Brickyard Healthcare - Merrillville Care Center

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 1 of 8 residents observed during medication administration. Two medication errors were observed during 27 opportunities for error in medication administration. This resulted in a medication error rate of 7.41%. (Resident 41) Finding includes: On 8/6/25 at 9:15 a.m., RN 1 was observed preparing Resident 41's medications. She placed aspirin 81 milligram (mg) enteric coated tablet, Certavite/multivitamin tablet, clopidogrel 75 mg tablet, escitalopram 5 mg tablet, levetiracetam 500 mg tablet, lisinopril 20 mg tablet, and metoprolol succinate extended-release 25 mg tablet into medication bags and crushed the medications. She then administered the crushed medications mixed with applesauce. Resident 41's record was reviewed at 9:20 a.m. The current August 2025 Physician's Order Summary indicated aspirin 81 mg chewable tablet once daily and metoprolol succinate extended release 25 mg once daily. During an interview on 8/6/25 at 10:58 a.m., RN 1 indicated that the…

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

Based on observation, interview, and record review, the facility failed to ensure infection control guidelines were in place and implemented, related to incorrect use of alcohol wipes during insulin administration for 1 of 1 resident observed for insulin administration and lack of physician's orders for contact isolation for 2 of 3 residents reviewed for transmission based precautions. (Residents 42, 39, and 14) Findings include: 1. During a medication pass observation on 8/5/25 at 11:06 a.m., RN 3 was observed preparing to administer an insulin injection for Resident 42. She performed hand hygiene and donned clean gloves. She opened the container holding the insulin lispro 100 unit/milliliter vial and wiped the top with an alcohol wipe. She used the same alcohol wipe and cleaned an area on the resident's abdomen to prepare the area for a subcutaneous injection. She then removed 24 units from the insulin lispro vial with a syringe and injected the medication into the resident's abdomen. During an interview on 8/5/25 at 11:36 a.m., RN 3 indicated she used the same alcohol swab for…

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, the facility failed to implement a complete discharge planning process and ensure that the discharge needs of each resident were identified and met related to lack of ongoing Physician follow up for an abnormal wound culture result, indicating an infection, prior to discharge from the facility, for 1 of 3 residents reviewed for skin conditions. (Resident B) The deficient practice was corrected by 7/31/24, prior to the start of the survey, and was therefore past noncompliance. The facility investigated the delay in treatment following the receipt of abnormal wound culture results, completed audits for all wound cultures in the last 90 days, educated all nursing staff on the policy for wound culture tracking and notifications, and implemented a Laboratory Tracking Log. Finding includes: Resident B's closed record was reviewed on 8/1/24 at 10:57 a.m. Diagnoses included, but were not limited to, motor vehicle injury, fracture of upper end of left humerus, fracture of medial condyle of left femur, fracture of left side rib, and insomnia. The admission…

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 medications were managed appropriately related to medications not signed out and given as ordered for 2 of 3 residents reviewed for unnecessary medications. (Residents B and G) Findings include: 1. Resident B's closed record was reviewed on 8/1/24 at 10:57 a.m. Diagnoses included, but were not limited to, motor vehicle injury, fracture of upper end of left humerus, fracture of medial condyle of left femur, fracture of left side rib, and insomnia. The admission Minimum Data Set (MDS) assessment, dated 7/9/24, indicated the resident was cognitively intact for daily decision making. There was an impairment to the upper and lower left extremities. He required substantial assistance for hygiene and transfers. A Physician's Order, dated 7/3/24 at 9:00 p.m., indicated Xanax (an anti-anxiety medication) extended release 1 milligram oral tablet once daily. The July 2024 Medication Administration Record indicated Xanax was not marked as administered from…

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 serve food under sanitary conditions related to dirty and greasy food equipment, an accumulation of dust on fan blades, food spillage, lack of hair restraints, touching food with gloved hands after touching other items, and the dishwasher gauge not functioning for 1 of 1 kitchen observed. (The Main Kitchen). This had the potential to affect 137 residents who received food from the kitchen. Findings include: 1. During the Kitchen Sanitation Tour on 6/10/24 at 9:10 a.m. with the Dietary Food Manager (DFM), the following was observed: a. A bag of noodles, located in the dry storage room, was not fastened. Loose noodles were observed on the shelves and on top of food boxes. b. The upper shelf located on the oven had an accumulation of crumbs and dust. c. There was an accumulation of dust and dried food spillage on the front of the convection oven. d. A large orange fan, located on a shelf in the dish room, had an accumulation of dust on the fan blades and fan cover. The fan was in use at that time and blowing…

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 ensure a sanitary environment was maintained related to an accumulation of dust and debris on floors, piping, and fan blades, as well as loose and detached base boards for 1 of 1 kitchen areas. (The Main Kitchen) Findings include: During the Kitchen Sanitation Tour on 6/10/24 at 9:10 a.m. with the Dietary Food Manager (DFM), the following was observed: a. The wall located behind the convection oven and the oven had an accumulation of dust and debris along the base of the wall. The white pipes located behind the convection oven and oven had an accumulation of dried food spillage. b. The ceiling vent located in between the steam table and the exit door to the kitchen had an accumulation of dust. c. A fan, anchored to the wall in the dish room, had an accumulation of dust on the fan blades and fan cover. The fan was not in use at the time. d. The base board located underneath the eye wash sink in the dish room was loose in some sections and pulled away from the wall. During an interview at that time, the DFM…

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 dependent residents received help with Activities of Daily Living (ADLs) related to build up on teeth for 1 of 7 residents reviewed for ADLs. (Resident 54) Finding includes: On 6/10/24 at 10:38 a.m., Resident 54 was observed sitting in bed. The resident's mouth was dry and crusty. His teeth were noted to be discolored and had build up on them. On 6/11/24 at 2:39 p.m., Resident 54 was observed sitting in bed. His mouth was dry and crusty when he opened it. His teeth were discolored and had build up on them. On 6/13/24 at 3:59 p.m., Resident 54 was observed in bed. His mouth was dry and crusty. His teeth were discolored and had build up on them. Resident 54's record was reviewed on 6/11/24 at 3:50 p.m. Diagnoses included, but were not limited to, cerebral infarction and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/19/24, indicated the resident was severely cognitively impaired. He was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. 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 ensure residents with impaired vision received the necessary services for 1 of 1 resident reviewed for vision. (Resident 70) Finding includes: During an interview on 6/10/24 at 2:49 p.m., Resident 70 indicated he needed to get his cataracts checked. He had an appointment set up over a year ago, but it was canceled. Resident 70's record was reviewed on 6/12/24 at 8:56 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and hyperlipidemia. The Quarterly Minimum Data Set assessment, dated 3/13/24, indicated the resident was cognitively intact. His vision was listed as adequate with no corrective lenses. A Progress Note, dated 1/27/23, indicated the resident had received a referral for a cataract evaluation from the optometrist. The appointment was scheduled for 2/7/23. A Progress Note, dated 2/3/23, indicated the resident wanted to cancel his scheduled eye appointment due to the cold weather and would like to reschedule when the weather was warmer. A Progress Note, dated 2/6/23, indicated…

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

Based on observation, record review, and interview, the facility failed to ensure a dependent resident was transferred with a Hoyer lift (a full body mechanical lift) as indicated on the Resident Care Sheet for 1 of 1 resident reviewed for accidents. (Resident 113) Finding includes: On 6/11/24 at 8:55 a.m., CNA 2 was observed attempting to transfer Resident 113 from her bed into her wheelchair. The resident was on her bed in a semi-seated position, her left arm was contracted and she had a splint on her right hand. Resident 113 was unable to sit upright on the side of bed by herself and was falling backward. The CNA was leaning forward in front of her, instructing Resident 113 to hold on to her neck as CNA 2 was attempting to hold the resident around her waist. The resident was unable to hold onto the CNA with her right arm only. Her legs were stretched forward and her feet were not securely on the floor. After several minutes, CNA 3 entered the room and indicated to CNA 2 that the resident could not be transferred like that, she needed a sit to stand lift (a device that assists…

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 ensure gastrostomy tube (peg tube) care was completed as ordered related to incorrect enteral feeding administration for 1 of 3 residents reviewed for peg tubes. (Resident 54) Finding includes: On 6/10/24 at 10:38 a.m., Resident 54 was observed in bed. He had a tube feeding pump connected to Jevity 1.5 cal (type of feeding) infusing at 70 milliliters per hour (ml/hour) On 6/11/24 at 2:39 p.m., Resident 54 was observed in bed. He had a tube feeding pump connected to Jevity 1.5 cal infusing at 70 ml/hour. Resident 54's record was reviewed on 6/11/24 at 3:50 p.m. Diagnoses included, but were not limited to, cerebral infarction and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/19/24, indicated the resident was severely cognitively impaired. He was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. A Care Plan, dated 7/27/23, indicated the resident was dependent on tube feedings. Interventions included, but were not limited to, elevate head of 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 observation, record review, and interview, the facility failed to ensure a resident received proper care and treatment related to oxygen administration flow rate for 1 of 1 resident reviewed for oxygen. (Resident 13) Finding includes: On 6/11/24 at 2:33 p.m., Resident 13 was observed in bed. He had a nasal cannula in his nares and the oxygen concentrator was set to a flow rate 4.5 liters per minute (lpm). On 6/13/24 at 8:57 a.m., Resident 13 was observed in bed. He had a nasal cannula in his nares and the oxygen concentrator was set to a flow rate 4.5 lpm. Resident 13's record was reviewed on 6/11/24 at 2:21 p.m. Diagnoses included, but were not limited to, acute respiratory failure, chronic bronchitis, and adult failure to thrive. The Significant Change Minimum Data Set (MDS) assessment, dated 4/8/24, indicated the resident was cognitively intact for daily decision making and was dependent on staff for all activities of daily living including, eating, hygiene, and bathing. The June 2024 Physician's Order Summary indicated oxygen at 3 liters per minute per nasal cannula 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 record review and interview, the facility failed to ensure a follow up for a pain specialist's medication order was completed for 1 of 1 resident reviewed for pain. (Resident 128) Finding includes: During an interview on 6/10/24 at 11:43 a.m., Resident 128's daughter indicated she had taken the resident to see a pain specialist in April. The resident had a history of spinal fusion surgery and would sometimes have pain when doing activities of daily living (ADLs) and therapy. She was aware the resident would not get back to her prior level of function and was worried about her being in pain. The specialist had ordered Tramadol (an opioid pain medication) as needed (PRN). The daughter had taken the prescription to a pharmacy, had the medication filled, brought the medication to the facility, and had given it to the resident's nurse. She had recently found out the resident had never received the Tramadol medication and she was not told why. She had asked the D Wing Unit Manager about it and was told there was no order for the medication and the pain assessment showed 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 update physician's orders after a medication regimen review was conducted for 1 of 5 residents reviewed for unnecessary medications. (Resident 68) Finding includes: Resident 68's record was reviewed on 6/12/24 at 11:38 a.m. Diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis. The Quarterly Minimum Data Set assessment, dated 4/22/24, indicated the resident was cognitively intact for daily decision making and received dialysis treatments. A Pharmacy Medication Regimen Review, dated 4/23/24, indicated a recommendation was made to reduce polypharmacy. Current orders included pantoprazole (decreases stomach acid) 40 milligrams (mg) every morning, melatonin (a sleep aid) 8 mg every night, hydroxyzine (antihistamine used to reduce itching) 25 mg every night and Zyrtec (treats allergy symptoms) 10 mg daily. The Physician/Prescriber response indicated to change hydroxyzine 25 milligrams by mouth to nightly as needed. The June 2024 Physician's Order Summary indicated hydroxyzine 25…

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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to a medication scheduled during the resident's routine dialysis time and blood sugars levels and insulin administration not documented, for 2 of 5 residents reviewed for unnecessary medications. (Residents 28 and 74) Findings include: 1. During an interview with Resident 28 on 6/11/24 at 8:54 a.m., he indicated he attended dialysis three times a week on Tuesdays, Thursdays and Saturdays. Tuesdays and Thursdays he was picked up around 9:30 a.m. and returned around 3:00 p.m. On Saturdays, he was picked up earlier, around 6 a.m. Resident 28's record was reviewed on 6/12/24 at 2:23 p.m. Diagnoses included, but were not limited to, Diabetes Mellitus, dependence on renal dialysis and cerebral infarction. The Quarterly Minimum Data Set (MDS) assessment, dated 4/24/24, indicated the resident was cognitively intact and was dependent for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a treatment for a pressure ulcer was administered as ordered and failed to thoroughly assess a resident's pressure ulcers upon admission into the facility, for 2 of 3 residents reviewed for pressure ulcers. (Residents D and B) Findings include: 1) During an observation on 3/4/24 from 9:53 a.m. to 11:19 a.m., the Nurse Practitioner (NP) Wound Specialist was completing the weekly assessments of Resident D's pressure ulcers. Nurse 1 and CNA's 1 and 2 assisted with the assessments. CNA 1 and CNA 2 positioned the resident on the right side and supported the resident to prevent rolling from the bed. Nurse 1 removed the transparent dressing and wound vacuum tubing over the left hip pressure area and the NP measured and assessed the the area. After the wounds were all assessed and measured, Nurse 1 attempted to change the wound vacuum dressing on the left hip. The left hip area was cleaned, then the Nurse placed the cut foam into the wound…

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 ensure infection control guidelines were implemented, related to hand hygiene with resident care and glove removal, changes of contaminated gloves, cleaning of reusable equipment, and contamination of gauze during an observation of wound care. (Resident D and Nurse 1) Finding includes: During an observation of wound care for Resident D on 3/4/24 from 9:53 a.m. to 11:19 a.m., Nurse 1 donned gloves. The wound dressing was removed from the right heel by Nurse 1 with a gloved hand. There was serosanguinous drainage on the dressing and slough on the right heel. Nurse 1 then reached for the bottle of spray wound wash, with the same gloved hands. He sprayed the wound wash on a gauze pad and patted the wound to cleanse. He then reached into the bag of gauze pads and obtained more pads with the same gloves he used to remove the dressing and clean the wound. He sprayed more wound wash from the bottle on the gauze, and continued to cleanse the wound. He then used his gloved hand to push his hair behind his ear. He then…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure each resident received the necessary treatment and services to promote healing for pressure ulcers, related to follow up with pressure ulcer treatment recommendations, for 1 of 3 residents reviewed for pressure ulcers. (Resident F) Finding includes: On 1/31/24 at 3:36 p.m., Resident F was observed lying in bed. The resident's pressure ulcers were observed with the Director of Nursing (DON) and 2 other staff. There was a dark maroon discoloration to her left heel, and a dark colored scabbed area to her right hip. No treatments were in place or completed to the areas at this time. The DON indicated the area to the right hip was hard like a scab. Record review for Resident F was completed on 1/31/24 at 12:00 p.m. Diagnoses included, but were not limited to, cerebral infarction, heart failure, and hypertension. The resident was admitted to the facility on [DATE]. A Progress Note, dated 1/23/24 at 8:13 p.m., indicated the resident had…

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 properly prevent and/or contain COVID-19 related to the use of personal protective equipment in an isolation room. (Resident B) Finding includes: On 1/31/24 at 11:55 a.m., CNA 1 arrived to Resident B's door with her lunch tray. The resident's door indicated Droplet/Contact Isolation. Proper Personal Protective Equipment (PPE): an isolation gown, protective eye wear, an N95 face mask, and gloves to both hands before entering. There was a PPE bin located right outside the door. The CNA set the tray down onto the PPE bin, and then proceeded to put on an N95 mask and a gown. The CNA then entered the resident's room with her room tray, and had not put on eye protection or gloves. Upon observation of the PPE bin, there was not any eye protection stored inside it. On 1/31/24 at 12:03 p.m., CNA 1 was observed sitting in a chair next to Residents B's bed. She was feeding the resident. The CNA had on a gown and an N95 mask. She was not wearing eye protection or gloves. The CNA indicated the resident had COVID-19. She indicated staff…

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 ensure infection control guidelines were in place and implemented related to respiratory masks uncovered when not in use and not cleaning a shared use blood pressure cuff and pulse oximeter between residents. (Residents 102, 46, 296 and 298) Findings include: 1. On 8/7/23 at 1:55 p.m., Resident 102 was observed in bed. There was a nebulizer (machine used to deliver breathing treatments) and a BiPap (bilevel positive airway pressure, a type of ventilator used to help breathing) on the table next to the bed. The BiPap mask was on the floor, uncovered. The nebulizer mask was resting on the nebulizer uncovered. On 8/10/23 at 8:36 a.m., and 8/11/23 at 8:08 a.m., the nebulizer mask was observed on the table uncovered. Interview with the Director of Nursing (DON), on 8/7/20 at 2:20 p.m., indicated when nebulizer and BiPap masks were not in use, they should be in plastic bags unless the nebulizer mask was drying from being cleaned, then it would be on a paper towel until dried. The policy, Nebulizer Therapy, 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, record review, and interview, the facility failed to ensure a dependent resident was provided with ADL (activities of daily living) care related to long, dirty fingernails for 1 of 3 residents reviewed for ADL care. (Resident 98) Finding includes: On 8/8/23 at 9:49 a.m., Resident 98 was observed laying in bed. His fingernails were long and had dark debris under them. He indicated they needed to be cut. On 8/11/23 at 8:10 a.m., the resident was observed in bed, his fingernails were long and had dark debris under them. He indicated they had not been cut yet. The record for Resident 98 was reviewed on 8/9/23 at 8:49 a.m. Diagnoses included, but were not limited to, asthma, chronic obstructive pulmonary disease and cerebral infarction. The Quarterly Minimum Data Set assessment, dated 6/8/23, indicated the resident was cognitively intact and required extensive 1+ assist for hygiene, bed mobility and transfers. Interview with the Director of Nursing, on 8/11/23 at 8:15 a.m., indicated ADL care included bathing, hair care, nail care and overall appearance. She…

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

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to oxygen administration flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 102) Finding includes: On 8/7/23 at 1:55 p.m., Resident 102 was observed in bed. Her oxygen nasal cannula was on and connected to the oxygen concentrator, but the concentrator was turned off. She indicated she was not feeling well and that was probably why. RN 1 was notified. The RN entered the room and turned the concentrator on to 3 liters per minute (lpm), she offered the resident a breathing treatment, then exited the room. The resident's record was reviewed on 8/7/23. Diagnoses included, but were not limited to, congestive heart failure and chronic obstructive pulmonary disease. The admission Minimum Data Set assessment, dated 6/23/23, indicated the resident used oxygen and was cognitively intact. A Physician's Order, dated 6/1/23, indicated the resident was to receive oxygen at 4 lpm. On 8/7/23 at 2:15 p.m., the RN was asked to check the setting 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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to a blood pressure medication administered outside of parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 98) Finding includes: The record for Resident 98 was reviewed on 8/9/23 at 8:49 a.m. Diagnoses included, but were not limited to, asthma, chronic obstructive pulmonary disease and hypotension (low blood pressure). The Quarterly Minimum Data Set assessment, dated 6/8/23, indicated the resident was cognitively intact and required extensive 1+ assist for bed mobility and transfers. The current Physician's Order indicated to give Midodrine (a medication used to raise blood pressure), 10 milligrams, three times daily. Hold the medication if the systolic blood pressure (top number in blood pressure, BP) was greater than 130. Review of the July and August 2023 Medication Administration Records indicated the 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 record review and interview, the facility failed to ensure residents were free from unnecessary medications, related to a lack of non-pharmacological interventions attempted before the administration of antipsychotic medication and a PRN (as needed) antipsychotic order in place longer than 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 30) Finding includes: The record for Resident 30 was reviewed on 8/10/23 at 2:07 p.m. Diagnoses included, but were not limited to, anxiety disorder, bipolar disorder, and major depressive disorder. A Physician's Order, dated 6/25/23, indicated Zyprexa (olanzapine, an antipsychotic medication) 2.5 mg (milligrams) every 12 hours PRN (as needed) for anxiety. The Medication Administration Record (MAR), dated 8/2023, indicated the resident received the Zyprexa medication on the following days: 8/2/23, 8/3/23, 8/4/23, and 8/7/23. The Medication Administration Record (MAR), dated 7/2023, indicated the resident received the Zyprexa medication on the following days: 7/1/23, 7/2/23, 7/3/23, 7/5/23, 7/7/23, 7/9/23, 7/10/23,…

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 Physician was notified of a abnormal laboratory test result for 1 of 5 residents reviewed for unnecessary medications. (Resident 98) Finding includes: The record for Resident 98 was reviewed on 8/9/23 at 8:49 a.m. Diagnoses included, but were not limited to, asthma, chronic obstructive pulmonary disease and cerebral infarction. The Quarterly Minimum Data Set assessment, dated 6/8/23, indicated the resident was cognitively intact and required extensive 1+ assist for bed mobility and transfers. A Pharmacy Recommendation, dated 1/10/23, indicated the resident was taking theophylline (medication for asthma symptoms), this medication had a narrow therapeutic range and it was recommended to obtain a theophylline level at least every six months. The Physician agreed. A Physician's Order, dated 2/17/23, indicated to obtain a theophylline level every six months. The lab result was not located in the resident's record. On 8/10/23, the Director of Nursing provided a copy of the lab result dated 2/20/23. The result was 2…

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 ensure a resident received routine and/ or emergency dental services related to a delay in scheduling a procedure to have teeth extracted for 1 of 1 residents reviewed for dental services. (Resident 34) Finding includes: On 8/7/23 at 10:20 a.m., Resident 34 was observed in her room. She had several missing teeth. She indicated her teeth were in bad condition and needed to be pulled so she could get dentures, but the facility hadn't scheduled that appointment yet. She had seen the dentist who comes to the facility, but they were unable to extract teeth. The resident's record was reviewed on 8/10/23 at 8:39 a.m. Diagnoses included, but were not limited to, congestive heart failure and chronic respiratory failure. The Quarterly Minimum Data Set assessment, dated 5/17/23, indicated the resident was cognitively intact and required extensive 1+ assistance for bed mobility and transfers. She had likely cavities or broken teeth. A Dental Note, dated 5/22/23, indicated the resident had many decayed and broken down…

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.