Brickyard Healthcare - Fountainview Care Center

Based on interview, observation and record review, the facility failed to notify the address a resident's pain timely and effectively for 1 of 1 residents reviewed for pain. (Resident 49) Finding includes: During an interview on 5/19/2025 at 9:30 A.M., Resident 49 indicated his Foley catheter (indwelling urinary catheter) was causing him pain and he rated the pain as a 7 out of 10, with 0 being no pain and 10 being the worst pain. He pulled his brief down and exposed his catheter. The leg strap of the catheter was stuck to the tip of Resident 49's penis with a dime size amount of blood noted on the catheter strap. During an observation and interview,on 5/19/2025 at 9:34 A.M., the Unit Manager (UM) put on gloves and assessed Resident 49's Foley catheter. Resident 49 again reported his pain as a 7 out of 10. The UM put the leg strap onto the resident's leg and repositioned the Foley catheter tubing. The UM indicated Resident 49 had scheduled pain medications ordered, but did not have any pain medication ordered for breakthrough pain. The UM indicated she had requested an as needed…

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 wear personal protective equipment (PPE) while providing Foley catheter (indwelling urinary catheter) care for 1 of 4 residents reviewed for Enhanced Barrier Precautions (EBP). (Resident 49) Finding includes: During an observation on 5/19/2025 at 9:34 A.M., the Unit Manager (UM) put on gloves, but did not put on a gown and assessed Resident 49's urinary catheter. The UM put the leg strap onto the resident's leg and repositioned the catheter. There was an Enhanced Barrier Precaution sign hanging on Resident 49's door and a three drawer cart with PPE supplies noted outside of the resident's room. Resident 49's record review was completed on 5/21/2025 at 9:26 A.M. Diagnoses included, but were not limited to: neurogenic bladder, schizophrenia, anxiety disorder, dysphagia, and major depressive disorder. A current Physician's order, dated, 5/23/2025, indicated Resident 49 was in EBP related to an indwelling catheter and gown and gloves should be worn for high contact resident care. During an interview with the UM on…

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

Based on record review and interview the facility failed to ensure resident grievances were responded to promptly and acted upon for 4 of 21 residents reviewed for grievances. (Residents 52, 30, 70 & 128) Findings include: Review of 21 resident grievance forms, on 7/12/2024 at 9:38 A.M., indicated there was no documentation of response and outcomes for 4 of the 21 grievances reviewed. 1. During an interview, on 07/12/2024 at 10:49 A.M., Resident 52 indicated he had waited about an hour on every shift to get care and he has had staff come in, turn the call light off and never came back. The grievance discussed his concerns related to having to wait an hour every shift to get the care he needed, staff turning his call light off, without meeting his care needs and never coming back to give him care. Resident 52 indicated he had not received any response, written or verbal regarding his grievances. On 6/7/2024 Resident 52 filed a personal grievance indicating he had asked for help to use the bathroom and had to wait over 40 minutes for help. The grievance was reviewed by the Executive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to follow the physician's orders for 1 of 17 residents whose physician's orders were reviewed (Resident 11), and failed to accurately assess and document a wound for 1 of 7 residents reviewed for non pressure skin conditions. (Resident 5). The facility failed to obtain treatment orders for a new admission (Resident 127) and failed to transcribe and administer prescribed treatment orders from a follow-up post operative appointment. (Resident 63) for 1 of 17 residents reviewed for quality of care. Findings include: 1. During an interview and observation, on 7/8/2024 at 2:18 P.M., Resident 11 indicated he had problems with water retention in both of his lower legs and feet, and was not on a fluid restriction and was given as much to drink as he wanted. He indicated he did not wear any devices to help with the fluid retention. The resident had a full 20 ounce cup of water,dated 7/8/2024 and his lower legs and feet were observed to be swollen.…

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

Based on interview and record review the facility failed to ensure the Medical Director or his designee attended the quarterly Quality Assurance and Performance Improvement (QAPI) meeting during the past year. Finding includes: During an interview on 7/12/2024 at 1:56 P.M., the Administrator indicated the Medical Director had not attended the quarterly meetings, but she reviewed them with him or sent the minutes from the meeting to the Medical Director via an e-mail. The Nurse Practitioner attended some facility meetings, such as the nutrition at risk/wound, behavior, morning meeting or stand down meetings, but the QAPI signature log did not indicate she had attended any QAPI meetings during the past year. On 7/12/2024 at 2:00 P.M., the Administrator provided a policy titled, Quality Assurance and Performance Improvement, undated and indicated the policy was currently the one used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: 2. The QAA Committee shall be Interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing…

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

Based on interview and record review, the facility failed to ensure residents were made aware of the facility's bed hold policy upon transfer to a hospital for 2 of 2 residents reviewed for hospitalizations. (Residents 28 and 64) Findings include: 1. A record review for Resident 28 was conducted on 7/9/2024 at 3:04 P.M., Diagnoses included, but were not limited to, type 2 diabetes mellitus and anxiety disorder. An Annual Minimum Data Set (MDS) assessment, dated 5/8/2024, indicated Resident 28 had moderate cognitive impairment. Nursing Progress Notes, dated 4/22/2024, indicated Resident 28 was admitted to the hospital due to a methicillin resistant staph aureus infection. The record indicated her family had been notified but did not indicate the bed hold policy was explained and/or a copy given to the resident. 2. A record review for Resident 64 was conducted on 7/11/2024 at 9:32 A.M. Diagnoses included, but were no limited to, acquired absence or right and left leg below the knee and type 2 diabetes mellitus. An admission Minimum Data Set assessment, dated 5/9/2024, indicated…

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

Based on observation, record review and interview, the facility failed to provide nail care for dependent residents for 3 of 5 residents who were reviewed for activities of daily living needs. (Residents 35, 5, & 28) Findings include: 1. During an observation on 7/8/2024 at 10:06 A.M., Resident 35's right hand was contracted and his fingernails were long and curled downward on both hands. During an observation on 7/9/2024 at 11:30 A.M., Resident 35's right hand was contracted and his nails were long and curled downward on both hands. During an observation on 7/11/2024 at 10:04 A.M., Resident 35's right hand was contracted and his nails were long and curled downward on both hands. Resident 35's record review was completed on 7/11/2024 at 10:40 A.M. Diagnoses included, but were not limited to, conversion disorder with seizures and convulsions, diabetes insipidus, bipolar disorder, dysphagia, anxiety, and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated, 5/8/2024, indicated Resident 35 was severely cognitively impaired and was dependent on staff for bathing and personal…

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 catheter was anchored to prevent excessive tension on the catheter for 1 of 1 resident reviewed for urinary catheters. (Resident 128) Finding includes: During an interview, on 7/9/2024 at 9:58 A.M., Resident 128 indicated he had asked multiple times for several days on all three shifts for a catheter strap. He had an issue with blood in his catheter and was fearful of it getting pulled out. A record review was completed on 7/9/2024 at 3:02 P.M., for Resident 128. Diagnosis included but not limited to: paraplegia, osteomyelitis of vertebra in the sacral and sacrococcygeal region, residual foreign body in soft tissue, pressure ulcer of unspecified site, unspecified stage, and unstageable pressure ulcer of sacral region. An admission Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated the resident had no cognitive impairment. During an observation of Resident 128's urinary catheter, on 7/10/2024 at 10:23 A.M., 7/11/2024 at 1:25 P.M., there was no catheter strap in place. A current Care Plan,…

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 interviews, the facility failed to ensure physician orders regarding tube feeding orders were followed for 1 of 1 residents with tube feeding. (Resident 53) Finding includes: During an observation, on 7/11/2024 at 10:45 A.M., Resident 35 had a container of Jevity 1.5 (Brand of food used in feeding tubes) with 350 mL of formula remaining in the bag. The bag was still connected to a feeding tube pump that was turned off. Resident 35's record review was completed on 7/11/2024 at 11:40 A.M. Diagnoses included, but were not limited to, conversion disorder with seizures and convulsions, diabetes insipidus, bipolar disorder, dysphagia, anxiety, and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 5/8/2024, indicated Resident 35 was severely cognitively impaired and had a feeding tube. A current Physicians Order indicated the resident was to receive 1050 mL (milliliters) of Jevity 1.5 daily. A July 2024 Medication Administration Record (MAR) indicated the resident had received the full amount of Jevity 1.5 on 7/11/2024. A current Care…

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 interviews, the facility failed to ensure physician orders regarding dressing changes were followed for 1 of 1 residents reviewed for intravenous fluids. (Resident 128) Finding includes: During an observation and interview on 7/9/2024 at 10:14 A.M., Resident 128 indicated his peripheral inserted central catheter (PICC) line dressing had only been changed once since he was admitted . The date on the dressing was 6/29. The dressing had gauze tape applied around the edges of the dressing. A record review was completed on 7/9/2024 at 3:02 P.M., for Resident 128. Diagnosis included but not limited to, paraplegia, osteomyelitis of vertebra, sacral and sacrococcygeal, region, residual foreign body in soft tissue pressure ulcer of unspecified site, unspecified stage, pressure ulcer of sacral region, unstageable. An admission Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated he had no cognitive impairment. A Physician's Order, dated 6/21/2024, indicated to the PICC line dressing was to be changed upon admission, then weekly and as needed,…

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 reconciliation of controlled drugs was completed for 3 of 3 carts reviewed for narcotic counts. (B-Wing Hall 1 medication cart, C-Wing Hall 1 medication cart, and C-Wing Hall 2 medication cart) Findings include: 1. During an observation of the B-Wing Hall 1 medication cart on 7/12/2024 at 9:48 A.M., with LPN 11, the narcotic reconciliation sheets were missing signatures between 6/17/2024 and 7/11/2024. During an interview, on 7/12/2024 at 9:58 A.M., LPN 11 indicated narcotics should be counted by the off going nurse with the oncoming nurse and the reconciliation sheet should be signed by both nurses every shift. 2. During an observation, of the C-Wing Hall 1 medication cart on 7/12/2024 at 10:34 A.M., with QMA 9, the narcotic reconciliation sheets were missing signatures between 6/13/2024 and 7/11/2024. During an interview, on 7/12/2024 at 10:35 A.M., QMA 9 indicated the reconciliation of narcotics should be done every shift and both the off going and oncoming nurses should sign the sheet. 3. During and observation of…

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

Based on interview and observation the facility failed to properly store medications in 1 of 3 carts reviewed for storage. (C-Wing Hall 1 medication cart) Finding includes: 1. During an observation of the C-wing Hall 1 medication cart on 7/12/2024 at 10:34 A.M. the following was noted: A. A bottle of Lantus insulin for Resident 176 was found unopened in the cart. It had a label which indicated t was to be refrigerated until opened. During an interview, on 7/12/2024 at 10:36 A.M., the IP nurse indicated the insulin should have been in the refrigerator until it was opened. B. A bottle of Timolol eye drops and Brimondine eye drops, both for Resident 177, were found opened but undated. During an interview, on 7/12/2024 at 10:34 A.M., QMA 9 indicated the eye drops should have been dated when opened. On 7/12/2024 at 12:42 P.M., the Regional Nurse Consultant provided a current, undated, policy titled, Medication Storage. The policy indicated, .All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room 3.1-25(j)

Based on observation, record review and interview, the facility failed to dispose of leftovers timely in the walk-in cooler of the kitchen. This had the possibility to affect 2 of 2 resident with altered diets who received their meals from the kitchen. Finding includes: During the initial kitchen tour with the Registered Dietician (RD) on 7/8/2024 at 9:45 A.M., three tray, dated 7/2/2024, were observed in the refrigerator and held 8 glasses of milk, 2 glasses of water, 3 glasses of cranberry juice and 2 glasses of orange juice. The RD indicated the drinks were all thickened for residents who had altered liquid diet orders and the date on the tray was the date the drinks were prepared. During an interview, on 7/8/2024 at 10:15 A.M., the Regional Certified Dietary Manager (RCDM) indicated left overs were good for three days and prepared food should containing a made on date and a discard date. On 7/9/2024 at 1:27 P.M., the RCDM provided an undated policy, titled, Storage of Refrigerated Foods, and identified it as the policy currently used by the facility. The policy indicated, .The…

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

Based on observation, interview and record review, the facility failed to ensure infection control practice was maintained regarding glove use and hand washing during a sterile procedure for 1 of 1 residents observed during a dressing change procedure. (Resident 128) Finding includes: During an observation of a peripheral inserted central catheter (PICC) line dressing change on 7/9/2024 from 4:03 P.M. to 4:10 P.M., LPN 15 placed the dressing kit on the Resident's nightstand without a barrier or disinfecting the surface prior to placing the kit on the nightstand. Then she opened the dressing kit, donned sterile gloves and removed the old dressing. Without changing her gloves, she took the antimicrobial sponge disk and cleaned an area below the insertion site, then did a circular motion to clean around the insertion site. She then applied skin prep on the whole area and then patted it with gauze, applied transparent dressing, removed her gloves and performed hand hygiene. The resident was not offered a mask or asked to turn his head away from the insertion site. His head was 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 record review and interview, the facility failed to document declination forms for COVID immunizations for 3 of 5 residents reviewed for immunizations. (Residents 1, 3, & 24) Finding includes: On 7/11/2024 at 1:06 P.M., a record review was completed for Residents 1, 3 & 24. The records lacked documentation of signed declination forms for the covid vaccine. During an interview, on 7/11/2024 at 2:55 P.M., the Infection Prevention Nurse indicated she did not have signed declination forms for residents 1, 3, or 24 and she should have had each resident sign a declination form. On 7/12/2024 at 11:17 A.M., the Regional Nurse provided the policy titled, COVID Vaccination, no date, and indicated it was the policy currently in use by the facility. The policy indicated, .The resident's medical record will include documentation of the following: If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal

Based on observation, interview and record review, the facility failed to maintain a temperature log for a resident's personal refrigerator for 1 of 2 residents reviewed for personal refrigerators. (Resident 9) Finding includes: During an observation, on 7/11/2024 at 12:30 P.M., Resident 9's personal refrigerator did not have a thermometer or a temperature log. During an interview, on 7/11/2024 at 3:05 P.M., the Unit Manager indicated there should have been a thermometer in the fridge and temperature log record sheet for the refrigerator. On 7/11/2024 at 1:25 P.M., the Administrator provided the policy titled, Resident Refrigerators, no date, and indicated it was the policy currently in use by the facility. The policy indicated, . 2. Staff shall record refrigerator temperatures weekly on a temperature log. a. A thermometer shall remain in the refrigerator. It shall be calibrated prior to use and periodically thereafter. 3. Nursing/housekeeping staff shall clean the refrigerator weekly and discard any foods that are out of compliance. 4. Residents and staff shall comply with safe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's abnormal vital signs were reported to the physician, for 1 of 3 residents reviewed for nursing services. (Resident B). Finding includes: On 4/1/24 at 1:45 P.M., Resident B's clinical record was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, toxic encephalopathy, anemia, atrial fibrillation , heart failure, hypertension, orthostatic hypotension, and paraplegia. An admission Minimum Data Set (MDS) assessment, dated 2/23/24, indicated the resident was cognitively intact, required extensive assistance with most activities of daily living, utilized an indwelling catheter, and required a wheelchair for locomotion. Current Physician's Orders indicated the following: Midodrine HCL 5 MG, 3 times daily for hypotension Amiodarone HCL 100 MG, 2 times daily for systolic congestive heart failure, dated 3/1/24 Ceftriaxone Sodium 1 gram injection every 24 hour for 7 days for urinary tract…

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 reassess a resident after a change in condition, for 1 of 3 residents who were reviewed for nursing services. (Resident B) Finding includes: On 4/1/24 at 1:45 P.M., Resident B's clinical record was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, toxic encephalopathy, anemia, atrial fibrillation , heart failure, hypertension, orthostatic hypotension, and paraplegia. An admission Minimum Data Set (MDS) assessment, dated 2/23/24, indicated the resident was cognitively intact, required extensive assistance with most activities of daily living, utilized an indwelling catheter, and required a wheelchair for locomotion. Current Physician's Orders indicated the following: Midodrine HCL 5 MG, 3 times daily for hypotension Amiodarone HCL 100 MG, 2 times daily for systolic congestive heart failure Ceftriaxone Sodium 1 gram injection every 24 hour for 7 days for urinary tract infection and leukocytosis…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was transferred, via a Hoyer lift (a resident lift/transfer device), with 2 staff persons, as directed by the plan of care. This resulted in a left femur fracture. (Resident G) Finding includes: On [DATE] at 12:00 P.M., a review of the clinical record for Resident G was conducted. The resident's diagnoses included, but were not limited to: cerebrovascular accident effecting left non-dominant side, depression, obesity and anxiety. A Discharge Minimum Data Set Assessment, dated [DATE], indicated the resident was totally dependent of 2 persons to assist him with transfers and was cognitively intact. A Care Plan, dated [DATE], indicated resident had a physical functioning deficit with mobility impairment. One of the interventions indicated the the resident required transfer assistance of 2 persons and the use of a Hoyer lift. A form titled, Resident Shower Sheet, dated [DATE], indicated shower was completed, on the day shift, for 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, interview and record review, the facility failed to ensure food items in the freezer were dated/labeled and sealed securely after opening and to ensure cooking utensils, skillets, microwave, and refrigerators were clean and in good condition in one kitchen observed. This deficient practice had the potential to affect 68 of 70 residents who received meals out of the kitchen. Finding includes: On 6/27/2023 at 10:49 A. M., during a follow up observation of the kitchen with [NAME] 3, the following were observed: -4 of 12 metal scoops had dried food substances on them. -A skillet had missing areas of black Teflon around the edges and on the skillet base. -The microwave had an area that appeared to be burnt with peeling plastic along the top edge. The refrigerator had a dried substance along the rubber seals. -The steam table had brown stains of grease running down the front of the table and 8 cans of vegetables/fruits that were dented. During an interview, on 6/27/23 at 11:00A.M, [NAME] 3 indicated: the scoops should have been cleaned; the skillet and the the…

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

Based on interview and record review, the facility failed to provide a dignified environment when conducting an interview for 1 of 3 residents reviewed for dignity. (Resident 176) Finding includes: During an interview on 6/26/2023 at 11:20 A.M., Resident 176 indicated she filed a grievance with the Activity Director, during an interview, concerning activities preferences. She indicated she reported a male nurse who insisted on completing code status forms while she was on the bed pan with her gown above her pelvis and bed covers around her private areas. She indicated she informed the male nurse she wanted to be cleaned up prior to completing the code status paperwork. She indicated the male nurse continued to ask questions and wanted her to sign the POST (Physician's Orders for Scope of Treatment) form. She again, informed the nurse she wanted cleaned up prior to completing the paperwork. The male nurse, then left the room, and got a certified nursing assistant (CNA) to complete the care needed. Resident 176 indicated she informed the Director of Nursing (DON) during interview as…

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

Based on interview and record review the facility failed to provide choices for care for 1 of 4 residents reviewed for showering. (Resident 176) Finding includes: During an interview on 6/27/2023 at 9:23 A.M., Resident 176 indicated that she was not given a choice of when to take a shower. She indicated the CNA's (Certified Nursing Assistant) are coming to her room at night to give her a shower. She indicated that she has never taken a shower at night in her life. A record review was completed on 6/28/2023 at 8:33 A.M. Diagnoses included, but were not limited to: anxiety disorder, osteoarthritis, and congestive heart failure. An admission Minimum Data Set (MDS) Assessment, dated 6/16/2023, indicated Resident 176 was cognitively intact and required extensive assistance with two or more staff members for bathing. A Care Plan, dated 6/13/2023, indicated Resident 176 had a self-care deficit. The interventions did not address bathing. A Resident Preference Evaluation, dated 6/14/2023 at 2:36 P.M., indicated it was very important to choose between a tub bath, shower, bed bath or sponge…

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

Based on interview and record review, the facility failed to ensure the Surety Bond amount was sufficient to cover the Resident's personal fund account daily. This deficient practice had the potential to effect 36 of 70 residents who had personal fund accounts in the facility. Finding includes: During an interview, on 6/30/2023 at 7:50 A.M., the Administrator indicated the Surety Bond amount was $70,000.00. On 6/30/2023 at 8:27 A.M., the Business Office Manager provided the monthly balances for the Resident Funds for March, April and May 2023. The balance for March 2023 was $72,188. 90, for April, the balance was $83,156.27. During an interview, on 6/30/2023 at 8:30 A.M., the Administrator indicated the amount of the bond had not covered the resident funds. On 6/30/2023 at 8:52 A.M., the Administrator provided the policy titled, Surety Bond Requirements, undated, and indicated the policy was the one currently used by the facility The policy indicated, . Any resident funds that are entrusted to the facility for a resident must be covered by the surety bond, including refundable…

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, observation and interview, the facility failed to inform a physician of a significant weight loss for 2 of 3 residents reviewed for nutrition. (Resident 59 & 39) Findings include: 1. During an interview, on 6/26/2023 at 10:40 A.M., Resident 59 indicated they (the staff) say I lost 30 lbs. A record review was completed on 6/28/2023 at 2:41 P.M. Resident 59's diagnoses included, but were not limited to: congestive heart failure, dementia, osteoarthritis, chronic kidney disease, retention of urine, and neurogenic bladder. A Quarterly MDS (Minimum Data Set) Assessment, dated 3/17/2023, indicated Resident 59 required extensive staff assist of 1 staff for bed mobility, transfers, dressing and limited assist of 1 staff for toilet use. Resident 59's weights included the following: On 12/16/2022 weight was 171.0. On 1/16/2023 weight was 172.0 On 2/14/2023 weight was 175.2. On 3/7/2023 weight was 174.2. On 4/14/2023 weight was 173.6. On 5/5/2023 weight was 172.8. On 6/13/2023 weight was 149.0. On…

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

Based on record review and interview, the facility failed to report to state agencies an injury of unknown source for 1 of 1 residents reviewed for injury of unknown source. (Resident 15) Finding includes: A record review was completed, on 6/29/2023 at 10:18 A.M. Resident 15's diagnoses included, but were no limited to depression, osteoarthritis, dementia, anxiety, insomnia, and heart failure. A Significant Change MDS (Minimum Data Set) Assessment, dated 4/18/2023, indicated Resident 15 was severely cognitive impaired, required extensive assist of 2 staff for bed mobility, transfers, toilet use and total assist for bathing, and was incontinent of bladder and bowels. A current care plan, dated 9/30/2021, indicated the resident had a physical functioning deficit related to: Self-care impairment due to history of stroke, dementia, arthritis, and chronic pain. Incontinent of bowel and bladder. Personal hygiene: one assistance. Toileting assistance. Offer to toilet after meals as resident tolerates requires one assist. Initiated on 6/27/2023. A Progress Note, dated 5/4/2023 at 5:15 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 a thorough investigation was completed for an injury of unknown origin for 1 of 2 residents reviewed for abuse. (Resident 15) Finding includes: A record review was completed, on 6/29/2023 at 10:18 A.M. Resident 15's diagnoses included, but were no limited to depression, osteoarthritis, dementia, anxiety, insomnia, and heart failure. A Significant Change MDS (Minimum Data Set) Assessment, dated 4/18/2023, indicated Resident 15 was severely cognitive impaired, required extensive assist of 2 staff for bed mobility, transfers, toilet use and total assist for bathing, and was incontinent of bladder and bowels. A current care plan, dated 9/30/2021, indicated the resident had a physical functioning deficit related to: Self-care impairment due to history of stroke, dementia, arthritis, and chronic pain. Incontinent of bowel and bladder. Personal hygiene: one assistance. Toileting assistance. Offer to toilet after meals as resident tolerates requires one assist. Initiated on 6/27/2023. A Progress Note, dated…

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 develop person-centered care plans related to mood, behaviors, and activities for 3 of 29 residents whose care plans were reviewed. (Residents 14, 37, and 39) Findings include: 1. On 6/28/2023 at 8:51 A.M., a record review was completed. Resident 14's diagnoses included, but were not limited to: dementia, major depressive disorder, bipolar disorder, and anxiety disorder. A current care plan, dated 5/13/2023, indicated Resident 14 had diagnoses of anxiety, bipolar, and depression, and received antidepressant and antipsychotic medications. The care plan goal was the resident will focus on the future and find one enjoyable thing. Interventions included but were not limited to: offer to help resident keep in touch with family, encourage activities, and give medications that help with depression. A current care plan, dated 2/27/2023, indicated resident 14 had cognitive loss related to dementia. The goal for care plan included, but were not limited to: resident developing skills to cope with cognitive decline. Interventions…

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 update/revise care plans related to falls, peripherally inserted central catheter (PICC), and significant weight loss for 3 of 29 residents whose care plans were reviewed. (Residents 7, 35, and 39) Findings include: 1. During an observation, on 5/26/2023 at 1:50 P.M., Resident 7 was in bed without a fall mat or non-skid strips next to the bed. A record review, completed on 6/29/2023 at 10:40 A.M., indicated Resident 7's diagnoses included, but were not limited to: benign prostatic hyperplasia, non-pressure chronic ulcer of right lower leg, tremor, personality disorder, and insomnia. A Quarterly MDS (Minimum Data Set) Assessment, dated 3/20/2023, indicated Resident 7 had severely impaired cognition, and required extensive assist with bed mobility, transfers, and toilet use. A current care plan, dated, 3/16/2023, indicated Resident 7 had a risk for falls related to history of falls, sitting self on floor from bed and wheelchair, and refusing to ask for assistance from staff when needed. Interventions included…

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 dressing tasks for 1 of 4 residents reviewed for activity of daily living. (Resident 16) Finding includes: During an interview on 6/27/2023 at 9:00 A.M., Resident 16 indicated he had been in the same clothing for two days, even sleeping in the clothing. He was wearing green Notre Dame pants, a veteran's t-shirt, an a red/black plaid flannel. On 6/27/2023 at 3:47 P.M., Resident 16 was observed sitting outside with blue sweatpants, a pullover shirt with buttoned neck, and a t-shirt. A record review was completed on 6/27/2023 at 3:47 P.M. Diagnoses included, but were not limited to: fatigue, post traumatic stress disorder, and dementia. An Annual Minimum Data Set (MDS) Assessment, dated 5/25/2023, indicated Resident 16 was cognitively intact, and required extensive assistance with the assistance of one staff member for dressing. A Care Plan, dated 6/18/2023, indicated Resident 16 had a physical functioning deficit related to mobility impairment related to increased weakness and fatigue. An intervention…

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 that a fractured humerus was mobilized in a sling per the physician order, and notify the physician of the resident's noncompliance for 1 of 1 residents reviewed for range of motion. (Resident 56). Finding includes: During an observation on 6/26/2023 at 11:08 A.M., Resident 56 was observed sitting in the hallway with a sling to her right arm. The sling did not immobilize the arm, and Resident 56 had her right arm resting on the wheelchair armrest with the right arm improperly positioned in the sling pocket to provide immobilization. A record review was completed on 6/29/2023 at 10:03 A.M. Diagnoses included, but were not limited to: fracture of right humerus, atrial fibrillation, and hypertension. A diagnostic imaging report of the right shoulder on 6/13/2023, indicated Resident 56 had an acute appearing fracture of the surgical neck and greater tuberosity. An AfterVisit Summary from the hospital dated 6/13/2023, indicated Resident 56 was seen for a fall with a humeral head fracture. She was prescribed…

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

Based on interview, record review, and observation, the facility failed to ensure infection control practices were maintained during the care of a pressure ulcer to prevent the spread of infection for 1 of 1 resident reviewed for pressure ulcers. (Resident 35) Finding includes: During an interview, on 6/27/2023 at 9:13 A.M., Resident 35 indicated she had pressure areas to her buttocks. A record review was completed on 6/29/2023 at 1:57 P.M. Resident 35's diagnoses included, but were not limited to: seizure disorder, anemia, neurogenic bladder, depression, paraplegia and spinabifada. A Significant Change MDS (Minimum Data Set) Assessment, dated 3/16/2023, indicated Resident 35 required extensive staff assist of 2 for bed mobility, dressing, and total assist of 2 staff for transfers. Had an Indwelling Foley catheter and pressure ulcers: 1 stage II, 1 stage III and 1 stage IV. During a pressure ulcer treatment administration, on 6/28/2023 at 9:29 A.M., the following was observed: RN 5 applied gloves, then remove them and left the room to get gauze. She then returned to the room 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 provide timely incontinence care and implement infection control practices to prevent the spread of infection for 1 of 2 residents reviewed for urinary incontinence (Resident 15 ) and failed to provide timely physician ordered testing for a resident with hematuria, urine retention, and pain in the abdomen for 1 of 3 residents (Resident 172) reviewed for urinary tract infection. Findings include: 1.During an interview, on 6/27/2023 at 9:57 A.M., the family of Resident 15 indicated the resident is left in the dining room and the staff don't change her. The staff have not changed or checked on her for 2-3 hours. A record review was completed, on 6/29/2023 at 10:18 A.M. Resident 15's diagnoses included, but were no limited to depression, osteoarthritis, dementia, anxiety, insomnia, and heart failure. A Significant Change MDS (Minimum Data Set) Assessment, dated 4/18/2023, indicated Resident 15 was severely cognitive impaired, required extensive assist of 2 staff for bed mobility, transfers, toilet use and total…

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 respiratory equipment was stored and maintained per physicians orders and standard of practice for 1 of 1 residents reviewed. (Resident 175) Finding includes: During an observation on 6/26/2023 at 10:19 A.M., the continuous positive airway pressure (C-Pap) mask was located on the bed, the oxygen concentrator tubing was not dated, and the portable oxygen tubing was observed on the seat of the wheelchair. On 6/26/2023 at 2:40 P.M., the oxygen concentrator tubing was observed on the floor, and the portable oxygen tubing was observed in the seat of the wheelchair. The tubing continued to not be dated. During an observation on 6/27/2023 at 3:36 P.M., Resident 175 was observed with the nasal cannula in his nose while wearing his C-Pap machine. The nasal cannula was disconnected from the oxygen concentrator, and the connection of the nasal canula was observed on the floor. A record review was completed on 6/28/2023 at 10:21 A.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary…

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 have 8 consecutive hours of RN coverage in the facility. Finding includes: The PBJ (Payroll Based Journal) staffing data report dated January, February, and March 2023, indicated the facility did not have 8 hours of continuous RN coverage on the following dates: 1/28/2023, and 2/25/2023; 2/11/2023 only 1.7 hours covered, 2/17/2023 only 5.68 hours covered, 3/11/2023 only 1.5 hours covered, 3/25/2023 5.77 hours covered, and 3/19/2023 only 7.87 hours covered. During an interview, on 6/28/2023 at 2:47 P.M., the Director of Nursing (DON) indicated the facility staffs the day shift with 1 Registered Nurse (RN), 2 Licensed Practical Nurses (LPN), and 6 Certified Nurse's Aides (CNA). They staff evening shifts with 2 LPNs, 2 Qualified Medication Aides (QMA) and 6 CNAs, and night shift should be staffed with 1 RN, 1 LPN, and 3 CNAs. The DON indicated if the facility were without RN coverage, the DON would be the one to come in and cover the shift, the facility was without a DON during the time no RN coverage was reported. A policy…

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 medication room was locked when not in use for 1of 1 medication rooms randomly observed. (Hall 100 medication room) Finding includes: During a random observation, on 6/30/2023 at 4:38 A.M., the medication door was observed propped open with a trash can and not locked. During an interview, on 6/30/2023 at 4:40 A.M., LPN 12 indicated the door should not have been propped open, On 6/30/2023 at 10:07 A.M., the Corporate Nurse provided the policy titled,Medication Storage, undated, and indicated the policy was the one currently used by the facility. The policy indicated .a. All drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls 3.1-25(m)