Brookside Care Strategies

Based on interview and record review, the facility failed to ensure residents, for whom the facility managed funds, or their representatives, received quarterly funds statements for 2 of 3 residents reviewed for quarterly statements. (Residents F and H)Findings include:A current 8/19/25, facility Trail Balance resident funds statement indicated the facility managed personal funds for 32 residents. Residents E, F and H names were listed on the account list.Quarterly statements were requested of facility management for review for Residents E, F, and H. Residents F and H did not have quarterly statements for review. During an interview on 8/20/25 at 1:36 p.m., the Administrator and Business Office Manager both indicated that quarterly statements had not been given to residents who did not have a responsible party to receive them. This had been an error and residents should have received the statements themselves.A current, 2017, facility policy titled, Deposit of Resident Funds, provided by the Business Office Manager on 8/20/21 at 1:38 p.m., indicated The resident is provided 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 interview and record review, the facility failed to provide a surety bond in sufficient amount to safeguard all resident funds. This deficient practice had the potential to impact 32 of 32 residents for whom the facility managed funds. Findings include: Review of a current 8/19/25, facility Trail Balance resident funds statement indicated the facility managed resident funds for 32 residents.Review of the facility's current, April 1, 2022, surety bond agreement indicated the resident funds were covered in liability surety for the amount of $30,000.00 (thirty thousand dollars).A review of bank statements for July 2025 (7/1/25 to 7/31/25), June 2025 (5/31/25 to 6/30/25) and May 2025 (5/1/25 to 5/30/25) indicated 23 days had a daily ledger balance greater than $30,000.00 as follows: 7/3/25 $41,381.03, 7/7/25 $41,422.03, 7/9/25 $43,429.03, 7/13/25 $42,740.03, 7/16/25 $43,099.03, 7/21/25 $31,950.82, 7/22/25 $32,192.32, 7/23/25 $31,869.32, 7/25/25 $31,773.27, 7/28/25 $30,109.89, 6/3/25 $42,544.15, 6/4/25 $48,374.65, 6/5/25 $39,050.65, 6/6/25 $37,644.65, 6/9/25 $38,670.65, 6/11/25…

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

Based on interview and record review, the facility failed to notify a resident's representative regarding change in condition for 1 of 3 residents reviewed for change in condition. (Resident C)Finding includes: Resident C's record was reviewed on 8/19/25 at 12:31 p.m. Medical diagnoses included paranoid schizophrenia, hypertension, and gastro-esophageal reflux disease (acid reflux).A 5/27/25, quarterly, quarterly Minimum Data Set (MDS) indicated the resident was mildly cognitively impaired.A nurse's note, dated 7/22/25 at 12:39 p.m. indicated the resident was found cool, clammy, tachycardic (high heart rate), and hypertensive (high blood pressure). The resident was encouraged to take her blood pressure medication and drink fluids, but verbally refused and swatted at a cup containing the medication. The note lacked notification of family or the resident representative.A progress note dated 7/22/25 at 2:57 p.m. indicated the resident was excessively sweating, tachycardic, hypertensive, and tachypneic (high respiratory rate) and continued to refuse medications and fluids. The nurse…

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

Based on observation, interview, and record review, the facility failed to obtain physician orders for oxygen services for 1 of 1 residents reviewed for oxygen use. (Resident 5)Finding includes:During an interview with Resident 5 on 8/19/25 at 10:05 a.m., he indicated he used oxygen at 3 liters per minute (lpm) via nasal cannula all the time, except when smoking. During the interview, the resident's oxygen concentrator was observed to be on 4 lpm of oxygen. The resident indicated he had not adjusted the flow rate. During an interview with Resident 5 on 8/20/25 at 8:42 a.m., he indicated his oxygen flow had not been adjusted. The oxygen concentrator remained on 4 lpm.Resident 5's record was reviewed on 8/20/25 at 10:35 a.m. Diagnoses included acute and chronic respiratory failure, atrial fibrillation (abnormal heart rhythm), and generalized anxiety disorder.Current physician orders included change nebulizer tubing weekly on Sunday night shift every Sunday, nebulizer machine for as needed (PRN) albuterol (respiratory medication) nebulization (changing a liquid medication into 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 complete and accurate daily nurse staffing information was posted and readily available for residents and resident representatives. This deficiency had the potential to affect 39 of 39 residents residing in the facility. Finding includes:During an observation, on 8/18/25 at 7:34 a.m., the 'Daily Staffing Posting without Units' information sheet was dated Thursday, 8/14/25. This was posted on the wall behind the nurse's station. On 8/18/25 at 9:30 a.m., the Daily Staffing Posting without Units was dated Monday, 8/18/25 and indicated there were no Registered Nurses (RN) or Licensed Practical Nurses (LPN) scheduled for the evening and night shifts, and there were no Certified Nursing Assistants (CNA) scheduled for the night shift. On 8/20/25 at 9:32 a.m., the 'Daily Staffing Posting without Units' indicated there were no RNs or LPNs on the evening shift. During an interview, on 8/21/25 at 1:45 p.m., QMA 9 indicated she was responsible for updating the nurse staffing post everyday. She arrived at work between 8:30 and…

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

Based on observation, interview, and record review the facility failed to provide social services regarding financial management regarding the management of cash savings and spending down of resources to remain eligible for Medicaid for 2 of 3 residents reviewed for assistance to manage finances. ( Resident C and D)Findings include:1.During an interview, Resident C's representative indicated the resident's funds had not been managed correctly. The resident had cash funds stored in the Social Service office, not the business office. There was no method to account for what funds had been spent. At the time of discharge, the representative was given cash in the amount of $700 dollars, and the family thought their loved one should have more money. The facility staff informed them the resident purchased lots of snacks, when they questioned the amount of money returned to them.During an interview on 8/21/25 at 1:00 p.m., the Administrator indicated he had not known Resident C had cash in the Social Service office until he witnessed it being given to the family at the resident's…

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 and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. Findings include:Review of the Summary Statement of Deficiencies, for the facility's last annual Recertification and State Licensure Survey completed on 9/26/24, indicated the facility failed to ensure nurse staffing information readily available in a readable format to residents and visitors daily. The plan of correction indicated, A new updated form was completed and placed in accessible area to resident and visitors, all staff that complete the daily nurse staffing information forms have been provided a revised form and provided education on the completion and accessibility to resident and visitors. Each morning, upon arrival to the facility the Administrator and/or Designee will ensure the current day's nurse staffing information was completed. Repeat concerns regarding complete and accurate daily nurse staffing posting were cited during the August 18, 2025, survey as follows:…

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 education for and to offer administration of influenza and/or pneumococcal vaccinations to residents for 3 of 5 residents reviewed for vaccinations. (Residents K, 5, and 7)Finding includes: 1.Resident 7's clinical record was reviewed on 8/19/25 at 1:25 p.m. Diagnoses included heart failure, asthma, and anxiety disorder. An 8/7/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The record lacked influenza and pneumococcal vaccine education or administration records. During an interview with the DON on 8/22/25 at 11:34 a.m., she indicated she was unable to locate information regarding resident 7's influenza or pneumococcal vaccination status. 2.Resident 5's record was reviewed on 8/20/25 at 10:35 a.m. Medical diagnoses included acute and chronic respiratory failure, hypertension, and anxiety disorder. A 7/17/25, quarterly, MDS assessment indicated the resident was cognitively intact. The clinical record indicated the resident received an unspecified pneumococcal vaccine in…

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 educate on offer the COVID-19 vaccination to employees for 1 of 1 employees reviewed for COVID-19 vaccination. (CNA 8)Finding includes:During an interview with CNA 8 on 8/22/25 at 8:45 a.m., she indicated she had worked at the facility for approximately two years. During her time at the facility, she had not been educated on or offered the COVID-19 vaccination.During an interview with the IP on 8/22/25 at 8:57 a.m., she indicated the facility had no documentation of vaccination education or offerings from 2024.A current facility policy titled, COVID-19 Vaccination Policy provided by the DON on 8/22/25 at 11:05 a.m. indicated the following, .7 The infection prevention and control measures that are implemented to address the SARS-CoV-2 are incorporated into the facility infection prevention and control plan. These measures include: a. encouraging staff, residents and visitors to remain up-to-date with all COVID-19 vaccine doses; b. providing resources and counseling about the importance of receiving the COVID-19 vaccine.

Based on observation, record review and interview, the facility failed to ensure the multi-use blood glucose monitoring device was sanitized per manufacturer's guidelines during a random observation of blood glucose testing. Findings include: During an observation of blood glucose testing on 2/20/25 beginning at 11:34 a.m., QMA 2 removed a blood glucose testing meter from the top drawer of the medication cart. She wiped the device with an alcohol swab. At 11:35 a.m., she entered Resident G's room and placed the cup with the device on the overbed table. She donned gloves, swabbed the resident's finger with an alcohol wipe, and obtained the sample and reading. At 11:39 a.m., she removed her gloves and wiped the device with an alcohol swab and performed hand hygiene. At 11:40 a.m., she entered Resident H's room and placed the cup with the device on the overbed table. She donned gloves and swabbed Resident H's finger and obtained the sample and reading. At 11:42 a.m., she removed her gloves and wiped the device with an alcohol swab and returned to the medication cart, placing the device…

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 insulin administration for 3 of 3 residents reviewed for insulin administration. (Resident B and C) Findings include: 1. Resident B's clinical record was reviewed on 2/19/25 at 11:50 a.m. Diagnoses included type 2 diabetes mellitus (DM), unspecified altered mental status, unspecified poly neuropathy, and long term use of insulin. A physician's order, dated 1/3/25, indicated Lantus (a diabetic medication to treat to DM), administer 30 units subcutaneously in the morning. The electronic medication administration record (eMAR) indicated the medication had not been administered. The progress notes lacked documentation regarding the missed dose. A physician's order, dated 9/10/24, indicated Lispro (a diabetic medication to treat to DM), administer 10 units subcutaneously before meals. The eMAR indicated the medication had not been administered on 1/2/25 for the 4:00 p.m. dose. An administration note indicated the resident only took 4 units and lacked indication of physician notification regarding decreased administered…

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 implement their abuse prohibition policy to ensure the safety of residents when an employee accused of abuse was permitted to remain in the facility during the investigation into the allegation. (Resident B and Care Specialist (CS) 1) Findings include: Resident B's clinical record was reviewed on 1/8/25 at 11:09 a.m Diagnoses included chronic obstructive pulmonary disease, chronic pain syndrome, hypertension, convulsions, psychoactive substance abuse and anxiety. Review of the most current significant change Minimum Data Set (MDS) assessment, dated 11/12/24, indicated the resident was cognitively intact. During an interview on 1/8/25 at 12:18 p.m., CS 1 indicated she was informed that Resident B had alleged she kicked the resident's foot. She was unaware of any physical contact with the resident. CS 1 indicated she was not suspended pending investigation, but instructed to stay away from Resident B. During an interview on 1/8/25 at 1:10 p.m., the Administrator indicated Resident B told him CS 1 had kicked the resident's 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.

Based on observation, interview, and record review, the facility failed to ensure refrigerators functioned at a level to maintain safe food temperatures. This deficient practice had the potential to impact 34 of 34 residents who resided in the facility. Findings include: During the initial kitchen tour on 9/22/24 at 9:50 a.m., the following concerns regarding food refrigeration were noted: The standard white, two-section, (freezer on top) refrigerator registered a temperature of 48 degrees Fahrenheit (F). Inside the refrigerator were multiple trays of pre-poured drinks (milk and juices) and blocks of sliced cheeses. During an interview at this time, [NAME] 13 indicated the refrigerator should register between 36 to 38 degrees F. He believed the door may have been left open too long during breakfast meal service. He would let the Dietary Manager know and keep and eye on the temperatures. Review of the Refrigerator Temperature Logs for September 2024 indicated the logs for the three refrigerator and/or freezer units in the facility kitchen had not been completed in multiple days. The…

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

Based on record review and interview, the facility failed to develop and implement approaches to maintain a Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies. The deficient practice the the potential to impact 34 of 34 residents. Findings include: Review of the Summary Statement of Deficiencies, for the facility's last annual recertification and licensure survey completed on 11/17/23, indicated the facility had deficiencies related to a lack of properly labeled medications and completed shift-to-shift narcotic reconciliation sheets. The plan of correction indicated, Ongoing corrective action will be monitored through the facility Quality Assurance and Performance Improvement Program to ensure ongoing compliance. During an interview on 9/26/24 at 4:53 p.m., the Administrator indicated he was unable to provide the facility's most recent QAPI plan because they did not have one. The facility needed a more formal process for QAPI, where minutes were part of the meetings. He did not have any record keeping of the minutes for the meetings that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a fully functional call light system for all resident rooms and resident bathrooms. This deficient practice impacted 34 of 34 residents who resided in the facility. Findings Include: During random observations of the facility the following resident rooms were noted to have a hand bell or table top bells placed on tables, chest of drawers, and/or refrigerator tops: a. Resident room [ROOM NUMBER] on 9/22/24 at 9:56 a.m. b. Resident room [ROOM NUMBER] on 9/22/24 at 10:59 a.m. c. Resident room [ROOM NUMBER] on 9/22/24 at 11:46 a.m. d. Resident room [ROOM NUMBER] on 9/23/24 at 10:00 a.m. e. Resident room [ROOM NUMBER] on 9/23/24 at 10:18 a.m. f. Resident room [ROOM NUMBER] on 9/23/24 at 2:54 p.m. g. Resident room [ROOM NUMBER] on 9/23/24 at 2:55 p.m. h. Resident room [ROOM NUMBER] on 9/23/24 at 2:57 p.m. Confidential interviews were conducted during the course of the survey. During a confidential interview, a resident indicated the call…

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 most recent survey results were readily accessible to residents and resident representatives. Findings include: A review of the facility survey binder on 9/22/24 at 10:04 a.m., located behind the nurse's station, indicated the most recent survey included in the survey binder was dated 11/27/23. The additional surveys included in the survey binder were all dated prior to 11/27/23. Signage at the nurse's station indicated to ask for the survey binder. During an interview, on 9/23/24 at 10:11 a.m., the Administrator indicated the survey dated 11/27/23 was the previous annual survey and the survey binder only needed to include annual surveys. He was not aware complaint surveys were required to be included in the survey binder. Review of survey activities conducted by the Indiana Department of Health indicated complaint surveys were conducted on the following dates: 12/21/23, 2/23/24, 3/15/24, 6/20/24, 7/24/24, and 8/20/24. A current facility policy, revised 4/07, titled, Survey Results, Examination of, provided by…

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 implement a grievance process according to facility policy for resident and resident representative concerns. Findings include: During record review on 9/24/24 at 10:30 a.m., the facility grievance binder, provided by the Administrator, indicated the following: The most recent grievance was filed on 1/23/24. During an interview, on 9/24/24 at 10:45 a.m., the Administrator indicated the Social Services Director (SSD) was the grievance official for the facility. During an interview, on 9/24/24 at 10:49 a.m., the SSD indicated she was the facility grievance official. Her grievance process was when a resident made a complaint or expressed a concern, it was investigated and resolved immediately. Since issues were resolved immediately there was no need to write the information on a grievance form. She indicated in the last 9 months, there had not been any concerns or complaints that had not been resolved immediately. A current facility policy, revised 4/17, titled, Grievances/Complaints, Filing, provided by the Administrator, 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 interview and record review, the facility failed to develop and implement an infection control program which enabled the facility to analyze patterns of known infectious symptoms, prevent the spread of infection, and/or develop programs to prevent recurrence. Findings include: A record review, on 9/24/24 at 10:20 a.m., of the Infection Control Binder, indicated the Infection Log and color coded mapping was completed utilizing the antibiotic Order Listing Report. This report was not printed until 9/23/24 (after the start of the survey), at which point it was printed for the following months: March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, and September 2024. The tracking log lacked indication of tracking and trending of resident infections prior to 9/23/24. During an interview, on 9/24/24 at 10:35 a.m., the Infection Preventionist (IP) indicated she had only been in this position since 9/11/24 and split her time between two different locations. She had printed out the antibiotic orders for the previous months on 9/23/24 and filled out the Infection Log…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure residents had safe, comfortable chairs in their rooms for resident use. This deficient practice had the potential to impact 34 of 34 of the facilities residents. Findings include: Confidential interviews were completed throughout the survey. 1. During a confidential interview, a resident indicated they would like a chair in their room. They sat on their bed or table. During an observation at that time, the resident sat on their bedside table. 2. During a confidential interview, a resident indicated would like a chair for guests. Visitors usually sit side by side with the resident on the bed. 3. During a confidential interview, a resident indicated it was hard to bring a chair from the dining room if you wanted to sit in a chair. 4. During a confidential interview, a resident indicated they would like a chair in their room. During random observation, the following resident rooms were observed to contain no chair: Resident room [ROOM NUMBER] 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 interview and record review, the facility failed to report an allegation of abuse to the Indiana Department of Health for 1 of 4 residents reviewed for abuse (Resident C) Finding includes: During an interview on 9/24/24 at 10:02 a.m., the Administrator indicated, on 8/11/24, Resident C reported an allegation of Resident D touching her breast that day in the common area. The Administrator had a file of the facility's investigation. Video surveillance had been reviewed for the specified time frame and the allegation was unsubstantiated by the facility. The facility had not reported the alleged abuse to the Indiana Department of Health. During an interview on 9/25/24 at 4:52 p.m., the Administrator indicated he felt Resident C's abuse allegation was not required to be reported the State of Indiana due to the resident's history of false allegations and the investigation results. The facility followed Indiana Department of Health guidelines for reporting of alleged abuse. A current facility policy, dated 2/1/23 and titled ABUSE PREVENTION AND PROHIBITION POLICY, provided by 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 conduct a complete and thorough investigation of alleged sexual abuse for 1 of 4 residents reviewed for abuse. (Resident C) Findings include: Confidential interviews were conducted during the course of the survey and indicated the following: Approximately three weeks ago, it was reported to the Social Services Director (SSD) and the Administrator that a male resident,without consent, touched Resident C's breast while seated in a high-backed reclining mobility chair near the entrance of the facility. The location was close to the surveillance camera and the alleged perpetrator was still a resident in the facility. It was reported to the SSD and the Administrator on the date it occurred. During an interview on 9/23/24 at 4:45 p.m., the Administrator indicated the facility had not received any allegations of resident to resident inappropriate touching from 8/3/24 to 9/22/24. The facility's investigations provided from 8/3/24 to 9/22/24 lacked alleged abuse investigations for Resident C or Resident D. During an interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan for 1 of 1 resident reviewed for pressure ulcers. (Resident 31) Finding includes: Resident 31's clinical record was reviewed on 9/24/24 at 2:42 p.m. She admitted to the facility on [DATE]. Diagnoses included pain in the right lower leg, alcohol abuse in remission, and stage 3 chronic kidney disease. The clinical record lacked a baseline care plan. During an interview on 9/26/24 at 2:51 p.m., RN 10 indicated a Braden Scale risk assessment should have been completed on admission to the facility. The risk for pressure ulcers was a guide to determine what pressure ulcer prevention interventions were implemented. During an interview on 9/26/24 at 4:27 p.m., the DON indicated she was unable to provide a copy of the resident's baseline care plan because it was not developed on admission. A current facility policy, dated 1/2023, titled Pressure Ulcer/Wound Care, provided by the Infection Preventionist on 9/26/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess a resident upon admission for risk of pressure ulcers and failed to develop and and implement interventions to prevent the development of pressure ulcers when risk was identified. (Resident 31) Finding includes: During an observation on 9/23/24 at 10:12 a.m., Resident 31 was in bed in her room. During an observation on 9/23/24 at 12:54 p.m., the resident was in her bed on her back. She was covered from toes to chin. During an observation on 9/24/24 at 1:44 p.m., the resident was asleep in her bed on her back. Her legs were bent at the knees with her heels directly against the mattress. During an observation on 9/24/24 at 2:24 p.m., the resident was in bed in her room and resting while covered with a blanket. Resident 31's clinical record was reviewed on 9/24/24 at 2:42 p.m. She admitted to the facility on [DATE]. Diagnoses included, pain in the right lower leg, alcohol abuse in remission, and stage 3 chronic kidney disease. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement care plan interventions to de-escalate a resident experiencing a behavioral difficulty in a common area with peers for 1 of 4 residents reviewed for behavior management. (Resident 13) Findings include: Confidential interviews were conducted throughout the survey. During a 9/24/24 confidential interview, a resident indicated that Resident 13 was out of control the previous night. Resident 13 beat on walls, punched holes, and threw furniture. He threw furniture that almost hit people. The interviewed resident indicated they were scared. Resident 13's record was reviewed on 9/24/24 at 2:20 p.m. Current diagnoses included schizophrenia, profound intellectual disability, generalized anxiety disorder, and borderline personality disorder. An 8/15/24, quarterly, Minimum Data Set (MDS) assessment indicated Resident 13 was severely cognitively impaired and had displayed both physical behavioral symptoms directed towards others and 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 ensure shift to shift narcotic count and reconciliation was completed for 2 of 2 carts reviewed for medication reconciliation. (West cart and East cart) Findings include: 1. During a medication storage observation of the [NAME] medication cart, on 9/22/24 at 11:21 a.m., accompanied by QMA 6, the Narcotic Count Sheet was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: a. August 2024- lacked a narcotic card count: 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st. September 2024- lacked a narcotic card count: 1st, 2nd, 3rd, 6th, 8th, 9th, 10th, 14th, 15th, and 16th. b. August 2024- lacked shift-to-shift narcotic reconciliation signatures: 8/16: 10:00 p.m. - 6:00 a.m., 8/17: 10:00 p.m. - 2:00 a.m., 8/21: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 9:00 p.m., 8/25: 6:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m., 8/27: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 8/29: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 6:00 p.m., 8/31:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to appropriately date stored medications, discard expired insulin vials, and label medications with resident information in 2 of 2 medication carts observed for medication storage. (West cart and East cart) Findings include: 1. During a medication storage observation of the [NAME] medication cart, on [DATE] at 11:21 a.m., accompanied by QMA 6, the following was observed: a. One Levemir (insulin) vial with approximately 25 units remaining, with an open date of [DATE]. b. Sixty-six (66) single packets of 4% lidocaine (topical anesthetic) patches without resident identifiers or manufacturer container information. During an interview, at the time of the observation, QMA 6 indicated she was not insulin certified and did not know how long insulin was good for. During an interview, at the time of the observation, the Director of Nursing (DON) indicated opened insulin was good for 30 days. 2. During a medication storage observation of the East medication cart, 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 observation, interview, and record review, the facility failed to ensure medications received from the contracted pharmaceutical company were labeled appropriately for 1 of 9 residents reviewed for medication use. Findings include: During a medication administration observation on 7/23/24 at 5:29 a.m., two bottles of oral Nystatin (antifungal) were observed in the medication cart and lacked labeling with resident identifiers and instructions. Bottle 1 lacked the resident's name, dosage and time/frequency the medication was to be given. The bottle also had a sticker with an opened date of 7/10/24. Bottle 2 lacked the resident's name, dosage, and time/frequency the medication was to be given. During an interview, on 7/23/24 at 5:29 a.m., RN 1 indicated she did not know to whom the medications were prescribed. There were two residents who were currently prescribed the medication. No other bottles of Nystatin were observed in the medication carts. The medications should have been labeled with the residents name and directions for use. During an interview, on 7/23/24 at 9:31…

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 provide supervision to prevent a sexual interaction between two cognitively impaired residents for 2 out of 5 residents reviewed for abuse. (Resident E and Resident F) Findings include: The clinical record for Resident E was reviewed on 2/22/24 at 2:33 p.m Diagnoses include dementia with behaviors, stage 3 kidney disease, and hypertension. The admission Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired. The clinical record for Resident F was reviewed on 2/22/24 at 2:43 p.m Diagnoses include severe dementia with agitation, delirium, and anxiety disorder. No MDS information available due to being newly admitted to the facility. Review of a facility self reportable, dated 2/15/24 at 3:05 p.m., indicated on 2/14/24 at 6:01 p.m., upon entering the room of Resident E, CNA 2 observed Resident F standing in front of Resident E while sitting in his wheelchair. Resident F had the front of her night gown…

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 staff reported an incident of inappropriate sexual contact between 2 cognitively impaired residents to the Administrator immediately, which delayed the submission and reporting of the incident within the required timeframe to the appropriate State Agencies for 1 of 3 facility reported incidents reviewed. (Resident E and Resident F) Findings include: The clinical record for Resident E was reviewed on 2/22/24 at 2:33 p.m Diagnoses include dementia with behaviors, stage 3 kidney disease, and hypertension. The admission Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired. The clinical record for Resident F was reviewed on 2/22/24 at 2:43 p.m. Diagnoses include severe dementia with agitation, delirium, and anxiety disorder. No MDS available due to being recently admitted to the facility. Review of a facility self reportable, dated 2/15/24 at 3:05 p.m., indicated on 2/14/24 at 6:01 p.m., upon…

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 record review and interview, the facility failed to develop and implement individualized care plan interventions and monitoring of behaviors for a cognitively impaired resident with dementia for 1 of 5 residents reviewed for behaviors. (Resident E) Findings include: The clinical record for Resident E was reviewed on 2/22/24 at 2:33 p.m Diagnoses include dementia with behaviors, stage 3 kidney disease, and hypertension. The admission Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was severely cognitively impaired. Review of a facility self reportable, dated 2/15/24 at 3:05 p.m., indicated on 2/14/24 at 6:01 p.m., upon entering the room of Resident E, CNA 2 observed a cognitively impaired female resident standing in front of Resident E while sitting in his wheelchair. The female resident had the front of her night gown pulled up and Resident E had his hands inside her briefs. When CNA 2 asked what they were doing, Resident E pulled his hands out of the female resident's brief. 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 and interview, the facility failed to maintain clean and uncluttered laundry facilities, clean bathroom air vents, and safe closet doors during random observations of the facility. Findings include: During a medication administration observation on 11/16/23 at 8:08 a.m., Resident 19 indicated he felt his sinus pressure was related to the debris in the bathroom ceiling fan, where you could not even see the fan blades for all the lint and mouse droppings. During an observation with QMA 4 at the time of the medication administration, the bathroom air vent had a large amount of dark, thick, dust-like debris. The bathroom walls were had a large number of gnats on them. The wall to the right of the heating and air unit was bowed out from the wall. On 11/16/23 at 8:10 a.m., room [ROOM NUMBER] was observed with the right bi-fold closet door out of the track and hanging loose. On 11/16/23 at 12:56 p.m., room [ROOM NUMBER] was observed with the right bi-fold closet door out of the track and hanging…

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 facility was free from pests and rodents. Findings include: During a confidential interview on 11/16/23, a staff member indicated mice were observed frequently in the halls and resident rooms. The facility cat had a mouse in his mouth in the hallway the morning of 11/15/23. During a confidential interview on 11/16/23 at 2:11 p.m., a staff member indicated the facility had a gnat and mouse problem. During a confidential interview on 11/16/23 at 2:18 p.m., a staff member indicated there was a mouse problem in the facility and they were seen frequently in inside the facility. During an observation in Resident 19's bathroom, all four walls had a large number of gnats and many were observed flying around the room. Gnats were observed flying in the hallway and dining area. During an interview on 11/16/23 at 11:24 a.m., the Administrator indicated pest control came to the facility monthly to treat for spiders, gnats, and mice. The pest control provider would come to the facility for other treatments as requested. 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 interviews and record review, the facility failed to protect a resident's right to be free from verbal abuse by CNA 12 for 1 of 5 residents reviewed for abuse (Resident B). Findings include: Review of video footage with audio, on 8/29/23 at 11:00 a.m., indicated on 8/19/23 Resident B was being escorted in his wheelchair to his room from the nurses station area. CNA 12 pushed his wheelchair while CNA 23 walked backwards holding his legs from touching the ground. LPN 8 held a gown on the right side of him to shield the other staff member from him spitting on them. As they entered his room, a staff member called Resident B a nasty a--. Resident B's clinical record was reviewed on 8/29/23 at 10:38 a.m. Diagnoses included uncomplicated alcohol dependence, Wernicke's encephalopathy, delusional disorders, mild cognitive impairment of uncertain or unknown etiology, other seizures, drug induced subacute dyskinesia, major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, psychotic disorder with hallucinations due to known physiological…

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 yearly dementia in-service training was conducted for 2 of 5 staff members reviewed for employee records (RN 15 and LPN 8). Findings include: Employee records were reviewed on 8/30/23 at 9:15 a.m. RN 15's last dementia training was completed on 6/1/22. LPN 8's last dementia training was completed on 2/23/22. During an interview with the Interim DON, on 8/30/23 at 12:46 p.m., she indicated the facility could not locate a policy regarding training at that time. No further information was provided prior to exit. This Federal tag relates to complaint IN00416170. 3.1-19(u)

Based on record review and interview, the facility failed to assess for root cause of falls and update care plans for 2 of 4 residents reviewed for falls (Resident K and L). Findings include: 1. The clinical record for Resident K was reviewed on 8/8/2023 at 11:17 a.m. Diagnoses included bipolar disorder, overactive bladder, dementia with anxiety, depression, conversion disorder with seizures, and fibromyalgia. A post fall risk assessment, dated 6/23/2023, indicated the resident was a high risk for falls. A progress note, dated 7/1/2023 at 7:50 a.m., indicated the resident had a witnessed fall. The resident indicated she lost her balance and fell, hitting her head on a table. The fall resulted in a small cut on her left side of her head by the hair line measuring 0.05 cm (centimeters) length x 0.05 cm width. A post fall risk assessment, dated 7/1/2023, indicated the resident was a high risk for falls. A current care plan for the problem of falls, dated 7/23/2019, was last revised on 3/8/2020. The most recent fall care plan intervention was dated 5/4/2023. The facility failed 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.