Waters Of Lagrange Skilled Nursing Facility, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure family notification of an episode of resident-to-resident contact for 1 of 2 residents reviewed (Resident 63). Findings include: Resident 63's record was reviewed on 9/30/24 at 1:13 PM. Diagnoses included dementia with mood disturbance, Parkinson's Disease, major depressive disorder, anxiety disorder and visual hallucinations. Resident 63's Quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). The MDS indicated Resident 63 required substantial to maximal assistance to roll left and right, to move from a lying to a sitting position and to move from a sitting to a standing position. Resident 63's Care Plan, dated 12/8/23, indicated the resident did not participate in many activities. The Care Plan Indicated Resident 63 mostly sat in the background and watched others. The target goal was for the resident to participate in activities of interest 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure contents of a urinary catheter bag were not visible from the hallway for 1 of 2 residents reviewed (Resident 44). Findings include: During an observation, on 9/25/24 at 9:42 AM, Resident 44 was lying in bed in a semi-reclined position with a catheter bag attached to the bedframe and facing the door. Resident 44's door was open, his bag was in plain sight and visible from the hallway. The bag was about half full of yellow liquid. During an observation on 9/26/24 at 6:44 PM, Resident 44 was lying in bed with a catheter bag attached to the bedframe and facing the door with about 200 milliliters of yellow liquid in the bag. The bag was in plain sight from the hallway. During an observation, on 9/27/24 at 2:50 PM, Resident 44 was lying in bed with a catheter bag attached to the bedframe and facing the hallway about two-thirds full of yellow liquid. During an interview, on 9/27/24 at 2:50 PM, Licensed Practical Nurse (LPN) 25 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent abuse for 1 of 2 residents reviewed (Resident 41). Findings include: An Indiana State Department of Health Survey Report System Incident Number 189, dated 9/13/24 at 2:45 PM, indicated Resident 41's family member got loud with the resident during a visit at the facility. Immediate action taken was the removal of Resident 41's visitor from the facility. A preventative measure was the visitor not being permitted at the facility during the investigation. Follow up on 9/20/24 indicated on 9/13/24 a verbal altercation was overheard in Resident 41's room. The visitor was identified as Resident 41's Power of Attorney (POA). The visitor seemed intoxicated as evidenced by their appearance and smell. The visitor was asked to leave the facility immediately. Resident 41 voiced concern the visitor would return. Adult Protective Services recommended a visit restriction and a possible guardianship change. Resident 41's visitation was to be monitored for 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 interview and record review, the facility failed to ensure unusual incidents were reported to the appropriate agencies for 2 of 2 residents reviewed (Resident 63 and Resident 19). Findings include: 1. Resident 63's record was reviewed on 9/30/24 at 1:13 PM. Diagnoses included dementia with mood disturbance, Parkinson's Disease, major depressive disorder, anxiety disorder and visual hallucinations. Resident 63's Quarterly Minimum Data Set (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 3 (severe cognitive impairment). The MDS indicated Resident 63 required substantial to maximal assistance to roll left and right, to move from lying to a sitting position and to move from a sitting to standing position. A Behavior Charting note, dated 9/18/24 at 5:19 PM, indicated Resident 63 kissed another resident (Resident 49) on the lips in the dining room. Separation of the residents was effective. Resident 63's progress notes, dated 9/18/24 through 9/30/24, did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the elopement of a resident was investigated for 1 of 2 residents reviewed (Residents 19). Findings include: Resident 19's record was reviewed on 9/27/24 at 10:00 AM. Diagnoses included bipolar disorder, anxiety disorder, delusional disorders, complete traumatic amputation of right lower leg, idiopathic peripheral autonomic neuropathy, muscle weakness, and lack of coordination. Resident 19's current quarterly Minimum Data Set (MDS), dated [DATE], indicated her Basic Interview for Mental Status (BIMS) score was 8, moderate cognitive impairment. The MDS indicated for 7 to 11 days in a period of 14 days, she felt tired or had little energy, had trouble concentrating, poor appetite and was on an antidepressant. The MDS indicated she had lost weight of 5% in the last month or 10% in last 6 months and was not on Physician prescribed weight loss regimen. The MDS indicated the resident was impaired on 1 side of her lower extremity and used…

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 showers were consistently offered for 1 of 6 residents reviewed (Resident 76). Findings include: During an interview, on 9/26/24 at 10:08 AM, Resident 48 indicated he was not getting showers on a regular basis. He indicated he was supposed to have a shower on Wednesdays and Saturdays at 3:00 pm. He indicated when staff did not show up to give him a shower, he would frequently go to the nurses' station to find out what was going on and was told they were short staffed. Resident 48's record was reviewed on 9/30/24 at 10:25 AM. Diagnoses included cerebral infarction due to thrombosis of right posterior cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left, non-dominant side, and diabetes mellitus, type 2 without complications. Resident 48's current quarterly Minimum Data Set (MDS) indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 48 required moderate assistance with bathing and rejection of care was not exhibited.…

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 supervision and maintain seizure precautions for 2 of 6 residents reviewed (Resident 32 and Resident 5). Findings include: During an observation, on 9/26/24 at 11:12 AM, upon entering the memory Care unit, a voice was heard calling for help. A staff member was observed entering the shower room. A voice was heard asking who the nurse was. The Director of Nursing (DON) wsa observed entering the shower room. On 9/26/24 at 11:55 AM, Resident 32 was observed leaving the unit on a gurney escorted by 2 paramedics. Resident 32 was covered with a blanket. In an interview, on 9/26/24 at 11:57 AM, Certified Nurse Aide (CNA) 30 indicated they had started working at the facility on 9/12/24 and they were being trained by CNA 35. CNA 30 indicated they entered the shower room after hearing the resident call for help. CNA 30 observed Resident 32 sitting on the floor in the shower with their right arm stuck in the handrail. CNA 30 indicated they 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide trauma informed care by identifying triggers to minimize re-traumatization for 1 of 2 residents reviewed (Resident 41). Findings include: Resident 41's record was reviewed on 9/27/24 at 3:00 PM. Diagnoses included systemic lupus erythema, adult failure to thrive, anxiety disorder, bipolar disorder, schizophrenia, cognitive communication deficit, obsessive compulsive disorder, depression, agoraphobia with panic disorder and posttraumatic stress disorder (PTSD). Resident 41's Quarterly Minimum Data Set, (MDS), dated [DATE], indicated their Brief Interview for Mental Status (BIMS) score was 6 (severe cognitive impairment). The MDS indicated Resident 41had a gastrointestinal (g tube) feeding tube. Resident 41's Care Plan, dated 5/20/24, indicated the resident had a diagnosis of PTSD. The target goal was for Resident 41 to be symptom free through 11/22/24. Interventions included sensitivity to the resident's feelings, encouragement of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure specific resident behaviors were identified, investigated and communicated with individualized interventions for a resident with dementia for 1 of 1 resident reviewed (Resident 49). Findings include: On 9/26/24 at 11:15 AM, Resident 49 was observed standing up from dining room table. Resident 49 was observed walking while pushing their locked wheelchair. Resident 49 spoke in an agitated voice when they were being followed. Resident 49's record was reviewed on 9/27/24 at 11:36 AM. Diagnoses included alcohol dependence with alcohol induced dementia, anxiety disorder, major depressive disorder, psychotic disorder with hallucinations and mild cognitive impairment. Resident 49's admission Minimum Data Set (MDS), dated [DATE], indicated Resident 49's Brief Interview for Mental Status (BIMS) was 10 (moderate cognitive impairment). The MDS indicated Resident 49 required partial to moderate assistance with mobility, bathing and dressing. 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 provide effective pain management for 1 of 1 residents experiencing pain (Resident L). Findings include: On 9/3/24 at 2:01 P.M., Resident L's record was reviewed. Diagnoses included unstageable pressure ulcer to the right heel, diabetes, intellectual disabilities, and neuropathy. The resident had been hospitalized for a hip fracture due to a fall. A quarterly Minimum Data Set (MDS ) assessment, dated 8/17/24, indicated her cognition could not be assessed due to intellectual disabilities. She had verbal behaviors and behaviors not affecting others 1-3 days of the assessment and when asked, indicated she had pain but was unable to give further details. She required maximal assistance with all Activities of Daily Living (ADL's ). Care plans with effective dates, indicated: -8/13/24: Resident had potential for pain related to neuropathy and recent hip fracture. The goal was her pain to be controlled at an acceptable level. Interventions included: assess pain using the 0-10 scale; administer pain medication 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 observation, interview and record review, the facility failed to develop and implement an effective behavior management plan for a resident with a history of alcohol abuse. This resulted in public resident to staff altercations (Resident G) and 5 residents fearing for their safety (Resident P, Resident Q, Resident S, Resident T, and Resident U). Findings include: On 7/16/24 at 11:06 A.M., during an initial tour of the southwest hallway, a middle aged appearing male resident (Resident G) was observed seated in a wheelchair at the nurses station, speaking with a staff member. His speech was slightly slurred and rapid. Seated behind the resident, approximately 5 feet away, sat a female resident in a wheelchair with her feet resting on foot pedals. She was observed to have a grimace on her face, furrowed eyebrows, and nervous expression as she stared at the back of Resident G's wheelchair. She shifted her weight several times as if trying to move her wheelchair herself. Residents seated in the adjacent lounge area, indicated there had been issues with Resident G and they 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 dementia care and services was provided to 1 of 3 residents reviewed for dementia care (Resident E). Findings include: A complaint reported to the Indiana Department of Health, alleged residents who resided on the memory care unit at the facility were unsafe due to lack of nursing staff, medications not being provided timely, and lack of activities. On 7/17/24 at 11:27 A.M., Resident E's record was reviewed. Diagnoses included dementia with behavioral disturbance, delusional disorder, insomnia, major depressive disorder, and diabetes. He had been hospitalized for 2 weeks in May 2024 for increased delusions and physical behaviors. Hospital notes indicated the plan of care was to minimize polypharmacy and provide a structured, secured environment. The resident returned to the facility on 5/20/24 with orders for 2 antidepressant medications and an antipsychotic medication which hadn't been prescribed prior to his hospitalization. A quarterly MDS (Minimum Data Set) assessment, dated 4/9/24, indicated…

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

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse for 1 of 3 residents reviewed (Resident Q). Findings include: A report, submitted to the Indiana Department of Health (IDOH), dated 3/26/24, indicated on 3/19/24 at 6:30 a.m., a CNA (Certified Nurse Aid) had used their cell phone to create a video of Resident Q without her permission. The video was shared with several staff members. On 4/2/24 at 2:16 P.M., Resident Q's record was reviewed. Diagnoses included dementia with behavioral disturbance, delusional disorder, and generalized anxiety disorder. A quarterly MDS (Minimum Data Set) assessment, dated 12/19/23, indicated Resident Q had severely impaired cognition and verbal behaviors of yelling out. A care plan, revised on 1/15/24, indicated Resident Q displayed mood issues such as yelling out at staff and calling them derogatory names, delusions, hitting, kicking, and barricading herself. An intervention, dated 3/27/24, was for care to be provided in pairs (2 staff members). In an interview on 4/2/24 at 9:55 A.M., the…

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

Based on interview and record review, the facility failed to ensure a timely report of suspected abusefor 1 of 3 residents reviewed. (Resident Q). Findings include: A report, submitted to the Indiana Department of Health (IDOH), dated 3/26/24, indicated on 3/19/24 at 6:30 a.m., CNA 7 (Certified Nurse Aid) had used their cell phone to videotape Resident Q without her permission. The video was shared with several staff members. Refer to F600. In an interview on 4/2/24 at 12:28 P.M., the Director of Nursing (DON) indicated, on 3/19/24, CNA 5 (Certified Nurse Aid) reported mistreatment of Resident Q by CNA 7 and provided a cell phone recording of the alleged event. CNA 7 was suspended pending investigation and allowed to return to work the following day after the allegation of mistreatment was unsubstantiated. The unauthorized recording of Resident Q, obtained while the resident was being provided pericare, was not reported to IDOH until someone reported to corporate. CNA 5 still had the recording on her phone. CNA 5 had not been suspended pending investigation after sharing the video…

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 protection from abuse for residents while an investigation of abuse was conducted for 1 or 3 residents reviewed (Resident Q). Findings include: A report, submitted to the Indiana Department of Health (IDOH), dated 3/26/24, indicated on 3/19/24 at 6:30 a.m., a CNA (Certified Nurse Aid) had used their cell phone to record Resident Q without her permission. The recording was shared with several staff members. The incident was not reported on 3/19/24 when it occurred. The involved CNA was not suspended until 6 days later. After 3/19/24, the CNA provided care to residents on 3/21/24, 3/23, and 3/24/24 from 6:30 p.m. until 7 a.m. Refer to F600. During an interivew on 4/2/24 at 12:28 P.M., the Director of Nursing (DON) indicated, on 3/19/24, CNA 5 (Certified Nurse Aid) reported mistreatment of Resident Q and provided a cell phone recording of the alleged event. The unauthorized recording of Resident Q, obtained while the resident was being provided pericare, was not reported nor was CNA 5 suspended for making the recording.…

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 maintain minimum staffing levels to ensure safety with 2 staff members to transfer 22 residents who required use of a mechanical lift daily. Findings include: An Indiana Report Form, dated 10/25/23, alleged the facility hadn't enough staff to transfer residents who required a mechanical lift with assistance from 2 staff members. The complainant alleged there was only one staff working on a hall with 31 residents, some who required use of a mechanical lift for transfers. On 11/27/23 at 1:18 P.M., a confidential interview with a resident identified as interviewable, indicated they had to wait to be transferred to and from bed because they needed a mechanical lift with 2 staff members. The facility didn't always have 2 staff on the hall and they would have to wait for a second person from another unit to come and help. On 11/29/23 at 11:17 A.M., during a Resident Council meeting, residents indicated the facility was short staffed, especially on weekends. Several residents present, indicated they required a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an episode of attempted self-harm for 1 of 1 resident reviewed (Resident 34). Findings include: On 11/27/23 at 12:12 PM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room. Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak). Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 was unable to respond. A progress note dated 5/31/23at 10:39 PM indicated Resident 34 had removed the bed sheets and had wrapped the alarm cord around her head and arm. Resident 34's current care plan entry dated 6/1/23 and revised on 11/21/23 indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to investigate an episode of attempted self-harm for 1 of 1 resident reviewed (Resident 34). Findings include: On 11/27/23 at 12:12 PM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room. Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak). Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 was unable to respond. A progress note dated 5/31/23 at 10:39 PM indicated Resident 34 had removed the bed sheets and had wrapped the alarm cord around her head and arm. A progress note dated 6/1/23 at 11:09 AM indicated Social Services…

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 services were provided for communication deficits and activities of daily living for 2 of 2 residents reviewed. (Resident 34, Resident 16). Findings include: 1. On 11/27/23 at 12:12 AM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room. Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak). Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak, was rarely or never understood. Resident 34's current care plan entry dated 7/30/23 and revised on 9/22/23 indicated the resident would communicate by yelling…

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

Based on observation, interview and record review, the facility failed to follow care planned interventions for 1 of 3 residents reviewed with pressure ulcers (Resident 35). Findings include: On 11/27/23 at 9:53 A.M., Resident 35 was observed lying in bed, covered up with blankets. 2 heel protectors sat on top of her covers at the bottom of the bed. A heel up cushion device sat in a chair next to her bed. On 11/29/23 1:10 P.M., the resident was observed sitting in her wheelchair in her room. She wore no heel protectors on her feet and her heels were lying on the the footrest of the chair. On 11/29/23 at 12:56 P.M., Resident 35's record was reviewed. Diagnoses included dementia. She had been receiving hospice services since 8/20/21 for Alzheimer's disease. A care plan, revised 9/10/22, indicated the resident was at risk for skin breakdown related to end of life, incontinence, and decreased mobility. The goal was for the resident to be be provided preventative measures in an attempt to avoid skin breakdown. Interventions included: Heels up cushion while in bed. A care plan, dated…

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

Based on observation, interview and record review, the facility failed to follow care planned interventions to prevent accidents for 2 of 5 residents reviewed (Resident 3 and Resident 74). Findings include: 1. On 11/27/23 at 10:10 A.M., Resident 3 was observed lying on her back in bed. The bed was low to the ground but there was no mat on the floor beside her. On 11/27/23 at 2:03 P.M., Resident 3's record was reviewed. Diagnoses included hemiplegia and hemiparesis following a stroke, dementia, and contracture of the left wrist. The resident had resided at the facility for several years and did not walk. An annual MDS (Minimum Data Set) assessment, dated 11/17/23, indicated the resident had severely impaired cognition. She was dependent on staff for bed mobility and transfers. A care plan, revised on 4/10/23, indicated the resident was at risk for falls due to confusion, and poor positioning and trunk control when seated. The goal was her risk factors would be reduced to avoid significant injury related to falls. Interventions included: 11/21/23-low bed and mat on floor next to bed;…

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 investigate and identify underlying causes of resident specific behaviors for 1 of 1 resident reviewed (Resident 34). Findings include: On 11/27/23 at 12:12 AM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room. Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak). Resident 34 was admitted to the facility on [DATE]. Resident 34's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak and was rarely or never understood. The MDS indicated the resident did not display behaviors of yelling, resistance of care, disrobing, wandering or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Social Services to identify and track abnormal behaviors for 1 of 1 resident reviewed (Resident 34). Findings include: On 11/27/23 at 12:12 AM Resident 34 was observed sitting on their bed holding stuffed toys. Resident 34 did not respond to a verbal greeting and avoided eye contact. There was no call light in Resident 34's room. Resident 34's record was reviewed on 11/28/23 at 2:27 PM. Diagnoses included dementia with psychotic disturbance, major depressive disorder, delusional disorder, anxiety, stroke with right side paralysis and aphasia (inability to speak). Resident 34 was admitted to the facility on [DATE]. Resident 34's most recent quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive impairment. The MDS indicated Resident 34 did not speak and was rarely or never understood. The MDS indicated the resident did not display behaviors of yelling, resistance of care, disrobing, wandering or smearing of food and/or…

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

Based on interview and record review, the facility failed to ensure 1 of 3 residents was treated with respect and dignity during non-care related interactions (Resident L). Findings include: An Indiana report, dated 8/14/23 at 12:13 p.m., indicated a resident reported an activity aide had shown her inappropriate photographs that were on the aides personal cell phone. On 8/16/23 at 11:58 A.M., Resident L, identified as interviewable, was interviewed. She was observed seated in her wheelchair, wearing her dark purple colored dress and white cap-covering which was indicative of her Amish expression of faith. She was animated, with her voice rising when expressing disbelief, while telling her story. The activity aide had shown her nude photos of herself as well as men she was dating on a dating app. The resident indicated this had occurred while she had been in the activity room working on puzzles approximately 1-2 weeks ago. She reported it, on Monday, 8/14/23 to the Activity Director. Resident L indicated she told the activity aide she hadn't wanted to see that and she could get into…

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.