Aperion Care Arbors Michigan City

Based on observation, record review, and interview, the facility failed to ensure fall precautions were in place for a resident with a history of falls for 1 of 4 residents reviewed for accidents. (Resident 9)Finding includes:During an interview on 12/1/2025 at 10:45 a.m., Resident 9 indicated she had a recent fall where she was trying to transfer herself out of bed into her wheelchair. She landed on the floor and bruised her face and chest area. During an observation at that time, the resident pulled down her shirt and her upper chest was still red in color from the fall. The non-skid strips that were located by the bed were observed to be missing in several spots. On 12/8/25 at 11:10 a.m., ADON 3 was in the resident's room. At that time, she was asked about the non-skid strips next to the bed. She indicated they were missing in areas and needed to be replaced. The record for Resident 9 was reviewed on 12/4/25 at 1:10 p.m. Diagnoses included, but were not limited to, dementia, psychotic disorder with delusions, anxiety disorder, heart disease, major depressive disorder, and heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure signs and symptoms of a urinary tract infection (UTI) were treated in a timely manner for 1 of 1 resident reviewed for urinary tract infections. (Resident 8)Finding includes: The record for Resident 8 was reviewed on 12/4/25 at 3:41 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing), Parkinson's disease, and dementia without behavioral disturbance. The Significant Change Minimum Data Set (MDS) assessment, dated 9/16/25, indicated the resident was cognitively impaired for daily decision making. The resident required partial to moderate assistance with eating and was incontinent of urine. A late entry documented in the nursing progress notes, dated 11/25/25 at 8:12 p.m., indicated the resident was observed with blood-tinged urine in his brief. The hospice agency was contacted and they indicated they would speak with the nurse practitioner and the resident's sister to inquire about obtaining a urine specimen. A…

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

Based on observation, record review, and interview, the facility failed to ensure residents received proper treatment and care related to following physician's orders for oxygen administration, and the lack of pre and post nebulizer assessments for 2 of 3 residents reviewed for respiratory care. (Residents 127 and 14) Findings include:1. On 12/1/25 at 11:00 a.m., Resident 127 was observed lying in bed. The resident had oxygen in place via nasal cannula. The oxygen concentrator flow rate was set between 2 and 2.5 liters. The resident indicated he was supposed to be on 3 liters. On 12/1/25 at 2:57 p.m. and again on 12/2/25 at 10:49 a.m., Resident 127 was observed sitting in the hallway in a wheelchair outside of his room. The resident was not wearing any oxygen. There was not a portable oxygen tank attached to the wheelchair. On 12/2/25 at 3:46 p.m., Resident 127 was observed lying in bed. The resident had oxygen in place via nasal cannula. The oxygen concentrator flow rate was set between 2 and 2.5 liters. Record review for Resident 127 was completed on 12/2/25 at 3:30 p.m. Diagnoses…

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 dental services and a denture follow up appointment had been completed for 2 of 2 residents reviewed for dental services. (Residents 5 and 9)Findings include:1.On 12/1/25 at 11:15 a.m., Resident 5 was observed with multiple areas of missing teeth. The resident indicated it had been a long time since he had seen the dentist. The record for Resident 5 was reviewed on 12/4/25 at 9:01 a.m. Diagnoses included, but were not limited to, altered mental status and mild intellectual disabilities. The Annual Minimum Data Set (MDS) assessment, dated 9/29/25, indicated the resident was moderately impaired for daily decision making. A Physician's Order, dated 6/27/25 and listed as current on the December 2025 Physician's Order Summary (POS), indicated the resident could receive dental care as needed. There was no documentation of any dental visits for the resident since the order was obtained on 6/27/25. Documentation provided by the Social Service Director indicated the dentist 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 record review and interview, the facility failed to ensure a dependent resident's family or representative was notified of changes related to a dislodged gastrostomy tube (g-tube; a tube inserted through the skin into the stomach to provide nutrition and mediations) and antibiotic orders for 1 of 3 residents reviewed for g-tubes. (Resident C)Finding includes:Resident C's record was reviewed on 10/8/25 at 9:34 a.m. Diagnoses included, but were not limited to, flaccid hemiplegia affecting the right side, aphasia (a language disorder that affects communication), dysphagia (swallowing difficulty) and g-tube status.The Quarterly Minimum Data Set assessment, dated 8/4/25, indicated the resident had severe cognitive deficits and was dependent for bed mobility and transfers.A care plan dated 11/14/21, indicated the resident had impaired cognition related to impaired short term and long-term memory and decision making. The family manages her care.The resident's profile indicated she was her own responsible party. Her family members were listed as emergency contacts.A Nurse Note,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents received the necessary care and treatment related to antibiotics not given as ordered, wound treatments not provided as ordered and incomplete wound assessments for 3 of 3 residents reviewed for infections. (Residents C, B and D)Findings include:1. Resident C's record was reviewed on 10/8/25 at 9:34 a.m. Diagnoses included, but were not limited to, flaccid hemiplegia affecting the right side, aphasia (a language disorder that affects communication), dysphagia (swallowing difficulty) and g-tube status. The Quarterly Minimum Data Set assessment, dated 8/4/25, indicated the resident had severe cognitive deficits and was dependent for bed mobility and transfers. A Physician's Order, dated 9/11/25, indicated to give amoxicillin-pot clavulanate (an antibiotic) 875-125 milligrams (mg), twice daily for ten days and doxycycline hyclate (an antibiotic) 100 mg, twice daily for ten days related to an infection of the g-tube site. The September…

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 activities of daily living (ADLs) were completed for a dependent resident related to lack of showers provided twice a week for 1 of 3 residents reviewed for ADLs. (Resident B)Finding includes:The record for resident B was reviewed on 7/29/25 at 2:04 p.m. Diagnoses included, but were not limited to, diabetes, adult failure to thrive, and chronic non-pressure ulcer of skin. The 5/20/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and required maximal assistance with ADLs and transfers.The Care Plan, revised on 4/11/25, indicated the resident had an ADL self-care performance deficit and required the assistance of 1-2 staff members to shower. The Tasks section of the resident's record indicated the resident was to receive a bath or shower on Tuesday and Friday evenings. The record lacked documentation of the resident being bathed from 7/1/2025 to 7/29/25. There was no bathing documented or refused for 7/4/25, 7/22/25, and 7/25/25. There were no…

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 treatment was completed as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions. (Resident D) Finding includes:On 7/30/25 at 9:08 a.m., LPN 2 was observed changing Resident D's non-pressure skin area on the right shin. She cleansed her hands, donned a gown and gloves, and removed the old dressing. She removed her gloves, cleansed her hands, donned new gloves, and then cleansed the wound with gauze and wound cleanser. She removed her gloves, performed hand hygiene, applied new gloves, and then applied xeroform to the wound and covered the area with a dry dressing. Resident 91's record was reviewed on 7/29/25 at 1:48 p.m. Diagnoses included, but were not limited to, dementia and cerebral infarction (stroke). The Quarterly Minimum Data Set (MDS) assessment, dated 5/6/25, indicated the resident was severely cognitively impaired for daily decision making. She had an unstageable pressure ulcer and was on hospice care. The Physician's Order, dated 7/17/25, indicated right shin skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain comfortable and safe temperature levels for 27 of 27 residents who resided on the memory care unit. Finding includes: During a confidential resident interview on 5/27/25 at 10:38 a.m., they indicated the unit had been very cold lately and they were informed by staff the heat was turned off earlier in May 2025. During a random observation on 5/29/25 at 9:30 a.m. in the memory care unit, many residents were observed sitting in both dining rooms and in the lounge area. At that time, the ambient air temperature was cold. The residents were dressed in long sleeves, were wearing sweaters and had blankets over them. At 10:50 a.m., the Administrator was asked to have the Maintenance Director check the temperature on the memory care unit. The Maintenance Director and the Administrator entered the memory care unit and the air temperature was 71 degrees right by the entrance to the unit. Walking down the hallway, the temperature was 70 degrees. There were…

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

Based on record review and interview, the facility failed ensure only licensed qualified persons poured, prepared, and passed medications for 5 memory care residents on the midnight shift. (Residents 14, 60, 86, 87, and 90) Findings include: 1. The record for Resident 14 was reviewed on 6/3/25 at 12:00 p.m. Diagnoses included, but were not limited to, vascular dementia, psychotic disorder and hypothyroidism. The 12/3/24 Annual Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Physician's Order, dated 3/17/24, indicated Levothyroxine 150 micrograms daily at 6:00 a.m. The 2/2025 Medication Administration Record (MAR) indicated the medication was signed out on 2/2/25 at 5:45 a.m. by LPN 3. 2. The record for Resident 60 was reviewed on 6/3/25 at 11:51 a.m. Diagnoses included, but were not limited to, dementia and hypothyroidism. The 1/7/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Physician's Order, dated 3/8/24, indicated Levothyroxine 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching toast with bare hands and transporting uncovered food down the hallway for 1 of 4 units. (The Memory Care Unit). This had the potential to affect 27 of 27 residents residing on the unit. Findings include: 1. During the lunch meal observation on 5/27/25 at 11:54 a.m. on the memory care unit, residents were observed in both dining rooms as well at the tables in front of the nursing station. CNA 3 was observed plating the food for the residents in Dining room [ROOM NUMBER] and CNAs 3 and 4 were observed passing the food to them. After they were finished in Dining room [ROOM NUMBER], CNA 1 pushed the cart with uncovered food out into the hallway and plated for 3 more residents. She then pushed the cart with uncovered food to Dining room [ROOM NUMBER] and plated and served the food to those residents. 2. During a lunch meal observation on 5/28/25 at 11:49 a.m. on the memory care unit,…

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 non-pharmacological interventions were documented and attempted prior to administering a PRN (as needed) anti-anxiety medication for 2 of 5 residents reviewed for unnecessary medications. (Residents 89 and 91) Findings include: 1. The record for Resident 89 was reviewed on 6/2/25 at 11:05 a.m. Diagnoses included, but were not limited to, major depressive disorder, anxiety, psychotic disorder, dementia, and Parkinson's disease. The 4/23/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and received an antipsychotic and antidepressant medications. A Physician's Order, dated 5/29/25, indicated Ativan (an anti-anxiety medication) 0.5 milligrams (mg), give 0.5 mg by mouth every 6 hours as needed for anxiety or agitation. A Care Plan, revised on 5/30/25, indicated the resident used an anti-anxiety medication as needed for his anxiety disorder. The May 2025 Medication Administration Record (MAR) indicated the Ativan was administered on 5/29/25 at 3:50…

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 an ongoing activity program was implemented for cognitively impaired and dependent residents for 1 of 1 resident reviewed for activities. (Resident 44) Finding includes: During a random observation on 5/27/25 at 10:31 a.m., Resident 44 was observed in her room in bed. The resident was positioned on her left side, her eyes were open and she was facing the wall. The resident's television was turned off and no music was playing. On 5/28/25 at 10:00 a.m., the resident was again observed in her room in bed. She opened her eyes when her name was called. The resident's television was not turned on and there was no music playing. On 5/29/25 at 9:32 a.m., the resident was in her room in bed. The television was not turned on nor was there music playing. At 11:10 a.m., the resident was seated in a broda chair (a positioning wheel chair) across from the 200 unit nurses's station. At 1:47 p.m., the resident was in bed. Her eyes were open and the television was turned off and there was no music playing. The record…

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 treatment was completed as ordered for 1 of 2 residents reviewed for non-pressure related skin conditions. (Resident 48) Finding includes: On 5/30/25 at 10:22 a.m., Wound Nurse 1 was observed changing the bandage to Resident 48's trauma wound on the right anterior heel. The dirty dressing was removed and a dry dressing was then placed on the wound and was wrapped in dry gauze. The wound was not cleaned with Normal Saline Solution (NSS) before applying the dry dressing. During an interview at the time, Wound Nurse 1 indicted she thought she did everything right. The record for Resident 48 was reviewed on 5/30/24 at 10:01 a.m. Diagnoses included, but were not limited to, after care following a joint replacement, COPD, seizures, and obstructive sleep apnea. The 5/20/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately intact for daily decision making and had two unstageable pressure ulcers on admission. A Physician's Order, dated 4/27/25, indicated to clean the right…

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 the appropriate treatment was completed for a resident with an existing pressure ulcer for 1 of 6 residents reviewed for pressure ulcers. (Resident 91) Finding includes: During a pressure ulcer treatment observation on 5/30/25 at 11:07 a.m., Wound Nurse 1 was observed preparing to complete the treatment for Resident 91. The resident was observed lying in bed, and CNA 3 assisted with positioning the resident onto her left side. Wound Nurse 1 removed the bandage from the right hip. The bandage had a quarter-size of dried bloody drainage noted and pressure ulcer was red and open. The Wound Nurse indicated at that time, to her knowledge this was the first time the wound was opened. She cleaned the wound with normal saline and patted it dry. She opened a package of skin prep (a protective interface to prepare intact skin for attachment sites, tapes, films, and adhesive dressings and should not be applied to open wounds). Wound Nurse 1 wiped the open area with the skin prep pad and then covered it with a dry…

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 resident with a limited range of motion had a physician-ordered splint in place for 2 of 2 residents reviewed for range of motion. (Residents 21 and 5) Findings include: 1. During random observations on 5/28/25 at 10:33 a.m. and 11:35 a.m., Resident 21 was observed with his left hand closed in a fist. There was no palm protector (an anti-contracture device) and/or rolled wash cloth in use to the left hand. On 5/29/25 at 3:30 p.m., the resident was observed in his room in bed. The resident was awake and his left hand remained closed in a fist. There was no palm protector and/or rolled wash cloth in use. The record for Resident 21 was reviewed on 5/28/25 at 4:02 p.m. Diagnoses included, but were not limited to, contracture (a structural change in the body's soft tissues that cause them to stiffen and shorten) of the left hand and wrist, hemiplegia/hemiparesis (muscle weakness/paralysis) following a stroke, and vascular dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents in the memory care unit were supervised during meals for 1 of 1 resident reviewed for supervision. (Resident B) Finding includes: During the lunch meal observation on the memory care unit on 5/27/25 at 11:54 a.m., there were eight residents, including Resident B in dining room [ROOM NUMBER]. CNA 3 plated the food for the residents and CNA 2 and CNA 4 served them. At 11:59 a.m., they were finished serving dining room [ROOM NUMBER], and they all left, leaving the residents with no supervision while eating. At 12:01 p.m., LPN 1 entered the room and left at 12:02 p.m., leaving all the resident unsupervised while eating. At 12:03 p.m., QMA 2 entered the dining room and left at 12:05 p.m. During the lunch meal observation on the memory care unit on 5/28/25 at 11:49 a.m., dietary staff brought the food into dining room [ROOM NUMBER]. At 11:51 a.m., there were 9 residents observed in dining room [ROOM NUMBER]. There were seated at tables with…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen and flow rate was documented per titration and oxygen was on at the correct flow rate for 2 of 2 residents reviewed for oxygen. (Residents 23 and 322) Findings include: 1. On 5/27/25 at 10:28 a.m., Resident 23 was observed walking from the bathroom, she was wearing oxygen via nasal cannula at four liters. On 5/28/25 at 9:44 a.m., the resident was observed sitting on the side of her bed, she was having difficulty breathing. Her oxygen flow rate was set at just below the four liter line. The record for Resident 23 was reviewed on 5/28/25 at 9:44 a.m. Diagnoses included, but were not limited to, psychotic disorder with delusions, dementia, COPD, depression, and hypertension (high blood pressure). The 4/16/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident required oxygen therapy. A Physician's Order, dated 3/6/25, indicated to administer oxygen at three liters continuously every shift. A Care Plan, revised on 4/15/25,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were stored properly and not expired for 2 of 5 medication carts observed. (100 Unit Cart 1 and 400 Unit Odd Cart) Findings include: 1. On [DATE] at 2:51 p.m., the following was observed on the 100 Unit Cart 1 with LPN 1: - An Admelog SoloStar Pen (insulin) with an open date on [DATE]. The expiration date was written for [DATE]. - An Admelog SoloStar Pen with an open date on [DATE]. The expiration date was written for [DATE]. During an interview at the time of the observation, LPN 1 indicated the insulins were only supposed to be kept for 28 days and both were expired and should have been discarded. 2. On [DATE] at 3:35 p.m., the following was observed on the 400 Unit Odd Cart with RN 1. - A Lantus SoloStar Pen (insulin) with an open date on [DATE]. The expiration date was written for [DATE]. During an interview at the time of the observation, RN 1 indicated the insulin was expired and should have been discarded. No policy related to…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were in place and implemented related to the disposal of used lancets into the garbage can for 1 of 1 glucometer (machine used to test blood sugar levels) testing observed and the placement of clean treatment materials on dirty tables for 2 of 5 treatments observed. (Residents 18, 48 and 317) Findings include: 1. On 5/27/25 at 3:43 p.m., LPN 2 indicated he was going to check Resident 18's blood sugar. The nurse washed his hands, applied gloves, and wiped the resident's fourth right finger with an alcohol wipe. He then poked the resident's finger with the lancet. Blood was observed on the resident's finger. The nurse then proceeded to check the blood sugar with the glucometer. He discarded the lancet into the garbage can next to the resident's bed. He was unable to get a reading on the glucometer and indicated he would have to poke the resident's finger again to check the blood sugar. He proceeded to wipe the resident's third right finger with an alcohol wipe. He then poked…

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 activities of daily living (ADLs) were completed for dependent residents related to greasy hair, incontinence care, providing assistance in getting out of bed, facial hair, dirty fingernails, assistance with turning and repositioning, and assistance with dressing for 7 of 9 residents reviewed for ADLs. (Residents Q, P, G, C, F, H, and R) Findings include: 1. On 12/9/24 at 10:07 a.m. and 1:51 p.m., Resident Q was observed ambulating in the hallway. His hair was in need of brushing and was greasy in appearance. At 3:11 p.m., the resident continued to ambulate up and down the hallway. His hair remained disheveled and greasy. The resident was also noted to have a strong urine odor. At 3:20 p.m., LPN 2 and CNA 2 took the resident to his room for incontinence care. The resident's incontinence brief was saturated with urine and had already started to fall down his legs. On 12/10/24 at 9:02 a.m., 2:03 p.m. and 3:15 p.m., the resident's hair remained in need of brushing and was greasy in appearance. On 12/11/24…

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 treatments were completed as ordered and bruises were assessed and monitored for 4 of 4 residents reviewed for non-pressure related skin conditions, medications were signed out as ordered for 2 of 5 residents reviewed for unnecessary medications, signs and symptoms of constipation were addressed for 2 of 2 residents reviewed for constipation, and assessments were documented prior to being discharged to the hospital for 1 of 1 resident reviewed for hospitalization. (Residents Q, G, F, D, B, M, N, and R) Findings include: 1. On 12/9/24 at 3:11 p.m., Resident Q was observed ambulating up and down the hall. At 3:20 p.m., LPN 2 and CNA 2 took the resident to his room for incontinence care. As the resident's pants were pulled down, a scabbed area was observed below the right knee and a reddish/purple area of discoloration was observed to the right lower shin. On 12/10/24 at 3:15 p.m., the resident was ambulating on the unit. He had no…

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 medications were properly stored in clean, sanitary conditions for 4 of 4 medication carts observed (Even Cart for 400 hall, Cart 1 for 200 hall, Odd Cart for 400 hall, and Cart 1 for 300 hall) and 1 of 2 medication storage rooms observed (200 hall). Findings include: 1. On 12/12/24 at 1:53 p.m., the Even Medication Cart for the 400 hall was observed with LPN 1. There were 2.5 pills of different sizes and colors that were loose and out of the packages in the bottoms of the drawers in the cart. 2. On 12/12/24 at 2:27 p.m., Medication Cart 1 for the 200 hall was observed with QMA 1. There were multiple pills of different sizes and colors that were loose and out of the packages throughout the bottoms of the drawers in the cart. The QMA indicated she wasn't sure who was responsible for cleaning the carts. 3. On 12/12/24 at 2:40 p.m., the 200 hall Medication Storage Room was observed with QMA 1. The floor was visibly dirty with tiles missing and old adhesive exposed. There was trash on the floor and the bottoms of the…

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

Based on observation, record review and interview, the facility failed to ensure residents had snacks available for 8 of 8 residents who attended the Resident Council meeting. (Residents 8, 13, 29, 39, 52, 63, 109 and 110) This had the potential to affect all residents who were able to request and receive oral snacks. Finding includes: During the Resident Council meeting on 12/12/24 at 1:35 p.m., the Activities Director indicated all eight residents in attendance (Residents 8, 13, 29, 39, 52, 63, 109 and 110) were cognitively intact for daily decision making. When the group was asked if snacks were offered to residents who asked for them, all eight residents responded that they do not ever get snacks. During an interview on 12/12/24 at 1:59 p.m., the Dietary Manager indicated snacks were prepared daily and delivered by 7:30 p.m. every night since the kitchen closed at 8:00 p.m. She indicated there was enough snacks on the trays delivered for every resident to get a snack if they wanted one. During an interview on 12/12/24 at 2:07 p.m., CNA 7 indicated she worked the second shift 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure infection control practices were in place and implemented related to having no personal protective equipment (PPE) in enhanced barrier precaution rooms, staff failing to perform hand hygiene after glove removal, using gloved hands to apply ointment for 1 of 10 pressure ulcer treatments observed, not cleaning multi-use equipment, soiled washcloth used during bathing to clean urinary catheter tubing and a gastrostomy tube site, and staff failing to remove soiled PPE during a treatment during random infection control observations. (Residents K, C, H, and U) Findings include: 1. During a random observation on 12/11/24 at 2:17 p.m., Resident K had her call light activated and asked to be laid down in the bed. At that time, CNA 5 and CNA 6 entered the room with the Hoyer (mechanical lift) lift to put the resident back in her bed. CNA 5 hooked the resident's lift pad to the machine and lifted her up in the air and placed her in the 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 each resident's dignity was maintained related to wearing a hospital gown while in bed during the day and a personal care sign posted above the bed for 2 of 4 residents reviewed for dignity. (Residents P and F) Findings include: 1. On 12/9/24 at 10:07 a.m. and 2:00 p.m., Resident P was observed in her room in bed. The resident was wearing a hospital gown at the time. On 12/10/24 at 9:23 a.m., 2:15 p.m. and 3:20 p.m., Resident P was in bed wearing a hospital gown. There was also a sign posted above the head of the resident's bed which indicated the pads were to be removed from the resident's hipsters (hip protectors) prior to them being sent down to laundry and the pads were to be put in the resident's drawer. On 12/11/24 at 9:43 a.m., 10:25 a.m., 1:35 p.m. and 3:15 p.m., the sign remained above the resident's bed. On 12/12/24 at 8:58 a.m., 11:55 a.m. and 2:00 p.m., the sign remained above the resident's bed. The record for Resident P was reviewed on 12/12/24 at 2:11 p.m. Diagnoses included, but were…

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

Based on observation, record review and interview, the facility failed to ensure a resident's right to participate in his care related to not being able to receive medications during their scheduled time window for 1 of 8 residents observed for medication administration. (Resident L) Finding includes: During medication administration on 12/11/24 at 8:57 a.m., LPN 3 prepared the following medications for Resident L after a staff member indicated the resident was outside smoking: Amlodipine Besylate 10 milligrams (mg) (a blood pressure pill), Furosemide 40 mg (a water pill), Losartan Potassium-HCTZ 100-25 mg (a blood pressure pill), Aspirin 81 mg, Flomax 0.4 mg (a prostate medication), Metformin 500 mg (a blood sugar pill), Sertraline HCl 100 mg (an anti-depressant), Trelegy Ellipta (an inhaler), Metoprolol Tartrate 50 mg (a blood pressure pill), and Potassium Chloride 10 milliequivalents (meq). The LPN took the medication to the door to the outside smoking area and called out to the resident that she had his pills for him. The resident indicated he had just started smoking. The LPN…

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 was assessed to self-administer medications and had Physician's Orders for the medications for 1 of 1 resident reviewed for self-administration of medication. (Resident 60) Finding includes: On 12/9/24 at 10:18 a.m. and 1:45 p.m., Resident 60 was observed in her room. There was a package of Gas-X (medication to relieve symptoms of extra gas), Systane eye drops (lubricating eye drops), and a bottle of Jet-Alert pills (caffeine pills) on a shelving unit across from the resident's bed. The resident indicated she used the Systane eye drops and would only use the Gas-X as needed. On 12/10/24 at 9:03 a.m., and again at 2:01 p.m., the medications were still observed on the resident's shelving unit across from her bed. Record review for Resident 60 was completed on 12/10/24 at 2:16 p.m. Diagnoses included, but were not limited to, diabetes mellitus, depression, and end stage renal disease. The Quarterly Minimum Data Set (MDS) assessment, dated 12/2/24, indicated the resident was cognitively intact.…

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 file a grievance form, thoroughly investigate, and resolve grievances for missing personal items that were reported to staff for 1 of 1 resident reviewed for grievances. (Resident S) Finding includes: During an interview on 12/9/24 at 11:46 a.m., Resident S indicated she had lost two cell phones and the first missing phone was reported to staff at the nurses' station. The second phone was not yet reported. The record for Resident S was reviewed on 12/12/24 at 11:55 a.m. Diagnoses included but were not limited to, anxiety, respiratory failure, kidney disease and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 12/12/24, indicated the resident was cognitively intact for daily decision making. There was no grievance/concern form filed for the resident's first missing cell phone. A Grievance/Concern form, dated 12/10/24 was filed for the resident's second missing cell phone. During an interview on 12/10/24 at 9:33 a.m., the 300 Unit Assistant Director of Nursing (ADON) indicated she was aware 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 record review and interview, the facility failed to ensure a resident was invited to attend and participate in care planning conferences for 1 of 4 residents reviewed for participation in care planning. (Resident U) Finding includes: During an interview on 12/9/24 at 2:57 p.m., Resident U indicated they had not attended a care plan meeting. The record for Resident U was reviewed on 12/12/24 at 8:52 p.m. Diagnoses included, but were not limited to, kidney disease, asthma, respiratory failure, depression, and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the resident was cognitively intact for daily decision making. A Care Plan Progress Note, dated 10/28/24 at 4:08 p.m., indicated the Director of Social Services met with the resident's son to discuss the resident's quarterly assessment. There was no documentation the resident attended the care conference. There was no documentation the resident was invited to attend a care conference. During an interview on 12/12/24 at 11:25 a.m., the Director of Social Services indicated the resident…

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 fall precautions were in place to prevent injury from a fall for 1 of 2 residents reviewed for accidents. (Resident J) Finding includes: On 12/10/24 at 8:53 a.m., Resident J was observed lying in bed with her eyes closed. The resident's wheelchair was observed at the end of the bed. The resident had a cushion to the wheelchair with no Dycem (non-slip gripper pad) observed in the wheelchair. On 12/10/24 at 2:49 p.m., the resident was observed propelling herself down the hallway in her wheelchair. During this time, CNA 1 was interviewed regarding whether the resident had a Dycem in her wheelchair. CNA 1 indicated she was unsure. She asked CNA 2 to help her lift up the resident to see if there was a Dycem on the cushion. The CNAs assisted the resident to a standing position and both indicated there was not a Dycem on top of the cushion. They then lifted the cushion and there was a Dycem pad underneath the cushion. Both CNAs indicated they were unsure if the Dycem should be above or below the cushion.…

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 food consumption logs were completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 3) Finding includes: Record review for Resident 3 was completed on 12/12/24 at 11:53 a.m. Diagnoses included, but were not limited to, dementia, hypertension, anxiety, bipolar, and schizophrenia. The Quarterly Minimum Data Set (MDS) assessment, dated 11/1/24, indicated the resident was cognitively impaired. The resident required a partial to moderate assistance for eating and was on a mechanically altered therapeutic diet. A Care Plan, dated 6/28/21 and revised 12/22/21, indicated the resident had a nutritional problem or potential problem related to the need for mechanically altered diet and thickened liquids. Interventions included to monitor/record and report to the physician any signs or symptoms of malnutrition, significant weight loss of 3 lbs (pounds) in 1 week, or greater than 7.5% loss in 3 months. An intervention also included to monitor intake and record every meal. 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, record review, and interview, the facility failed to ensure a resident's peg tube (a tube inserted directly into the stomach for nutrition) was monitored, assessed and being cleaned as ordered for 2 of 4 residents reviewed for tube feeding. (Residents C and H) Findings include: 1. During an observation on 12/10/24 at 3:00 p.m., LPN 6 was asked to perform an assessment to the peg tube stoma site for Resident C. At that time, the resident was observed in bed and the tube feeding was turned off. The LPN lifted the resident's gown and there was a white split gauze bandage with a date of 12/10/24 to the stoma site. The LPN attempted to remove the bandage, however, it was sticking to her skin, so she poured normal saline on the bandage and it was removed. The stoma site was clean with a moderate amount of drainage noted. The record for Resident C was reviewed on 12/10/24 at 2:05 p.m. Diagnoses included, but were not limited to, hemiplegia (paralysis or weakness) right side, stroke, high blood pressure, anemia, and peg tube (a tube inserted directly into the stomach…

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' pain medications were available for administration for 2 of 3 residents reviewed for pain. (Residents K and 101) Findings include: 1. During an interview on 12/10/24 9:42 a.m., Resident K indicated the facility had issues with running out of her scheduled pain medications. The record for Resident K was reviewed on 12/12/24 at 2:06 p.m. Diagnoses included, but were not limited to, morbid obesity, type 2 diabetes, respiratory failure, cellulitis of the left lower limb, non pressure chronic ulcers, pain disorder, adult failure to thrive, pressure ulcers, anxiety disorder, major depressive disorder, and fibromyalgia (chronic condition that caused widespread pain and tenderness in the muscles and soft tissues of the body). The 11/7/24 Quarterly Minimum Data Set (MDS) assessment indicted the resident was cognitively intact for daily decision making and received scheduled pain medication. The resident had pain occasionally and rated the pain a 4 out of 10. A Care Plan, dated 2/5/24, indicated the resident…

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 medications were given as ordered to prevent significant medication errors for 1 of 8 residents observed for medication administration. (Resident L) Finding includes: During a medication administration observation on 12/11/24 at 8:37 a.m., LPN 3 indicated she was preparing a dose of Furosemide 40 mg (a diuretic) for Resident L. LPN 3 was observed dispensing four tablets of Amlodipine 10 mg (a blood pressure pill) into a medicine cup. The LPN then indicated she did not see the resident's Amlodipine in the cart, so she went to the med storage room, got another card of Amlodipine, and dispensed one tablet into the medication cup. The LPN took the cup of pills to the resident's room, knocked and called out that she was bringing the resident his pills. She was stopped at that point. After returning to the cart and reviewing the medications she had prepared, LPN 3 indicated she accidentally put 40 mg (four tabs) of Amlodipine instead of Furosemide into the medicine cup, and if given as prepared, she would…

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

Based on observation, record review, and interview, the facility failed to provide ADL (activities of daily living) assistance to dependant residents related to bathing, incontinence care, nail care, oral care, and dressing for 5 of 7 residents reviewed for ADL care. (Residents B, E, C, D, and F) Findings include: 1. During an interview on 6/24/24 at 10:06 a.m., Resident B indicated she didn't always get two bed baths and/or showers a week. The record for Resident B was reviewed on 6/26/24 at 1:53 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), right above the knee amputation, and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 5/9/24, indicated the resident was cognitively intact and required maximum assist for bathing. A Care Plan, dated 2/5/24, indicated the resident had an ADL self-care/mobility performance (functional abilities) deficit that could fluctuate with activity throughout the day related to impaired balance, limited ability, shortness of breath (SOB), COPD, weakness, and sleep disorder. 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 ensure pain medication was administered as ordered by the Physician, for 2 of 3 residents reviewed for hospice. (Residents D and E) Findings include: 1. The record for Resident D was reviewed on 3/25/24 at 1:10 p.m. Diagnoses included, but were not limited to, breast cancer, vascular dementia, Alzheimer's dementia, major depressive disorder, cerebral ischemia, osteoarthritis, delusional disorder, blood pressure, and anxiety. The 12/20/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making. The resident received scheduled pain medication, and she currently had no pain during the assessment period. The resident received hospice services as a resident. The Care Plan, revised on 3/22/24, indicated the resident had the potential for pain related to breast cancer and arthritis. The approaches were to administer pain medications as ordered. The Care Plan, revised on 3/12/24, indicated the resident received hospice services. The approaches were to medicate for pain…

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 establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to incomplete and inaccurate documentation of narcotic medications, for 1 of 3 residents reviewed for hospice. (Resident E) Finding includes: Record review for Resident E was completed on 3/25/24 at 11:25 a.m. Diagnoses included, but were not limited to, heart failure, hypertension, diabetes mellitus, end stage renal disease and anxiety. An MDS (Minimum Data Set) assessment, dated 3/9/24, was completed for death in facility. A Nurses Note, dated 3/8/24 at 6:30 p.m., indicated the nurse was called into the resident's room. The resident was unresponsive. The nurse attempted to wake the resident without success. The resident's blood pressure was unable to be obtained, pulse was 36 and oxygen saturation was 74% (percent). The nurse increased the resident's oxygen to 5 L (liters) and oxygen saturation raised to 86%. The nurse alerted hospice care and the family of resident's status.…

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 medical record was complete and accurately documented, related to a resident death, for 1 of 3 residents reviewed for hospice. (Resident E) Finding includes: Record review for Resident E was completed on 3/25/24 at 11:25 a.m. Diagnoses included, but were not limited to, heart failure, hypertension, diabetes mellitus, end stage renal disease and anxiety. An MDS (Minimum Data Set) assessment, dated 3/9/24, was completed for death in facility. A Nurse's Note, dated 3/8/24 at 6:30 p.m., indicated the nurse was called into the resident's room. The resident was unresponsive. The nurse attempted to wake the resident without success. The resident's blood pressure was unable to be obtained, pulse was 36 and oxygen saturation was 74% (percent). The nurse increased the resident's oxygen to 5 L (liters) and oxygen saturation level raised to 86%. The nurse alerted hospice care and the family of the resident's status. Hospice gave a verbal order to discontinue all medications except hospice comfort medications. There was a lack…

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 were free from physical abuse, related to a physical altercation by a resident with a history of aggression towards others, which resulted in physical contact with two residents, and was witnessed by another resident. (Residents D, E, and S) Findings include: Resident C was observed on 1/22/24 at 9:30 a.m., walking independently in the hallway to the front lobby area. At 10:02 a.m., he was in his room and was sitting on the bed. He was unable to verbalize the situation that had occurred with other residents in the facility, and indicated everything was okay now. He indicated he now went out the front door to smoke his cigarettes. Resident D was observed on 1/22/24 at 10:42 a.m. in his room, and independently transferred himself from the bed to the wheelchair. He indicated he was, viciously attacked by Resident C. He did not feel real safe, though the facility was doing everything possible to keep them safe. He indicated Resident C no longer smoked in the Courtyard with him. The day of the…

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

Based on record review and interview, the facility failed to ensure adequate supervision was provided to residents in the designated smoking area, which resulted in resident to resident physical altercations involving 3 residents. (Residents C, D, and E) Finding includes: An undated facility reported incident to IDOH, indicated Residents C, D, and E were in the designated smoking area on 1/5/24 at 9:01 a.m. Resident C made contact with Resident E's and D's faces. The residents were separated. Residents E and D had first aid administered and denied request for x-rays and emergency room evaluations. Resident C was placed on one-on-one observation with a staff member until Law Enforcement arrived at 9:15 a.m., and he was then transferred to the hospital. Cross reference F600. 1. Resident C's record was reviewed on 1/23/24 at 8:49 a.m. The diagnoses included, but were not limited to, Parkinson's disease and psychosis. A Quarterly Minimum Data Set (MDS) assessment, dated 11/1/23, indicated an intact cognitive status, no behaviors, no physical impairments of the extremities, 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, record review, and interview, the facility failed to ensure gastrostomy tubes (g-tubes/ feeding tubes) were cleaned at the insertion site as ordered by the Physician, for 2 of 3 residents reviewed for g-tubes. (Residents B and M) Findings include: 1. During an observation on 1/22/24 at 10:58 a.m. with Employee 1 and Employee 3, Resident B was lying in bed. The g-tube insertion site had no dressing, had a light drainage and dark crusting was observed around the insertion area. Employee 1 indicated there was drainage, and the area was to be cleansed every shift. She indicated there was no order for a dressing, and the g-tube was not used except for flushes. G-tube insertion site care was completed by Employee 1 after other care was rendered. Resident B's record was reviewed on 1/22/24 at 2:17 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 12/3/23, indicated an intact cognitive status, required set up for meals, received a mechanically altered diet, and there was no feeding or fluid intake by way…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was sanitary and comfortable, related to dirty bathrooms, broken and chipped toilets, dirty walls, debris on the floor, unsanitary storing of personal use items, holes in the walls, unmade beds, a dirty fan, over the bed table veneer loose and coming off, flooring coming up in the bathroom, and tears on the wheelchair arms for 11 of 24 rooms observed on 4 of 4 units (100, 200, 300, and 400) Findings include: During an Environmental Tour observation on 10/31/23 from 5 p.m. through 6:13 p.m. the following was observed: a. 300 Hall room [ROOM NUMBER], there was debris under the bed by the window, a dried dark liquid spot on the toilet seat, a black substance on the wall by the toilet, and a hole in the wall behind the bed by the door. room [ROOM NUMBER], the bathroom light was dim, the toilet seat was broken, the floor was sticky, there was dirt in the corners, and the linoleum was coming unglued on the floor 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 record review and interview, the facility failed to ensure a resident was thoroughly assessed for self-administration of insulin and received a Physician's Order that the resident was appropriate for self-administration for 1 of 1 resident reviewed for self-administration of medications. (Resident S) Finding includes: Resident S's record was reviewed on 11/2/23 at 1:11 p.m. The diagnoses included, but were not limited to, diabetes mellitus and congestive heart failure. An admission Minimum Data Set assessment, dated 8/7/23, indicated an intact cognitive status an had no behaviors. The Physician's Orders, dated 8/1/23, indicated orders to monitor the blood sugar and Humulog insulin was to be administered with a dosage amount in relationship to his blood sugar result (sliding scale) before meals and an order on 8/7/23 for a routine dose of Lantus insulin, 15 units was to be administered nightly at bedtime. There was no Physician's Order for the resident to self-administer the insulin dosages. A Self-Administration Assessment, dated 9/12/23, 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 record review and interview, the facility failed to notify a Physician for a follow up consult/appointment as ordered and failed to notify a resident's responsible party in a timely manner about skin tear injuries for 2 of 13 residents reviewed for Physician notification. (Residents B and M) Findings include: 1) Resident B's record was reviewed on 10/31/23 at 11:55 a.m. The diagnoses included, but were not limited to, dementia and anxiety. A CT of the pelvis result, dated 9/15/23, indicated a chronic un-united fracture of the left hemipelvic and multiple compression fractures of the lumbar spine with severe spinal canal stenosis. A Nurse's Progress Note, dated 9/22/23 at 12:44 p.m., indicated Physician Orders were received for an Orthopedic Consult. An attempt was made to schedule an appointment and a voicemail with a detailed message was left for the Orthopedic Physician. A return call was requested. There was no further documentation the Orthopedic Consult had been completed or scheduled. During an interview on 10/31/23 at 4:13 p.m., the Director of Nursing (DON),…

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 injuries to residents were thoroughly investigated for the cause of the injury to rule out potential abuse for 2 of 4 residents reviewed for injuries and abuse. (Residents M and L) Findings include: 1) During an observation on 10/31/23 at 10:51 a.m., Resident M was lying in bed, the Wound Nurse and the Director of Nursing (DON) were in the room and the Wound Nurse had just completed the dressing change to the left arm skin tears. Resident M was unable to explain how he received the skin tears. The DON indicated an investigation for the cause of the skin tears was not completed. The nurse who had provided the care and found the skin tears had written a statement in the record and on the investigation on how the skin tears occurred. Resident M's record was reviewed on 11/2/23 at 6:20 a.m. The diagnoses included, but were not limited to, dementia. An admission Minimum Data Set assessment, dated 10/17/23, indicated a severely impaired cognitive status and required maximum to dependent assistance with all…

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 individualized Care Plans were developed and implemented related to behaviors and self-administration of medications, for 3 of 13 residents reviewed for care plan development and implementation. (Residents M, Q, and S) Findings include: 1) Resident M's record was reviewed on 11/2/23 at 6:20 a.m. The diagnoses included, but were not limited to, dementia. A Nurse's Progress Note, dated 10/24/23 at 5:09 a.m., indicated three skin tears to the right forearm had been found after care was completed and the resident had been combative during care. Cross Reference F610. There was no Care Plan developed and implemented for the resident's reported ongoing behaviors of agitation/ resistance/ combativeness when care was attempted. 2) Cross Reference F676. During an observation of the lunch meal on 11/1/23 at 12:08 p.m. Resident Q was served a soft taco, refried beans, green beans, lettuce, tomato, shredded cheese, and cake. He placed an unfolded napkin on the table, and placed the refried beans, the green beans,…

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 who required set up assistance with eating was assisted with his supper meal for 1 of 6 residents reviewed for meal assistance. (Resident Q) Finding includes: During an observation on 10/31/23 at 5:40 p.m., Resident Q received his evening meal, which consisted of breaded fish, spinach, rice, a dinner roll and a health shake in a milk carton container. He received butter and tarter sauce on the side of his plate. His plate was removed from the tray and placed in front of him. The staff had not offered to place tartar sauce on the fish nor butter on the roll. The health shake was opened, the shake had not been poured into a glass, nor was a straw provided. The resident opened his napkin up on the table and he used his spoon to scoop the spinach onto the napkin. He took two bites of rice and spit the bites out. He then scooped the rice on top of the spinach in the napkin and half of the dinner roll. Staff were walking by the table and no one stopped to assist him, cue him, or to offer him an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident who was dependent for dietary and fluid intake was assisted with the evening meal and was fed slowly and in an enjoyable manner, for 1 of 2 dependent residents observed during meal times. (Resident H) Finding includes: During an observation on 10/30/23 at 6:16 p.m., Employee 3 entered Resident H's room to assist her with her supper meal. The resident was in bed with the head of the bed elevated. She began to feed the resident the puree meal of macaroni and beef, peas, and mandarin oranges. There was also thickened punch drink. Employee 3 fed the resident quickly with one bite after another until the meal was 100% consumed at 6:19 p.m. She then gave the resident a drink of her fluid on the tray. During an interview on 10/30/23 at 6:21 p.m., Resident H indicated she had been fed too quickly. Resident H's record was reviewed on 10/1/23 at 2:18 p.m. The diagnoses included, but were not limited to, dementia and severe…

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 adequate supervision was provided to a resident during a transfer related to a mechanical lift transfer (Resident H). The facility also failed to ensure a Care Planned intervention was in place to prevent injury to the skin related to geri-sleeves (skin protector) for 2 of 4 residents reviewed for injuries and assistive devices. (Resident L) Findings include: 1) During an observation on 10/31/23 at 1:45 p.m., Employee 4 was in Resident H's room. Resident H had been lifted up with the assistance of a mechanical lift and was positioned in the sling on the lift and was above the reclining chair where she had been sitting. Employee 4 then transferred the resident into her bed with the mechanical lift. She indicated she should have had another staff member assist her with the transfer. The nurse had asked her to transfer the resident to bed before her shift ended. She indicated there were three other staff members assigned to the unit and they must had been with other residents when she looked for someone…

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 who had a Physician's Order for a dietary supplement to assist with caloric and protein needs, received the supplement as ordered for 1 of 4 residents reviewed for nutritional status. (Resident Q) Finding includes: During an observation of the lunch meal on 11/1/23 at 12:08 p.m., Resident Q was served a soft taco, refried beans, green beans, lettuce, tomato, shredded cheese, and cake. A nutritional health shake supplement was not served. He received an alternate meal of grilled cheese sandwich due to not eating the taco. He consumed 100% of the grilled cheese sandwich and cake then left the Dining Room at 12:30 p.m. Resident Q's record was reviewed on 11/2/23 at 11:35 a.m. The diagnoses included, but were not limited to, dementia and mild intellectual disabilities. An Annual Minimum Data Set assessment, dated 10/11/23, indicated a severely impaired cognitive status, no behaviors, required set up or clean up with eating, and had no significant weight gain or loss. A Care Plan, dated 12/12/22,…

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 record review and interview, the facility failed to manage medications appropriately, related to missing medication doses, not administering or ensuring insulin was administered, and blood sugar monitoring not completed as ordered for 1 of 4 residents reviewed for unnecessary medications. (Resident S) Finding includes: During an interview on 10/31/23 at 5:30 p.m., Resident S indicated he was not receiving his medications as ordered by the Physician. Resident S's record was reviewed on 11/2/23 at 1:11 p.m. The diagnoses included, but were not limited to, diabetes mellitus and congestive heart failure. An admission Minimum Data Set assessment, dated 8/7/23, indicated an intact cognitive status an had no behaviors. A Physician's Order, dated 9/30/23, indicated furosemide (diuretic) 20 milligrams was to be given once a day for congestive heart failure. The Medication Administration Record (MAR), dated 10/2023, indicated the furosemide had not been administered on October 1 and 2 at 9 a.m. as ordered by the Physician. Physicians Orders, dated 8/1/23, indicated orders to monitor…

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 psychotropic medications related to a lack of a GDR (Gradual Dose Reduction) for anti-anxiety and antidepressant medications completed for 2 of 4 residents reviewed for unnecessary medications. (Residents B and H) Findings include: 1. Resident B's record was reviewed on 10/31/23 at 11:55 a.m. The diagnoses included, but were not limited to, dementia, anxiety, and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 10/4/23, indicated an intact cognitive status, no behaviors, and received anti-anxiety medication and antidepressant medications. The Physician's Orders, indicated the following: - 1/5/22 Ativan (anti-anxiety) 0.5 mg (milligrams) twice a day for anxiety - 10/19/22 sertraline HCL (Zoloft) (antidepressant) 150 mg daily for depression. An Encounter Progress Note (Psychiatry Progress Note), dated 7/12/22, indicated A GDR of the .Ativan was contraindicated at this time There was no further documentation another GDR of the Ativan had been attempted or a rationale…

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.