Waters Of Clifty Falls, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. During a continuous observation, on 05/29/25 from 1:38 P.M. through 1:44 P.M. the following was observed: - At 1:38 P.M., a computer screen was opened on Medication Cart 1 on the 100 Hallway that was sitting between resident rooms [ROOM NUMBERS]. The screen had Resident 66's name and medication list visible. - At 1:39 P.M., a resident in a wheelchair propelled by the cart and looked towards the computer and kept going, - At 1:40 P.M., LPN 8 who had been standing at Medication Cart 2 outside of room [ROOM NUMBER], approximently ten feet from Medication Cart 1, walked into room [ROOM NUMBER] next to Medication Cart 1 out of visible sight of both Medication Carts 1 and 2. The LPN did not close the open computer screen on Medication Cart 1. - At 1:41 P.M., a resident in a wheelchair propelled by the cart, - At 1:42 P.M., a staff member walked past the cart, and LPN 8 walked out of room [ROOM NUMBER] and returned to the second medication cart, - At 1:43 P.M., a resident in a wheelchair propelled by cart, spoke to…

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

Based on record review, interview, and observation, the facility failed to follow physician's orders related to cardiac medication hold parameters and follow manufacturer's guidelines related to insulin pen usage for 5 of 20 residents reviewed for Quality of Care. (Residents 2, 93, 7, 78, and 29) Findings include: 1. Resident 2's clinical record was reviewed on 06/04/25 at 10:17 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/20/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, hypertension, and chronic kidney disease. An open-ended physician's order, with a start date of 01/31/25, indicated the nursing staff were to administer the resident's Metoprolol 12.5 milligrams (mg) daily at 9:00 A.M. and 9:00 P.M. for hypertension. The medication was to be held if the resident's systolic blood pressure (top number/heart at work) was less than 110, the diastolic blood pressure (bottom number/heart at rest) was less than 60, or the resident's heart rate was less than 60. The May 1 through June 3, 2025 Electronic…

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 store foods appropriately to prevent contamination for 1 of 2 kitchen observations. Findings included: 1. The initial kitchen tour was conducted on 05/29/25 at 10:48 A.M., and the following was observed: - A large clear plastic container sitting on a metal shelf contained flour. The lid was ill-fitting and not designed for the container, - A large clear plastic container sitting on a metal shelf contained sugar with a plastic scoop sitting inside. During an interview on 05/29/25 at 10:50 A.M., Dietary Aide 13 indicated the scoop should not have been left in the sugar and the lids were not the right ones for the containers. During the initial kitchen tour, the noon time meal was completely prepared and no staff were actively using the flour or sugar. An exterior door was within ten feet of the inappropriately sealed flour and sugar bins. The current facility policy titled, Food Storage (Dry, Refrigerated and Frozen), dated 08/12/23, was provided by the Administrator on 06/04/25 at 10:50 A.M. The policy indicated, .5. All open…

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.

3. The clinical record for Resident 52 was reviewed on 06/03/25 at 2:08 P.M. A Quarterly MDS assessment, dated 02/24/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, a stroke, depression, obesity, and weakness. An open-ended physician's order, with a start date of 06/02/25 at 2:31 P.M., indicated the resident was in enhanced barrier precautions for a pressure wound. During an observation, on 06/03/25 at 2:09 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Staff must wear a gown and gloves for high contact resident care activities, including but not limited to, Wound Care: any skin opening requiring a dressing. Supplies, including gowns and gloves were in a plastic container with drawers outside the resident's room. LPN 17 and NP 16 entered the resident's room and provided wound care to the resident's pressure ulcer without donning gowns. Based on observation, interview, and record review, the facility failed to follow infection control…

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

Based on observation, record review, and interview, the facility failed to store medications appropriately for 1 of 1 resident reviewed for self-administering medications. (Resident 7) Findings include: During an observation and interview, on 05/29/25 at 12:04 P.M., Resident 7 was lying in his bed. His over the bed table was sitting beside the bed and contained two medicine cups. One cup had one pill in it and the other had seven pills in it. The resident indicated the medications had been there for some time. He believed the medication was his gabapentin, muscle relaxer, and his cholesterol medications. He was unsure what the others were. There were no nursing staff in the room. The clinical record for Resident 7 was reviewed on 06/02/25 at 9:57 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/17/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, hypertension, diabetes, hyponatremia, and depression. The clinical record lacked an assessment for the resident to self-administer his medications or a physician order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for 1 of 20 resident assessments reviewed. (Resident 85) Findings include: The clinical record for Resident 85 was reviewed on 06/03/25 at 12:11 P.M. A Discharge assessment, dated 12/28/24, indicated the resident admitted to the facility from the hospital on [DATE]. The resident discharged from the facility on 12/28/24. The discharge was unplanned, and the resident went home. The assessment history indicated the assessment was never added to a batch to be transmitted to CMS. During an interview on 06/04/25 at 2:36 P.M., the Regional MDS Coordinator indicated it didn't look like the discharge assessment was transmitted. It should have been sent out sooner. The facility did not have a policy related to transmitting MDS assessments. They followed the RAI (Resident Assessment Instrument) manual. 3.1-31(a)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to revise a resident's care plan related to the resident's leg prosthesis for 1 of 20 residents reviewed for care plans. (Resident 75) Findings include: Resident 75 was observed in his room on 05/29/25 at 11:30 A.M. The resident was sitting in his wheelchair. The resident had a below the knee amputation of his left leg and was wearing a prosthetic leg. On 06/02/25 at 10:57 A.M., the resident was observed in his room with a family member. The resident was wearing his prosthetic leg. On 06/03/25 at 12:02 P.M., the resident was in his room with a family member. The resident was wearing his prosthetic leg. The resident indicated he had the prosthetic for 3 or 4 years. He had no problems with it. Nursing staff assisted him with putting it on every day. He did not put it on himself. The clinical record for Resident 75 was reviewed on 06/04/25 at 1:25 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 05/16/25, 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 facility failed to follow physician's orders related to wound treatments for pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. (Resident 78) Findings include: Resident 78 was observed on 06/03/25 at 1:52 P.M., with the Wound Nurse Practitioner (NP) and the Assistant Director of Nursing (ADON). The resident had a wound to the left ischium (lower hip bone area) that had no signs of infection and measured 0.5 centimeters (cm) by (X) 0.3 cm X 0.2 cm, and the resident had a wound to the sacrum (bottom of the spine) that measured 0.8 cm X 0.8 cm X 0.4 cm. The clinical record for Resident 78 was reviewed on 06/03/25 at 10:03 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/12/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cerebral palsy, orthostatic hypotension, depression, pressure ulcer to the left buttock, and adult failure to thrive. A Wound NP Assessment Report, dated 10/28/24, indicated the resident had a Stage 4…

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 splint devices were in applied as ordered for 1 of 1 resident reviewed for range of motion. (Resident 84) Findings include: Resident 84 was observed in his room on 05/29/25 at 11:00 A.M. The resident was in bed and the head of his bed was elevated. The resident was not wearing hand or elbow splints. During an interview, on 05/30/25 at 10:51 A.M., the resident's family member indicated the resident never wore his hand or elbow splints. The splints were up in the closet, and they were supposed to be on his arms. The resident was observed in his room on 06/02/25 at 9:16 A.M. The resident was in bed. There were no hand or elbow splints in place. The resident was observed in his room on 06/02/25 at 10:48 A.M. The resident's arms were folded over his chest. There were no splint devices in place. The resident was observed in his room on 06/03/25 at 9:14 A.M. The resident was in bed. There were no splint devices in place. The resident was observed in his room on 06/03/25 at 2:00 P.M. The resident was in 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.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were addressed timely for 1 of 5 residents reviewed for drug regimen review. (Resident 75) Findings include: The clinical record for Resident 75 was reviewed on 06/04/25 at 1:25 P.M. A Quarterly Minimum Data Set assessment, dated 05/16/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, diabetes, non-Alzheimer's dementia, anxiety, and depression. A pharmacy recommendation, dated 02/15/25, indicated the resident was currently receiving citalopram (an antidepressant) 40 milligrams (mg) twice a day. The dose exceeded the maximum recommended dose of 40 mg per day. The resident was receiving double the recommended dose and the pharmacist recommended reducing the order to 40 mg per day. The Nurse Practitioner agreed with the recommendation on 02/26/25. The resident's Electronic Medication Administration Record (EMAR) for February and March 2025 indicated the resident continued to receive 40 mg of citalopram twice…

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 store medications appropriately for 2 of 3 medication carts (Split Cart and Living Well Cart) reviewed and 1 of 2 medication rooms (Dementia Unit) reviewed. Findings include: 1. The Split Medication Cart was observed on 06/04/25 at 10:26 A.M., with Licensed Practical Nurse (LPN) 12. The medication cart contained an unopened and undated Fiasp insulin pen that belonged to Resident 22. The LPN indicated she was unsure when the insulin pen was removed from the refrigerator as she had not been the one to remove it, and it should have stayed in the refrigerator untill it was needed. 2. The Living Well Medication Cart was observed on 06/04/25 at 10:46 A.M., with LPN 4. The cart contained the following: - An opened Combivent inhaler that belonged to Resident 12 with no open date, and - An opened Ellipta inhaler that belonged to Resident 301 with no open date. The current Fiasp insulin pen package insert was provided by the Regional Clinical Consultant on 06/04/25 at 11:38 A.M. The insert indicated, .Not-in-use (unopened)…

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 that critical laboratory (lab) test results were received and reported to the physician in a timely manner; and a lab test was completed after a fall related to seizure medication for 2 of 6 residents reviewed for lab services. (Residents 11 and 20) Findings include: 1. Resident 11's clinical record was reviewed on 06/02/25 at 1:02 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 04/05/25, indicated the resident was moderately cognitively impaired. The resident's diagnoses included, but were not limited to, heart failure, hypertension, renal insufficiency, and diabetes. A Progress Note, dated 05/28/25 at 6:29 P.M., indicated the Nurse Practitioner (NP) reviewed the resident's recent Basic Metabolic Panel (BMP) lab results. The resident's potassium level was critical at 2.4 (the normal range for potassium was 3.5 to 5.3). The resident was to receive oral potassium tablets, and a BMP was to be re-drawn on 05/30/25. A Progress Note, dated 05/30/25 at 5:42 P.M., indicated the BMP was obtained on 05/30/25, 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 record review, interview, and observation, the facility failed to document colostomy care for 1 of 25 residents' records reviewed. (Resident 26) Findings include: The clinical record for Resident 26 was reviewed on 06/02/25 at 11:08 A.M. A Significant Change Minimum Data Set assessment, dated 04/07/25, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, degenerative disease of basal ganglia, non-Alzheimer's dementia, Parkinson's disease, anxiety, depression, bipolar, psychotic disorder, schizophrenia, oppositional defiant disorder, mild intellectual disabilities, and colostomy status. The resident had an ostomy. An open-ended physician's order, with a start date of 09/15/21, indicated the staff were to change the resident's colostomy appliance as needed. The clinical record lacked documentation that the resident's colostomy appliance had been changed in the months of March, April, May, or as of June 3, 2025. During an interview, on 06/03/25 at 1:45 P.M., Licensed Practical Nurse 9 indicated the resident had a…

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

Based on observation and interview, the facility failed to provide a sanitary homelike environment for 1 of 20 residents reviewed. (Resident 53) During an observation and interview, on 06/02/25 at 10:26 A.M., Resident 53 was lying in bed and her eyes were closed. She opened her eyes and denied any concerns. On the floor approximately ten inches from the foot of her bed were a stack of linens that included, but were not limited to, a sheet and a pair of disposable underwear that smelled strongly of urine. The resident was lying on clean sheets. During an observation, of Resident 53's room, on 06/02/25 at 10:47 A.M., on the floor approximately ten inches from the foot of bed remained a stack of linens that included, but were not limited to, a sheet and a pair of disposable underwear that smelled strongly of urine. During an interview, on 06/02/25 at 10:51 A.M., Licensed Practical Nurse (LPN) 8, indicated the Certified Nurse Aide (CNA) had been around to check on the resident recently. The dirty linens should not have been placed directly on the floor or left on the floor after the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide functioning bathroom call lights for 4 of 6 residents reviewed for resident call system. (Residents D, E, F, and G) Findings include: 1.a.During an observation and interview, on 02/24/25 at 2:57 P.M., Resident D indicated her bathroom call light had been broken for two weeks. Earlier that morning she had to hit the call light by her bedside for her roommate who was in the bathroom and needed help getting off the toilet. An observation of the bathroom indicated there was an open electrical box with five wires hanging out loosely situated left of the residents' toilet. The wires had blue caps on the ends of each wire. There was no bell or alternative alert system in sight or within reach when the resident was in the bathroom. An Annual Minimum Data Set (MDS) assessment, dated 12/12/24, indicated Resident D was cognitively alert and oriented. The resident's diagnoses included, but were not limited to, anemia, arthritis, and heart…

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 was treated with respect and dignity for 1 of 3 residents reviewed. (Resident B) Finding included: A progress note, dated 01/22/25 at 3:30 P.M., indicated a Qualified Medical Assistant (QMA) reported that she witnessed another staff member tell Resident B, you are a fat a and referred to the resident by calling her [the name of a weight loss spokesperson]. An Annual Minimum Data Set (MDS) assessment, dated 12/10/24, indicated Resident B was severely cognitively impaired. The resident's diagnoses included, but were not limited to, cerebral palsy, contracture, and adult failure to thrive. During an interview, on 02/24/2025 at 10:24 AM, QMA 3 indicated Certified Nurse Aide (CNA) 4 called Resident B a Fat a while they assisted her pulling up her pants. Then the CNA referred to the resident as [the name of a weight loss spokesperson] before laying her back down. The resident didn't really react due to her level of cognition. After care was provided, QMA 3 immediately notified management and CNA 4 was sent…

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

Based on record review and interview, the facility failed to ensure misappropriation of a resident medication did not occur for 1 of 3 residents reviewed for misappropriation. (Resident D) Findings include: The clinical record for Resident D was reviewed on 08/30/24 at 4:35 P.M. An Annual MDS (Minimum Data Set) assessment, dated 06/14/24, indicated the resident was cognitively intact. The diagnosis included, but were not limited to, diabetes mellitus, manic depression, psychotic disorder, and schizophrenia. A facility incident report, dated 08/29/24 at 7:01 A.M., indicated upon shift change, a narcotic medication card and narcotic count sheet were unable to be located. A current physician's order, with a start date of 10/10/23, indicated the staff were to administer Percocet (a pain medication), 7.5-325 mg (milligrams), 1 tablet by mouth every six hours as needed for pain. A current physician's order, with a start date of 09/28/23, indicated the staff were to administer morphine sulfate (a pain medication) oral tablet, 30 mg by mouth, three times a day for chronic pain. During 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 record review and interview, the facility failed to store medications in a secure manner related to medications left on top of the medication cart unattended for 1 of 3 medication carts reviewed. (Living Well Long Hall Cart) Findings include: The clinical record for Resident D was reviewed on 08/30/24 at 10:15 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/14/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, osteomyelitis, bipolar disorder, psychotic disorder, psychoactive substance abuse, and schizophrenia. The Progress Notes for Resident D were provided by the Administrator on 08/30/24 at 3:28 P.M., and included, but not limited to, the following: - A Nursing Progress Note, dated 08/21/24 at 12:02 A.M., indicated Resident D was following a QMA (Qualified Medication Aide) during medication pass, even after being asked multiple times to keep going down the hallway. The QMA turned to take a resident's blood pressure when Resident D took a cup of pills off of the medication cart. A CNA (Certified Nurse…

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 alleged violation was reported to the Indiana Department of Health in a timely manner related to an allegation of misappropriation of residents' medications for 1 of 1 allegations of misappropriation of residents' property. (QMA 2) Findings included: During an interview on 07/17/24 at 11:24 A.M., a Complainant indicated someone she associated with told her they were getting residents' medications from a QMA (Qualified Medication Aide) that worked in the facility. It was easy for the QMA to take the medications. The Complainant notified the Facility Administrator of her concerns related to QMA 2. The Administrator told her she would look into the matter. During an interview on 07/17/24 at 2:10 P.M., the Administrator indicated there were no allegations of misappropriation of medications during the few months she had been working in the facility. Someone did call the facility and indicated a QMA 2 was stealing medications from residents and giving them to someone she knew. The facility conducted an investigation.…

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 thoroughly investigate an allegation of abuse related to a staff member and misappropriation of medications for 1 of 4 staff reviewed. (QMA 2) Findings include: During an interview on 07/17/24 at 2:10 P.M., the Administrator indicated there were no allegations of misappropriation of medication since she had been working in the facility. Someone did call the facility and indicated a QMA (Qualified Medication Aide) was stealing medications from residents and giving them to someone she knew. The facility conducted an investigation. They reviewed residents' narcotic sheets and didn't see any discrepancies. They checked with the pharmacy and there were no irregularities with medication orders. They interviewed the staff member in question and performed a drug screen on her. The drug screen was negative. They interviewed some staff members that reported no suspicious activity with any other staff members. They did not formally suspend the staff member pending the results of the investigation. During an interview on 07/17/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to store medications appropriately for 4 of 4 medication carts observed. (1 cart on the In Motion Hallway and 3 carts on the Living Well Hallways) Findings include: 1. During an observation of an In Motion Medication Cart on 06/24/24 at 11:14 A.M., with LPN (Licensed Practical Nurse) 3 the following was observed: - a vial of Humalog insulin for Resident 82 with an open date of 05/15/24, the vial was 3/4 full and - a Humalog insulin pen for Resident 82 with and open date of 05/02/24, that was 3/4 full. LPN 3 indicated the insulin was good for 30 days after it was opened. 2. During an observation of a Living Well Short Medication Cart on 06/24/24 at 11:22 A.M., with LPN 9, the following was observed: - a Fiasp insulin pen for Resident 45 with an open date of 05/22/24 and 50 units left in the pen. The nurse indicated the insulin pen was good for 28 days after it was opened and should have been discarded on 06/20/24. 3. During an observation of a Living Well…

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 infection control guidelines during meal preparation related to the use of hair nets and failed to provide a clean and sanitary kitchen for 93 of 95 residents who received food from the kitchen. Findings include: 1. During the initial kitchen tour with the DM (Dietary Manager) on 06/18/24 at 11:07 A.M., the following was observed in the open kitchen / food prep areas: - The back door to the outside was cracked open about 1/2 inch, - A trash can, near the back door, had a swarm of gnats, greater than 10, flying around it. The DM indicated the trash can was for dirty rags, - A metal rack, that was stationed near the trash can and gnats, contained trays of individual desserts. The top tray was covered, only on the top, with a piece of paper that hung over the edge of the tray and covered 1/2 of the top of second tray on the next lower level. Two and half trays were left uncovered, - The bottom shelves of three food prep tables, one with plastic ware, tubs of cereal, and plate warmers, one with syrups 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 identify and follow physician's orders for 3 of 4 residents reviewed for pressure ulcers. (Residents 15, 37, and 38) Findings include: 1. During an observation of Resident 15's pressure wound on 06/21/24 at 12:02 P.M., LPN (Licensed Practical Nurse) 3 obtained the necessary supplies, donned a gown, washed her hands, and donned gloves. The resident was notified of providing treatment to the wound. The old dressing was removed with no odor observed. The wound to the left iliac crest was observed to be a half dollar size. There was no drainage, and the wound bed was pink. The treatment was completed without any concerns. The clinical record for Resident 15 was reviewed on 06/21/24 at 1:35 P.M. An admission MDS (Minimum Data Set) assessment, dated 09/05/23, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension and heart failure. The resident was at risk for pressure ulcers and admitted with a Stage 3 (Full-thickness skin loss in which…

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

Based on observation, record review, and interview, the facility failed to provide appropriate urinary catheter care for a resident with recent history of UTIs (Urinary Tract Infections) for 1 of 2 residents reviewed for UTIs. (Resident 88) Findings include: During an observation on 06/21/24 at 02:17 P.M., CNA (Certified Nurse Aide) 4 donned gloves and began providing peri-care for Resident 88. CNA 4 assisted the resident onto her right side and began removing her brief. A brown granular substance was observed behind the resident's tailbone. The substance was also visible on the portion of the urinary catheter tubing closest to the resident's body. CNA 4 began wiping away the brown substance behind the resident's tailbone. The CNA did not cleanse the substance off the catheter tubing. CNA 4 then removed the soiled brief and placed a new brief underneath the resident. CNA 4 reached into her own shirt pockets with her gloved hands and removed two black trash bags. CNA 4 put the soiled linens and brief into separate bags and tied them up at the bedside. Then covered the resident with…

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 the physician's order in regard to the amount of water prescribed for flushing the feeding tube and failed to gently/slowly administer the liquid nourishment without a rapid force for 1 of 2 residents reviewed for feeding tubes. (Resident 33) Findings include: During an observation on Resident 33 was observed on 06/20/24 at 1:16 P.M., while they were receiving their bolus liquid nourishment via their feeding tube administered by RN 2. The resident was sitting up in their wheelchair. The RN washed her hands, donned gloves, and placed a towel under the resident's tube on their stomach. The nurse checked for placement of the tube, checked the residual, then drew up 30 cc (cubic centimeters) of water and flushed the tube by pushing the water in using the plunger on the syringe. The RN poured the carton of liquid nourishment into an open dry container. She then drew up three syringes of the liquid nutritional formula and pushed the formula rapitly with force (over a few seconds, less than one minute), using…

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 adequately monitor a dialysis access site for 1 of 2 residents that received dialysis treatments. (Resident 20) Findings include: Resident 20 was observed in his room on 06/20/24 at 2:20 P.M. A clean dressing was in place on the resident's right forearm. The resident indicated he had an AV (arteriovenous) graft in his right arm for dialysis. They started using it less than a month ago, before that he had an access site in his chest. The nursing home facility staff didn't assess his graft site. The resident's clinical record was reviewed on 06/20/24 at 1:17 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/03/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, renal insufficiency, anxiety, and depression. The resident received dialysis treatment. The resident's current physician's orders were reviewed and lacked an order to monitor the AV graft site. During an interview on 06/20/24 at 3:05 P.M., RN 2 indicated the resident did…

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

Based on record review and interview, the facility failed to ensure PRN as needed orders for psychotropic medications were limited to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 20) Findings include: Resident 20's clinical record was reviewed on 06/20/24 at 1:17 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 05/03/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, heart failure, renal insufficiency, anxiety, and depression. The resident's physician's orders included an open-ended order, with a start date of 02/22/24, for Alprazolam (an anti-anxiety medication), 0.5 mg (milligrams) every 8 hours as needed for anxiety. A Note to Attending Physician/Prescriber, dated 03/15/24, indicated the resident was currently receiving Alprazolam 0.5 mg every 8 hours as needed for anxiety from 02/22/24. Per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if…

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

Based on interview and record review, the facility failed to ensure residents' medication administration records accurately reflected the administration of narcotic pain medication for 4 of 4 residents; and failed to account for controlled drug record forms for 3 of 4 residents reviewed for medical records. (Residents C, D, E and F) Findings include: 1. The clinical record for Resident C was reviewed on 4/3/24 at 12:01 p.m. The resident's diagnoses included, but were not limited to, neuropathy and chronic pain. The January 2024 and February 2024 medication administration records (MAR) indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) 4 times a day for pain at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. The January MAR lacked documentation of the administration of the medication on 1/8/24 at 5:00 p.m. and the February 2024 MAR lacked documentation of the administration on 2/20/24 at 5:00 p.m. The clinical record lacked documentation of the resident's administered narcotic count sheets (controlled drug reports) 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.

Based on interview and record review, the facility failed to ensure medication errors did not occur for 1 of 4 residents reviewed for medication administration. Findings include: The clinical record for Resident E was reviewed on 4/3/24 at 12:30 p.m. The diagnosis included, but was not limited to, anxiety. The physicians order, dated 6/9/23, indicated the resident was to receive Clonazepam (narcotic anti-anxiety medication), 0.5 mg (milligrams) three times a day. The January 2024 medication administration record(MAR) indicated the Clonazepam was to be administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Review of the January 2024 controlled drug record indicated on 1/5/24, the resident received an additional dose at 9:00 a.m. The clinical record lacked documentation of a physicians' order for the additional dose administered on 1/5/24. The January 2024 MAR indicated on 1/26/24 at 10:00 p.m., the resident received the scheduled dose of Clonazepam. The January 2024 controlled drug record lacked documentation of the administration of the Clonazepam. On 4/4/24 at 1:13 p.m., the Assistant…

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 notify an emergency contact of a resident's falls for 1 of 3 residents reviewed for falls. (Resident B) Findings include: The clinical record for Resident B was reviewed on 02/27/24 at 9:32 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/08/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, diabetes, and Parkinson's disease. The following SBAR (Situation Background Appearance Review and Notify) forms for falls indicated the resident was the person notified of the each fall: - 10/13/23 at 10:45 A.M., - 10/18/23 at 10:30 A.M., - 12/03/23 at 7:00 P.M., - 12/19/23 at 5:50 P.M., and - 12/25/23 at 2:30 P.M. During an interview on 02/27/24 at 10:53 A.M., LPN (Licensed Practical Nurse) 2 indicated when a resident had a fall it would be documented in a Progress Note, SBAR, and a Risk Management Assessment. The family would be notified. During an interview on 02/27/24 at 11:01 A.M., LPN 3 indicated when a resident had a fall, she would…

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 follow care planned interventions and implement an appropriate intervention after a fall for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: 1a. The clinical record for Resident B was reviewed on 02/27/24 at 9:32 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 09/08/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, hypertension, diabetes, and Parkinson's disease. A Progress Note, dated 12/03/23 at 7:00 P.M., indicated the resident was found on the floor at the side of her bed, closest to the window. There were no injuries noted. The resident continued with generalized weakness and was incontinent at the time. A neurological assessment was initiated. A new intervention was initiated to offer toileting approximately 30 minutes before bed and after meals. An IDT (Interdisciplinary Team) Note, dated 12/04/23 at 5:46 P.M., indicated the note was related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have adequate staff available to provide Activities of Daily Living related to showers for 4 of 5 residents reviewed for ADL's. (Residents B, D, N, and G) Findings include: 1. The clinical record for Resident B was reviewed on 9/27/23 at 11:20 A.M. The resident's diagnoses included, but were not limited to, heart failure, hypertension, chronic venous hypertension with ulcer of bilateral lower extremity, lymphedema, and aphasia. The resident's Shower/Bath report for September 2023 was provided by the Administrator on 09/27/23 at 5:01 P.M., and indicated the resident had received the following: - A PBB (Partial Bed Bath) on 09/09/23, - A PBB on 09/10/23, - A Complete Bed Bath on 09/11/23, - A PBB x2 on 09/14/23, - A PBB x2 on 09/16/23, - A PBB on 09/18/23, - A PBB on 09/20/23, - A Complete Bed Bath x2 09/21/23, - A PBB on 09/23/23, - A Complete Bed Bath on 09/25/23, and - A PBB on 09/26/23. The Shower Sheets for September 2023 were provided…

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 identify wound development, complete neurological assessments after a fall, and follow physician orders for wound care for 3 of 12 residents reviewed for Quality of Care. (Residents D, L, and G) Findings included: 1. During an observation and interview on 09/28/23 at 8:40 A.M., LPN (Licensed Practical Nurse) 9 indicated to Resident D that they were going to administer a wound treatment. The resident's left sock and shoe were removed. The resident had a dressing to the left lateral heel. The wound was pink in color and about the size of a pencil eraser. The LPN indicated the resident's dressing was changed every other day. The clinical record for the resident was reviewed on 09/27/23 at 11:52 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/15/23, indicated the resident was cognitively intact. The diagnoses included but were not limited to, stroke, hypertension, diabetes, and anxiety. A Podiatry Note, dated 03/23/23, indicated the resident pedal pulses were nonpalpable to the bilateral feet. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent and identify pressure ulcers that resulted in a resident developing a Stage 3 and an Unstageable pressure ulcer for 3 of 4 residents reviewed for pressure ulcers. (Residents B, C, and G) Findings include: 1. During an observation and interview on 09/27/23 at 3:48 P.M., LPN (Licensed Practical Nurse) 8 had the supplies gathered and entered Resident B's Room. She closed the door with her bare hands, donned gloves, and assisted the resident with removing a pillow from her right side. The pillow was flat and had not been keeping the resident off her bottom. The resident was assisted with turning to her right side. The LPN removed two bordered gauze bandages from her buttocks that were dated 09/27/23. The right buttock wound was covered in eschar and measured 9.25 cm (centimeters) x 5.5 cm. The wound had a slight odor. The LPN cleansed the wound with normal saline, cleansed with Dakins solution, and covered the wound with a hydrocolloid…

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 prevent a female resident with a diagnosis of dementia and a history of wandering from being inappropriately touched by a male resident when she wandered into his room unsupervised for 2 of 4 residents reviewed for dementia care. (Residents E and F) Findings include: 1. The clinical record for Resident F was reviewed on 09/27/23 at 9:32 A.M. An admission MDS assessment, dated 06/11/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, anemia, non-Alzheimer dementia, malnutrition, and psychotic disorder. The resident had a limb prosthesis and didn't use a walker or wheelchair. The resident required the assistance of one staff member for ADLs. A Progress Note, dated 07/27/23 at 9:30 P.M., indicated Resident F was found lying down in a male resident's bed, with the male resident's hand was down her pants. The residents were separated immediately, and the female resident was assisted back to her room. She was assessed from head to toe with no skin impairment or trauma…

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 store and prepare foods in a safe and sanitary manner related to open trash containers, hair net usage, and labeling foods for 4 of 5 kitchen and snack refrigerators observations. Findings include: 1. The initial kitchen tour was conducted on 03/29/23 at 10:10 A.M., and the following was observed: - A large silver stock pot, approximately two gallon size, was inverted on a low shelf of a silver food prep table next to the hand washing sink. The half of the pot nearest the sink was splatter with white dry drops and had a layer of dust on the bottom. - A medium size open box that sat on the floor next to the trash can by the hand washing sink was full of trash and contained wadded up gloves and paper products. - The DM (Dietary Manager) had a one inch by three inch shock of hair next to her right ear protruding from her hair net as she walked around the kitchen in the food prep areas. The walk-in refrigerator contained the following: - A clear plastic gallon bag of diced chicken, as identified by the DM, that was not labeled.…

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 reasonable accommodations to meet the needs and preferences of a resident related to placement in the locked Dementia Unit for 1 of 24 residents reviewed for Residents' Rights. (Resident 50) Findings include: During an observation and interview on 03/29/23 at 2:14 P.M., Resident 50 was sitting in a wheelchair in her room on the locked Dementia Unit, Unit 3. She indicated she had talked to the nurse on the unit and told her that she did not like living on Unit 3. She liked it on Unit 2. She went over on Unit 2 the other day for therapy and residents were out by the nurse's station talking and they greeted her. She used to live over there. They didn't do many activities on the Dementia Unit. She used to participate in all kinds of activities on Unit 2. She felt sorry for the people on Unit 3 because most of them had mental problems. She told staff several weeks ago that she wanted to go back to Unit 2. If you go out in the hall…

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 accurately complete MDS (Minimum Data Set) assessments related to anticoagulant medication and diagnoses for 2 of 18 residents reviewed for accuracy of assessments. (Residents 60 and 50) Findings include: 1. The clinical record for Resident 60 was reviewed on 03/31/23 at 11:20 A.M. A Significant Change MDS assessment, dated 02/27/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, Chronic Obstructive Pulmonary Disease, dementia, anxiety, and depression. The resident had received an anticoagulant for seven of seven days during the review period. The physician's order for February 2023, indicated the resident was prescribed Clopidogrel (an antiplatelet) 75 mg (milligrams) once a day. The February 2023 EMAR (Electronic Medication Administration Record) lacked documentation that the resident had received an anticoagulant during the review period. During an interview on 04/04/23 at 11:04 A.M., the MDS Coordinator indicated Plavix (Clopidogrel) was coded in error…

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 administer physician ordered wound treatments and identify pressure ulcers in a timely manner for 2 of 5 residents reviewed for pressure ulcers. (Residents 57 and 36) Findings include: 1a. Resident 57 was observed in her room on 03/30/23 at 2:59 P.M. The resident was laying on her right side in bed. The resident indicated she was admitted to the facility last year with a pressure ulcer on her backside; and surgical wounds and pressure ulcers on her feet. The resident saw the Wound NP (Nurse Practitioner) in the facility and went to a local wound clinic. The resident's clinical record was reviewed on 03/31/23 at 11:25 A.M. An admission MDS (Minimum Data Set) assessment, dated 09/07/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, sub-acute osteomyelitis of the left ankle and foot, anemia, cirrhosis with ascites, diabetes, and acquired absence of left toes. The resident required extensive assistance from two staff members for toileting, had an indwelling…

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 Fall Care Plan interventions related to identified falls for 1 of 5 residents reviewed for accidents. (Resident 43) Findings include: During an observation and interview on 03/30/23 at 10:09 A.M., Resident 43 was sitting in her room in a wheelchair. She indicated she had recently fallen a few times and was supposed to call for help to get up. She had felt faint and lightheaded at times. The clinical record was reviewed on 04/03/23 at 1:12 P.M. A Significant Change MDS (Minimum Data Set) assessment, dated 03/06/23, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, diabetes, hypertension, dementia, anxiety, depression, and muscle weakness. The resident required supervision and one staff member's physical assistance with transfers, toilet use, and personal hygiene. The resident had two or more falls since the last assessment. The Progress Notes for February 2023, were provided by the Administrator on 04/04/23 at 9:45 A.M. An IDT (Interdisciplinary Team) Note,…

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 monitor residents while taking psychotropic medications for adverse side effects for 2 of 5 residents reviewed for unnecessary medications. (Residents 44 and 50) Findings include: 1. The clinical record for Resident 44 was reviewed on 04/03/23 at 10:00 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 12/01/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, hypertension, diabetes, anxiety, depression, and schizophrenia. The August, September, and October 2022 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident was administered the following medications: - Aripiprazole (an antipsychotic medication) 15 mg (milligrams) once a day for paranoid schizophrenia, with a start date of 08/29/22, - Trazodone (an antidepressant medication) 50 mg, at bedtime for insomnia, from 08/26/22 through 09/23/22, - Trazodone 100 mg, at bedtime for insomnia, from 09/23/22 through 10/21/22, and - Eszopiclone (a…

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

Based on record review and interview, the facility failed to prevent significant medication errors and monitor side effects related to Coumadin (a blood thinner medication) for 1 of 5 residents reviewed for unnecessary medications. (Resident 44) Findings include: 1a. During an observation on 04/03/23 at 4:08 P.M., Resident 44 was outside with staff and other residents. The clinical record for Resident 44 was reviewed on 04/03/23 at 10:00 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 12/01/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, anemia, hypertension, diabetes, anxiety, depression, and schizophrenia. A Physician's Note, dated 09/02/22, indicated the facility was to discontinue the residents Aspirin and Clopidogrel (an aniplatelet), and start Warfarin 5 mg once a day for prosthetic heart valve. A physician's order, dated 09/03/22 through 09/11/22, indicated the staff were to administer Warfarin (Coumadin), 5 mg (milligrams), once a day. A physician's order, dated 09/09/22 through 09/11/22, indicated the staff 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 store medications appropriately for 2 of 3 medication carts reviewed. (100 Hall and 200 Hall medication carts) Findings include: 1. During a random observation on 03/29/23 at 9:56 A.M., the 100 Hall medication cart was left unattended. On top of the medication cart were approximately eight medication cards filled with medications. The medication cards were labeled with the resident's name, the name of the medication, the dosage, and how often the resident was to take the medication. The nurse was standing approximately 12 feet away from the medication cart. She was talking with a visitor. The nurse left the area, walked down the hall away from the medication cart. A few minutes later the Administrator walked to the medication cart, gathered the medication cards, placed them in a secure office. During an interview on 03/29/23 at 10:00 A.M., the Administrator indicated the medications should not have been left unattended on top of the medication cart. 2. During a medication administration observation 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.