Newburgh Health and Rehab

Based on interview and record review, the facility failed to notify the provider of weight changes outside of order parameters for 1 of 2 residents reviewed for weight change. (Resident 5) Finding includes:On 4/14/26 at 9:58 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and chronic kidney disease.The most current Discharge Minimum Data Set (MDS) Assessment, dated 3/10/26, indicated Resident 5's cognitive function was assessed by staff and the resident's memory was OK and he was independent in making decisions about his daily life. He required supervision of staff for transferring and partial to moderate assistance (staff does less than half the work) for toileting. He weighed 226 pounds (lbs) and had no weight loss.A nutritional risk care plan, initiated 12/18/25, included an intervention to monitor weights as ordered.A fluid overload care plan, initiated 12/14/25, included an intervention to weigh as scheduled.Physician orders included but were not limited to:Fax weekly weights to Nursing Home Triage (NHT)…

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 ordered an as needed (PRN) anti-anxiety medication had a specific duration, or stop date, for the medication prescribed for 2 of 2 residents reviewed for hospice and 1 of 2 residents reviewed for choices. (Resident 4, Resident 48, and Resident 7) Findings include: 1. On 4/15/26 at 9:13 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 3/24/26, indicated Resident 4 was rarely understood and was dependent on staff for eating, bathing, toileting, and transfers (staff do all of the work). Physician orders included, but were not limited to: Lorazepam (an antianxiety medication) oral tablet 0.5 MG (milligrams) Give one tablet by mouth every 30 minutes as needed for anxiety/restlessness; Start date 3/15/26 The order lacked a stop date for PRN lorazepam. Resident 4's electronic medication administration record (eMAR) from March 2026 through April 2026 was reviewed. As needed…

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

Based on interview and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS) Assessments were completed timely for 1 of 3 closed records reviewed and 1 of 3 residents reviewed for wounds. (Resident C and Resident 49) Findings include:1. On 4/14/26 at 1:20 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, cerebrovascular disease. Resident C was discharged from the facility to the hospital on 3/27/26 and did not return to the facility. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident C was not assessed for cognitive impairment and required substantial to maximal assistance (staff does more than half the work) for toileting. A Discharge MDS Assessment was not completed. During an interview on 4/16/26 at 2:20 P.M., the MDS Coordinator indicated that the previous MDS Coordinator did not complete Resident C's Discharge MDS Assessment. 2. On 4/14/26 at 1:58 P.M. Resident 49's clinical record was reviewed. Diagnosis included, but was not limited to, osteoarthritis. The most…

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 Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 1 residents reviewed for Resident Assessment. (Resident 6)Finding includes: On 4/6 at 11:26 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, disorder of the kidney and ureter and essential primary hypertensionThe most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] but was not completed until 4/10/26. During an interview on 4/17/26 at 10:35 A.M., the Social Services Director indicated care plan conferences needed to be done every 3 months.On 4/17/26 at 10:40 A.M., the Administrator provided a current policy Care Planning dated 2/2026. The policy indicated . The facility will discuss the care plan with the resident and/or representative at regularly scheduled care plan conferences, initially, at routine intervals, and after significant changes .410 Indiana Administrative Code 16.2-3.1-31(d)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to implement care plan interventions for 1 of 4 residents reviewed for accidents and 1 of 1 resident reviewed for restraints, and develop a care plan for 1 of 5 residents reviewed for unnecessary medications. Interventions for call lights to be within reach were not implemented and there was no care plan developed for antianxiety and antidepressant medications use. (Resident 3, Resident 2, and Resident 38)Findings include:1. During an observation on 4/13/26 at 11:22 A.M., CNA 2 and QMA 4 were observed using a sit to stand lift to transfers Resident 3 from the bathroom to the wheelchair. Resident 3's call light was under the bed and out of reach. During an observation on 4/15/26 10:20 A.M., Resident 3 was observed in bed and the call light was on the floor under the foot of the bed. During an observation on 4/16/26 at 8:52 A.M., Resident 3 was laying in bed; two wheelchairs were in the resident's within line of sight and the call light 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 interview and record review, the facility failed to ensure residents dependent on staff for ADLs (activities of daily living) were showered for 1 of 3 residents reviewed for ADL care. (Resident C) Finding includes:During an anonymous interview on 4/14/26 at 1:20 P.M., it was indicated that Resident C was transported to the hospital from the facility on 3/27/26. Upon arrival in the emergency room, Resident C appeared generally unkempt.On 4/14/26 at 1:25 P.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, cerebrovascular disease.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/4/26, indicated Resident C was not assessed for cognitive impairment and required partial to moderate assistance of staff (staff does less than half the work) for bathing.A current assistance with self-care and mobility tasks care plan, dated 12/15/25, indicated Resident C required substantial to maximal assistance (staff does more than half the work) for bathing.On 4/16/26 at 12:30 P.M., Licensed Practical Nurse (LPN) 6 provided shower…

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 with signs and symptoms of fluid overload were monitored according to physician order for 1 of 2 residents reviewed for significant weight change. (Resident 5) Finding includes:On 4/14/26 at 9:58 A.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure and chronic kidney disease.The most current Discharge Minimum Data Set (MDS) Assessment, dated 3/10/26, indicated Resident 5's cognitive function was assessed by staff and the resident's memory was OK and he was independent in making decisions about his daily life. He required supervision of staff for transferring and partial to moderate assistance (staff does less than half the work) for toileting. He weighed 226 pounds (lbs) and had no weight loss.A nutritional risk care plan, initiated 12/18/25, included an intervention to monitor weights as ordered.A fluid overload care plan, initiated 12/14/25, included an intervention to weigh as scheduled. (Signs and symptoms of fluid overload include…

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 pharmacist medication recommendations were reviewed and acted upon by the physician for 1 of 5 residents reviewed for unnecessary medications. (Resident 8) Finding includes: On 4/14/26 at 9:19 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Diagnosis included, but was not limited to, pulmonary embolism.The most recent Significant Change MDS, dated [DATE], indicated Resident 8's cognition was not assessed, the resident required partial assistance for toileting, substantial assistance from staff for bathing, and received anticoagulant medication during the lookback period. Physician orders included, but were not limited to:Eliquis (an anticoagulant medication) oral tablet 2.5 MG (milligrams) Give one tablet by mouth in the morning related to pulmonary embolism; Start date 3/13/26On 4/15/26 at 12:13 P.M., the Administrator provided a pharmacy document titled New admission Review, dated 3/13/26. The document…

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 enhanced barrier precautions were implemented during 1 of 2 random observation of care and infection control practices were not implemented during 1 of 2 insulin administrations. Findings include: 1. During an observation on 4/13/26 at 11:22 A.M., CNA 2 and QMA 4 entered Resident 3's bathroom. Resident 3 was cleaned up and assisted off of the toilet and on to the sit to stand lift. Resident 3 was moved from the bathroom to the wheelchair in the bedroom. Resident 3 was not offered to wash his hands; CNA 2 and QMA 4 wore gloves but did not wear gowns during the care and transfer of Resident 4. On 4/14/26 at 10:40 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behavioral disturbances, anxiety, and post traumatic stress disorder. The most recent Discharge MDS, dated [DATE], indicated Resident 3's cognition was not assessed, the resident required partial assistance for…

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 were given at the ordered time for 2 of 3 residents during morning medication pass, and signed as given on the Electronic Medication Administration Record (EMAR) for 1 of 3 residents reviewed for pharmaceutical services. (Resident B, Resident C, Resident D) Finding includes: 1. On 2/9/26 at 10:58 a.m, QMA 2 (Qualified Medication Aide) was observed preparing medications for Resident D. The following medications were observed to be taken out of the packaging and put into a medication cup: aspirin (nonsteroidal anti-inflammatory) 81 mg (milligram) ferrous sulfate ((mineral supplement) 325 mg QMA 2 was observed to look for Resident D's Lasix (diuretic) 40 mg in the medication cart. LPN 3 came to the cart, and QMA 2 left to go look for more of the medication. At 11:04 a.m., LPN 3 (Licensed Practical Nurse) indicated she had already given Resident D her morning medications, and she would let QMA 2 know when she got back to the cart. LPN 3 indicated she had been passing morning medications and had…

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 Dietary Manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. (Dietary Manager) Finding includes: During an interview on 2/10/25 at 11:39 A.M., the Dietary Manager indicated he did not have a dietary manager certification and was not currently enrolled in a program. On 2/11/25 at 10:15 A.M., the Dietary Manager's employee file was reviewed. The Dietary Manager started employment as a dietary cook on 8/5/23, and signed a job description on the start of the role as Dietary Manager on 10/3/24. During an interview on 2/12/25 at 9:27 A.M., the Administrator indicated the dietician worked through a contract and was only in the facility approximately once a week. On 2/13/25 at 9:54 A.M., the Administrator provided a policy titled Dietary Manager Job Description, dated 1/17, that indicated Completion of approved dietary manager training course is preferred. Employee is required to enroll and successfully complete the course after hire if certification has not been completed at the time…

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 comprehensively complete and implement a facility assessment to accurately determine the care and resources needed for resident care. This had the potential to affect 59 residents in the facility. Finding includes: On 2/9/25 at 10:03 A.M. during the Entrance Conference with the Administrator, the facility assessment was requested. Census at that time was 59 residents. On 2/11/25 at 3:00 P.M., the Administrator provided a facility assessment and indicated it had been completed by the Administrator and Director of Nursing (DON) that day (2/11/25). She indicated a facility assessment had not been completed or updated for the facility since 2022. At that time, she indicated it should be updated annually. On 2/13/25 at 10:44 A.M., the Minimum Data Set (MDS) Coordinator provided a Facility Assessment Tool policy, dated 8/18/17, that indicated To ensure the required thoroughness, individuals involved in the facility assessment should, at a minimum, include the administrator, a representative of the governing body, the 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 interview and record review, the facility failed to ensure Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) meetings were held quarterly and the required staff were present. This had the potential to affect 59 residents in the facility. Finding includes: During an interview on 2/9/25 at 10:03 A.M., the Administrator indicated census in the facility was 59 residents. On 2/13/25 at 8:30 A.M., the QAA and QAPI Minutes sign in sheet for a meeting held on 1/15/25 was reviewed. The sign in sheet lacked documentation that the Medical Director (MD) or a designee was present for the meeting. During an interview on 2/13/25 at 9:13 A.M., the Administrator indicated that the QAPI meeting on 1/15/25 was the first QAPI meeting held since she began employment at the facility on 4/17/24. She indicated QAPI was supposed to meet quarterly. During an interview on 2/13/25 at 10:09 A.M., the Director of Nursing (DON) indicated the QAPI committee had not been meeting as consistently as it should. On 2/10/25 at 10:30 A.M., the Administrator 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 observation, interview, and record review, the facility failed to ensure hand hygiene and Enhanced Barrier Precautions (EBP) were implemented for 2 of 2 residents observed for care (Resident 41 and Resident 10) and opportunities for waterborne illness were tested for 59 of 59 residents who consume water in the facility. Findings include: 1. During an observation on 2/11/25 at 9:51 A.M., Qualified Medication Aide (QMA) 7 entered Resident 41's room. QMA 7 put on gloves and began administering medications through Resident 41's percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted through the abdominal wall into the stomach). Resident 41's PEG tube began leaking the medication and stomach contents back out of the tube. QMA 7 exited the room and came back into the room with two nurses who assisted QMA 7 in changing the adapter valve on the PEG tube. QMA 7 began administering medications again. Hand hygiene was not performed during care of Resident 41, and a gown was not worn by QMA 7 or either of the nurses providing direct patient care to Resident 41. On 2/11/25 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 interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP had not received specialized training in infection prevention and control when starting the IP role and did not dedicate at least part time hours to the role of IP for 1 of 1 staff members reviewed for IP. Finding includes: During an interview on 2/12/25 at 10:17 A.M., the Assistant Director of Nursing (ADON) indicated that she was responsible for the Infection Prevention and Control Program in the facility but did not have a current Infection Preventionist certification. She indicated she was able to dedicate approximately 12 hours per week to the infection control program. On 2/12/25 at 1:12 P.M., the ADON's employee file was reviewed. The employee file lacked any job description or roles in the facility related to infection preventionist. On 2/9/25 at 12:30 P.M., the Administrator provided a policy titled Infection Prevention and Control Program, revised 10/2018, that indicated The infection prevention and control program is coordinated and overseen…

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 3. On 2/10/25 at 11:54 A.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with anxiety and major depression. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 36 was moderately cognitively impaired, required substantial to maximal assistance of staff (staff does more than half) with showering, dressing, and transferring, and had one fall since the prior assessment. Current physician orders included, but were not limited to: Encourage resident to wear proper footwear when out of bed every shift for fall prevention, dated 4/17/23. The most current fall risk assessment, dated 2/12/25, indicated that the resident was at high risk for falls. An Interdisciplinary Team (IDT) Care Plan Health Meeting note, dated 1/14/25 at 2:00 P.M., indicated that the care plan was reviewed and the facility would continue the current plan of care. The most current Fall Risk care plan, dated 4/18/23, included the following interventions:…

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

Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 2 of 2 residents reviewed for Activities of Daily Living (ADL) assistance. (Resident 6 and Resident 13) Findings include: 1. On 2/11/25 at 9:22 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and type 4 fracture of sacrum. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 11/15/24, indicated Resident 6 had mild cognitive impairment and required substantial to maximal assistance of staff (staff does more than half) for eating, toileting, and bathing. The most current care plan conference was completed on 7/10/24 at 1:00 P.M. On 2/12/25 at 10:49 A.M., the Social Services Director (SSD) provided a document entitled Care Plan Meetings that indicated a letter had been sent on 9/10/24 to invite Resident 6's family to a care plan conference. The clinical record lacked documentation to indicate a care plan conference had been completed at that time or at any time since 7/10/24. 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, observation, and interview, the facility failed to ensure care plans were being developed and implemented after new diagnoses and physician orders for 1 of 2 residents reviewed for nutrition and 1 of 1 resident reviewed for urinary tract infections. (Resident 43 and Resident 46) Findings include: 1. On 2/11/25 at 9:56 A.M., Resident 43's clinical record was reviewed. The resident had diagnoses that included, but were not limited to, pneumonia and congestive heart failure. An admission Minimum Data Set (MDS) Assessment, dated 1/16/25, indicated Resident 43's cognition was significantly impaired, required partial to moderate assistance of staff (staff does less than half) with eating, and substantial to maximum assistance of staff (staff does more than half) with bathing, toileting and bed mobility, and no weight loss during the last month. Current physician orders included, but were not limited to: mirtazapine tablet 7.5 mg (milligrams) - one tablet by mouth at bedtime for appetite, ordered 1/27/25. Nursing Measure: Fax Daily Weights every day shift every…

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 revise the care plan to reflect changes to a resident's gastrostomy device for 1 of 1 reviewed. (Resident 41) Finding includes: On 2/11/25 at 12:27 P.M., Resident 41's clinical record was reviewed. The resident had diagnoses that included, but were not limited to, cerebral palsy. A Quarterly Minimum Data Set (MDS) Assessment, dated 12/10/24, indicated the resident was not cognitively intact, was dependent on staff (staff does everything) for bed mobility, and had an enteral feeding tube. Current physician orders included, but were not limited to: Percutaneous endoscopic gastrostomy (PEG) tube 18F (French), 7-10 cc (cubic centimeters) in place, dated 4/30/23. The clinical record lacked an order for a Mic-Key gastro tube button. On 12/10/24, an Interdisciplinary Team care plan conference meeting was held for Resident 41 and the assessment indicated to continue current plan of care. Care plans for Resident 41 included, but were not limited to: The resident requires tube feeding related to: dysphagia, dated…

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

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was properly labeled and respiratory services were provided according to professional standards for 3 of 4 residents reviewed for respiratory care. (Resident 25, Resident 16, Resident 13) Findings include: 1. On 2/9/25 at 9:30 A.M., Resident 25 was observed lying in bed with Oxygen (O2) at 3 Liters Per Minute) L/m per nasal cannula and the oxygen tubing was not dated. On 2/10/25 at 8:48 A.M., Resident 25 was observed lying in bed with O2 at 3L/m per nasal cannula and the oxygen tubing was not dated. On 2/11/25 at 8:34 A.M., Resident 25 was observed lying in bed with O2 at 3L/m per nasal cannula and the oxygen tubing was not dated. On 2/12/25 at 10:20 A.M., Resident 25 was observed lying in bed with O2 at 3L/m nasal cannula and the oxygen tubing was not dated. On 02/10/25 at 11:27 A.M., Resident 25's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Diseased (COPD). The most current Annual Minimum Data Set (MDS) Assessment, dated…

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

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 4 residents (Residents 54 and Resident 36) observed during medication pass. Two medication errors were observed during #25 opportunities for error in medication administration. This resulted in a medication error rate of eight (8) percent. Findings include: 1. During a medication administration observation on 2/11/25 at 11:59 A.M., Registered Nurse (RN) 5 prepared an insulin injection for Resident 36. RN 5 attempted to prime the insulin pen without the needle attached. RN 5 then administered 14 units of insulin lispro (an antidiabetic injection medication) into Resident 36's upper right arm. On 2/11/25 at 12:30 P.M., Resident 36's clinical record was reviewed. Physician orders included, but were not limited to: Admelog (insulin lispro) - Inject 14 units subcutaneously in the afternoon, dated 11/26/24 2. During a medication administration observation on 2/12/25 at 1:02 P.M., Licensed Practical Nurse (LPN) 6 prepared an insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment during 3 random observations. The hallway floors were sticky and soiled. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Main Dining Hall) Findings include: 1. During an initial walkthrough of the facility on 12/18/24 at 10:55 A.M., the hallway floor outside room [ROOM NUMBER] was noted to have a large red sticky substance with smaller drip marks next to it. The hallway floor in between rooms [ROOM NUMBERS] was noted to have a large black substance. During a reinspection of the hallway floors on 12/18/24 at 2:11 P.M., the hallway floor outside room [ROOM NUMBER] was noted to have a large red sticky substance with smaller drip marks next to it. The hallway floor in between rooms [ROOM NUMBERS] was noted to have a large black substance. 2. On 12/19/24 at 8:26 A.M., the hallway floor outside room [ROOM NUMBER] was noted to have a large red sticky substance with smaller…

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 dignity was respected for 1 of 1 residents reviewed for dignity and 3 of 3 random observations. (Resident 53, Resident 20, Resident 31, Resident F) Findings include: 1. On 12/13/23 at 8:06 A.M., CNA (Certified Nurse Aide) 21 was observed in Resident 20's room assisting the resident to eat breakfast. CNA 21 was standing in front of the resident who was sitting in her wheelchair and was using her cell phone. On 12/13/23 at 10:58 A.M., Resident 20's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's Disease and COVID-19. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 9/21/23, indicated the resident's mental status could not be assessed because the resident was rarely or never understood, and required total assistance of 1 (one) staff for eating. A current late loss ADL (Activities of Daily Living) care plan, revised 4/26/23, included an intervention of see Nurse Aide assignement [sic] sheet for details on staff assist needed. The most recent CNA…

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 proper storage of medications in 2 of 2 medication carts and 2 of 2 medication rooms reviewed. Loose pills were observed in medication carts with improperly labeled medications, and the medication refrigerator lacked temperature readings. (West Hall Medication Cart, [NAME] Hall Medication Room, East Hall Medication Room) Findings include: On 12/13/23 at 9:17 A.M., the following was observed in one of the two [NAME] Hall Medication carts: 1 round white pill with 210 1 blue caplet oblong with number 675 1/2 oblong white pill 1 small round with TP 1 bottle of Valporic Acid opened and not dated bottom drawer was sticky On 12/13/23 at 9:30 A.M., the following was observed in the other [NAME] Hall Medication Cart: 1 yellow piece 1 round multicolored brown pill 1 small yellow round pill with heart on it 1 round peach colored pill with letter M 1/2 white pill 1 white pill with the letters CL On 12/14/23 at 10:30 A.M., the following was observed in the East Hall Medication refrigerator: beer - no name boost -…

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 reviews, the facility failed to properly prevent and/or contain COVID-19 for 7 of 11 residents reviewed for infection control. (Resident 20, Resident 53, Resident 41, Resident 27, Resident 38, Resident 314, Resident 315) Findings include: 1. On 12/13/23 at 8:06 A.M., CNA (Certified Nurse Aide) 21 was observed in Resident 20's room assisting her to eat. CNA 21 was not wearing any PPE and her surgical mask was pulled down around her chin. At that time, the sign outside the resident's room indicated that the resident was on contact precautions for COVID-19. On 12/13/23 at 8:14 A.M., QMA (Qualified Medication Aide) 17 indicated staff should have on gown, gloves, a face shield, and an N95 mask while in COVID-19 rooms. She further indicated CNA 21 needed to have on PPE while in Resident 20's room. At that time, CNA 21 indicated she hung her gown on the back of the door in resident 20's room to reuse later. On 12/13/23 at 10:58 A.M., Resident 20's clinical record was reviewed. Diagnosis included, but was not limited to, COVID-19. The most recent…

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 promote and facilitate resident self-determination related to bathing for 1 of 3 residents reviewed for Activities of Daily Living (ADLs). A resident's preference for showers and to have hair washed three times a week was not honored. (Resident F) Findings include: On 12/11/23 at 10:09 A.M., Resident F indicated she had requested her hair to be washed three times a week (twice by staff and once by the beauty shop), and it was not being done. She indicated she had currently gone two weeks without her hair being washed. Resident F indicated she would rather take showers, but staff was currently only providing bed baths. Resident F indicated staff did not wash her hair with every bed bath. On 12/12/23 at 12:39 P.M., Resident F's clinical record was reviewed. Diagnosis included, but were not limited to, morbid obesity, anxiety, and depression. The most recent state optional and quarterly MDS (minimum data set) Assessment, dated 11/6/23, indicated no cognitive impairment, no rejection or refusals of care, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure notification of change for 1 of 1 resident reviewed for elevated blood pressure. The physician was not notified timely of a resident's decline in condition. (Resident 31) Finding includes: On 12/13/23 at 11:27 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage and hypertension. The most recent admission MDS (Minimum Data Set) Assessment, dated 9/12/23, indicated the resident had severe cognitive impairment with no behaviors. The clinical record indicated Resident 31 had a history of stroke. Resident 31 was admitted to the facility on [DATE] following a hemorrhagic stroke with right hemiparesis. The Resident was sent to the hospital on 9/23/23 for a CVA (cerebrovascular accident). Current physician orders included, but was not limited to: Clonidine HCl (an antihypertensive medication) oral tablet 0.1 MG (milligram) - Give 1 tablet by mouth every 4 hours as needed…

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

Based on observation, interview, and record review, the facility failed to ensure PRN (as needed) antianxiety medications were evaluated every 14 days for 2 of 2 residents reviewed for ADL (Activities of Daily Living) and 1 of 1 resident reviewed for dialysis (Resident 265, Resident 48, Resident F). Findings include: 1. On 12/14/23 at 9:18 A.M., Resident 265's clinical record was reviewed. Resident 265's diagnosis included, but was not limited to, anxiety disorder. The most recent admission MDS (Minimum Data Set) Assessment, dated 11/4/23, indicated Resident 265 was cognitively intact and received an antianxiety medication during the 7 day look back period. Current physician orders included, but was not limited to: Lorazepam (an antianxiety medication) Oral Tablet 0.5 MG (milligrams) - Give 1 tablet by mouth as needed for anxiety three times a day as needed, dated 11/27/2023 The November 2023 MAR (medication administration record) indicated Resident 265 received lorazepam on 11/28, 11/29, and twice on 11/30. The December 2023 MAR indicated Resident 265 received lorazepam on 12/2,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate supervision was in place to prevent a resident with dementia from exiting the facility and returning home for 1 of 1 residents reviewed for elopement. (Resident C) Finding includes: During an observation on 8/21/23 at 8:40 A.M., the facility's front door was unlocked, and no staff were present at the front desk. During a review of facility reported incidents on 8/21/23 at 9:30 A.M., an incident reported by the DON on 8/4/23 included that Resident C was noted to not be in his room. Staff conducted a search on the unit, an elopement code was initiated for the building, and staff searched the facility grounds and neighboring area. Resident C's wife notified the facility around 12:00 P.M. that Resident C was attempting to walk home and requested a ride from someone. Resident C was discovered after his wife arrived home from an appointment. During record review on 8/21/23 at 9:45 A.M., Resident C's diagnoses included, but 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.