Life Care Center Of Michigan City

Based on observation, record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to a lack of documentation of blisters for 1 of 1 resident reviewed for non-pressure skin conditions (Resident 67), and inaccurate meal consumption documentation for a resident who was NPO (nothing by mouth) for 1 of 1 resident reviewed for hospice. (Resident 11)Findings include: 1. During a random observation on 8/4/25 at 8:41 a.m., Resident 67's legs were wrapped in gauze. At that time, the resident indicated there used to be blisters on her legs, but she was not sure if they were still there.During an observation of treatment on 8/07/25 at 1:11 p.m., a small, dark, circular discoloration was observed to the resident's left shin. At that time, the Assistant Director of Nursing (ADON) indicated it used to be a blister. She indicated the resident used to have multiple small blisters to both legs, but they had healed. The record for Resident 67 was reviewed on 8/5/25 at 3:07 p.m. Diagnoses included, but were not limited to, legal…

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 practices were in place and implemented related to enhanced barrier precautions (EBP) not followed while assisting a resident who had a Foley catheter to the bathroom and emptying an indwelling Foley catheter during random infection control observations. (Residents 5 and 56)Findings include:1. During a random observation on 8/5/25 at 9:15 a.m., Occupational Therapy Assistant (OTA) 1 was assisting Resident 5 with a toilet transfer. The OTA was wearing gloves but was not wearing an isolation gown. The resident had an indwelling Foley catheter. During a random observation on 8/6/25 at 1:11 p.m., CNA 1 was draining the resident's Foley catheter leg bag. The CNA had donned a pair of gloves, but she was not wearing an isolation gown. The record for Resident 5 was reviewed on 8/7/25 at 3:42 p.m. Diagnoses included, but were not limited to, displaced comminuted fracture of the shaft of the left femur and neuromuscular dysfunction of the bladder (nerve damage that impaired the bladder's ability…

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 responsible party was notified of a unwitnessed fall in a timely manner for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: Resident B's record was reviewed on 3/31/25 at 10:47 a.m. Diagnoses included, but were not limited to, fracture of the left femur, hypertension (high blood pressure), depression, chronic kidney disease, history of falling and dementia. A Nurse's Note, dated 1/8/25 at 12:25 a.m., indicated Resident B was noted on the floor in her room by the CNA. The resident was assessed and was alert and oriented to situation and self. The resident was noted to have a bruise to the left frontal side of her head with a small bump. The resident had also complained of soreness to her left hip and back. The resident refused pain medication and refused to go to the hospital. A message was left to notify the Nurse Practitioner. A Nurse's Note, dated 1/8/25 at 1:04 a.m., indicated medication was given for pain in the left hip and lower back. A Nurse's Note, dated 1/8/25 at 3:12 a.m.,…

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

Based on observation, record review, and interview, the facility failed to ensure fall interventions were updated to prevent injury for a resident with multiple falls for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 3/31/25 at 12:09 p.m., Resident D was not observed in his room. There was a mattress leaning on the side of the wall, there was a touch pad call light, gym shoes by the bedside, and the bed had two half side rails. Resident D's record was reviewed on 3/31/25 at 1:17 p.m. The diagnoses included, but were not limited to, dementia, chronic obstructive pulmonary disease (COPD), hypertension (high blood pressure), stroke, and hemiplegia (paralysis on one side of the body). The admission Minimum Data Set (MDS) assessment, dated 1/16/25, indicated the resident was severely impaired for daily decision making. The resident required substantial/maximum assistance for bed mobility, transferring and toileting. A Care Plan, last updated on 1/31/25, indicated the resident was at risk for falls related to decreased mobility, weakness, high blood pressure,…

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 discharge summary was completed at the time of discharge for a resident going home who required home health services for 1 of 3 residents reviewed for discharge (Resident B). Finding includes: Resident B's record was reviewed on 9/11/24 at 9:43 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body), chronic kidney disease stage 3, and high blood pressure. The Discharge Minimum Data Set assessment, dated 9/1/24, indicated the resident was cognitively intact for daily decision making. He was totally dependent on staff for toileting, bathing, and transfers. He had an indwelling catheter and an ostomy (an artificial opening). He was taking antipsychotic, antidepressant, and anticoagulant medications. Resident B's Care Plans upon discharge included, but were not limited to, the resident would be long term care, had an ostomy, required extensive assistance for his activities of daily living (ADL) tasks for bed mobility, transfers, and toileting, had an indwelling Foley (urinary)…

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 there was an adequate indication for use of a scheduled antifungal powder for 1 of 3 residents reviewed for non-pressure skin conditions (Resident B) Finding includes: Resident B's record was reviewed on 9/11/24 at 9:43 a.m. The diagnoses included, but were not limited to, paraplegia (paralysis of lower body), chronic kidney disease stage 3, and high blood pressure. The Discharge Minimum Data Set assessment, dated 9/1/24, indicated the resident was cognitively intact for daily decision making. He was totally dependent on staff for toileting, bathing, and transfers. A Physician's Order, dated 7/16/24, indicated nystatin external powder (antifungal powder) 100,000 unit/gram, apply to right and left skin folds topically every shift for skin irritation. The July and August 2024 Medication and Treatment Administration Record indicated the nystatin powder was administered three times each day to the groin area. A Weekly Skin Assessment was completed on 7/20, 7/27, 8/3, 8/10, 8/17, 8/24, and 8/31/24. There were no 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.

Based on observation, record review, and interview, the facility failed to ensure a resident received the assistive devices needed to maintain hearing related to hearing aids not administered to a resident as per the physician's order for 1 of 2 residents reviewed for vision/hearing. (Resident 4) Finding includes: On 6/11/24 at 11:48 a.m., Resident 4 was observed sitting in the dining area with other residents. The resident kept saying huh when other people were talking. The resident did not have hearing aids observed to either ear. On 6/11/24 at 3:08 p.m., Resident 4 was sitting in a wheelchair in his room. The resident indicated he could not hear the questions being asked. The resident did not have hearing aids observed to either ear and was unaware where his hearing aids were. Record review for Resident 4 was completed on 6/11/24 at 3:11 p.m. Diagnoses included, but were not limited to coronary artery disease, heart failure, and hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 3/26/24, indicated the resident was cognitively impaired. 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 record review and interview, the facility failed to ensure food consumption logs were completed for residents with a history of weight loss for 3 of 5 residents reviewed for nutrition. (Residents 59, 14, and 42) Findings include: 1. Record review for Resident 59 was completed on 6/12/24 at 3:11 p.m. Diagnoses included, but were not limited to, hypertension, dementia, and failure to thrive. The Quarterly Minimum Data Set (MDS) assessment, dated 5/13/24, indicated the resident was cognitively impaired. The resident required a substantial maximal assistance with eating. A Care Plan, dated 1/11/24, indicated the resident had unplanned/unexpected weight loss related to poor food intake. Interventions included to alert the dietician when consumption was poor for more than 48 hours and to record food intake at each meal. The resident weighed 109 pounds on 11/30/23. A weight obtained on 6/7/24 indicated the resident weighed 97 pounds, which was a 11.01 % (percent) weight loss. The Task Meal Consumption Logs were documented with percentage of meals eaten. The last 30 days lacked…

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 was at the correct flow rate for 2 of 3 residents reviewed for oxygen use. (Residents 42 and 48) Findings include: 1. On 6/10/24 at 11:25 a.m., Resident 42 was observed lying in bed wearing oxygen via nasal cannula. The oxygen flow rate was set under 2 liters. On 6/10/24 at 12:04 p.m., the resident's oxygen was in place and the flow rate was set under 2 liters. On 6/11/24 at 11:59 a.m., the resident was observed lying in bed and oxygen was in place via nasal cannula. The flow rate was set just under 2 liters. On 6/11/24 at 3:36 p.m., the resident was observed asleep in bed. Oxygen was in place and the flow rate was set below 2 liters. The record for Resident 42 was reviewed on 6/10/24 at 12:19 p.m. The diagnoses included, but were not limited to, atrial fibrillation (abnormal heart rhythm), dementia, depression, muscle weakness, adult failure to thrive, anxiety, and left shoulder fracture. The Significant Change Minimum Data Set (MDS) Assessment, dated 5/29/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents had an assessment and Physician's Orders to self-administer their own medications, for 4 of 4 residents reviewed for self-administration of medication. (Residents C, F, G and H) Findings includes 1. During a random observation on 4/1/24 at 1:37 p.m., Resident C was observed in bed and awake. The resident was confused and not oriented to time and place. At that time, there was a tube of Bacitracin ointment on the dresser and 1 over the counter bottle of Genteal tears eye solution. The bottle of eye drops was located on a high top dresser and completely out of reach for the resident. During a random observation, on 4/2/24 at 8:25 a.m., the resident was observed in bed. At that time, the bottle of eye drops was still located on the high top dresser and out of reach for the resident. The record for Resident C was reviewed on 4/1/24 at 3:20 p.m. Diagnoses included, but were not limited to, contusion right lower leg and foot,…

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 was sent to the hospital in a timely manner, related to complaints of increased pain and leg swelling, for 1 of 3 residents reviewed for accidents. The facility also failed to ensure treatments were completed for diabetic ulcers and an assessment was completed for new non-pressure wounds to the toes, for 3 of 3 residents reviewed for skin conditions non-pressure related. (Residents D, B, C, and F) Findings include: 1. The closed record for Resident D was reviewed on [DATE] at 1:04 p.m. Diagnoses included, but were not limited to, history of falling, metabolic encephalopathy (an infection that causes brain damage), and osteomyelitis (bone infection). The Significant Change Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident was cognitively impaired for daily decision making and dependent on staff for bed mobility and transfers. A Care Plan, dated [DATE], indicated the resident required ADL (activities…

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

Based on record review and interview, the facility failed to ensure the resident's Physician was notified in a timely manner of increased pain and leg swelling, for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: The closed record for Resident D was reviewed on 4/1/24 at 1:04 p.m. Diagnoses included, but were not limited to, history of falling, metabolic encephalopathy (an infection that causes brain damage), and osteomyelitis (bone infection). The Significant Change Minimum Data Set (MDS) assessment, dated 2/22/24, indicated the resident was cognitively impaired for daily decision making and dependent on staff for bed mobility and transfers. An Event Note, dated 3/14/24 at 3:00 p.m., indicated the CNA asked LPN 1 to look at the resident's right leg. The resident's leg was assessed and their left leg was observed to be pressing against the right leg. An indentation from the left leg was visible on the right leg. The right leg had bruising and a stage one area to the right leg. The Nurse Practitioner (NP), Director of Nursing (DON), and the resident's spouse…

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 in the shower for a resident who was leaning in their shower chair, for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: The closed record for Resident D was reviewed on 4/1/24 at 1:04 p.m. Diagnoses included, but were not limited to, history of falling, metabolic encephalopathy (an infection that causes brain damage), and osteomyelitis (bone infection). The Significant Change Minimum Data Set (MDS) assessment, dated 2/22/24, indicated the resident was cognitively impaired for daily decision making and dependent on staff for bed mobility and transfers. A Care Plan, dated 1/23/24, indicated the resident required ADL (activities of daily living) assistance and therapy services to maintain or attain their highest level of function. Interventions included, but were not limited to, extensive assist of 2 to complete transfers. Nurses' Notes, dated 2/11/24 at 10:05 p.m., indicated the CNA notified the writer the resident was on the floor in the shower room. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure skin tears and areas of bruising were assessed, monitored, and treatments were completed as ordered for 4 of 5 residents reviewed for skin conditions non-pressure related and 1 of 2 residents reviewed for anticoagulant (a blood thinner) medication side effects. The facility also failed to ensure an edema glove was in use as ordered for 1 of 1 residents reviewed for edema and treatment was completed timely for 1 of 1 residents reviewed for a change in condition. (Residents 1, 74, 181, 59, and 384) Findings include: 1. On 4/24/23 at 1:46 p.m., Resident 1 was observed in her room in bed. She did not have an edema glove to her right hand. On 4/26/23 at 9:30 a.m., 11:30 a.m., and 1:40 p.m., the resident's edema glove to the right hand was not in use. On 4/27/23 at 9:10 a.m., the resident's edema glove to the right hand was not in use. The record for Resident 1 was reviewed on 4/26/23 at 1:28 p.m. Diagnoses included, but were not limited…

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 oxygen was set at the correct flow rate and positioned correctly for 5 of 5 residents reviewed for oxygen. (Residents 1, 132, 59, 69, and 37) Findings include: 1. On 4/24/23 at 11:36 a.m. and 1:46 p.m., Resident 1 was observed in her room in bed. Her nasal cannula was not in her nares and her oxygen concentrator was set at 2 liters. On 4/25/23 at 2:09 p.m., the resident's oxygen concentrator was set at below 2 liters. At 3:13 p.m., the resident's oxygen prongs were not in both nares. The oxygen concentrator remained below 2 liters. The record for Resident 1 was reviewed on 4/26/23 at 1:28 p.m. Diagnoses included, but were not limited to, cerebral palsy, profound intellectual disabilities, and disorder of the nose and nasal sinuses. The 3/27/23 Significant Change Minimum Data Set (MDS) assessment indicated the resident was severely impaired for daily decision making and she was receiving oxygen while a resident of the facility. A…

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

Based on observation and interview, the facility failed to ensure a sanitary kitchen related to two dishes of food sitting open and not covered on the top of the stove and an accumulation of grease and dried food spillage in and around the stove in 1 of 1 kitchen observed. (Main Kitchen). This had the potential to affect 87 residents who received food from the kitchen. Findings include: During the initial kitchen tour on 4/24/23 at 8:58 a.m. with the Food Service Manager the following was observed: a. Two dishes filled with green beans, carrots and corn were opened and not covered on top of the stove. b. There was accumulation of grease on the stove and on the back splash. c. Inside the oven was a large amount of burnt substances with aluminum foil scattered on the bottom of the oven. d. There was a large accumulation of grease and dry food spillage inside the convection oven. e. There was an accumulation of grease and dust in the slats of the oven hood. f. The pipes in the kitchen had a buildup of grease and dust next to the stove right by the stove top. Interview with the Food…

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 the kitchen area was clean and in good repair related to dirty floors, cabinets, pipes and walls in 1 of 1 kitchens observed. (Main Kitchen) Findings include: During the initial kitchen tour on 4/24/23 at 8:58 a.m. with the Food Service Manager, the following was observed: a. The floor had a buildup of dirt and debris. b. Dirt was observed on the pipes in kitchen and underneath the dishwasher. c. Dirt was observed underneath the cabinets in the dish room. d. There was an accumulation of dirt and dust on the wall behind the stove. Interview with the Food Service Manager at that time, indicated all the above areas needed to be cleaned. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure residents had an assessment to self-administer their own medications for 2 random residents reviewed for self-administration of medication. (Residents 50 and 74) Findings include: 1. On 4/24/23 at 10:52 a.m., Resident 50 was observed in her room with a nasal spray and an inhaler at her bedside. The record for Resident 50 was reviewed on 4/26/23 at 10:36 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD) and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 3/30/23, indicated the resident was cognitively intact. A Care Plan, dated 5/23/22 and revised on 3/31/23, indicated the resident had a Physician's Order for self-administration of Vicks Vapo Rub, saline nasal spray, sore throat spray, Luden's throat drops, and an inhaler. Interventions included, but were not limited to, assess the resident's ability to safely self-administer medications specified on admission/readmission, quarterly, with a change in medication orders, and 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 dependent residents received assistance with activities of daily living (ADLs) related to nail care. (Resident 69) Finding includes: Interview with Resident 69 on 4/24/23 at 10:35 a.m., indicated her toenails were very long and they needed to be cut. The resident had told staff that she needed assistance cutting them, but they had not helped her. The resident's toenails were observed during the interview and were noted to be very long. Resident 69's record was reviewed on 4/26/23 at 1:22 p.m. Diagnoses included, but were not limited to, heart disease, chronic obstructive pulmonary disease, end stage renal disease, and type 2 diabetes mellitus. A Significant Change in Status Minimum Data Set (MDS) assessment, dated 3/28/23, indicated the resident was cognitively intact for daily decision making. She required extensive assistance with one person physical assist for personal hygiene. Interview with the Assistant Director of Nursing on 4/27/23 at 2:38 p.m., indicated the resident was on the list to be seen…

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 the resident received 1 to 1 activities at least 3 times a week for 1 of 1 residents reviewed for activities. (Resident 6) Finding includes: On 4/24/23 at 1:33 p.m. Resident 6 was observed in bed. At that time, the television was on, however, there was no sound and it was trying to connect to the internet. On 4/25/23 at 9:00 a.m., the resident was observed in bed with his eyes closed. There was no television or radio playing. The record for Resident 6 was reviewed on 4/26/23 at 1:45 p.m. Diagnoses included, but were not limited to, pericardial effusion, cerebral hemorrhage, intellectual disabilities, altered mental status, acute kidney failure, and expressive language disorder. The resident was admitted to the hospital on [DATE] and returned on 4/17/23 with hospice services. A Significant Change Minimum Data Set (MDS) Assessment, dated 4/21/23, was in progress. The Quarterly Minimum Data Set (MDS) assessment, dated 1/30/23,…

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 observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the treatment and services necessary to promote healing related to treatments not being completed as ordered and pressure reduction devices not being used for 2 of 3 residents reviewed for pressure ulcers. (Residents 1 and 50) Findings include: 1. On 4/28/23 at 10:59 a.m., Resident 1 was observed in her room in bed. Agency LPN 2 used hand sanitizer and donned gloves and proceeded to remove the resident's blanket exposing her feet. Three foam dressings, dated 4/24/23, were observed on the resident's right foot. Three foam dressings on the resident's overbed table, were dated 4/28/23. The LPN indicated she would take care of the resident's dressings and proceeded to remove each dressing one at a time and replace them with the pink foam dressings, dated 4/28. The LPN did not cleanse the wounds with normal saline and Medihoney (a debriding ointment) was not applied. The record for Resident 1 was reviewed on 4/26/23 at 1:28 p.m. Diagnoses included, but were not…

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 free from accidents and received supervision with medications related to proper interventions not in place to prevent the resident from falling and not staying with the resident until all of her medications were consumed for 1 of 3 residents reviewed for accidents. (Resident 27) Finding includes: On 4/25/23 at 9:00 a.m., Resident 27 was observed lying sideways in bed. At that time, she had on a pair of fuzzy socks, there was nothing on the bottom of them to prevent the resident from falling. Her wheelchair was parked by the bed and there was no dycem on top of the cushion to prevent the resident from sliding out of the wheelchair. There was no floor mat beside her bed. On 4/25/23 at 10:00 a.m., the resident was observed sitting up in her wheelchair, wearing the same fuzzy socks and self-propelling her wheelchair On 4/25/23 at 2:00 p.m., the resident was observed lying sideways in bed, wearing the same pair of fuzzy socks. There was no floor mat on the ground beside the bed, nor was there…

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 maintained acceptable parameters of nutritional status related to meal consumption records not completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 74) Finding includes: The record for Resident 74 was reviewed on 4/27/23 at 8:58 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, malignant neoplasm of right bronchus of lung, and emphysema. The admission Minimum Data Set (MDS) assessment, dated 3/27/23, indicated the resident was moderately impaired for daily decision making. He required supervision with eating and received a therapeutic diet. A Care Plan, dated 3/29/23, indicated the resident was at risk for weight fluctuations related to his current health status. He had the diagnosis of cancer and his body mass index (BMI) was 22. Interventions included, but were not limited to, assistance with meals as needed and diet per order. A Physician's Order, dated 3/23/23, indicated the resident was to…

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

Based on record review and interview, the facility failed to ensure psychotropic medications were monitored for side effects and effectiveness as well as ensuring Abnormal Involuntary Movement Scale (AIMS) assessments were completed for 1 of 5 residents reviewed for unnecessary medications. (Resident 47) Finding includes: Resident 47's record was reviewed on 4/25/23 at 1:31 p.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety, and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 3/24/23, indicated the resident was cognitively intact for daily decision making. She received antidepressant, anti-anxiety, and antipsychotic medications. A Physician's Order, dated 2/17/22, indicated the resident was to receive brexpiprazole (an antipsychotic medication) 0.5 milligrams (mg) one time a day. The order was discontinued on 6/12/22. A Physician's Order, dated 6/15/22, indicated the resident was to receive brexpiprazole 0.5 mg one time a day. The order was discontinued on 8/15/22. 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, interview, and record review, the facility failed to ensure a resident was free from significant medication errors related to the incorrect administration of insulin for 1 of 5 residents observed during medication pass. (Resident 331) Finding includes: During a medication administration observation on 4/28/23 at 10:50 a.m., RN 1 prepared Resident 331's insulin and checked the resident's orders. She dialed the resident's Lispro insulin pen to 2 units. She washed her hands and applied her gloves. She cleaned the resident's right arm and injected the insulin pen into the resident's arm. She had not primed the insulin pen or performed an air shot prior to administering the insulin. Interview with RN 1 on 4/28/23 at 11:04 a.m., indicated she did not know she was supposed to prime the insulin pen prior to administering insulin to the resident. Interview with the DON on 4/28/23 at 11:12 a.m. indicated RN 1 should have primed the insulin pen prior to injecting the resident and she would inservice RN 1. A facility policy titled, Medication Storage and Administration…

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 for safety, labeled, and dated for 1 of 1 medication storage rooms observed. (West Wing Medication Storage Room). Finding includes: During a medication storage observation on 4/28/23 at 10:12 a.m., the [NAME] Wing Medication Storage Room was observed with LPN 2. Ativan (2 vials) were found in the refrigerator inside a plastic container. The plastic container did not have a lock on it. The Medication room was locked, however the refrigerator was not locked. Interview Agency LPN 2 and she indicated she thought the plastic zip tie on the container was a lock. 4/28/23 10:18 a.m., the DON indicated the Ativan should have been in a locked box, or the refrigerator should have a lock on it. The pharmacist had told her to put a lock on the refrigerator a while ago. A facility policy titled, Medication Storage and Administration Quick Reference Guide, Medication Cart Security and HIPPA, provided by the DON as current, indicated, . Med storage keys are retained by designated staff. Controlled…

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.