Homewood Health Campus

Based on interview and record review, the facility failed to ensure catheter urine output was accurately recorded as ordered for 1 of 1 resident reviewed for urinary catheters. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 5/14/25 at 1:49 p.m. The diagnoses included, but were not limited to, sepsis, infection and inflammatory reaction due to indwelling urethral catheter, bacteremia, hematuria, obstructive and reflux uropathy, and retention of urine. A physician's order, dated 11/11/24, indicated to place an indwelling urinary catheter for obstructive and reflux uropathy. A physician's order, dated 1/26/24, indicated to monitor the catheter output three times a day. A physician's order, dated 7/31/24, indicated give 20 milligrams of Lasix (a diuretic medication) twice a day for edema (swelling). A facility document, dated 5/1/25 through 5/15/25, indicated the following: On 5/2/25 at 3:19 a.m., large was recorded. On 5/2/25 at 9:13 a.m., large was recorded. On 5/3/25 12:28 p.m., medium was recorded. On 5/3/25 10:22 p.m., large was recorded. On…

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

Based on observation, interview and record review, the facility failed to ensure physician's orders were obtained and followed for 2 of 2 residents reviewed for oxygen administration. (Resident C and 109) Findings include: 1. During an observation, on 5/12/25 at 12:16 p.m., Resident C was observed in the dining room with a portable oxygen tank set to administer two (2) liters per minute of oxygen via nasal cannula. During an observation, on 5/13/25 at 9:43 a.m., Resident C was in an activity with a portable oxygen tank set to administer two (2) liters per minute of oxygen via nasal cannula. During an interview, on 5/13/25 at 9:53 a.m., the Director of Nursing (DON) reviewed Resident C's physician's orders. She indicated Resident C was to receive four (4) liters per minute of oxygen and Resident C's tank was set at two (2) liters. During an observation, on 5/13/24 at 1:54 p.m., Resident C's oxygen was set at four (4) liters per nasal cannula. The clinical record for Resident C was reviewed on 5/14/25 at 10:45 a.m. The diagnoses included, but were not limited to, saddle embolus of 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 Abnormal Involuntary Movement Scale (AIMS) assessments were completed for evaluation of adverse reactions related to antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications. (Resident 19) Findings include: The clinical record for Resident 19 was reviewed on 5/14/25 at 11:10 a.m. The diagnoses included, but were not limited to, psychosis not due to a substance or known physiological condition, dementia with psychotic disturbance, psychotic disorder with hallucinations due to a known physiological condition, delirium due to known physiological condition, major depressive disorder, anxiety disorder, auditory hallucinations, and visual hallucinations. A physician's order, dated 8/12/24, indicated to give olanzapine (an antipsychotic medication) 5 milligrams at bedtime. A psychiatry progress note, dated 9/23/24, indicated the resident was taking olanzapine and the last AIMS assessment was completed on 6/21/23. A care plan, dated 11/1/24, indicated Resident 19 was at risk for adverse…

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

Based on observation, interview and record review, the facility failed to ensure medications were labeled with pharmacy labels and the date the medications were opened in 2 of 2 medication carts reviewed for medication storage. (100 hall and 200 hall) Findings include: 1. The medication cart, on the 100-hall, was reviewed on 5/15/25 at 10:11 a.m. The following was observed: a. The first drawer contained an open bottle of Carbamide Peroxide 6.5% (ear drops). The medication was not labeled with the date it had been opened. b. The second drawer contained an open bottle of liquid Haloperidol (an antipsychotic medication). The bottle was half empty and was not labeled with the date the medication had been opened. During an interview, on 5/15/25 at 10:20 a.m., LPN 2 indicated the medications should have been labeled with the date they were opened. 2. The medication cart, on the 200-hall, was reviewed on 5/15/25 at 10:55 a.m. The following was observed in the top drawer: a. Spiriva (an inhalation spray), with a sticker, indicating the medication should be discarded 90 days after being…

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 personal protective equipment (PPE) correctly, performed hand hygiene, and changed gloves for 2 of 2 randomly observed staff members reviewed for infection control. (QMA 10 and RN 7) Findings include: During an observation, on 5/15/25 at 1:17 p.m., RN 7 and QMA 10 tied PPE gowns at the back of their neck, neither staff member tied the gowns closed at their waist and entered Resident C's room. 1. QMA 10 with gloves on, cleaned Resident C's mouth with a toothette (an oral swab) and discard it. QMA 10 then moved the mechanical lift into place. She picked up the resident's catheter drainage system with her left gloved hand and attached the bag to the mechanical lift strap. She ensured the sling was properly connected to the mechanical lift and used the control to lift the resident. The resident was then lowered to the bed. QMA 10 removed the resident's hearing aids and put them onto the charger. She assisted the resident to turn onto her left side. QMA 10 was then observed to handle 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 an elopement of a resident was reported to the Indiana Department of Health for 1 of 2 residents reviewed for elopement (Resident B). Finding includes: During an observation on 08/20/24 at 8:58 a.m., Resident B was in her room dressed, clean and dry and wearing a wander guard bracelet on her wrist. She was alert, able to sit up on the side of the bed without assistance and very friendly. She currently resided in the Legacy Memory Care Unit of the Assisted Living Facility. Her wheel chair was noted to be parked in close proximity to her bed and within reach. During an interview on 08/21/24 at 10:29 a.m., the Corporate Support Nurse indicated on 07/18/24, Resident B exited the campus out the 300 hall door. The alarm did sound and a family member observed the resident exit and reported it to staff immediately. The staff responded. The resident used the side walk to the Health Care Center parking lot and crossed the street. She was observed by the home owner, across the street, who was out in the yard.…

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 timely investigate an elopement when the incident occurred for 1 of 1 resident, reviewed for eloping from the facility (Resident B). Finding includes: During an interview on 08/21/24 at 10:29 a.m., the Corporate Support Nurse indicated on 07/18/24, Resident B exited the campus out the 300 hall door. The alarm did sound and a family member observed the resident exit and reported it to staff immediately. The staff responded. The resident used the side walk to the Health Care Center parking lot and crossed the street. She was observed by the home owner, across the street, who was out in the yard. Responding staff did get to the resident. It took about three (3) minutes. The resident had been last observed by a nurse at 8:22 p.m. The nurse then had to go print reports, due to the internet outage. The responding staff returned Resident B to the facility at 8:33 p.m. Staff did all the right things (followed the elopement policy) and it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to personalize resident care plans for advanced directives for 5 of 5 residents reviewed for advance directive care plans (Resident 11, 19, 32, 35, and 40). Findings include: 1. On [DATE] at 12:52 p.m., a record review was completed for Resident 11. She had the following diagnoses which included, but not limited to urinary tract infection, chest pain, chronic obstructive pulmonary disease (COPD), atrial fibrillation (A-Fib), hyperlipidemia, and dementia. Resident 11 had a care plan indicating she had chosen to have the following advanced directive, but failed to indicate whether she was to have CPR (cardiopulmonary resuscitation) or DNR (do not resuscitate). She had an order, dated [DATE], for a DNR. 2. On [DATE] at 2:46 p.m., a record review was completed for Resident 19. He had the following diagnoses which included but were not limited to COPD, type II diabetes mellitus, morbid obesity, chest pain, heart failure, and major depression with psychotic…

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 properly dispose of medications belonging to residents for 1 of 6 resident reviewed for medication disposition (Resident 204, 205 and 50). Findings include: 1. On [DATE] at 11:36 a.m., a record review was completed for Resident 204. He has the following diagnoses which included but were not limited to hypertension, hyperlipidemia, hypothyroidism, insomnia, and pain. He was discharged from the facility on [DATE]. He had the following medications unaccounted for after being discharged from the facility. a.) Amlodipine 5 milligrams (mg) b.) Aspirin 81 mg c.) Atorvastatin 80 mg d.) Cholecalciferol 1,250 micrograms (mcg) (50,000 unit) e.) Ipratropium-albuterol 0.5 mg - 3 mg (2.5mg/3ml) f.) Levothyroxine 112 mcg g.) Melatonin 5 mg h.) Ondansetron 4 mg i.) Tylenol 325 mg 2. On [DATE] at 11:47 a.m., a record review was completed for Resident 205. She had the following diagnoses which included but were not limited to hypertension, heart failure, diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to date and/or label insulin pens, eye drops, and inhalers when opened, and remove expired insulin pens and lorazepam from the cart when expired for 2 of 3 medication carts and 1 of 1 medication storage room reviewed for medication storage. Findings include: 1. The following medications were in the 100-hall medication cart: a. Resident 14 had a bottle of lorazepam 2mg/ml in the refrigerator. It expired on [DATE]. b. Resident 29 had basaglar insulin dated [DATE]. It was expired. c. Resident 33 had basaglar insulin with no date to indicate when it was opened. She also had lantus insulin with a date opened of [DATE]. It was expired. She had a bottle of refresh eye drops in the cart. The drops lacked a label. d. Resident 5 had an albuterol inhaler HFA 90mcg per actuation. It lacked a date to indicate when it was opened. She had an inhaler trelegy ellipta 100mcg/62.5mcg/25mcg in the cart. It lacked a date to indicate when it was opened. e. Resident 42 had an…

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 hand hygiene was completed between residents during meal service for 1 of 1 observation of dining (Residents 26, 18, and1) Findings include: On 5/14/24 at 11:43 a.m., 37 residents were observed during a lunch service. Dietary Aide (DA) 12 was observed to serve milk to Resident 26, then moved his wheelchair into a better position in front of the lunch table. He was observed to hold the handles of his wheelchair with his bare hands. DA 12 did not use hand washing and hand sanitizer before providing a drink to Resident 18. After a short conversation with Resident 18, he went to a cabinet, used his bare hand to open it and retrieved a clothing protector and placed it on the resident. DA 12 did not do any hand hygiene and provided a drink for an unidentified resident. DA 12's bare hands were observed on the Resident's 1 wheelchair handles as he brought her into the lunch room. He did not do any hand hygiene, then went to a cabinet area and opened a drawer with his bare hand. He removed a plate and retrieved a Styrofoam cup…

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 the infection control program objectives were followed regarding the influenza vaccinations for residents in a timely manner for 5 of 22 residents reviewed for 2023/2024 flu season (Resident 8, 22, 23, 38, and 46). This deficiency was corrected on 4/26/24 prior to the start of the survey and was therefore Past noncompliance. Finding include: On 5/16/23 at 12:04 p.m., Resident 46's immunizations were reviewed. The last flu vaccination for her was provided on 1/27/23. On 5/16/24 at 3:30 p.m., the Regional Clinical Support (RCS) indicated the facility did not offer Resident 46 a flu vaccination for the 2023/24 flu season. She indicated when the Director of Health Services (DHS) started at the facility in 2/12/24, she updated everyone with tuberculous (TB) screenings, and was working on updates for flu vaccinations. On 5/16/24 at 11:20 a.m., the Infection Preventionist (IP) indicated flu shots were mandatory at this facility. Resident should have…

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, (Resident E) was treated with respect and dignity during a transfer observation, and failed to ensure a resident, (Resident B) was treated with respect and dignity during a treatment observation for 2 of 3 residents reviewed for dignity. Findings include: 1. On 5/17/24 at 11:25 a.m., the following was observed: Certified Nursing Aides (CNA) 14 and 15 entered Resident E's room to lay her roommate down. Resident E was observed sitting up in bed as she attempted to get out of bed. She was observed to have had an incontinent episode and stool was noted as it seeped from the edges of her brief. Resident E complained that her bottom was burning and itching very bad and she continued to attempt to get out of bed. CNA 14 indicated they would get Resident E cleaned up first since her roommate was comfortably asleep in her Broda chair. CNA 14 looked in the resident's closet, but indicated there were no pants so she left the room to go get Resident E a new pair of pants. After CNA 14 left, CNA 15…

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

Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) preferences were honored and implemented for a totally dependent resident for 1 of 3 residents reviewed for ADLs, (Resident B). Findings include: During a continuous observation and interview on 5/15/24 from 2:00 p.m., until 2:22 p.m., Resident B was observed in bed. She was lying flat on her back in her bed. She wore a hospital gown, and her hair was matted and tangled. Thick build up of eye drainage was observed caked in her eye lashes, and there were flakes of dandruff in her hair. A napkin from lunch remained on her chest, where bits of food crumbs had fallen, and there was food crust/stains around her mouth. Resident B indicated, no one had helped her get cleaned up after lunch. During a confidential interview during the survey, it was indicated that several complaints had been made and were ongoing related to Resident B's care. She went days or weeks without getting her teeth brushed, her hair was not washed with her special shampoo, and she was often left in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a person-centered and meaningful activity program was implemented for a resident (Resident B) to maintain and/or enhance her quality of life for 1 of 3 residents reviewed for activities. Findings include: During a continuous observation and interview on 5/15/24 from 2:00 p.m., until 2:22 p.m., Resident B was observed in bed. The lights were off, there were personal items stacked in front of her TV which was off. Resident B was alert and oriented and engaged in conversation. Resident B indicated she did not get invited to activities, and any activity she wanted to try, staff did not have her up and ready in time. She required a Hoyer lift for transfers which was painful, especially when staff often rushed through the task and did not take their time to help make sure she was comfortable, it was too much trouble. During the interview, activity staff was heard in the hallway inviting other residents to activities. Resident B asked who…

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

Based on observation, interview, and record review, the facility failed to prevent the potential for accidents during a resident's transfer, ensuring the implementation of routine monitoring for an electronic wheelchair seatbelt and by ensuring a new mattress was appropriately measured and fitted to the bed frame for 3 of 3 residents reviewed for accidents (Residents E, 8 and C). Findings include: 1. On 5/17/24 at 11:25 a.m., the following was observed. Certified Nursing Aides (CNA) 14 and 15 entered Resident E's room to lay her roommate down. Resident E was observed sitting up in bed as she attempted to get out of bed. She was observed to have had an incontinent episode and stool was noted as it seeped from the edges of her brief. Resident E complained that her bottom was burning and itching very bad and she continued to attempt to get out of bed. CNA 14 indicated they would get Resident E cleaned up first since her roommate was comfortable asleep in her broad chair. CNA 14 looked in the resident's closet, but indicated there were no pants so she left the room to go get Resident E…

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 respiratory equipment was stored according to the facility policy for 1 of 1 residents reviewed for respiratory equipment (Resident 44). Findings include: On 5/14/24 at 1:48 p.m., Resident 44's continuous positive airway pressure (CPAP) facial equipment was observed uncovered on the resident's bedside table. On 5/17/24 at 11:14 a.m., Resident 44's CPAP facial equipment was observed uncovered on the resident's bedside table. On 5/17/24 at 2:09 p.m., Resident 44's record was reviewed. He was admitted on [DATE]. His diagnoses included, but were not limited to, obstructive sleep apnea (OSA) (difficulty breathing while sleeping), dementia (progressive loss of intellectual functioning), chronic obstructive pulmonary disease (COPD) (lung disease including constriction of the airways), hypotension (low blood pressure), altered mental status (AMS), asthma (chronic disease of bronchial airways causing difficulty breathing). Physician orders…

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 indicate the rationale for the use of medications for residents reviewed for medication use for 2 of 2 residents (Resident 33 and 19). Findings include: 1. On 5/15/24 at 2:55 p.m., a record review was completed for Resident 33. She had the following diagnoses which included but were not limited to type 2 diabetes mellitus, depression, major depression, and heart disease. She had the following medication orders that lacked an indication for use. a. Atorvastin (medication typically used for hyperlipidemia) 80 milligrams (mg) at bedtime for an indication of use of not applicable (N/A). b. Basaglar kwikpen U-100 insulin (medication typically used for diabetes mellitus) 20 units at bedtime. The medication order lacked an indication for use. c. Clonidine (medication typically used for hypertension and heart failure) 0.2 mg give with 0.3 mg to equal 0.5 mg daily with an indication for use of N/A. d. Ferrous sulfate (medication typically used for anemia) 325 mg two times daily for an indication of use of N/A. e. Levothyroxine…

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

Based on interview and record review, the facility failed to ensure residents who received high risk antipsychotic medication had the risks and benefits reviewed with them and/or their representatives for 2 of 5 residents reviewed for unnecessary medications. (Resident 40 and 29) Findings include: 1. The record for Resident 40 was reviewed on 03/02/23 at 4:02 p.m. Diagnoses included, but were not limited to, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician's order, initiated on 01/27/23, indicated to give Seroquel (an antipsychotic) 25 mg times two tablets every bedtime for Alzheimer's delusions. This order was a dosage change. A care plan, initiated on 07/28/22, indicated Resident 40 was at risk for adverse consequences related to the use of an antipsychotic medication. A facility document, titled Observation Detail List Report, with a completed date of 06/09/22 and provided by the Corporate Support Nurse on 03/07/23 at 1:32 p.m., indicated the resident was using an antipsychotic medication. The name of 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 the IDT (Interdisciplinary Team) determined which medications may be self-administered and failed to ensure a physician's order to use and keep medications at the bedside was obtained for 1 of 1 resident reviewed for self-administration. (Resident 20) Finding includes: During an observation, on 03/07/23 at 8:46 a.m., Resident 20 had on his bedside table a bottle of dorzol/timol solution (eye drops) 2 percent, a bottle of dorzolamide (eye drops) 2 percent, a bottle of brimonidine solution (eye drops) 0.2 percent and a bottle of ipratropium (a nasal spray) spray 0.6 percent. Resident 20 indicated he administered the medications himself and then nursing picks them up. The record for Resident 20 was reviewed on 03/07/23 at 1:43 p.m. Diagnosis included, but were not limited to, age related debility, syncope and collapse, and acute respiratory distress. There was no self-administer of medication assessment in the record at the time of the review. There were no orders to self-administer any medications in 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 licensed staff member assessed a resident prior to an as needed medication (PRN) was administered by a QMA for 1 of 1 randomly observed resident receiving a PRN medication. (Resident 31) Finding includes: During an observation, on 03/03/23 at 3:33 p.m., the spouse of Resident 31 approached QMA 7 and asked if Resident 31 was given his Mucinex (a medication for cough and congestion). She indicated he was congested. The QMA removed the Mucinex and prepped the medication for administration. The QMA then briefly spoke with LPN 5 in the hall, and then went into the room. The QMA was observed to administer the medication to the resident. The nurse was not observed to assess the resident prior to the administration of the medication. The record for Resident 31 was reviewed on 03/07/23 at 10:27 a.m. Diagnoses included, but were not limited to, hypertensive heart disease with heart failure (heart problems which occur because of high blood pressure), chronic congestive heart failure (the heart has trouble…

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 fall interventions were being followed to prevent further falls for 3 of 3 residents reviewed for accidents. (Resident 39, 16, and 30) Findings include: 1. During an interview, on 03/02/2023 at 1:28 p.m., a concerned family member of Resident 39 indicated she had received a call from the facility approximately 3 weeks prior to inform her the resident had fallen while being transferred in the bathroom. She was concerned a gait belt was not used at the time of the transfer. Resident 39 had a stroke and required a gait belt during transfers. The record for Resident 39 was reviewed on 03/02/2023 at 3:40 p.m. Diagnoses included, but were not limited to, history of significant fracture of the shaft of the right fibula, history of falls, hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the right dominant side, hypertension, anxiety disorder, tremors, and generalized muscle weakness. A progress noted, dated 10/29/22 at 12:46 p.m., indicated the resident was assisted to the floor by…

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

Based on interview and record review, the facility failed to ensure medication orders contained the appropriate indication for the administration of the medications for 1 of 5 residents reviewed for medications. (Resident 40) Finding includes: The record for Resident 40 was reviewed on 03/02/23 at 4:02 p.m. Diagnoses included, but were not limited to, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A physician's order, initiated on 05/23/22, indicated to give finasteride (a medication for an enlarged prostate) 5 milligrams (mg) once a day. The indication for use was Alzheimer's disease, contact with and (suspected) exposure to COVID-19, dementia with behavioral disturbance, and vomiting. A physician's order, initiated on 05/23/22, indicated to give folic acid (vitamin B-9) 1 mg once a day. The indication for use was Alzheimer's disease, contact with and (suspected) exposure to COVID-19, dementia with behavioral disturbance, and vomiting. A physician's order, initiated on 05/23/22, indicated to give a multivitamin tablet once…

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 appropriate diagnosis for use of psychotropic medications (antipsychotic medication) for 2 of 5 residents reviewed for psychotropic medications. (Resident 29 and 40) Findings include: 1. The record for Resident 29 was reviewed. Diagnoses included, but were not limited to, unspecified dementia with other behavioral disturbance. During an interview, on 03/03/23 at 8:48 a.m., Resident 29's family member indicated Resident 29 was aggressive in the hospital. He was having delusions in the hospital, thinking he was in other places. A physician's order, with a start date of 2/23/23, indicated to give Risperidone (an antipsychotic medication). There was no documented diagnosis. The physician's order indicated a Safety Alert which indicated a Drug-to-Condition Interaction Alert for Risperidone .should be used with extreme caution when senile dementia, a condition related to .Unspecified dementia, unspecified severity, with other behavioral disturbance exists. A review of the Prescription Fax Request for Resident 29,…

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 remove a used brief from a room which caused the room to smell of urine (Resident 45), failed to ensure floors were not sticky (room [ROOM NUMBER]), failed to removed soiled linen and trash from a room (Resident 207), failed to ensure soiled linen was not left on furniture (Resident 207) and failed to make repairs to dry wall (Rooms 103, 111 and 112) observed for environment. Findings include: 1. During an observation, on 03/01/23 at 10:31 a.m., Resident 45 was sitting up in his room. The room smelled of urine. A used brief was observed in the trash can. During an interview, on 03/01/23 at 10:47 a.m., RN 2 indicated the brief should have been removed. 2. During an observation, on 03/01/23 at 11:26 a.m., the floor of room [ROOM NUMBER] was found to be very sticky throughout the room as evidenced by shoes sticking to the floor with every step. 3. During an observation, on 03/01/23 at 11:44 a.m., Resident 207's bed was observed to be stripped…

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.