Waters Of Muncie, The

Based on observation, interview, and record review, the facility failed to post complete nurse staffing information daily for residents and visitors. This deficiency had the potential to affect 46 of 46 residents in the facility. Finding includes: During an observation, on 3/25/25 at 9:30 a.m., the Daily Report of Nursing Staff was posted on the wall by the receptionist desk. The posting was dated 3/21/25. During an observation on 3/26/25 at 9:37 a.m., the Daily Report of Nursing Staff remained unchanged, showing 3/25/24. During an observation on 3/26/25 at 2:37 p.m., the Daily Report of Nursing Staff remained unchanged, showing 3/25/24. During an observation on 3/27/25 at 9:48 a.m., the Daily Report of Nursing Staff was posted on the wall by the receptionist desk. The posting was dated 3/26/25. During an observation on 3/27/25 at 1:42 p.m., the Daily Report of Nursing Staff remained unchanged showing 3/26/25. During an observation on 3/27/25 at 3:41 p.m., the Daily Report of Nursing Staff remained unchanged showing 3/26/25. During an observation on 3/28/25 at 9:21 a.m., the Daily…

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 provide individualized interventions to prevent resident to resident physical altercations for cogntively impaired residents with dementia for 1 of 4 residents reviewed for physical altercations. (Resident B) Finding includes: Review of an Indiana State Department of Health facility reported incident, dated 1/22/25 at 8:30 p.m., indicated the facility initiated an investigation of a resident to resident altercation. The incident was identified on 1/22/25 at 8:30 p.m. The brief description indicated Resident B had entered another residents room and refused to leave. The other resident made contact with his hand to Resident B's chest. The nurse removed Resident B from the room. The immediate actions taken were separation of the residents and Resident B was given a one to one staff supervision. Resident B was assessed for injury and/or pain. The police were notified. A follow-up on 1/31/25 indicated the investigation was complete without any findings. No further behaviors noted and care plans updated as needed. Resident B'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to review and implement the hospice provider's plan of care resulting in a resident receiving Cardiopulmonary Resuscitation efforts for a resident who had signed a Do Not Resuscitate Directive for 1 of 3 resident reviewed for death. (Resident E) Findings include: Resident E's closed clinical record was reviewed on [DATE] at 11:48 a.m. Diagnoses included nontraumatic intracerebral hemorrhage/stroke, muscle wasting and atrophy, and dysphagia. The resident was admitted to hospice services on [DATE] at 6:59 p.m. A signed physician's order, dated [DATE], indicated the resident was a Full Code (CPR was to be initiated as appropriate). A signed physician's order, dated [DATE], indicated hospice was to evaluate and treat. A health care plan, dated [DATE], indicated the resident had elected a Full Code status. The care plan and interventions had no review or revised dates. A health care plan, dated [DATE], indicated the resident received hospice services. The goal…

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, observation, and record review, the facility failed to ensure residents had the freedom and assistance to exercise their rights to go outside for fresh air for 6 of 6 residents interviewed about residents rights during the Resident Council group interview. Findings include: During a resident council group interview, on 5/15/24 at 1:15 p.m., 5 of 5 residents present indicated they wanted to be able to sit outside in the fresh air but were not permitted to do this as the facility was unable to find staff to supervise them. This concern was discussed at the previous meeting and the grievance form was filled out. Resident 38 indicated she felt like a prisoner in the facility and would like to sit outside alone and de-stress. The Resident Council Meeting Minutes, dated 2/8/24 and provided by the Activity Director on 5/13/24 at 1:27 p.m., indicated the following concern: residents not being able to leave without responsible party and the staff were not taking residents out for smoke breaks at the scheduled times. No resolution was documented. The Resident Council…

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 meaningful, structured activities and/or an environment with available diversionary materials within the secured dementia care unit for 3 of 4 residents reviewed for dementia services (Residents 25, 7, and 42). Findings include: During a confidential interview, a resident representative indicated the activity calendar posted in the dementia unit was not followed. Often times, the residents simply sat and watched TV. What was offered was not always meaningful to the residents. When activities were held, staff did not always invite everyone on the dementia unit to attend. The facility completed Resident Matrix document, provided on 5/13/24 following the entrance conference, indicated 22 residents resided on the dementia unit. The May 2024 Memory Care Unit/Hope Springs activity calendar, which was posted on the wall of the unit, had no activity before 10:30 a.m. listed for Monday through Friday. The first activity on Saturday and Sunday was scheduled for 10:00 a.m. The activity calendar for 5/13/24…

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

Based on interview and record review, the facility failed to ensure controlled medication counts were completed and acknowledgements signed to account for controlled medications for 2 of 3 medication carts reviewed. (300 Unit and Hope Springs Unit medication carts) . Findings include: During an observation on 5/15/25 at 10:17 a.m., QMA 4 indicated she had not signed the 300 Unit Narcotic Count Sheets at the beginning of her shift on 5/15/24. Additionally, two narcotic shift counts with acknowledgments were incomplete on the 300 Unit Narcotic Count Sheets for shifts on 5/9/24. Offgoing and oncoming staff members assigned to the carts should have both signed at the beginning and end of each shift. This was an opportunity to have missing medications when narcotic shift counts when acknowledgements were incomplete. Review of the 300 Unit Shift to Shift Narcotic Count Verification Log from 5/8/24 to 5/15/24 indicated a lack of the following information: 5/9/24 Day shift- Oncoming Shift Signature, 5/9/24 Evening shift - Offgoing Shift Signature, and 5/15/24 Day shift- Oncoming Shift…

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 wound treatment was completed as ordered by the physician for 1 of 3 residents reviewed for pressure injuries. (Resident 47) Finding includes: Resident 47's clinical record was reviewed on 5/14/24 at 4:21 p.m. Diagnosis included, peripheral vascular disease, heart failure, atrial fibrillation, type 2 diabetes mellitus, and encounter for palliative care. A physician's order, dated 5/5/24, included the following: every day shift, cleanse area to right side of back with wound wash or normal saline, pat dry, apply medi-honey (wound treatment) and collagen (wound treatment), and cover with bordered foam. This order was discontinued on 5/14/24. A current physician's order, dated 5/15/24, included the following: every day shift, cleanse area to right side of back with normal saline, pat dry, apply medi-honey, and cover with bordered foam for wound care. A quarterly Minimum Data Set (MDS) assessment, dated 4/12/24, indicated the resident was severely cognitively impaired. Rejection of care behaviors were not…

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

Based on interview and record review, the facility failed to provide services as recommended by the Registered Dietitian to maintain acceptable parameters of nutrition for 1 of 3 residents reviewed for nutrition. (Resident 50) Finding includes: During an interview on 5/13/24 at 3:04 p.m., Resident 50 indicated she had lost some weight since she admitted to the facility. She received wound care to her buttock every day. She also received a juice supplement. Resident 50's clinical record was reviewed on 5/14/24 at 3:22 p.m. Diagnosis included, type 2 diabetes mellitus, depression, and generalized weakness. An order, dated 4/19/24, included a general diet, regular texture, thin liquids, and a nutritional juice. An order, dated 4/22/24, included mirtazapine (appetite stimulant) 7.5 milligrams (mg) tablet by mouth daily in the evening. An order, dated 4/22/24, included Zofran (anti-nausea) 4 mg tablet every six hours as needed. An order, dated 5/12/24, included fluoxetine hydrochloride (anti-depressant) 40 mg capsule by mouth daily in the morning. Review of the resident's weights were 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 record review and interview, the facility failed to ensure complete and accurate communication records between the facility and a hospice provider for 1 of 1 resident reviewed for hospice services. (Resident 4) Findings include: The clinical record for Resident 4 was reviewed on 5/16/24 at 10:23 a.m. Diagnosis included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, neoplasm of the left breast, and vascular dementia. A physician's order, dated 12/22/23, indicated to admit to hospice services. A hospice care plan, initiated 12/22/23, indicated admittance to hospice for left breast cancer. Interventions included the following: keep hospice CNA/nurse updated on any care changes (12/29/23), keep hospice notified of all transfers and discharges (12/29/23), notify Hospice nurse of any new orders and changes in condition (12/29/23). A significant change Minimum Data Set (MDS) assessment, dated 1/5/24, indicated Resident 4 received hospice services. A review of the facility hospice communication binder, on 5/16/24 at 3:00…

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.

Based on interview and record review, the facility failed to ensure residents were spoken to in a dignified manner for 3 of 7 residents reviewed for abuse. (Residents C, D, and F) Findings include: Confidential interviews were conducted during the survey. During a confidential interview, it was indicated reports of potential verbal abuse allegations were brought to the DON, Administrator, and the ADON, a few days after Thanksgiving, regarding potential verbal abuse from CNA 2 directed towards Residents C, D, and F. In response to Resident C's request for something, CNA 2 yelled at Resident C, What do you need now? Other staff member concerns regarding potential verbal abuse was reported to include the name of another staff member who also came forward regarding the concerns of CNA 2's disrespectful responses to Resident D and Resident F when CNA 7 reported allegations of potential verbal abuse. CNA 2 rolled her eyes and sighed as if annoyed whenever the residents would need things on a regular basis. CNA 2 was rude and disrespectful in her demeanor when she responded to 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 interview and record review, the facility failed to report allegations of abuse to the Indiana Department of Health for 3 of 7 residents reviewed for abuse. (Residents C, D, and F) Findings include: Review of a facility investigation report on 12/27/23 at 5:04 p.m. indicated a lack of evidence allegations were reported to the Indiana Department of Health when it was brought to the facility's attention on 11/28/23 or 11/29/23. CNA 2 was not suspended on 11/28/23 pending an investigation. There were no statements nor interviews on 11/28/23 from Resident C or Resident D recorded for review in the facility investigation file. The facility investigation lacked an interview or a statement with CNA 7, CNA 3, or the Business Office Manager on 11/28/23 prior to determining the allegtions were not potential abuse. CNA 2 continued to provide care to the residents on the 300 and 400 units without restrictions. Due to a report to the home office from the Business Office Manager, the Corporate Nurse Consultant got…

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 complete a thorough and timely investigation of allegations of verbal abuse for 3 of 7 residents reviewed for abuse. (Residents C, D, and F) Findings include: Review of a facility investigation report on 12/27/23 at 5:04 p.m. indicated a lack of evidence allegations were reported to the Indiana Department of Health when it was brought to the facility's attention on 11/28/23 or 11/29/23. CNA 2 was not suspended on 11/28/23 pending an investigation. There were no statements nor interviews on 11/28/23 from Resident C or Resident D recorded for review in the facility investigation file. The facility investigation lacked an interview or a statement with CNA 7, CNA 3, or the Business Office Manager on 11/28/23 prior to determining the allegtions were not potential abuse. CNA 2 continued to provide care to the residents on the 300 and 400 units without restrictions. Due to a report to the home office from the Business Office Manager, 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 observation, interview, and record review, the facility failed to ensure narcotics were reconciled per facility policy for 2 of 3 nursing unit's medication carts reviewed for medication storage. (300 Hall cart and 400 Hall cart) Findings include: 1. During a medication storage observation on 6/28/23 at 11:57 a.m. with LPN 5, the narcotic book on the 300 Hall medication cart lacked any shift-to-shift sign-in/out sheets or narcotic count reconciliation documentation. LPN 5 indicated there were no sheets to document the narcotic counts that she was aware of, and the nurses counted the narcotics in the drawer during shift change, but did not document this anywhere. 2. During an observation of the narcotic book on the 400 Hall medication cart with the ADON on 6/28/23 at 12:07 p.m., the book lacked any shift-to-shift sign-in/out sheets or narcotic count reconciliation documentation. The ADON indicated each nurse was to report off to the on-coming nurse. The narcotic medication in the drawers were counted. There was no sign-in/out sheets or documentation of narcotic counts or…

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 sufficient staffing based on resident acuity to meet the needs and preferences for 3 of 3 residents reviewed for sufficient staffing. (Residents B, C, and D) Findings include: The Resident Census and Condition of Residents form (CMS form 672), which was completed by the MDS Coordinator and dated 6/26/23, indicated the facility residents had the following acuity levels and care needs: a. 12 of 52 residents required assistance for bathing. b. 38 of 52 residents were totally dependent on the staff for bathing. c. 48 of 52 residents required assistance for dressing. d. 2 of 52 residents were totally dependent on the staff for dressing. e. 45 of 52 residents required staff assistance for physically transferring. f. 3 of 52 residents were totally dependent on the staff for physically transferring. g. 47 of 52 residents required staff assistance for toileting needs. h. 3 of 52 residents were totally dependent on staff for toileting…

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 residents who resided on the secured dementia unit had physician orders to reside on a secured unit, had assessments to reside on a secured dementia unit, and had care plans regarding the need to reside on a dementia unit for 4 of 4 residents reviewed for dementia services (Residents 24, 25, 33 and 39). Findings include: 1. During an observation on 6/26/23 at 10:23 a.m., Resident 24 was in his room on the secured dementia unit. He was in bed watching TV. He was calm. During an observation on 6/26/23 at 1:50 p.m., the resident was napping in his bed. During an observation on 6/29/23 at 9:44 a.m., the resident was napping in bed with his TV playing. Resident 24's clinical record was reviewed on 6/27/23 at 3:46 a.m. Current diagnoses included dementia with behavioral disturbances and bradycaria. The resident was moved to reside on the secured dementia unit on 11/3/21. A 4/2/23, quarterly Minimum Data Set (MDS) assessment indicated he was severely cognitively impaired and displayed zero maladaptive…

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 honor dietary preferences for 4 of 4 residents reviewed for food preferences. Finding includes: During an interview on 6/26/23 at 12:13 p.m., Resident 20 indicated he disliked chicken salad. He had spoken to the Dietary Manager regarding his dislikes and discussed dislikes in resident council. Regardless of the list of dislikes, the items continued to be sent on his meal tray on a regular basis. During the interview, the resident's meal tray was delivered to his room. His lunch was a chicken salad sandwich, a cup of peas, cookie, and lemonade. The meal ticket on his tray listed peas and chicken as dislikes. The resident indicated the cookie and the lemonade were the only items on his tray that he would consume. During a meeting with the Resident Council group, on 6/29/23 at 11:00 a.m., the following concerns were indicated during confidential interviews: A resident indicated pears were listed on the meal ticket dislikes and the resident continued to receive them on the meal trays. A resident indicated green beans were listed…

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 promptly implement enhanced barrier precautions (EBP) for residents at high risk for acquiring or spreading multi-drug resistant organisms (MDRO's) for 5 of 5 residents reviewed for infection control. (Residents B, 46, 20, 4, and 16) This deficient practice had the potential to effect 52 of 52 residents who resided in the facility. Findings include: During a facility tour observation on 6/26/23 at 11:47 a.m., the resident rooms on the 300 and 400 units lacked isolation signs in place or personal protective equipment (PPE) canisters. 1. During an observation on 6/26/23 at 10:23 a.m., Resident B's room lacked a sign for transmission based precautions. A PPE canister was not readily available with PPE. Two staff members answered the resident's call light. No personal protective equipment was donned prior to entering the resident's room for care. During an interview on 6/26/23 at 4:13 p.m., Resident B indicated he was receiving intravenous…

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 provide bathing assistance according to residents' preferences for 2 of 3 residents reviewed for choices. (Residents B and C) Findings include: 1. During an interview on 6/26/23 at 4:13 p.m., Resident B indicated he preferred to have showers twice a week. The resident had not received a shower in approximately two months. He had not refused any showers. Staff were only washing his genital areas and his legs due to his incontinence. He required two staff members to provide his care due to his inability to assist himself. During an interview on 6/27/23 at 10:45 a.m., CNA 7 indicated Resident B had never refused care from her. The resident got upset when there was a lack of staff due to a decrease in the amount of aides because he required assistance of two staff members for his care. When they only had one aide scheduled on each unit, there were times in which a resident's care was postponed to wait for a nurse or a Qualified Medication Aide (QMA) to get…

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 quarterly statements to resident representatives for 3 of 4 residents reviewed for resident funds (Residents 33, 23, and 32). Findings include: An untitled resident funds balance sheet, provided by the Business Office Manager on 6/27/23 at 4:00 p.m., indicated the following: a. Resident 33 had a 6/27/23 balance of $1,925.68 (one thousand nine hundred twenty five dollars and sixty eight cents). b. Resident 23 had a 6/27/23 balance of $2,733.48 (two thousand seven hundred thirty three dollars and forty eight cents). c. Resident 32 had a 6/27/23 balance of $2,803.65 (two thousand eight hundred and three dollars and sixty five cents). On 6/29/23 at 5:28 p.m., untitled resident funds documents were provided by the Corporate Nurse Consultant. The documents lacked documentation supporting when quarterly statements were mailed and to whom. During an interview on 6/30/23, at 9:55 a.m., the Business Office Manager indicated she had only been serving in her position for approximately three months. She had received training…

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 complete PASRR (pre-admission screening and resident review) assessments after a new diagnosis for 1 of 3 residents reviewed for PASRR. (Resident 23) Findings include: Resident 23 clinical record was reviewed on 6/27/23 at 11:51 a.m. Diagnoses included major depressive disorder, anxiety, cognitive communication deficit, and schizoaffective disorder. The resident had a current order for Seroquel (antipsychotic) 25 mg daily. The Level 1 clinical assessment, dated 4/26/19, indicated Resident 23 did not have a major mental illness. The record indicated the diagnosis of schizoaffective disorder was added on 7/14/21. A nursing care plan dated 7/14/21, indicated Resident 23 was at risk for behavioral disturbances related to diagnosis of schizoaffective disorder and used an anti-psychotic medication. During an interview on 6/28/23 at 1:54 p.m., the SSD indicated that she was looking for the PASSAR information for Resident 23, and the facility was working a Performance Improvement Project (PIP) for auditing new schizophrenia…

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 qualified medication assistant (QMA) failed to obtain authorization from a licensed nurse or physician prior to administering an as needed (PRN) medication for 1 of 4 residents observed during medication administration observation. (Resident 30) Findings include: During medication administration observation on 6/28/23 at 8:45 a.m., QMA 9 was observed administering Resident 30's medication. The resident requested a Tessalon Perl (benzonatate) (to treat a cough) from QMA 9 after taking her regular medication. She indicated she had a cough. QMA 9 indicated she would return with the medication. QMA 9 obtained the resident's requested medication from the cart, returned to the resident's room, and administered the medication. The clinical record for Resident 30 was reviewed on 6/28/23 at 10:40 a.m. Diagnoses included atrial fibrillation, history of pulmonary embolism, and diastolic heart failure. A current physician's order, dated 5/2/23, indicated resident could have benzonatate 100 mg (milligram), one capsule every eight hours 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.