Rolling Hills Healthcare Center

Based on observation, interview and record review, the facility failed to ensure narcotic medications were not signed out prior to administration times for 7 of 11 residents reviewed for medication storage. (Resident E, Resident M, Resident N, Resident R, Resident S, Resident T and Resident U) Findings include: On 1/27/25 at 11:24 a.m., during an observation of the 400 hall controlled drug administration records with LPN (Licensed Practical Nurse) 6, the following narcotic medications had been signed out but not administered: -Resident E - Hydrocodone-APAP 5-325 mg (milligrams) signed out on 1/27/25 at 1:00 p.m. -Resident M - Oxycodone IR 5 mg (2 tabs to equal 10 mg) signed out on 1/27/25 at 2:00 p.m. -Resident N - Oxycodone IR 10 mg signed out on 1/27/25 at 2:00 p.m. -Resident R - Oxycodone IR 10 mg signed out on 1/27/25 at 1:00 p.m. -Resident S - Hydrocodone-APAP 5-325 mg signed out on 1/27/25 at 1:00 p.m. -Resident T - Oxycodone-APAP 5-325 mg signed out on 1/27/25 at 1:00 p.m. -Resident U - Hydrocodone-APAP 10-325 mg signed out on 1/27/25 at 1:00 p.m. 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.

Based on interview and record review, the facility failed to ensure medication administration records reflected the administration of narcotic medications for 4 of 11 residents reviewed for medical records. (Resident M, Resident N, Resident O and Resident V) Findings include: 1. The clinical record for Resident M was reviewed on 1/28/25 at 11:04 a.m. The diagnosis included, but was not limited to, stage 4 sacral pressure ulcer (wound that extends through all layers of the skin, reaching the underlying muscle, tendon or bone). The physician's order, dated 1/14/25, indicated the resident was to receive Oxycodone (narcotic pain medication) HCl (hydrochloride) 10 mg (milligrams) every 4 hours as needed for pain. The January 2025 controlled drug administration record indicated the resident received the medication on the following dates and times: - 1/20/25 at 6:00 a.m., 10:00 a.m. and 2:00 p.m. - 1/21/25 at 6:00 a.m., 10:00 a.m., 2:00 p.m. and 8:00 p.m. - 1/22/25 at 6:00 a.m., 10:00 a.m., 3:00 p.m. and 8:00 p.m. - 1/23/25 at 1:00 a.m., 6:00 a.m., 10:00 a.m. and 2:00 p.m. - 1/24/25 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 observation, interview and record review, the facility failed to ensure Indwelling catheter care orders were implemented for 1 of 3 residents reviewed for Indwelling catheters. (Resident M) Findings include: On 1/28/25 at 11:29 a.m., the resident was observed sitting in a chair in her room with an Indwelling catheter in place. The clinical record for Resident M was reviewed on 1/28/25 at 11:04 a.m. The resident's diagnosis included, but was not limited to, stage 4 sacral pressure ulcer (wound that extends through all layers of the skin, reaching the underlying muscle, tendon or bone). The care plan, dated 1/13/25, indicated the resident had an Indwelling catheter and to provide catheter care every shift. The clinical record lacked documentation of any Indwelling catheter care for Resident M. During an interview on 1/28/25 at 9:55 a.m., Staff Member 11 indicated Indwelling catheter care orders should be implemented upon admission. On 1/28/25 at 2:44 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Catheter Care. It…

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

Based on interview and record review, the facility failed to ensure the anti-psychotic medication was documented as administered (Resident G) and failed to ensure resident's (Resident C and Resident E) medication administration records reflected the administration of narcotic medication for 3 of 5 residents reviewed for medical records. Findings include: 1. The clinical record for Resident G was reviewed on 12/18/24 at 3:00 p.m. The resident's diagnosis included, but was not limited to, dementia with behavioral disturbance. The physician's order, dated 10/28/24, indicated the resident was to receive Divalproex Sodium (mood stabilizer) delayed release, 125 mg (milligrams) three times a day in the morning, afternoon and at bedtime. The November 2024 medication administration record (MAR) indicated the medication was not signed out as given on the following scheduled administration times: - On 11/12/24 in the morning - On 11/18/24 in the morning On 11/25/24, the Divalproex Sodium was discontinued and a new order was implemented for Divalproex Sodium 500 mg three times a day in the…

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

Based on interview and record review, the facility failed to ensure behaviors were care planned and monitored for 3 of 4 residents reviewed for behavior management. (Residents B, D, and G) Findings include: 1. The clinical record for Resident B was reviewed on 12/19/24 at 1:24 p.m. The resident's diagnoses included, but were not limited to, dementia with agitation and schizoaffective disorder. During an interview on 12/19/24 at 10:15 a.m., the Memory Care unit manager indicated Resident B would actively seek out Resident C and had done so for a couple of months. She did not know if the resident had been care planned for the behavior. During an interview on 12/19/24 at 10:24 a.m., the Director of Nursing indicated she and the Executive Director had went back to the unit. As they were going down the hallway, there were two females (Residents B and D) in Resident C's room. One was standing up and the other was sitting on the bed. She inquired about the two females in the male resident's room and the staff reported that there was nothing going on. It was not appropriate for females 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 observation, interview and record review, the facility failed to ensure affective interventions were in place for a resident with increased sexually inappropriate behaviors for 1 of 8 residents reviewed for dementia care. (Resident C) Findings include: 1. The clinical record for Resident C was reviewed on 12/18/24 at 2:15 p.m. The resident's diagnosis included, but was not limited to, dementia with agitation. The care plan, dated 10/6/24, indicated the potential for behavior problem related to a history of sexually acting out. The interventions included, but were not limited to, assist in developing more appropriate methods of coping and interacting and to encourage more male friends and group/public areas with male and female setting; discourage resident wanting to focus continually on one female per family recommendation; encourage the resident be in in eye sight of staff when out of room and if reasonable, discuss behaviors; intervene as necessary to protect the rights and safety of others. The progress note, dated 10/27/24 at 8:42 p.m., indicated the resident continued…

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 fall interventions were in place for 1 of 3 residents reviewed for accident hazards. (Resident C) Findings include: The clinical record for Resident C was reviewed on 8/28/24 at 12:50 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease and epilepsy. The care plan, dated 3/4/22, indicated the resident was at risk for falls and to apply non-skid strips to the left side of the bed. During an observation with the DON (Director of Nursing) on 8/28/24 at 2:53 p.m., the care planned intervention of non-skid strips to the left side of Resident C's bed were not in place. During an interview on 8/28/24 at 2:43 p.m., the DON indicated if the intervention was on the resident's plan of care, they should be in place. On 8/29/24 at 10:10 a.m., the Executive Director provided a current, undated copy of the document titled Fall Prevention and Management. It included, but was not limited to, It is the policy of this facility to provide resident centered care that meets the .needs .of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the resident's call lights were within reach for 10 of 108 residents observed for call light placement. (Residents 20, 77, 256, 60, 47, 91, 11, 38, 46 and 94) Findings include: 1. During an observation on 5/10/24 at 8:15 a.m., Resident 20's call light was laying on the floor underneath the resident's bed. No staff were present in the resident's room. The record for Resident 20 was reviewed on 5/16/24 at 9:18 a.m. The resident's diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), major depressive disorder, difficulty walking, muscle wasting and atrophy, the need for assistance with personal care, cognitive communication deficit, dysphagia and dementia. The Quarterly MDS (Minimum Data Set) assessment, dated 3/18/24, indicated the resident was rarely or never understood. The resident required the use of a wheelchair for mobility. 2. During an observation on 5/9/24 at 8:30 a.m., Resident 77's call…

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

Based on interview and record review, the facility failed ensure Administration was taking resident concerns seriously or being visible to the residents for 11 of 13 Resident Council meetings (3/23, 4/23, 5/23, 6/23, 7/23, 9/23, 10/23, 1/24, 3/24. 4/24, and 5/24). This deficient practice had the potential to affect 108 of 108 residents currently residing in the facility. Findings include: 1. The Resident Council meeting held on 3/21/23, the residents indicated their concerns were not resolved or acted upon for the following: - There was no improvement in Administration taking the resident's concerns seriously. The residents heard the same excuse over and over. - Nothing was being done about the lack of staff. - The resident's indicated they saw nursing staff walking past the resident's rooms who needed assistance. It was hard to get a nurse to come and see what residents needed at night. - The meals were not being balanced out with the residents' diet. When the ticket said double portions, they were not getting it every meal. The residents were still hungry. The residents 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.

Based on record review and interview, the facility failed to ensure the CNAs (Certified Nurse Aides) tested for their licensure, prior to 120 days after of employment and worked past the 120 days for 6 of 33 CNAs reviewed. (CNAs 13, 14, 16, 15, 19, and 17) Findings include: During the review of the employee records on 5/15/24 at 11:10 a.m., the following was identified: -CNA 14 was hired on 9/6/23. -CNA 13 was hired on 8/2/23. Date of hire on the employee records indicate 5/3/23. -CNA 16 was hired on 2/10/20. -CNA 15 was hired on 8/2/23. -CNA 19 was hired on 3/29/23. -CNA 17 was hired on 6/29/23. -CNA 20 was hired on 6/21/23. During an interview on 5/15/24 at 1:25 p.m., the ED (Executive Director) indicated there wasn't a HR (Human Resources) person up to 4/5/24 and the ED looked at all staff for licenses. She found that 8 facility staff who were licensed in Kentucky had not taken their CNA licensure test in the 120 days required in Indiana. All 8 staff were taken off of the work schedule until they passed their CNA licensure test. -CNA 13's 120th day was 11/29/23. She worked 70…

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

Based on observation and interview, the facility failed to ensure meals were at appropriate temperatures and palatable for residents, during 3 of 3 meal test trays. This had the potential to affect 106 of 108 residents who ate meals at the facility. (100, 400, and 200 Hall Test Trays) Findings include: 1. During an observation of the 100 Hall lunch test tray on 5/14/24 at 12:00 p.m., the following temperatures were obtained: -The baked ziti had a temperature of 145 degrees F (Fahrenheit). The appearance was palatable. The flavor was bland and salt was applied for more flavor. -The Caesar salad had a temperature of 65.6 degrees F. The appearance and flavor were appetizing. 2. During an observation of the 400 Hall lunch test tray on 5/14/24 at 12:25 p.m., the following temperatures were obtained: -The baked ziti had a temperature of 135 degrees F. -The Caesar salad had a temperature of 63.5 degrees F. 3. During an observation of the 200 Hall lunch test tray on 5/16/24 at 11:52 a.m., the following temperatures were obtained: The pepperoni pizza had a temperature of 168.8 degrees F. 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 and interview, the facility failed to ensure the kitchen was cleaned and in good repair 2 of 2 observations. This had the potential to affect 106 of 108 residents who consumed meals at the facility. Findings include: 1. During an interview and observation of the kitchen on 5/9/24 at 9:25 a.m., Server/Dishwasher 10 indicated the dishwasher was currently working, but it had not been previously. When it was checked, she indicated, oh good it is working. The dishwasher was observed running. The wash cycle temperature was 145 degrees F (Fahrenheit) and the rinse cycle had a temperature of 170 degrees F. At 11:15 a.m., during observation of the kitchen ceiling the ceiling plaster around the vent had flaked off. The vent was over the preparation table and the flaked off areas were at each corner of the vent. The ceiling was brown stained along the left side of the vent. The two vents over the serving table at the end of the steamer were brown and grease covered. The back metal panel of the burners on the stove had brown streaks of grease. The ceiling around the vent in…

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

Based on interview and record review, the facility failed to identify a resident's right heel pressure ulcer prior to the wound being first identified as an open blister, no longer holding fluid for 1 of 3 residents reviewed for pressure ulcers. (Resident 8) Findings include: The record for Resident 8 was reviewed on 5/14/24 at 2:10 p.m. The resident's diagnoses included, but were not limited to, non-traumatic intracerebral hemorrhage, hemiplegia (partial paralysis on one side of the body) and hemiparesis, dementia, anxiety disorder, unsteadiness on feet, assistance with personal care, difficulty walking, and cognitive communication disorder. The Quarterly MDS (Minimum Data Set) assessment, dated 2/29/24, indicated the resident's cognition was moderately impaired. The resident required substantial or maximal staff assistance with his ADL's (Activities of Daily Living). The care plan, dated 3/23/23, indicated Resident 8 had impaired skin integrity or altered skin integrity related to immobility. The interventions included, but were not limited to, apply barrier creams post…

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 adequate staffing which contributed to the lack of resident care, the distribution of fluids, and supervision. This deficient practice had the potential to affect 104 of 104 residents residing in the facility. Findings include: During an interview on 2/27/23 at 11:45 a.m., Resident N's family member indicated the resident did not get the help and care needed without having to wait a long time. The family member indicated in the morning, the resident would have brown rings from urine on the sheets. It took bleach to launder them. The night shift would just let the residents lay in bed unchanged. Family felt the need to stay with the resident from 10:30 p.m. to 2:00 a.m., to provide care for the resident. The family had to start feeding the resident at every meal, because of the resident's weight loss. During an interview on 2/27/23 at 11:45 a.m., Resident M's family member indicated she felt the staff wouldn't pay attention to call lights at times. The facility recommended hospice care for 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 and interview, the facility failed to ensure meals were healthy and appetizing for residents, during 1 of 2 meal test trays. This had the potential to affect all 104 residents who ate meals at the facility. Findings include: During an interview on 2/27/23 at 9:38 a.m., Resident 63 indicated the food was bad and it was cold sometimes. During an interview on 2/27/23 at 9:40 a.m., Resident 211 indicated the food was not good. During a lunch meal test tray observation and tasting on 3/2/23 at 11:26 a.m., the residents were served chicken salad sandwiches, broccoli salad, and potato salad. All 3 of the salads had mayonnaise in the recipe. The potatoes and the broccoli were undercooked. During an interview on 3/2/23 at 12:45 p.m., Resident 15 indicated the food was terrible today. The potatoes and broccoli were hard. If there was only one salad dish, it wouldn't have been so bad, but it was too many salads. The menu repeated all of the time. During an interview on 3/2/23 at 12:46 p.m., Resident 96 indicated she didn't like the potato salad. There was too many salad…

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

Based on observation and interview, the facility failed to ensure residents' rooms were clean and free of debris for 4 of 5 random observations of the facility environment and for 5 of 104 residents that reside in the facility. (Residents 81, 105, 67, 20, and 33) Findings include: During an observation of Residents 81's and 105's room on 2/28/23 at 2:25 p.m., there was a heavy soiled area of food particles under and around both beds. During an observation of the 200 Hall on 3/1/22 between 2:30 p.m. and 2:45 p.m., in Resident 67's room there were three strips of bacon, a sausage patty, and a heavy accumulation of other unidentifiable food debris on the floor under the resident's night stand. In Resident 20 and 33's room there was a heavy buildup of food debris under the bed and a heavy buildup of brown debris built up on the floor near the walls throughout the room. During an observation of the 200 Hall on 3/2/22 at 2:50 p.m., in Resident 67's room there were three strips of bacon, a sausage patty, and a heavy accumulation of other unidentifiable food debris on the floor under 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, record review, and interview, the facility failed to ensure the residents' rooms were free of hazards related to multiple medications, including controlled substances, were found on the bedroom floors in 5 of 61 resident rooms. (Residents 15, 32, 86, 20, and 97) Findings include: 1. The clinical record for Resident 15 was reviewed on 3/2/23 at 8:19 a.m. The diagnoses included, but were not limited to, dementia with agitation and cognitive communication deficit, generalized anxiety disorder and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 12/7/22, indicated the resident was cognitively intact, had no mood or behavior issues, no hallucinations or delusions, had no swallowing issues, and was mobile in a wheelchair with no impairments in functional range of motion. During a random environmental observation of Resident 15's room on 3/1/23 at 2:40 p.m., on the floor in front of her nightstand there were 2 small white pills observed. During an interview on 3/1/23 at 2:45 p.m., LPN (Licensed Practical Nurse) 4 was shown both white…

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

Based on observation and interview, the facility failed to ensure the kitchen equipment was cleaned and in good repair, and food was stored properly in the dry goods room and refrigerator. This had the potential to affect all 104 residents who consumed meals at the facility. Findings include: During a tour of the kitchen on 2/27/23 at 9:12 a.m., the following concerns were observed: -There was a black loose charcoal substance on the bottom of the oven. -There was a black burned greasy area on the metal panel and plaster wall above the metal panel, to the left of the stove top burners. -There was a black greasy area to the right of the burners on the metal panel. -There was food debris and a build-up of a black charcoal substance on three of the aluminum lined drip pans under the burners. The drip pan on the left had grease under the aluminum. The fourth drip pan would not open. -In the dry goods storage room, the lid on the storage container, which had an open bag of dry milk, was ajar over half of the top. -the stand alone refrigerator had an internal temperature of 54 degrees…

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

Based on record review and interview, the facility failed to ensure the residents were COVID-19 tested in accordance with their policy for 6 of 12 residents reviewed for COVID testing. (Residents 80, 76, 89, 70, 87 and 92). Findings included: 1. The clinical record for Resident 76 was reviewed on 3/1/23 at 11:01 a.m. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease) and large-B-cell lymphoma. The Quarterly MDS (Minimum Data Set) assessment, dated 12/15/22, indicated the resident was severely cognitively impaired. On 6/9/22, the resident received new physician orders for Respiratory/COVID Screener: Any of the following S/Sx (signs/symptoms) of COVID-19 observed: If any S/Sx noted; complete the Respiratory/COVID Symptoms Evaluation, every shift, and for COVID-19 testing as needed; may use PCR (polymerase chain reaction) or POC (rapid viral test) testing as needed. A care plan, dated 6/13/22, indicated the resident had COPD with shortness of breath. The interventions included, but were not limited to, administer medications per medical…

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 protect the resident's right to be free from physical abuse by another resident for 3 of 4 residents reviewed for abuse. (Residents B, H, and J) Findings include: 1. The clinical record for Resident B was reviewed on 2/28/23 at 1:42 p.m. The diagnoses included, but were not limited to, schizoaffective disorder, dementia with agitation, paranoid personality disorder, anxiety disorder, depression, and cognitive communication deficit. The social services note, dated 8/10/22 at 2:40 p.m., indicated the resident's cognition assessment indicated her cognition was severely impaired. There were no behaviors at that time. The incident note, dated 10/21/22 at 9:12 a.m., indicated Resident B was observed with abrasions or scratches on her chest and below her right eye area. Upon investigation, the resident indicated another resident allegedly made contact with her, causing the areas. This was not witnessed by any staff members. The resident was assessed by a licensed nurse with no other areas identified. The family and…

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

Based on record review, interview, and observation, the facility failed to ensure misappropriation of a resident's property had not occurred, related to a missing narcotic card for 1 of 3 residents reviewed for misappropriation. (Resident 71) Findings include: The review of the Incident Report, dated 1/29/23, indicated the facility discovered Resident 71's card of Hydrocodone-APAP, 10-325 mg, was missing. A pain assessment was completed, and the resident denied pain. RN 8 indicated he worked Friday, 1/27/23, on the 200-Hall from 6:00 p.m. to 6:30 a.m. The RN received a card of Hydrocodone 10-325 mg, containing 30 tablets, from the pharmacy delivery at approximately 8:00 p.m. It was the only narcotic card he had received. The card was for Resident 71. He locked the card in the narcotic cart. Then he put the sheet in the narcotic book and added the narcotic to the Control/Shift change count book. LPN 9 (Licensed Practical Nurse) was scheduled to work the 6:00 a.m. to 6:00 p.m. on the 400- Hall. The LPN arrived at the facility at 6:07 a.m. Another nurse came to LPN 9 and handed her the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure preventative interventions were implemented for 3 of 4 residents reviewed for pressure ulcers. (Residents E, O, and F) Findings include: 1. The clinical record for Resident E was reviewed on 2/28/23 at 12:00 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and homonymous bilateral field defects of left side. The admission assessment, dated 2/2/22, indicated the resident had no skin areas observed. The Braden scale indicated the resident was chairfast, had slightly limited mobility, adequate nutrition, had a potential problem with friction and shearing, and was identified as a potential risk for skin breakdown. Suggested interventions included explain risk versus benefits to resident/family and the importance of changing positions for prevention of pressure ulcers, encourage small frequent position changes, turning and repositioning at least every 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 observation, record review, and interview, the facility failed to provide proper perineal and catheter care for 2 of 3 residents reviewed for bowel and bladder. (Residents M and D) Findings include: 1. The clinical record for Resident M was reviewed on 3/1/23 at 11:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, hyperosmolality and hypernatremia. The Annual MDS (Minimum Data Set) assessment, dated 2/2/23, indicated the resident was severely cognitively impaired. The infection note, dated 12/5/22 at 2:09 p.m., indicated the hospice company called and a new order was received to start Ciprofloxacin 500 mg (milligrams) twice daily for 7 days related to a UTI (urinary tract infection). The nurse's note, dated 12/9/22 at 1:27 p.m., indicated the resident continued to receive Ciprofloxacin for a UTI. No signs or symptoms of urinary issues were observed. His temperature was 98.3 degrees. During a confidential interview between 2/7/23 and 3/3/23, Staff B indicated it had been a while since the resident has had a UTI. He was not cooperative with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure residents were monitored for weight loss and provided with assistance for eating for 3 of 6 residents reviewed for nutrition (Residents 89, 59, and 70) Findings include: 1. The clinical record for Resident 89 was reviewed on 3/1/23 at 11:31 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, celiac disease, depression, anxiety disorder, hyperlipidemia, hyperosmolality, and hypernatremia. The resident was admitted on [DATE] with a weight of 182.4 pounds. The care plan, dated 11/29/21 and last revised on 1/26/23, indicated the resident was at risk for nutritional decline related to dementia, hyperlipidemia, weight loss, and gluten allergy. The interventions, dated 11/29/21, included but were not limited to, staff were to ensure dentures were utilized for meals; establish a baseline weight; identify the resident's food and beverage preferences; monitor his meal intake; notify the medical provider and 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 record review and interview, the facility failed to ensure appropriate interventions were implemented to prevent recurrent resident to resident aggressive behaviors for 1 of 3 residents reviewed for behaviors. (Resident 45) Findings include: The clinical record for Resident 45 was reviewed on 2/28/23 at 1:00 p.m. The diagnoses included, but were not limited to, dementia with agitation, major depressive disorder, and anxiety disorder. The care plan, dated 8/11/21, indicated the resident had a potential for alteration in mood and behavior related to dementia, depression, previous homelessness causing fight or flight behaviors, and previous inpatient stays. His behaviors included being verbally aggressive with staff. He had altercations with other residents on 12/7/18, 8/4/21,12/8/21, 9/15/22, and 12/22/22. The interventions included, but were not limited to, allow personal space and quiet time, anticipate and meet the resident's needs, assist the resident to his room as preferred, assist the resident to develop more appropriate methods of coping and interacting with others,…

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 appropriate Infection Control practices related to transmission-based precautions (TBP) were implemented related to Aerosol-Generating Procedures (AGP's) for 2 of 2 random observations of care. (Resident 87) Findings include: 1. During an observation on 3/3/23 at 8:31 a.m., Resident 87 was observed in her bed in her room utilizing a nebulizer treatment. There was fine aerosol mist observed exiting the end of the nebulizer mouthpiece which she was utilizing. The resident's room door was open. The sign on the resident's door indicated she was in aerosol contact precautions. The sign indicated every one must wear a N95 or higher respirator, eye protection, gown, and gloves when entering and keep the door closed. During an interview and observation on 3/3/23 at 8:33 a.m., LPN (Licensed Practical Nurse) 20 indicated Resident 87 was receiving a breathing treatment which she had set up for her. She was not aware of the sign to keep the door closed. She thought since the resident was in the second bed 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.