Aperion Care Marion LLC

Based on observation, interview, and record review, the facility failed to ensure a resident was free from verbal abuse and intimidation by a staff member for 1 of 3 residents reviewed for abuse. (Resident C)Findings include:Resident C's clinical record was reviewed on 9/29/25 at 12:10 p.m. Diagnoses included chronic obstructive pulmonary disease (COPD), hypertension, depression, atrial fibrillation, and congestive heart failure.An admission Minimum Data Set (MDS) assessment, dated 8/4/25, indicated Resident C was cognitively intact, had depression, required supervision for bed mobility, transfers, toileting, and eating. Resident C did not exhibit hallucinations, delusions, or behaviors.A current care plan, initiated on 7/30/25, indicated Resident C had a diagnosis of depression. Interventions included administering medications as ordered, encouraging socialization, and observing signs and symptoms of depression (crying, seclusion from others, isolation, decreased appetite, withdrawal).A current care plan, initiated on 9/22/25, indicated Resident C used antidepressant medication…

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 physician orders for blood pressure and heart rate parameters were followed when medications were administered for 2 of 3 residents reviewed for blood pressure medications. (Resident B and Resident D) Findings include: 1. Resident D's clinical record was reviewed on 9/9/25 at 11:11 a.m. Diagnoses included essential hypertension, hypertensive heart disease with heart failure, atherosclerotic heart disease of native coronary artery (plaque buildup in the artery) with unspecified angina pectoris (severe chest pain), and heart failure, unspecified. Physician orders included metoprolol tartrate (for blood pressure) 50 milligrams (mg) two times a day - hold for systolic blood pressure (SBP) less than 100 either/or heart rate (HR) less than 60 (started 4/16/25 and discontinued 8/9/25), metoprolol tartrate 50 mg two times a day - hold if SBP less than 100 or HR less than 50 (started 8/9/25), losartan potassium (for blood pressure) 100 mg daily - hold for SBP less than 110 or diastolic blood pressure (DBP) less than 60…

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 ensure the resident environment remained free of potential hazards for 2 of 4 residents reviewed for smoking. (Resident B, Resident E)Findings include:1.During an observation, on 7/16/25 at 12:14 p.m., Resident B held her cigarettes and lighter as she walked away from the designated smoking area. Resident B indicated she smoked independently and she was headed back to her room to store her cigarettes and smoking supplies. Resident B's clinical record was reviewed on 7/17/25 at 1:44 p.m. Diagnoses included hypertension (high blood pressure), chronic obstructive pulmonary disease (progressive lung disease that makes it hard to breathe), depression, and anxiety.An admission Minimum Data Set (MDS) assessment, dated 5/1/25, indicated Resident B was cognitively intact.Resident B's clinical record lacked an order for smoking.A smoking safety risk assessment, dated 4/28/25, indicated Resident B smoked daily and used cigarettes and a lighter. She did not have a history or currently present with unsafe…

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

Based on interview and record review, the facility failed to ensure the Dietary Manager completed the required education to meet the qualifications for a dietary manager. This deficiency had the potential to impact 58 of 58 facility residents who received meals from the facility kitchen. Finding includes: The employee record form, completed by the facility and provided following entrance conference on 4/27/25, indicated the Dietary Manager had been employed by the facility since 2/1/25 and lacked a dietary manager certification. During an interview, on 4/30/25 at 3:00 p.m., the Dietary Manager indicated he was in the process of getting his food manager certification. During an interview, on 5/1/25 at 11:59 a.m., the Nurse Consultant indicated the Dietary Manager did not have any food service manager certifications. During an interview, on 5/1/25 at 3:08 p.m., the Dietary Manager indicated he had twenty years of food service experience but was not technically a dietary manager until he started at the facility. He was not currently certified but was getting ready to take 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 and interview, the facility failed to ensure food was prepared and served under safe sanitary conditions regarding food handling and hand washing. This deficient practice had the potential to affect 55 of 55 residents who received their meals from the kitchen. Findings include: During a lunch service observation, on 04/29/25 12:30 p.m. to 1:15 p.m., the following food handling and food service concerns were observed: Dietary Employee 7 (DE 7) propelled a resident forward in her wheelchair and locked the wheelchair brake. She did not perform hand hygiene before touching a set of tongs to place a lemon slice into a drink. She then touched the back of another female staff member before she lifted a container of lemon slices, with her left thumb touching the inside of the lemon slice container. Dietary Employee 8 (DE 8) grabbed a hot dog bun with his bare hands, place it on a plate, and opened it. No hand hygiene was performed. DE 8 crossed his ungloved hands, placing his hands on his waist and lower back. He went through meal tickets one by one like he was dealing…

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 mail was distributed to the residents on Saturdays. This deficiency had the potential to affect 58 of 58 residents who resided in the facility. Findings include: During a Resident Council meeting, on 4/30/25 beginning at 3:35 p.m., Resident 40 indicated the facility did not deliver mail to the residents on Saturdays. The activity department staff was to deliver mail after the business office manager sorted it. The business office manager did not work weekends. Residents 41, 45, 58, 10, 28, 51, 2, 33, and 25 indicated they did not receive mail on Saturdays. During an interview, on 5/1/25 at 10:06 a.m., the Activity Director (AD) indicated the activity department delivered mail to the residents. Mail was distributed on the days that the Business Office Manager /Financial Coordinator (BOM) was at the facility. The BOM received and sorted the mail and placed it on the front desk when it was ready for distribution to the residents. During an interview, on 5/1/25 at 10:14 a.m., the BOM indicated that she sorted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents and/or resident representatives received a copy of their baseline care plans on admission for 5 of 5 residents reviewed for care plans. (Resident 8, 52, 57, 61, and 264) Findings include: 1. Resident 52's clinical record was reviewed on 4/29/25 at 10:48 a.m. Diagnoses included alcoholic hepatic (liver) failure without coma, hepatic encephalopathy (disease or damage that affects the brain, leading to a change in mental state), type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified anemia, and thrombocytopenia (low platelet count in the blood which can cause prolonged bleeding). A progress note, dated 12/5/24 at 12:45 p.m., indicated the resident was admitted to the facility. The clinical record lacked documentation that the resident or the resident's representative was provided with a copy of the baseline care plan prior to the completion of the comprehensive care plan. During an interview, on 5/1/25 at 11:04 a.m.,…

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

During observation, record review, and interview, the facility failed to change, label, and date oxygen and nebulizer supplies for 4 of 4 residents (Resident 5, 34, 56, and 264) and ensured residents received the correct flow rate of oxygen for 1 of 4 residents reviewed for oxygen use of 8 residents in the facility who required supplemental oxygen (Resident 56). Findings include: 1. Resident 34's clinical record was reviewed on 4/30/25 at 9:53 a.m. Diagnoses included respiratory failure, hypertension (high blood pressure), anxiety, and heart failure. Current orders included change out, date, and label oxygen humidifier and tubing every Sunday night. Oxygen at 4 liters per minute (LPM) continuously via nasal cannula. During an observation, on 4/27/25 at 2:55 p.m., Resident 34's oxygen tubing bag was dated 2/2/25. During an observation, on 4/30/25 at 10:32 a.m., Resident 34's oxygen tubing bag was dated 2/2/25. During an interview, on 4/27/25 at 3:54 p.m., QMA 21 indicated Resident 34's oxygen tubing bag was labeled 2/2/25. During an interview, on 4/29/25 at 1:39 p.m., LPN 22…

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 meals were at an appetizing temperature for 12 of 15 residents reviewed for palatable meals. (Resident 17, 35, 61, 116, 23, 4, 53, 38, 56, 7, 2, and 30) Findings include: During an interview, on 4/27/25 at 10:12 a.m., Resident 61 indicated the food was always cold. During an interview, on 4/27/25 at 4:28 p.m., Resident 17 indicated the food was generally not hot at all. She was getting used to eating cold scrambled eggs. During a Resident Council meeting, on 4/30/25 at 3:35 p.m., the resident group indicated the room tray meals, especially in the evening, were cold. A facility document, provided during the entrance conference on 4/27/25, indicated breakfast was at 7:45 a.m., lunch at 12:30 p.m., and dinner at 5:45 p.m. During an observation, on 4/30/25 at 6:27 p.m., a closed meal cart was on the D Hall unit. At the same time, RN 6 indicated the meal cart had just arrived. During an observation, on 4/30/25 at 6:31 p.m., CNA 18, 19, and 20 began serving trays. During an observation, on 4/30/25 at 6:47…

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 honor a resident's right to self-determination and communication for 1 of 1 resident reviewed for Resident Rights. (Resident 19) Findings include: During an observation on 4/27/25 at 10:50 a.m., Resident 19 was lying in bed with a touch pad call light within reach. She indicated she was unable to turn and reposition herself and unable to call her family member. She relied on staff to help with all activities of daily living (ADLs). The Administrator had spoken to her about her frequent calls to her family member, telling her she called him too much and gave him too much information. Resident 19's clinical record was reviewed on 5/1/25 at 11:30 a.m. Diagnoses included cerebral palsy, obsessive-compulsive disorder, mild intellectual disabilities, fibromyalgia, and other abnormalities of gait and mobility. The resident's cognitive status was moderately impaired. An admission Minimum Data Set (MDS) assessment, dated 3/9/25, indicated Resident 19 was dependent on staff for eating, oral hygiene, toileting hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide an accurate code status for 1 of 1 resident reviewed for advance directives. (Resident 10) Findings include: Resident 10's clinical record was reviewed on [DATE] at 10:13 a.m. Diagnoses included hypertension and dementia. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was moderately cognitively impaired. The current, main page on Resident 10's electronic health record indicated a Do Not Resuscitate (DNR) code status. A current physician's order, dated [DATE], indicated Do Not Resuscitate. A current care plan, initiated on [DATE], indicated Resident 10 had a signed and valid DNR in the event she should stop breathing and display no pulse, as a result of failure of the heart to contract effectively or at all. Interventions included I will be enabled to live to the limit of my potential ability physically, mentally, and spiritually, administer medications as ordered, encourage the resident and family members 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 interview and record review, the facility failed to follow physician orders regarding physician/nurse practitioner notification of a resident's weight gain for 1 of 23 residents reviewed for medications. (Resident 17) Findings include: Resident 17's clinical record was reviewed on 4/29/25 at 12:01 p.m. Diagnoses included essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with diabetic neuropathy, personal history of other diseases of the urinary system, presence of urogenital implants, presence of cardiac pacemaker, obstructive and reflux uropathy (blockage and flow from the bladder backs up into the ureters which connect to the kidneys), and chronic kidney disease, stage 3a (moderate decline in kidney function). A current order, dated 3/27/25, indicated to weigh the resident daily and notify the physician or nurse practitioner if the resident had a weight gain of three pounds in a day or five pounds in a week. The resident weighed 178 pounds on 4/11/25. On 4/18/25, she weighed 183.4 pounds with a greater than five-pound weight gain 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 maintain a homelike environment related to a clean, sanitary environment in a resident's room for 1 of 3 resident's reviewed for environment. (Resident 34) Findings include: During an observation on 4/27/25 at 2:55 p.m., Resident 34's trash can overflowed. Trash was on the floor beside the bed. A mask lay on the floor in the entryway of the room. A second mask lay on the floor beside the oxygen concentrator. The bedside table was visibly dirty. A pile of clothing was on the bathroom floor underneath the sink. A navy-blue clothing item lay on top of the pile. During an observation on 4/28/25 at 10:48 a.m., the resident's room continued to have trash surrounding the trash can and on the floor beside her bed. The previously observed masks remained on the floor, laying in the same locations. The bedside table had a large area (the size of large dining plate) of dried, sticky residue. During an interview on 4/29/25 at 9:54 a.m., Resident 34 indicated that housekeeping emptied her trash and swept the floor 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 record review and interview, the facility failed to ensure the resident's representative or resident was notified in writing of transfer/discharge appeal rights for 2 of 3 residents reviewed for hospitalizations. (Resident 31 and 52) Findings include: 1. Resident 52's clinical record was reviewed on 4/29/25 at 10:48 a.m. Diagnoses included alcoholic hepatic (liver) failure without coma, hepatic encephalopathy (disease or damage that affects the brain, leading to a change in mental state), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and thrombocytopenia (low platelet count in the blood which can cause prolonged bleeding). A progress note, dated 12/8/24 at 5:50 p.m., indicated the resident was admitted to the hospital for hepatic encephalopathy. The resident's clinical record lacked indication that the resident and the resident's representative were notified of the transfer/discharge appeal rights in writing for the resident's transfer to the hospital. During an interview, on 5/1/25 at 2:59 p.m., RN 6 indicated she was not sure if the notice of transfer…

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 the resident's representative or resident received a written notice of the bed hold policy at the time of transfer for 2 of 3 residents reviewed for hospitalizations. (Resident 31 and 52) Findings include: 1. Resident 52's clinical record was reviewed on 4/29/25 at 10:48 a.m. Diagnoses included alcoholic hepatic (liver) failure without coma, hepatic encephalopathy (disease or damage that affects the brain, leading to a change in mental state), type 2 diabetes mellitus with hyperglycemia (high blood sugar), and thrombocytopenia (low platelet count in the blood which can cause prolonged bleeding). A progress note, dated 12/8/24 at 5:50 p.m., indicated the resident was admitted to the hospital for hepatic encephalopathy. The resident's clinical record lacked indication that the resident and the resident's representative were notified of the bed hold policy in writing at the time of the resident's transfer to the hospital. During an interview, on 5/1/25 at 2:59 p.m., RN 6 indicated she was not sure if the bed hold…

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 recapitulation of the resident's stay was included in the discharge summary when the resident discharged from the facility. (Resident 27) Finding includes: Resident 27's clinical record was reviewed on 4/29/25 at 1:01 p.m. Diagnoses included atrial fibrillation (irregular heartbeat), obstructive sleep apnea, other specified diabetes mellitus with diabetic neuropathy, bipolar disorder, unspecified, peripheral vascular disease, unspecified, gangrene, not elsewhere classified, and chronic kidney disease, stage 4 (severe). The resident was admitted on [DATE] and discharged on 4/21/2025 at 10:00 a.m. to another long-term care facility. Her discharge paperwork lacked a summary of the resident's stay in the facility. A facility form, provided by the DON on 4/30/25 at 3:30 p.m., titled Discharge instructions, included the resident's vital signs, the resident's ordered medications, the resident's equipment and referral needs, the resident's dietary…

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

Based on interview and record review, the facility failed to follow physician orders regarding daily weight monitoring and administration of blood pressure medication according to ordered parameters for 2 of 23 residents reviewed for medications. (Residents 17 and 5) Findings include: 1. Resident 17's clinical record was reviewed on 4/29/25 at 12:01 p.m. Diagnoses included essential (primary) hypertension (high blood pressure), type 2 diabetes mellitus with diabetic neuropathy, personal history of other diseases of the urinary system, presence of urogenital implants, presence of cardiac pacemaker, obstructive and reflux uropathy (blockage and flow from the bladder backs up into the ureters which connect to the kidneys), and chronic kidney disease, stage 3a (moderate decline in kidney function). A current order, dated 3/27/25, indicated to weigh the resident daily and notify the physician or nurse practitioner if the resident had a weight gain of three pounds in a day or five pounds in a week. The medication administration record for 4/1/25 through 4/1/28 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 interview and record review, the facility failed to protect a resident's right to be protected from sexual abuse perpetrated by an employee engaging in sexually-toned conversations and behavior for 1 of 1 resident reviewed for sexual abuse. (Resident B) Findings include: A facility reportable document, dated 2/3/25 at 6:01 p.m., indicated it was reported to the DON and the Administrator that an employee, CNA 3, was texting Resident B inappropriate pictures. The employee was suspended and an investigation was initiated. During an interview on 2/13/25 at 12:45 p.m., Resident B indicated he had received pictures from CNA 3. He was okay with their relationship. He had no concerns with the situation except the CNA lost her job. He managed his own money and had given CNA 3 $50.00, but this was not for the photos. He had not asked her to send them to him, but he had not minded receiving them. CNA 3 and her husband had come to the facility to take him to a department store to buy a phone card, but were stopped by facility staff from transferring him into their vehicle. A clinical…

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 the active licensure of a Practical Nurse (PN) who provided care to residents for 1 of 55 employees reviewed for active licensure. (PN 2) Findings include: During Employee Record Review, PN 2's nursing license was indicated as expired on [DATE] on the MyLicense.IN.gov website, accessed on [DATE] at 11:20 a.m. PN 2 worked as a nurse, providing resident care, following the expiration of her licensure on the following dates: [DATE], 8, 9, 10, 13, 14, 18, 19, 22, 23, 24, 27, and 28, 2024. [DATE], 6, 7, 8, 11, 12, 16, 17, 20, 21, 22, 25, 26, 30, and 31, 2024. [DATE], 5, 8, 9, 13, 14, 17, 18, 19, 22, 23, 27, 28, and 31, 2025. During an interview on [DATE] at 3:52 p.m., the DON indicated human resources was responsible for tracking staff licensure. PN 2 was allowed to continue working in her role as an LPN due to the facility not realizing her licensed had expired. She should not have been on the schedule until her licensure was updated and valid. The…

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

Based on record review and interview and observation, the facility failed to ensure sanitary kitchen food storage and handling conditions. This deficient practice had the potential to effect 59 of 59 facility residents who received their meals from the facility kitchen. Findings include: During a kitchen tour with [NAME] 1, on 12/11/24 at 10:10 a.m., the following concerns were observed: a. An open bag of sugar in a bin containing unknown particles of and trash in the bottom of the bin. b. Clean cups, bowls, and plates stored upright, exposing the eating surfaces. c. A cart holding clean dishes visibly soiled with dried food and splash stains. d. A bucket with dirty mop water and a mop leaning against the clean dishes rack. e. A cleaning bucket with used cleaning cloths stored under the oven. f. Soiled serving utensils on the preparation table. g. Dried spillage and trash over the surface of the floor. h. An open sleeve of bread on the preparation table with no open date on the packaging. i. An open, uncovered box of cream of wheat with no open date on the packaging. j. The three…

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 report a resident to resident altercation to the State Agency. (Resident F and Resident G) Findings include: During an interview on 12/16/24 at 12:31 p.m., Resident F indicated she was hit by another resident in the chest. Resident F indicated she was attempting to enter the dining room and Resident G was blocking the entry way. She asked Resident G to move and the other resident became aggressive. Resident F indicated she had a bruise on her chest as a result of being hit. Resident F indicated she hit Resident G in response and there were staff witnesses to the incident. Resident F's residential clinical record was reviewed on 12/16/24 at 1:16 p.m. The clinical record lacked indication of behavioral concerns. Resident G's nursing home clinical record was reviewed on 12/16/24 at 1:25 p.m. Diagnoses included depression, dementia, anxiety, schizoaffective disorder, and hypertension. The resident had a history of verbally aggressive behaviors. During an interview on 12/16/24 at 2:19 p.m., the Corporate Regional [NAME]…

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 prevent a significant medication administration error for 1 of 5 residents reviewed for medication administration. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/14/24 at 11:27 a.m. Diagnoses included cervical region spinal stenosis, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility, and depression. Physician orders for October 2024 indicated the resident had an order for hydrocodone-acetaminophen (opioid analgesic) 10-325 mg every 6 hours as needed for pain, dated 10/10/24 and discontinued on 10/18/24. An order for hydromorphone (opioid analgesic) 4 mg every 4 hours as needed for severe pain was dated 10/11/24 and discontinued 10/18/24. The Medication Administration Record (MAR) for October 2024 indicated the following for Resident B: a. RN 1 administered hydrocodone-acetaminophen 10-325 mg on 10/12/24 at 10:38 p.m. On 10/12/24 at 10:35 p.m.,hydromorphone 4 mg was given. The pain rate…

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 nursing staff were competent in the administration of controlled medications as evidenced by RN 1 administering two opioid analgesics together to a resident (Resident B). Findings include: The clinical record for Resident B was reviewed on 11/14/24 at 11:27 a.m. Diagnoses included cervical region spinal stenosis, type 2 diabetes, muscle wasting and atrophy, abnormalities of gait and mobility, and depression. Physician orders for October 2024 indicated the resident had an order for hydrocodone-acetaminophen (opioid analgesic) 10-325 mg every 6 hours as needed for pain, dated 10/10/24 and discontinued on 10/18/24. An order for hydromorphone (opioid analgesic) 4 mg every 4 hours as needed for severe pain was dated 10/11/24 and discontinued 10/18/24. The Medication Administration Record (MAR) for October 2024 indicated the following for Resident B: a. RN 1 administered hydrocodone-acetaminophen 10-325 mg on 10/12/24 at 10:38 p.m. On 10/12/24 at…

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

Based on interview and record review, the facility failed to ensure a qualified dietary manager supervised the kitchen staff and operations. This deficiency had the potential to affect 54 of 55 residents who received meals from the facility kitchen. Finding includes: During an interview, on 6/24/24 at 10:13 a.m., the Head [NAME] indicated the kitchen had been without a manager for six to seven months. During an interview, on 6/24/24 at 4:14 p.m., the Administrator indicated the facility did not currently have a dietary manager. She was filling in as the dietary manager. The employee records, provided by the Administrator on 6/25/24 at 9:50 a.m., did not include a dietary manager. During an interview, on 6/27/24 at 9:24 a.m., the Head [NAME] indicated she was not certified as a dietary manager, but she and the Administrator had been discussing getting her into a certification class. She indicated the dietician came in about three times a month. During an interview, on 6/28/24 at 11:55 a.m., the Administrator indicated a new dietary manager had started on 6/24/24. The prior dietary…

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 obtain physician orders for medications and assess residents for self-administration of medications for 2 of 2 residents with medications stored in their rooms. (Resident 35 and Resident 52) Findings include: 1. During an observation, on 6/24/24 at 11:38 a.m., a mometasone furoate nasal spray (used to treat and prevent symptoms of seasonal and perennial hay fever) was on Resident 52's bedside table. Resident 52 indicated she gave herself a spray in each nostril in the morning and evening. During an observation, on 6/26/24 at 12:41 p.m., the nasal spray remained on the resident's bedside table. During an observation, on 6/27/24 at 2:37 p.m., the nasal spray remained on the resident's bedside table. Resident 52's clinical record was reviewed on 6/25/24 at 2:19 p.m. and lacked a physician's order for mometasone furoate spray and a self-administration of medication assessment. During an interview, on 6/27/24 at 3:57 p.m., LPN 8 indicated the residents were permitted to have medications in their rooms if there 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 interview and record review, the facility failed to ensure advance directives were developed and signed by the resident, who was cognitively intact and their own representative, for 1 of 2 residents reviewed for advance directive. (Resident 35) Findings include: Resident 35's clinical record was reviewed on 6/26/24 at 9:23 a.m. Diagnoses included unspecified adrenocortical insufficiency (Addison's disease), epilepsy, unspecified, not intractable, without status epilepticus, and cirrhosis of liver. Current physician's orders included full code (9/7/23). An admission Minimum Data Set (MDS) assessment, dated 9/9/23, indicated the resident was cognitively intact. An Indiana Physician Orders for Scope of Treatment (POST) form was completed on 9/7/23. Section E indicated in order for the POST form to be effective the patient or legally appointed representative must sign and date the form. Under the signature of patient or legally appointed representative section, the resident's representative had signed the form on 9/7/23. The resident's profile indicated the resident was the…

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

Based on record review and interview, the facility failed to accurately code medications on the Minimum Data Set (MDS) assessments for 1 of 3 residents reviewed for medication use. (Resident D) Finding includes: Resident D's clinical record was reviewed on 6/25/24 at 4:12 p.m. Diagnoses included depression, delusional disorders, hallucinations, unspecified, vascular dementia, moderate, with agitation, and atherosclerotic heart disease of native coronary artery (a build-up of fats, cholesterol, and other substances in and on the artery walls causing obstruction of blood flow) without angina pectoris (chest pain). Current physician orders included the following: clopidogrel bisulfate (antiplatelet - used to inhibit blood clot formation) 75 mg daily (11/20/23), mirtazapine (antidepressant) 7.5 mg daily at bedtime (2/16/24), risperidone (antipsychotic) 0.5 mg daily in the morning (3/2/24), risperidone 1 mg daily at bedtime (3/1/24), and sertraline (antidepressant) 100 mg daily (1/24/24). A quarterly MDS assessment, dated 2/20/24, indicated the resident received insulin. The assessment…

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 grooming assistance (Resident C and D) and provide scheduled showers (Resident D) for 2 of 4 residents reviewed for activities of daily living (ADLs). Findings include: 1. During an interview, on 6/25/24 at 11:43 a.m., Resident D's representative indicated the resident's fingernails were always dirty. During an observation, on 6/25/24 at 4:26 p.m., Resident D was lying in bed. Her fingernails had a brown substance under the tips. During an observation, on 6/26/24 at 9:44 a.m., the resident was lying in bed. A brown substance was under her fingernail tips. The resident indicated she wanted a sponge bath. Resident D's clinical record was reviewed on 6/25/24 at 4:12 p.m. Diagnoses included depression, delusional disorders, hallucinations, unspecified, vascular dementia, moderate, with agitation, and need for assistance with personal care. A quarterly Minimum Data Set (MDS) assessment, dated 5/5/24, indicated the resident was moderately cognitively impaired. No behaviors were identified. She required…

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 implement interventions to prevent the development of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 31) Finding includes: During an observation, on 6/24/24 at 12:15 p.m., Resident 31 was lying on his back in bed with heel boots on. During an observation, on 6/25/24 at 2:19 p.m., the resident was lying on his back in bed with heel boots on. During an observation, on 6/26/24 at 12:42 p.m., the resident was lying on his back in bed with heel boots on. Resident 31's clinical record was reviewed on 6/26/24 at 2:25 p.m. Diagnoses included methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, nontraumatic hematoma of soft tissue, other mechanical complication of surgically created arteriovenous fistula, dependence on renal dialysis, type 2 diabetes mellitus with diabetic neuropathy, peripheral vascular disease, diastolic (congestive) heart failure, and need for assistance with personal care. Current physician orders included 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 address the dietary needs for a dialysis resident related to impaired nutrition for 1 of 1 resident reviewed for dialysis. (Resident 28) Finding includes: During an observation, on 6/25/24 at 2:32 p.m., Resident 28 was sitting in a wheelchair in his room. His lunch tray was sitting on his table in front of him with meatloaf, mixed vegetables, a dessert, coffee and an empty cup with remnants of a brown liquid. He ate less than 25% of his meatloaf and nothing else. He indicated the food lacked something but could not verbalize what. There were no condiments on his tray. He stated, It's just too hard with these teeth. He was wearing dentures. During an observation, on 6/26/24 at 9:19 a.m., the resident was eating his breakfast while watching TV. His breakfast plate was empty and he indicated his food was actually warm today. He did not eat any of the oatmeal. He drank his coffee and there was a milk carton on his tray. He indicated that he did not get lunch prior to or during dialysis that he attended every…

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.

2. Resident 108's clinical record was completed on 6/26/24 at 9:36 a.m. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), abnormalities of gait and mobility, unsteadiness on feet, and a need for assistance with personal care. An admission MDS assessment, dated 6/22/24, indicated the resident was cognitively intact. A physician's order, dated 6/20/24 at 6:00 p.m., indicated the resident should be assessed for pain every shift. A physician's order, dated 6/19/24 at 5:00 p.m., included Hydrocodone-Acetaminophen (a narcotic pain reliever) 5-325 mg, 1 tablet by mouth, every 4 hours, as needed, for moderate pain. A current care plan, dated 6/20/24, indicated to give medications as ordered by physician and to monitor and document side effects and effectiveness of medications. A review of routine shift pain assessments indicated a zero (0) pain rating, on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, was documented by nursing on 6/20/24, 6/21/24, 6/22/24, 6/23/24, 6/25/24, and 6/26/24. On 6/20/2024 at 9:30 a.m., the resident had rated his…

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 pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications. (Resident 1) Findings include: Resident 1's clinical record was reviewed on 6/26/24 at 2:39 p.m Diagnoses included schizophrenia, major depressive disorder, unspecified intellectual abilities, and anxiety disorder. A quarterly Minimum Data Set evaluation, dated 5/20/24, indicated the resident was cognitively intact and required substantial to maximal assistance from staff for activities of daily living. A gradual dose reduction recommendation from the pharmacist, dated 11/22/23, indicated the resident was receiving the antipsychotic medication Risperdal (antipsychotic) 2 mg by mouth twice a day. Residents taking Risperdal required an AIMS (abnormal involuntary movement scale) assessment to be performed every 6 months. The last assessment, noted by the pharmacist, was performed on 5/22/23. The resident was due for an AIMS assessment at the time of the recommendation. On 12/18/23, a second request from the pharmacist…

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

Based on observation, interview, and record review, the facility failed to provide prompt dental services for ill-fitting dentures to 1 of 2 residents reviewed for dental services (Resident 28). Finding includes: The resident's record review was completed on 6/25/24 at 2:39 p.m. Medical diagnoses included, but were not limited to: unspecified protein-calorie malnutrition; anemia in Chronic Kidney Disease (CKD); and unspecified dementia with unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Current physician orders included regular diet,thin consistency with no tomatoes, bananas, orange juice or potatoes (5/20/2024). The annual Minimum Data Set (MDS) assessment completed on 5/13/24 indicated the resident did not have broken or loosely fitting full or partial dentures (chipped, cracked, uncleanable, or loose). A current care plan, initiated on 9/12/21, included: I exhibit dental/mouth problems: I have no natural teeth (9/12/21), I will not develop oral/dental complications (5/20/24), report changes in oral status to MD…

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 implement infection prevention strategies related to enhanced barrier precautions (EBP) for 2 of 4 residents reviewed for transmission-based precautions. (Resident 44 and Resident 53) Findings include: 1. During an observation, on 6/24/24 at 12:15 p.m., Resident 53 was lying in his bed. The resident's door and room had no posted signage. During an observation, on 6/25/24 at 2:19 p.m., the resident was lying on his back in bed with his eyes closed. The resident's door had no posted signage. Resident 53's clinical record was reviewed on 6/26/24 at 2:25 p.m. Diagnoses included methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, nontraumatic hematoma of soft tissue, other mechanical complication of surgically created arteriovenous fistula, and dependence on renal dialysis. The physician orders lacked an order for enhanced barrier precautions. A progress note, dated 1/19/24 at 1:24 p.m., indicated the resident readmitted to the facility with a wound to the left…

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 honor a resident's preference to utilize a foot pedal for her wheelchair for 1 of 3 resident reviewed for resident rights. (Resident C) Findings include: Resident C's clinical record was reviewed on 2/7/24 at 11:25 a.m. Diagnoses included embolism and thrombosis of other specified veins, recurrent, unsteadiness on feet, need for assistance with personal care, other abnormalities of gait and mobility, and unspecified fracture of shaft of right tibia (lower leg bone), subsequent encounter for closed fracture with routine healing. Her orders included fondaparinux sodium (blood thinner) 0.4 milliliter subcutaneously daily and weight bearing as tolerated to her right lower extremity. During an interview with Resident C, on 2/7/24 at 12:18 p.m., she indicated she had broken her right leg, it was swollen from the knee down, and she couldn't put the brace on it for her foot drop (unable to flex foot toward knee). She wanted to be able to put her foot up because of the swelling. They told her to elevate her leg 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 ensure competent treatement for a pressure injury was completed according to physician's orders for 1 of 2 residents reviewed for wound care. (Resident D) Findings include: Resident D's clinical record was reviewed on 2/7/24 at 3:26 p.m. Diagnoses included methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere, type 2 diabetes mellitus with diabetic neuropathy and peripheral vascular disease. His physician's orders included Santyl ointment (enzymatic debridement), apply to right heel topically daily. Wash wound with wound cleanser, pat dry, apply to wound bed, cover with nonstick pad, and wrap with Kerlix. He had an unstageable (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) pressure ulcer to his right heel that measured 2.5 cm (centimeters) length by 3.5 cm width. During a wound care observation for Resident D, on 2/7/24 at 2:34 p.m., LPN 15 applied medical grade honey (autolytic debridement) with a gauze pad to the…

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

Based on interview and record review, the facility failed to ensure annual resident rights training was completed for 1 of 4 employees (the Administrator) reviewed for annual resident rights training. Findings include: Employee records were reviewed on 2/8/24 at 1:56 p.m. and indicated the following: The Administrator annual resident rights training was not completed. During an interview with the Administrator, with the Nurse Consultant present, on 2/8/24 at 3:22 p.m., she indicated a lot of the inservices had not opened yet. They opened according to the employee's hire date, but the employees should had completed last year's inservices. A current facility policy, dated 10/1/22, titled Employee Education, provided on the conference room table on 2/8/24 at 3:41 p.m., indicated the following: .Guidelines: The facility shall provide a Staff Education Plan in accordance with State and Federal regulations .4. The staff education plan shall ensure that education is conducted annually for all facility employees, at a minimum, in the following areas .e. Resident rights This citation relates…

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 required abuse training was completed for 2 of 4 employees reviewed for annual abuse training. (Administrator and LPN 12) Findings include: Employee records were reviewed on 2/8/24 at 1:56 p.m. and indicated the following: The Administrator's annual abuse training was not completed. LPN 12's annual abuse training was not completed. During an interview with the Administrator, with the Nurse Consultant present on 2/8/24 at 3:22 p.m., she indicated a lot of the inservices had not opened yet. They opened according to the employee's hire date, but the employees should had completed last year's inservices. A current facility policy, dated 10/1/22 and titled Employee Education, provided on the conference room table on 2/8/24 at 3:41 p.m., indicated the following: .Guidelines: The facility shall provide a Staff Education Plan in accordance with State and Federal regulations .4. The staff education plan shall ensure that education is conducted annually for all facility employees, at a minimum, in the following areas .c.…

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 report a communicable disease outbreak to the Indiana Department of Health (IDOH) involving 7 of 44 residents who resided in the facility (Residents 3, 7, 16, 24, 33, 34, and 36). Finding includes: During on observation, on 12/12/23 at 9:30 a.m., a sign on the facility entrance doors indicated the facility had COVID-19 in the building. During an interview, on 12/12/23 at 9:40 a.m., the Administrator indicated they had an outbreak of COVID-19 in the building. Four residents were currently infected with COVID-19. She was uncertain of the number of staff who were infected. During an observation, on 12/12/23 at 11:00 a.m., signage on the doors of rooms 135, 136, 140, and 142 indicated transmission-based precautions were required to enter the rooms. A line list for COVID-19 surveillance, provided by the Administrator on 12/12/23 at 3:16 p.m., indicated three residents had tested positive for COVID-19 on 11/25/23. Four residents had tested positive for COVID-19 on 12/4/23. Eleven employees had tested positive…

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 A. Based on interview and record review, the facility failed to develop a care plan to prevent further falls for 1 of 3 residents reviewed for falls. (Resident C) B. Based on observation and interview, the facility failed to develop care plans for residents with pressure related wounds for 3 of 3 residents reviewed for wounds (Resident B, D and F). Findings include: A. Resident C's clinical record was reviewed on 11/8/23 10:52 a.m. Diagnoses included type 2 diabetes mellitus without complications, essential (primary) hypertension, epilepsy, unspecified, intractable, with status epilepticus, Parkinson's disease, other abnormalities of gait and mobility, muscle weakness (generalized), aftercare following joint replacement surgery, cognitive communication deficit, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An admission Minimum Data Set (MDS) assessment, dated 7/25/23, indicated she was severely cognitively impaired. She required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a wound VAC (Vacuum - Assisted Closure) was placed on a resident's wound after a surgical procedure in a timely manner for 1 of 3 residents reviewed for wounds (Resident B). Findings include: Resident B's clinical record was reviewed on 11/8/23 at 9:47 a.m. Diagnoses included chronic viral hepatitis, essential (primary) hypertension, heart failure, unspecified, chronic kidney disease, unspecified severe protein-calorie malnutrition, and other specified postprocedural states. A significant change Minimum Data Set (MDS) assessment, dated 10/24/23, indicated she was cognitively intact. She required supervision for bed mobility, transfers, and toilet use. She had a surgical wound. A hospital Discharge summary, dated [DATE], indicated Resident B had a history of a bowel obstruction and diverticular stricture which resulted in multiple bowel resections with end colostomy. She underwent colostomy reversal. She had minimal pain and tolerated her diet.…

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.