was signed by Resident 13 at 3:57 p.m. requesting the Covid-19 immunization. A vaccination record for the resident, received from the Clinical Support Nurse on 2/4/25 at 9:00 a.m., indicated the resident received a Covid-19 vaccine on 10/4/24 at 1:40 a.m. During an interview, on 2/4/25 at 11:00 a.m., the Clinical Support Nurse indicated the resident's medical record…

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

Based on interview and record review, the facility failed to ensure a resident with a Brief Interview for Mental Status (BIMS) which showed intact cognition was invited to participate in the care plan meetings for 1 of 3 residents reviewed for care plan meetings. (Resident 57) Finding includes: During an interview, on 12/13/23 at 3:41 p.m., Resident 57 indicated she was not aware of care plan meetings. The record for Resident 57 was reviewed on 12/18/23 at 3:41 p.m. Diagnosis included, but were not limited to, bipolar II disorder, frontotemporal neurocognitive disorder, anxiety, and degenerative disease of the basal ganglia. A Minimum Data Set (MDS) assessment, dated 7/28/23, indicated the resident had a BIMS score of 14 which indicated intact cognition. A Resident First Meeting (care plan meeting), dated 7/27/23 at 5:32 p.m., indicated the resident's representative attended the meeting. The attendees included the Social Services Director (SSD), Licensed Practical Nurse (LPN), the facility Administrator, the Assistant Director of Health Services (ADHS) and the resident's spouse. 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 a resident who was on the memory care unit was provided with preferred activities while in isolation for Covid-19 for 1 of 1 resident reviewed for activities. (Resident 59) Finding includes: During an observation, on 12/13/23 at 1:09 p.m., staff were in the room to assist the resident. He was sitting up in his wheelchair. There was no reading material, no television on, and no music playing in the room. During an observation, on 12/14/23 at 11:30 a.m., the resident was sitting up in his room on the side of the bed. The television was not on, there was no music playing, and no books or other activity material observed in the room. During an observation, on 12/14/23 at 12:30 p.m., QMA 11 went into the resident's room, she indicated he did not watch the television, did not listen to music, usually just sat in his wheelchair in the room, and did not participate in any activities. During an interview, on 12/14/23 at 2:22 p.m., the resident's daughter indicated he used to watch old westerns on television and…

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

Based on interview and record review, the facility failed to keep a cognitively impaired resident safe from elopement for 1 of 3 residents reviewed for elopement. (Resident 118) This deficient practice was corrected on 11/24/23, prior to the start of the survey, and was therefore past noncompliance. Finding includes: The record for Resident 118 was reviewed on 12/14/23 at 10:27 a.m. Diagnoses included, but were not limited to, metabolic encephalopathy, atherosclerotic heart disease, abdominal aortic aneurysm, unspecified dementia, and dysphagia (difficulty swallowing). A Facility Reported Incident (FRI), dated 11/13/23 at 4:51 p.m., indicated the resident exited the campus and was seen sitting in the grass outside the campus door. A progress note, dated 11/13/23 at 5:15 p.m., indicated at approximately 4:51 p.m., the Executive Director (ED) was notified the resident was outside of the Legacy Unit and was laying in the grass. The resident indicated she was just resting in the yard. The resident showed no signs of pain or discomfort. A progress note, dated 11/13/23 at 5:45 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 record review and interview, the facility failed to reweigh a resident with a weight loss and to notify the provider of a weight loss for 1 of 3 residents reviewed for nutrition. (Resident 55) Finding includes: The record for Resident 55 was reviewed on 12/18/23 at 11:03 a.m. Diagnoses included, but were not limited to, unspecified dementia, chronic kidney disease stage 3, age related physical debility, and altered mental status. A weight log indicated the following weights: a. On 8/5/23, the weight was 207.2 pounds. b. On 8/14/23, the weight was 212.6 pounds. c. On 8/21/23, the weight was 209 pounds. d. On 8/28/23, the weight was 199.2 pounds. There was a 6.3% weight loss from 8/21/23 to 8/28/23 (14 days). During an interview, on 12/19/23 at 10:57 a.m., the Clinical Support Nurse indicated their Electronic Health Record (EHR) did not trigger for a significant weight loss. There should have been a reweight completed to confirm the resident's weight. During an interview, on 12/19/23 at 2:23 p.m., the Clinical Support Nurse indicated there was no provider notification about…

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 clear a clogged feeding tube (gastric tube) using an approved procedure for 1 of 3 residents reviewed for feeding tubes. (Resident 18) Finding includes: The record for Resident 18 was reviewed on 12/14/23 at 5:10 p.m. Diagnoses included, but were not limited to, unspecified protein-calorie malnutrition, dysphagia, oropharyngeal phase, and artificial openings of gastrointestinal tract status. A progress note, dated 11/27/23 at 12:33 p.m., indicated the resident had a clogged feeding tube (gastric tube). The nurse tried coke (soda) to unclog the feeding tube after another nurse tried, without success. The nurse received an order to send the resident to the emergency room. There was no physician's order to use coke to unclog the feeding tube. During an interview, on 12/20/23 at 5:06 p.m., the Clinical Support Nurse indicated the policy did not include to put coke in the feeding tube to unclog it. A current policy, titled Administering Gastric/Jejunostomy Tube Medications, dated as reviewed 12/31/23 and received from 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 accurately assess a resident's mouth for teeth and dentures and to show documentation of the dental status and the need for a dental appointment had been documented for 1 of 2 residents reviewed for dental. (Resident 59) Finding includes: During an interview, on 12/14/23 at 2:28 p.m., the resident's daughter indicated the resident's dentures did not fit well and the staff indicated the dentist would come to the facility. The resident did not chew well because of the fit of the dentures. The record for Resident 59 was reviewed on 12/14/23 at 5:04 p.m. Diagnosis included, but were not limited to, old myocardial infarction, osteoarthritis, hearing loss, age related cataracts, and a history of malignant neoplasm of the large intestine. A physician's order, dated 9/29/23, indicated the resident may see the dentist as needed. An admission observation, dated 9/29/23 at 5:53 p.m., indicated the resident had full dentures which included upper and lower dentures. A care plan, dated 10/12/23, 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, interview and record review, the staff failed to wear the required PPE (Personal Protective Equipment) into an isolation room and to follow the PPE protocol for 1 of 4 hallways reviewed for transmission-based precautions (the Legacy hallway) and to ensure a catheter bag was not touching the ground for 1 of 2 residents reviewed for urinary catheter. (Resident 269) Findings include: 1a. During an observation, on 12/13/23 at 1:03 p.m., LPN 13 had on a N95 mask and put a face shield over the mask. She entered Resident 59's room to provide care. When LPN 13 came out of Resident 59's room, she took off her face shield and did not remove the N95 mask. She wore the same N95 into the hallway. During an interview, on 12/13/23 at 1:22 p.m., LPN 13 indicated she should have removed her N95 mask when leaving the resident's room. 1b. During an observation, on 12/19/23 at 2:43 p.m., CRCA 5 and CRCA 6 entered an isolation room on the Legacy unit. Both wore a surgical mask with face shield, and both were not wearing N95 masks. During an interview, on 12/19/23 at 2:44 p.m., LPN…

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 follow an antibiotic stewardship program which included antibiotic use protocols and a system to monitor antibiotic use for 6 of 12 months reviewed for antibiotic stewardship. (July 2023-December 2023) Findings include: During a record review, on 12/20/23 at 2:45 p.m., the Antibiotic Stewardship binder had antibiotic monitoring starting January 2023 to June 2023. There was no documentation, tracking of infections, and antibiotic monitoring from July 2023 to December 2023. During an interview, on 12/20/23 at 2:45 p.m., the Clinical Support Nurse indicated the Infection Preventionist (IP) would make sure the antibiotics were monitored and met the McGeer (an infection surveillance for long-term care facilities) criteria. The IP would map the trends of infections and depending on the infections the facility would in-service staff. During an interview, on 12/20/23 at 2:53 p.m., the Clinical Support Nurse indicated the Antibiotic Stewardship binder did not contain information of tracking infections past June 2023. A current…

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.