Signature Healthcare Of Muncie

Based on observation, interview, and record review, the facility failed to distribute food with the correct temperatures for safety and palatability. This deficient practice had the potential to affect 114 of 114 residents who received food from the facility kitchen. Findings include:During a test meal tray temperature check observation on 2/20/26 at 12:47 p.m., accompanied by the Dietary Manager, the following was observed: Milk temperature was 46 degrees Fahrenheit (F) and coleslaw was 64.2 degrees F. The Dietary Manager indicated the temperature was too high for the milk to be served.During an interview on 2/20/26 at 11:40 a.m., the Dietary Manger indicated food had temperature checks prior to plating and placed in the meal carts. The food was then delivered to the appropriate halls for food distribution.A current policy, dated 5/2014, titled Food: Quality and Palatability was provided by the Administrator on 2/24/26 at 3:46 p.m. The policy indicated the following: Policy StatementFood will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be…

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 complete neurological assessments as indicated by facility protocol following falls for 1 of 3 residents reviewed for accidents. (Resident C)Finding includes:Resident C's clinical record was reviewed on 11/17/25 at 2:42 p.m. Diagnoses included vascular dementia, cerebral infarction, essential primary hypertension, repeated falls, unspecified fracture of facial bones, unsteadiness on feet, and generalized muscle weakness. Current orders included tramadol (narcotic for pain) 25 mg three times daily as needed for pain, metoprolol succinate (blood pressure) 25 mg 0.5 tablet once daily, and aspirin (blood thinner for coronary artery disease) 81 mg once daily. A physician order for clopidogrel (blood thinner for coronary artery disease) 75 mg once daily was ordered on 7/15/25 and discontinued on 11/14/25. Review of the Medication Administration Records for August, September, October and November 2025 indicated the resident was taking both aspirin and clopidogrel during those months. Clopidogrel was discontinued 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.

A. Based on interview and record review, the facility failed to report to the Indiana Department of Health (IDOH) an unusual occurrence, related to potential neglect, when an unprescribed controlled medication was found in a dependent resident's system during a hospital stay for 1 of 3 residents reviewed for neglect. (Resident B)Findings include:Resident B's clinical record was reviewed on 10/22/25 at 11:09 a.m. Diagnoses included unspecified dementia, essential primary hypertension, unspecified asthma, unspecified convulsions, and heart failure. The medication allergy list included gabapentin. Physician's orders included levothyroxine (thyroid medication) 25 milligrams (mg) by mouth once every morning and primidone (seizure medication) 50 mg by mouth at bedtime. An 8/20/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She required set-up assistance from staff for eating, oral hygiene, toileting hygiene, and rolling left to right. The resident did not take opioids. A hospital progress note, dated 9/25/25 at 9:51 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 interview and record review, the facility failed to complete a thorough investigation of an unusual occurrence related to potential neglect when an unprescribed substance was found in a resident during a hospital stay for 1 of 3 residents reviewed for neglect. (Resident B)Findings include:Resident B's clinical record was reviewed on 10/22/25 at 11:09 a.m. Diagnoses included unspecified dementia, essential primary hypertension, unspecified asthma, unspecified convulsions, and heart failure. The medication allergy list included gabapentin (seizure medication). Physician's orders included levothyroxine (thyroid medication) 25 milligrams (mg) by mouth once every morning and primidone (seizure medication) 50 mg by mouth at bedtime. An 8/20/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. She required set-up assistance from staff for eating, oral hygiene, toileting hygiene, and rolling left to right. The resident did not take opioids. A care plan, revised 8/26/25, indicated the resident had an allergy to gabapentin.…

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 thoroughly assess and intervene to promote the healing of pressure injuries for 1 of 3 residents reviewed for injuries (Resident C). Finding includes:Resident C's clinical record was reviewed on 9/30/25 at 9:39 a.m. Diagnoses included fracture of unspecified part of neck of right femur, chronic kidney disease, stage 3, severe protein-calorie malnutrition, and dementia. Orders included wound nurse practitioner (NP) to provide wound management assessment and treatment by provider as needed (9/9/25), heel protectors while in bed, as tolerated (9/9/25), pressure relieving/redistribution mattress (9/8/25), pressure redistribution cushion to wheelchair (9/8/25), quetiapine (antipsychotic) 100 mg daily, trazodone (antidepressant) 100 mg daily, and sertraline (antidepressant) 25 mg daily. An admission Minimum Data Set (MDS) assessment, dated 9/12/25, indicated the resident was severely cognitively impaired. She had an impairment to her functional range of motion to her lower extremity on one side. She required substantial/maximal…

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 notify a resident's representative and/or family when an accident, resulting in injury, occurred for 1 of 1 resident reviewed for accidents. (Resident M)Findings include:Resident M's closed clinical record was reviewed on 9/15/25 at 2:40 p.m. Diagnoses included type 2 diabetes mellitus, hypothyroidism, chronic obstructive pulmonary disease (COPD), major depressive disorder, and mild intellectual disabilities.Resident M's first emergency contact was a community social services employee and the second contact was a relative. Current physician's orders included buspirone 5 milligrams (mg) twice daily for depression, and diclofenac sodium gel 1% to be applied to right knee for pain four times a day.An admission Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident was cognitively intact, did not exhibit hallucinations, delusions, or behaviors, and had an intellectual disability. It was very important for Resident M's family and/or close friends to be involved in discussions about her 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, interview, and record review, the facility failed to ensure a resident was free from willful intimidation and verbal abuse by a staff member for 1 of 1 resident reviewed for abuse. (Resident N) This deficient practice was corrected on 8/24/25, prior to the start of survey, and was therefore past noncompliance.Findings include:Resident N's clinical record was reviewed on 9/15/25 at 10:38 a.m. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting his right, dominant side, chronic obstructive pulmonary disease (COPD), chronic kidney disease, generalized anxiety disorder, major depressive disorder, unsteadiness on feet, dementia without behavioral disturbance, and congestive heart failure.Current physician's orders included hydrocodone-acetaminophen 10-325 milligrams (mg) every six hours for pain, memantine 10 mg twice a day for dementia, sertraline 100 mg once a day for depression, alprazolam 0.25 mg twice a day for anxiety, and galantamine 8 mg twice a day for dementia.An annual Minimum Data Set (MDS) assessment, dated 6/12/25,…

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

Based on record review and interview, the facility failed to report a suspected drug diversion to the appropriate regulatory agencies for 4 of 6 residents reviewed for narcotic medication administration. (Residents H, J, K, and M) Findings include: 1. Resident H's record was reviewed on 7/2/25 at 10:45 a.m. Diagnoses included migraine, osteoarthritis (bone pain), fibromyalgia (nerve pain) , and chronic pain syndrome. Physician orders included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 milligram (mg) give one tablet by mouth every four hours only while awake. Resident H's electronic medication administration record (eMAR) indicated she received a dose of oxycodone on 6/2/25 scheduled at 6:00 p.m. but was charted at 8:22 p.m. with the comment per lpn by LPN 15. A dose of oxycodone scheduled for 6/2/25 at 10:00 p.m. was charted on 6/3/25 at 9:39 a.m. as not given due to condition, signed by QMA 20. A dose scheduled for 6/3/25 at 2:00 a.m. was charted as refused on 6/3/25 at 4:10 a.m. by QMA 2 due to the resident sleeping. Resident H's narcotic sign out sheet, provided…

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 through investigation of an suspected drug diversion for 4 of 6 residents reviewed for medication admnistration. (Residents H, K, L,and M) Findings include: 1. Resident H's record was reviewed on 7/2/25 at 10:45 a.m. Diagnoses included migraine, osteoarthritis (bone pain), fibromyalgia (nerve pain) , and chronic pain syndrome. Physician orders included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 milligram (mg) give one tablet by mouth every four hours only while awake. Resident H's electronic medication administration record (eMAR) indicated she received a dose of oxycodone on 6/2/25 scheduled at 6:00 p.m. but was charted at 8:22 p.m. with the comment per lpn by LPN 15. A dose of oxycodone scheduled for 6/2/25 at 10:00 p.m. was charted on 6/3/25 at 9:39 a.m. as not given due to condition, signed by QMA 20. A dose scheduled for 6/3/25 at 2:00 a.m. was charted as refused on 6/3/25 at 4:10 a.m. by QMA 2 due to the resident sleeping. Resident H's narcotic sign out sheet, provided by the Corporate 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 interview and record review, the facility failed to ensure controlled medication administration was accurately documented and medication amounts reconciled according to facility policy for 4 of 6 residents reviewed for medications (Residents H, K, L, and M) Findings included: 1. Resident H's record was reviewed on 7/2/25 at 10:45 a.m. Diagnoses included migraine, osteoarthritis (bone pain), fibromyalgia (nerve pain) , and chronic pain syndrome. Physician orders included oxycodone-acetaminophen (narcotic pain medication) 7.5-325 milligram (mg) give one tablet by mouth every four hours only while awake. Resident H's electronic medication administration record (eMAR) indicated she received a dose of oxycodone on 6/2/25 scheduled at 6:00 p.m. but was charted at 8:22 p.m. with the comment per lpn by LPN 15. A dose of oxycodone scheduled for 6/2/25 at 10:00 p.m. was charted on 6/3/25 at 9:39 a.m. as not given due to condition, signed by QMA 20. A dose scheduled for 6/3/25 at 2:00 a.m. was charted as refused on 6/3/25 at 4:10 a.m. by QMA 2 due to the resident sleeping. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to allow a resident to return to the facility following a hospital outpatient observation and failed to indicate supporting rationale or documentation for the discharge . (Resident C) Findings include: Resident C's clinical record was reviewed on 6/2/25 at 11:01 a.m Diagnoses included chronic congestive heart failure, chronic obstructive pulmonary disease, pressure ulcer of sacral region, chronic osteomyelitis, polyneuropathy, muscle spasm, chronic stage 3 kidney disease, opioid use, chronic pain syndrome, and depressive disorder. The resident was admitted to the facility on [DATE]. A 3/28/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident C was cognitively intact and had moderate depression. Review of Resident C's care plans indicated the resident displayed verbal aggression. The clinical record lacked a care plan for physical aggression. Review of a progress note, dated 5/1/25 at 1:35 p.m., indicated Unit Manager 1 heard Resident C…

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 adequate dietary staff to ensure room tray meals were delivered in a timely manner for 3 of 9 Units. (100 Unit, 300 Unit, and 400 Unit) Findings include: Review of a Meal/Cart Delivery Time schedule, provided by the facility on 1/15/25, indicated the dinner service meal carts were scheduled to arrive at the following times on the specified units: 100 Unit - 5:35 p.m. 300 Unit - 5:55 p.m. 400 Unit - 6:05 p.m. During observations of dinner service meal tray delivery, on 1/21/25, the meal trays were observed delivered at the following times on the specified units: 100 Unit - 6:19 p.m.: This was a 44 minute delay. The last tray was delivered at 6:25 p.m. 300 Unit - 6:52 p.m.: This was a 57 minute delay. The last tray was delivered at 6:59 p.m. 400 Unit - 7:02 p.m.: This was a 57 minute delay. The last tray was delivered at 7:12 p.m. During an observation on 1/21/25 at 7:03 p.m., Resident 76 was seated in her wheelchair in the doorway of her room with the door open and gazed down the unit. The resident…

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

Based on interview and record review, the facility failed to ensure residents who entered into a binding arbitration agreement were granted the right to verbally rescind the agreement within 30 days of signing it and were granted the right to rescind the original agreement for a subsequent stay if discharged and re-admitted to the facility or admitted to another facility owned by the same corporation in the future. This deficiency has the potential to affect 57 of the 127 residents who reside in the facility. Findings include: During an interview, during the entrance conference, on 1/15/25 at 10:10 a.m., the Administrator indicated the facility utilized arbitration agreements. The facility's arbitration agreement provided by the administrator with entrance conference paperwork on 1/15/25, was reviewed on 1/17/25 at 9:15 a.m. The arbitration agreement was included in the residents' admission paperwork and indicated the following: .Unless rescinded within thirty (30) days under Paragraph 10 below, this agreement will also remain valid and of full force and effect even if the resident…

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

Based on observation, record review, and interview, the facility failed to ensure a self-administration assessment was completed for 1 of 1 residents reviewed for self-administration of medication. (Resident 17) Finding includes: During an observation, on 1/15/25 at 11:11 a.m., Resident 17 was in bed with a plastic container on her bedside table. The plastic container held five bottles of eye drops. During an interview, on 1/16/25 at 10:41 a.m., Resident 17 was seated in her wheelchair at the side of her bed. There was a plastic container and a rectangular white box on her bedside table. The plastic container held five bottles of eye drops. The white box contained one bottle of eye drops. Resident 17 indicated she used her eye drops twice a day, was allowed to keep them in her room, and the staff were aware. The plastic container had the following eye drop bottles: 1. Rocklatan (netarsudil and latanoprost) 0.02% drops (a prescription eye drop to reduce eye pressure) without a label or resident identifiers. 2. Systane (an over the counter eye lubricant) night gel 10 grams (g). 1 to 2…

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

Based on record review and interview, the facility failed to prevent the misappropriation of resident funds for 1 of 3 residents reviewed for personal property. (Resident B) Finding includes: A 12/24/24, facility reported incident indicated Resident B reported that he discovered his debit card, grocery card from insurance company and drivers license missing from wallet upon returning from dialysis on 12/24/24. Reported that CNA 31 had assisted him with an online order that night before. The immediate actions taken included reported to the Administrator, local police were called and CNA 31 was suspended pending outcome. The investigation was underway. Preventative measures taken included the suspension of CNA 31 and the police were called. Resident B's clinical record was reviewed on 1/17/25 at 1:31 p.m. Diagnoses included dependence on renal dialysis, end stage renal disease, and need for assistance with personal care. A 11/25/24, Admission, Minimum Data Set (MDS) indicated Resident B was cognitively intact and had reasonably consistent decision making. Resident B required partial…

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 increased monitoring and assessment and interventions for a resident experiencing a worsening change in condition for 1 of 1 resident reviewed for a urinary tract infection. (Resident 76) Finding includes: During an interview on 1/15/25 at 10:53 a.m., Resident 76 indicated, in November 2024, she had a really bad urinary tract infection (UTI). She had vomiting and diarrhea, and two nurses would not send her out to the hospital for further evaluation. She begged them to send her out. When she finally was sent out, the hospital gave her a peripherally inserted central catheter (PICC) line and admitted her. She was concerned because the facility was so slow to give antibiotics. The resident's clinical record was reviewed on 1/17/25 at 10:10 a.m. Diagnoses included sepsis, unspecified organism, overactive bladder, dysuria, and post COVID-19. A current physician order, dated 12/14/24, included Macrobid (antibiotic) 100 milligrams (mg) capsule by mouth once daily given for UTI prevention. A physician order,…

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 resident smoking materials were securely stored for 1 of 4 residents reviewed for accidents. (Resident 86) Finding includes: During an interview on 1/16/25 at 10:31 a.m., Resident 86 was in her room. She indicated she was a smoker and signed herself out to go smoke. She received her cigarettes and lighter from the facility when she signed out on leave of absence early in the day. Then, she kept her smoking paraphernalia for the day, in her purse in bed on her side. She returned the smoking paraphernalia to the facility at the end of the day. Resident 86's clinical record was reviewed on 1/17/25 at 10:26 a.m. Diagnoses included chronic respiratory failure with hypoxia and current tobacco use. A current physician order, dated 8/10/24, indicated the resident used oxygen therapy at 2 liters per minute via nasal cannula. An annual Minimum Data Set (MDS) assessment, dated 7/5/24, indicated the resident was cognitively intact. She used tobacco. A quarterly MDS assessment, dated 11/16/24, 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 medications, treatments, and biological products were properly labeled and stored for 2 of 2 medication rooms and 2 of 6 medication carts reviewed for medication storage. (Medication Room East for 100/200/300/400 halls, Medication Room [NAME] for the 500/600/700 halls, Medication Cart for the 200 hall, and Treatment Cart for the 500/800 halls) Findings include: 1. During an observation, on 1/21/25 at 10:11 a.m., with the Director of Nursing (DON), the refrigerator in the Medication Room East contained an open vial of influenza vaccine and an open vial of tuberculin purified protein derivative (PPD). The vial and box containing the influenza vaccine vial lacked an open date. The vial and plastic package containing the PPD lacked an open date. The temperature log indicated the temperature was taken daily. The DON indicated, at the time of the observation, that the temperature was taken daily on the medication refrigerators and the vials should have open dates. 2. During an observation, on 1/21/25 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.

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. Finding includes: Review of the Summary Statement of Deficiencies, for the facility's last annual recertification and licensure survey completed on 2/9/24, indicated the facility had deficiencies related to failure to follow infection control guidelines related to isolation procedures and failure to ensure medications were labeled with resident identifiers and directions. During an interview, on 1/23/25 at 4:19 p.m., the Administration indicated the Quality Assessment and Assurance (QAA) committee met quarterly to review current facility concerns. The QAA committee utilized an online program to assist with streamlining the process, assessing trends, and documentation of these meetings. The current nursing topics were wounds and falls. During a follow-up interview, on 1/23/25 at 4:43 p.m., the Administrator indicated the facility did not have any current QAPI or Performance Improvement…

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 develop and implement an infection control program which provided Enhanced Barrier Precautions (EBP) and/or isolation services in order to eliminate or reduce the risk of spread of contagions for 2 of 5 residents reviewed for infection prevention. (Residents 66 and 86) Findings include: 1. During an observation on 1/15/25 at 11:39 a.m., Resident 66's door had two signs posted. The first sign was a red stop sign posted on pink paper. The second sign was instructions regarding how to correctly apply PPE (personal protective equipment). The door signs did not contain direction regarding what type of isolation the resident was under, what was required to enter the room, when a staff or visitor needed to wear P.P.E. During an interview on 1/15/25 at 11:42 a.m., QMA 19 indicated Resident 66 was on some type of precautions, however she was unsure of the type and it might be droplet isolation. She left and quickly returned stating the resident was on Enhanced Barrier Precautions (EBP) or contact isolation due to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure the automated external defibrillator (AED) was maintained in safe operating condition. (Resident F) Finding includes: Resident F's clinical record was reviewed on [DATE] at 2:23 p.m. A progress note, dated [DATE] at 11:13 a.m., indicated the resident was observed unresponsive without a pulse. Facility staff had called a code (a medical term for cardiac arrest) and begun cardiopulmonary resuscitation (CPR). Emergency services (EMS) were contacted. A progress note, dated [DATE] at 12:11 p.m., indicated the facility staff had transferred CPR and rescue breathing to the EMS, who continued without success. CPR was ceased at 11:28 a.m. During an interview, on [DATE] at 11:51 a.m., RN 29 indicated when a code blue (a medical term for cardiac arrest) was called the staff would get the crash cart from the end of the 700 hall and the AED off the wall, at the junction of the 800 hallway. He indicated the AED was in working order as it was…

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

Based on record review and interview, the facility failed to prevent verbal abuse from a staff member and failed to implement the facility abuse policy to protect the resident from the possibility of further abuse for 1 of 3 residents reviewed for abuse. (Resident F) Findings include: An 11/5/24, facility self-reported incident indicated the following: Brief Description of Incident: A resident reported that a staff member was impatient, making comments regarding her incontinence and pushed her back towards the bathroom when the resident attempted to leave bathroom. The immediate actions taken were the completion of a skin assessment with no signs of injury and the suspension of the staff member pending an investigation. The Director of Nursing, Administrator, and Physician were notified. Preventative measures taken included the social services department was to do a psychosocial follow-up and the staff member was to remain suspended pending investigation. Resident F's clinical record was reviewed on 11/12/24 at 3:11 p.m. Diagnoses included unspecified convulsions, adult failure to…

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

Based on record review and interview, the facility failed to accurately and consistently assess a new pressure injury and failed to promptly initiate wound treatment to promote healing of pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident B). Findings include: Resident B's closed clinical record was reviewed on 11/12/24 at 11:07 a.m. Diagnoses included ventricular tachycardia, subsequent encounter for closed fracture of the neck of the left femur, muscle weakness, and unspecified dementia. A 9/3/24, admission Minimum Data Set (MDS) Assessment indicated Resident B was cognitively intact, had no wounds or pressure ulcers, and required partial assistance from staff for bed mobility and transferring. A skin integrity care plan, initiated 9/3/24, indicated the resident was at risk for pressure ulcers related to decreased mobility. Approaches included to report changes in skin status and to complete treatments per physician order. A Skin Integrity Event, dated 9/9/24, indicated a skin tear to the sacrum, measuring 2.5 centimeters (cm) length x 2.0 cm width x…

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 a resident-centered careplan and interventions to address a resident's use of alcohol and physical aggressive behaviors. (Resident K) Findings include: The clinical record for Resident K was reviewed on 8/29/24 at 9:34 a.m. Diagnoses included history of pulmonary embolism, history of other venous thrombosis and embolism, fracture of neck of right femur, pressure ulcer of sacral region, osteomyelitis, acute kidney failure, polyneuropathy, chronic stage 3 kidney disease, opioid use, chronic congestive heart failure, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, gastro-esophageal reflux disease, anemia, hyperkalemia, and vitamin D deficiency. The most recent annual Minimum Data Set (MDS) assessment, dated 7/30/24 indicated Resident K was cognitively intact. Review of the clinical record indicated a lack of a care plan and interventions to address Resident K's alcohol consumption and physical aggression. A progress note, dated 08/19/24 at 3:59 p.m., indicated Resident K had been…

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 ensure a resident was free from verbal abuse from a staff member for 1 of 3 residents reviewed for abuse. (Resident F) Findings include: During an interview with Resident L, on 7/3/24 at 11:03 a.m., she indicated she witnessed CNA 6 tell Resident F that the resident needed to get out of the facility. She didn't need to live there, and needed to move in with her ex-husband and mooch off him. The CNA also told Resident F that her grandkids didn't love her. During an interview with Resident K, on 7/3/24 at 11:58 a.m., she indicated she had witnessed CNA 6 arguing with Resident F because she intentionally did not pass ice to Resident F. Resident F reported it, and CNA 6 told Resident F that she was a bully and she needed to move back in with her husband and that her children only wanted her for her money. During an interview with Resident F, on 7/3/24 at 12:29 p.m., she indicated CNA 6 would not give her ice water and told her that she had to…

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

Based on interview and record review, the facility failed to report an allegation of abuse to the State Agency in a timely manner for 1 of 3 reportable abuse allegations reviewed. Findings include: A facility reported incident indicated an allegation of verbal abuse occurred on 6/27/24 at 4:45 p.m. when Resident F alleged CNA 6 intentionally skipped providing ice water to her because CNA 6 felt Resident F could get it herself. This led to a loud verbal exchange during which angry language was used by each party. The confirmation email for the incident indicated it was submitted to the Indiana State Department of Health on 6/30/24 at 8:27 a.m. During an interview with the Administrator, on 7/3/24 at 4:18 p.m., he indicated abuse was to be reported within 24 hours unless it involved physical abuse, then it was to be reported within two hours. A current facility policy, titled Abuse, Neglect and Misappropriation of Property, provided by the Nurse Consultant on 7/3/24 at 4:51 p.m., indicated the following: .Reporting Guidelines: Any abuse allegations must be reported to State within 2…

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

Based on interview and record review, the facility failed to ensure dependent residents received showers/bed baths per the resident care plan and resident preference for 2 of 4 residents reviewed of activities of daily living. (Residents E and M) Findings include: 1. The clinical record for Resident E was reviewed on 7/5/2024 at 11:21 a.m. Diagnoses included cerebral infarction, hydronephrosis, chronic obstructive pulmonary disease, need for assistance with personal care, muscle weakness, dysphagia, anxiety disorder, depressive disorder, osteoarthritis, hearing loss, and chronic pain syndrome. The most recent quarterly Minimum Data Set (MDS) assessment indicated Resident E was cognitively intact and required supervision and touch assistance for showers and shower transfers. Review of the facility shower schedule indicated Resident E was scheduled for showers on Mondays, Thursdays and Saturday evenings. Review of Resident E's care plans indicated bathing preferences had not been assessed and recorded. Review of Resident E's care plans indicated a history of refusal for treatment/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure physician ordered medication was obtained to continue treatment for a resident for 1 of 1 residents reviewed for neglect. (Resident B) Findings include: The closed clinical record for Resident B was reviewed on 7/2/24 at 6:45 p.m. Diagnoses included anemia, nausea with vomiting, history of stroke with right side hemiplegia, and copper deficiency. The resident was admitted to the facility on [DATE] at approximately 7:00 p.m., from an acute care hospital stay. The hospital discharge orders included copper sulfate (supplement) 2 mg (milligram) daily for the duration of 30 days for anemia due to gastrointestinal blood loss. A physician hematology consultation report, dated 6/3/24, completed during the resident's acute hospital stay included the following: Copper deficiency. Start copper sulfate 2 mg orally daily, to continue even on discharge, for 1 month. The resident's physician admission orders, dated 6/7/24, included Copper Sulfate (cupric…

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 was prepared, served, and distributed in a manner to prevent possible cross contamination for 1 of 1 food service line observations on 2/7/24 lunch meal service. This deficient practice had the potential to impact 116 of 116 resident who consumed meals prepared in the facility kitchen. Findings include: During an observation of the lunch meal service line on 2/7/24 from 11:30 a.m. to 11:48 a.m., the following concerns regarding possible cross contamination of foods were observed: At 11:40 a.m., the Dietary Manager (DM), using gloved hands, touched a bun, left the meal service area wearing the same gloves, opened drawers and retrieved utensils with the same gloves, and returned to the food service area wearing the same contaminated gloves. Using the same contaminated gloves, she touched lettuce, cheese, pickles, and tomatoes. She left the food service area again and returned to the area with the same gloves and continued meal service. At 11:41 a.m., [NAME] 2 touched a bread slice with her gloved…

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 utilize the grievance process to promptly resolve resident grievances/concerns/complaints and follow up with a corrective action for 2 of 2 residents reviewed for grievances (Resident F and G) and 6 of 6 residents interviewed in a group setting. Findings include: Confidential interviews were completed during the survey. During a confidential interview, it was indicated there was nothing to look forward to when it came to meals. The portion sizes were much like toddler portions and they would still be hungry if family didn't keep their room stocked with groceries. The pizza tasted like a biscuit with ketchup on it and a small amount of cheese. Yesterday, the sweet potatoes were water-logged, lacked flavor due to being over cooked, and mushy. Many of the different meats were gray on the inside and tough, and were difficult to chew. The bread was served soggy on the plate along with undrained vegetables. Nearly every meal, the food needed to be reheated which made the tough meat worse. As recent as last night, grilled cheese…

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 was attractive, palatable, and contained satisfying portions for 12 of 12 residents reviewed for food satisfaction and palatability, and 6 of 6 residents interviewed in a group setting. Findings include: Confidential interviews were completed during the survey. During confidential resident interviews, the following concerns were expressed regarding food attractiveness, portion size, and palatability: a. The portions are not large enough. I am usually hungry after I finish eating. The food is often unappetizing. Regarding a recent breakfast, all I got was a biscuit, nothing else. I did not have funds to purchase a snack. b. They are frequently not careful when they place the food on the plate. They got a lot of veggie juice on the plate and the roll would be all wet and soggy, so I didn't eat it. It was not attractive or palatable. c. Many times, the menu does not reflect what was served. Last night, the tray card that lists menu items to be served, listed tomato soup and grilled cheese. The tray…

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 complete thorough investigations of alleged abuse for 2 of 3 residents reviewed for abuse. (Residents E and L) Findings include: 1. Resident E's clinical record was reviewed on 2/6/24 at 4:33 p.m. Diagnoses included unspecified dementia without behavioral disturbance, need for assistance with personal care, and other reduced mobility. A Nurse's Note, dated 12/13/23 at 4:19 p.m., indicated the resident verbalized a CNA was mean to her. The resident was more tearful and had increased confusion. The family, provider, and DON were aware. A review of the facility's investigation of the abuse allegation was completed on 2/7/24 at 4:04 p.m. The investigation documentation, dated 12/13/23, lacked interviews/statements from the following individuals: the alleged perpetrator, the nurse on duty during the alleged event, and other staff members who worked with the alleged perpetrator. The file included an undated skin assessment. The alleged perpetrator continued to work with residents during the investigation. 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 notify the Ombudsman of resident discharge for 2 of 3 residents reviewed for Ombudsman notification. (Residents 112 & G) Findings include: 1. Resident 112's closed clinical record was reviewed on 2/8/24 at 11:21 a.m. The resident's discharge diagnoses included acute duodenal ulcer with perforation, peptic ulcer, and anemia. The resident was discharged to the hospital via ambulance on 12/12/23 and was admitted . The resident chose not to return to the facility following his hospitalization. Review of a facility email indicated the Ombudsman notification of residents who were discharge in December 2023 was sent to the Ombudsman 2/9/24. The December 2023 Discharge and Transfer Form Ombudsman Fax Log, listed Resident 112's name and date of discharge. During an interview, on 2/9/24 at 12:18 p.m., the Social Services Director indicated the December 2023 discharge form had not been sent in January as required. The lack of timely notification was caused by a…

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

Based on observation, interview, and clinical record review, the facility failed to develop a discharge care plan and assist a resident to obtain his discharge goals for 1 of 1 residents who desired to discharge home following therapy. (Resident 12) Findings include: During an interview on 2/6/24 at 10:53 a.m., Resident 12 indicated he had come to the facility for therapy and desired to return to a home living environment now that his therapy was completed. He didn't really know what the plan was. He believed he needed to get on a list for income based housing. He needed some help with the process and hoped the facility would help him. At this point, he was unsure of what was happening. During an observation at this time, the resident was neat and clean. He was dressed appropriately for the weather. He was wearing rubber soled shoes and walking independently with a cane. Resident 12's clinical records was reviewed 2/8/24 at 10:33 a.m. Current diagnoses include, chronic obstructive pulmonary disease (COPD), anxiety, and atrial fibrillation. A 11/13/23 at 4:52 p.m., admission progress…

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

Based on record review and interview, the facility failed to notify the physician of weights outside the ordered parameters for 1 of 2 residents reviewed for edema. (Resident 265) Findings include: The clinical record for Resident 265 was reviewed on 2/6/24 at 3:27 p.m. Diagnoses included diabetes mellitus type II, diastolic congestive heart failure, acute osteomyelitis right foot/ankle, and peripheral vascular disease. A current physician's order, dated 1/18/24, indicated to obtain daily weights and to notify the physician or nurse practitioner for a greater than two pound weight gain in one day or greater than five pound weight gain in a week. A care plan, dated 1/29/24, indicated the resident was at risk for actual fluid imbalance related to diuretic therapy. The goal included the resident would be free of complications from fluid overload. An approach for the care plan included to obtain weights as indicated and to report significant changes to the physician or nurse practitioner. The resident had weights documented as follows: On 1/18/24, the resident's weight was documented 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 observation, interview, and record review, the facility failed to ensure narcotics were reconciled per facility policy for 1 of 5 medication carts reviewed for medication storage. (800 hall cart) Findings include: During a medication storage observation of the 800 hall cart, accompanied by LPN 11 on 2/9/24 at 11:02 a.m., the Narcotics Sheet Count was reviewed, and the following dates lacked shift to shift reconciliation of controlled medications: In December 2023- 12/6: 7:00 a.m.- 7:00 p.m. shift and 7:00 p.m.- 7:00 a.m. shift 12/7: 7:00 p.m.- 7:00 a.m. shift 12/8: 7:00 p.m.- 7:00 a.m. shift 12/9: 7:00 p.m.- 7:00 a.m. shift 12/10: 7:00 p.m.- 7:00 a.m. shift 12/11: 7:00 p.m.- 7:00 a.m. shift 12/16: 7:00 p.m.- 7:00 a.m. shift 12/21: 7:00 a.m.- 7:00 p.m. shift 12/26: 7:00 p.m.- 7:00 a.m. shift 12/27: 7:00 a.m.- 7:00 p.m. shift 12/28: 7:00 p.m.- 7:00 a.m. shift In January 2024- 1/1: 7:00 p.m.- 7:00 a.m. shift 1/2: 7:00 a.m.- 7:00 p.m. shift and 7:00 p.m.- 7:00 a.m. shift 1/3: 7:00 p.m.- 7:00 a.m. shift 1/8: 7:00 p.m.- 7:00 a.m. shift 1/9: 7:00 p.m.- 7:00 a.m. shift 1/10: 7:00…

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.

A. Based on observation and interview, the facility failed to ensure medications stored in the medication refrigerator in the hall medication storage room were labeled with resident identifiers and directions for 1 of 2 medication storage rooms reviewed (100 hall) and for 13 of 13 residents' treatments stored in the treatment carts. (800 and 500 halls) Findings include: 1. During a medication storage observation of the 100 unit medication room, accompanied by LPN 8 on 2/8/24 at 9:47 a.m., sixteen unlabeled 650 mg (milligrams) acetaminophen (to treat fevers or mild pain) suppositories were in the refrigerator. During an interview, at the time of the observation, LPN 8 indicated there were no labels present on the medication and she did not know why the suppositories were stored in the medication room. 2. During a medication storage observation of the treatment cart for the 800 and 500 halls, accompanied by LPN 11 on 2/9/24 at 11:30 a.m., the following medications were observed without resident identifiers and directions: Two tubes of Woun'Dres collagen hydrogel (to promote wound…

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

Based on observation, interview and record review, the facility failed to follow infection control guidelines related to isolation procedures for 1 of 1 residents on isolation precautions. (Resident 267) Finding include: During an observation on 2/5/24 at 10:00 a.m., Resident 267's room door had signage indicating Enhanced Barrier Precautions and had a personal protective equipment (PPE) cart outside her door. RN 15 and an unidentified CNA were observed entering the resident's room to pull her up in the bed. The staff had not donned PPE. During an interview at the time of the observation, RN 15 indicated she was unsure if the resident was actually on transmission based precautions and thought the PPE was not longer necessary. She had not had a chance to check. During an observation on 2/7/24 at 12:33 p.m., the resident's door continued to have signage indicating Enhanced Barrier Precautions and a PPE supply cart outside her door. Resident 267's clinical record was reviewed on 2/7/24 at 12:40 p.m. Diagnoses included vancomycin-resistant enterococcus (resistant bacterial infection) 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 record review, the facility failed to ensure a resident was treated with dignity for 1 of 3 residents reviewed for nursing services. (Resident G) Findings include: Resident G's clinical record was reviewed on 11/29/23 at 10:25 a.m. Diagnoses include muscle weakness (generalized) other reduced mobility, need for assistance with personal care, other abnormalities of gait and mobility, cognitive communication deficit, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 8/22/23, indicated she was cognitively intact. A quarterly MDS assessment, dated 10/20/23, indicated her cognitive status was not assessed. She required substantial/maximal assistance for toileting hygiene, upper and lower body dressing and personal hygiene. She was dependent on staff to roll left and right. She was always incontinent of bladder and frequently incontinent of bowel. A facility investigation for Resident G, reviewed on 11/29/23 at 12:20 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify a resident' representative regarding an allegation of neglect in a timely manner for 1 of 2 residents reviewed for notifications. (Resident G) Findings include: Resident G's clinical record was reviewed on 11/29/23 at 10:25 a.m. Diagnoses include muscle weakness (generalized) other reduced mobility, need for assistance with personal care, other abnormalities of gait and mobility, cognitive communication deficit, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was cognitively intact. A facility investigation for Resident G, reviewed on 11/29/23 at 12:20 p.m., indicated the following: A typed interview statement for Resident G, completed by the interim DON and dated 11/28/23, indicated Resident G stated CNA 6 came into her room assisted her into bed. Once she was in bed, CNA 6 left and she never…

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 an allegation of neglect was immediately reported to the Administrator for 1 of 4 residents reviewed for abuse. (Resident G) Findings include: Resident G's clinical record was reviewed on 11/29/23 at 10:25 a.m. Diagnoses include muscle weakness (generalized) other reduced mobility, need for assistance with personal care, other abnormalities of gait and mobility, cognitive communication deficit, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS), dated [DATE], indicated she was cognitively intact. A quarterly MDS, dated [DATE], indicated her cognitive status was not assessed. She required substantial/maximal assistance for toileting hygiene, upper and lower body dressing and personal hygiene. She was dependent on staff to roll left and right. She was always incontinent of bladder and frequently incontinent of bowel. During 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.

Based on observation, interview, and record review, the facility failed to ensure staff practiced appropriate infection control practices while providing care for a resident in transmission-based precautions during a random observation. Findings include: The clinical record for Resident J was reviewed on 11/30/23 at 10:04 a.m. Diagnoses include dementia, hypertension, and COVID-19. During an observation on 11/29/23 at 11:37 a.m., CNA 1 was delivering lunch room trays. The CNA entered an isolation room (Resident J's room) without donning additional PPE. The door to the resident's room displayed signage for appropriate PPE use. An isolation cart was located outside the door. CNA 1 exited the room carrying an empty tray (from breakfast). During an interview, at the time of the observation, CNA 1 indicated they did not don the appropriate PPE, but should have. During an interview on 11/29/23 at 11:42 a.m., The Rehab Unit Manager indicated CNA 1 should have donned the appropriate PPE before entering an isolation room. During an interview on 11/29/23 at 3:34 p.m., LPN 3 indicated all…

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

Based on interview and record review the facility failed to notify the resident's physician when blood sugars were outside of parameters for 2 of 3 residents reviewed for blood sugars (Resident C and Resident M). Findings include: 1. Resident C's clinical record was reviewed on 9/26/23 at 10:00 a.m. Diagnoses included type 2 diabetes mellitus without complications, cognitive communication deficit, aphasia, dietary counseling and surveillance, type 2 diabetes mellitus with ketoacidosis without coma, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. His medications included take blood sugar at 6:00 a.m. daily, insulin glargine (treat high blood sugar) 22 units daily (7:00 a.m. to 11:00 a.m.), insulin lispro (treat high blood sugar) 5 units before meals (7:00 a.m., 11:15 a.m. and 5:00 p.m.), insulin lispro per sliding scale three time daily (8:00 a.m., 12:00 p.m. and 5:30 p.m.) , if his blood sugar was less than 60, call the physician .if his blood sugar was greater than 500, call the physician, Glucagon…

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 observations, interviews, and record review, the facility failed to protect the resident's right to be free from verbal abuse by CNA 4 for 1 of 7 residents reviewed for abuse (Resident B and CNA 4). Findings include: On 9/26/23 at 3:09 p.m., Resident B was observed ambulating with her walker in the hallway. She indicated staff was nice to her and they better be. No one had ever been mean to her and she wouldn't put up with it, she paid the bill at the facility. On 9/28/23 at 4:02 p.m., Resident B was observed ambulating with her walker in the hallway. Resident B's clinical record was reviewed on 9/26/23 at 11:45 a.m. Diagnoses included major depressive disorder, recurrent, Alzheimer's disease. unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 7/5/23, indicated she was unable to complete the Brief Interview for Mental Status (BIMS). She had a current care plan for being at risk for change in mood state, she report a stakeholder hit and grabbed…

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 ensure allegations of abuse were reported to the State Agency timely for 3 of 7 residents reviewed for abuse allegations (Resident L and CNA 6, Resident K and CNA 6 and Resident F and CNA 13.) Findings include: Confidential interviews were conducted during the course of the survey. During a confidential interview, it was indicated Resident L yelled at CNA 6 to get out of her face because she didn't want her hair brushed. CNA 6 told Resident L when someone told her to get out of her face, she won't, because no one would talk to her like that. That same day, Resident K said something about CNA 6's mom. CNA 6 told Resident K that no one talked about her mom and if she did she was going to go to jail. Resident K had anxiety and with CNA 6 telling her she was going to go to jail caused her more anxiety and she began to cry and got worked up. They were taught about the signs of abuse through education and to report. The incidents 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 ensure allegations of abuse were investigated for 3 of 7 residents reviewed for abuse allegations (Resident L and CNA 6, Resident K and CNA 6 and Resident F and CNA 13). Findings include: Confidential interviews were conducted during the course of the survey. During a confidential interview, it was indicated Resident L yelled at CNA 6 to get out of her face because she didn't want her hair brushed. CNA 6 told Resident L when someone told her to get out of her face, she won't, because no one would talk to her like that. That same day, Resident K said something about CNA 6's mom. CNA 6 told Resident K that no one talked about her mom and if she did she was going to go to jail. Resident K had anxiety and with CNA 6 telling her she was going to go to jail caused her more anxiety and she began to cry and got worked up. They were taught about the signs of abuse through education and to report. The incidents were immediately reported to the DON…

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

Based on interview and record review the facility failed to prevent staff to resident verbal abuse for 2 of 3 residents reviewed for abuse. (Residents B, Resident D, CNA 13 and CNA 14 ) Findings include: 1. The clinical record for Resident B was reviewed on 9/11/2023 at 10:44 a.m. Diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, depressive disorder, and anxiety disorder. Review of the most current quarterly Minimum Data Set (MDS) assessment, dated 6/2/2023, indicated the resident was cognitively intact. Review of a facility reportable, dated 8/25/2023, indicated on 8/25/2023 CNA 13 used inappropriate language with Resident B when he requested assistance. During an interview, on 9/11/2023 at 11:58 a.m., Resident B indicated CNA 13 cussed him out when he requested assistance getting off the bedpan and told him he needed to get his a _ _ up and go to the bathroom. She would not let it go. She kept yelling and cussing. Finally, I lost it and started yelling back. 2. The clinical record for Resident D was reviewed…

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 report allegations of staff to resident abuse for 1 of 3 allegations of abuse reviewed (CNA 14 and Resident D). Findings include: The clinical record for Resident D was reviewed on 9/11/2023 at 3:25 p.m. Diagnoses include chronic obstructive pulmonary disease, chronic respiratory failure, chronic kidney disease, hypertension, Type 2 diabetes mellitus, and peripheral vascular disease. Review of the most current quarterly Minimum Data Set (MDS) assessment, dated 5/2/2023, indicated the resident was moderately cognitively impaired. During an interview Employee 7 indicated they witnessed CNA 14 using an excessively loud voice and inappropriate language with Resident D. The Employee indicated they felt CNA 14 was being intimidating towards Resident D. Employee 7 did not report the incident. They indicated they should have reported the incident to the Administrator. During an interview on 9/11/2023 at 1:45 p.m., RN 11 indicated on 9/10/2023 they witnessed Resident D taking ice from the ice chest in the clean utility. CNA 14…

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.