Plainfield Health Care Center

Based on record review and interview the facility failed to ensure pharmacy recommendations were appropriately reviewed and addressed timely by a medical professional for 2 of 5 Residents (Resident 11 and 81) reviewed for unnecessary medications.Findings include:A pharmacy recommendation dated 10/28/25 indicated Resident 11 had an order for Aspirindaily, Carbidopa/Levodopa (a medication used to treat Parkinson's disease.) extended release three times a day and Nitrofurantoin (an oral antibiotic used primarily to treat and prevent uncomplicated bacterial urinary tract infections). The pharmacist recommended to discontinue the Aspirin due to risk of bleeding, discontinue Nitrofurantoin due to liver toxicity and lowering the frequency of Carbidopa/Levodopa from three times a day to two times a day. The Nurse Practitioner (NP) indicated they would discontinue Aspirin, keep Carbidopa/Levodopa according to neurology orders and keep Nitrofurantoin with no rational for keeping that medication. The recommendation was signed 10/30/25.A pharmacy recommendation dated 11/16/25 indicated 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 documentation of assessment and treatment progress of pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged pressure, shear, or friction) were completed for 1 of 3 residents reviewed for wounds (Resident C). Findings include:Resident C's record was reviewed on 3/10/26 at 2:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dislocation of internal left hip prosthesis (the artificial ball has popped out of the artificial socket), age-related osteoporosis (a common condition, particularly in adults over 50, where bones naturally lose density, becoming porous, brittle, and weak), and unspecified protein-calorie malnutrition (a medical condition where the body does not get enough protein and energy [calories] to function properly, resulting in muscle wasting, weight loss, and weakened immunity). An admission skins assessment, dated 1/23/26, indicated the resident had re-admitted to the facility from the hospital…

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 notify the physician or family following identifying an injury of unknown origin for 1 of 4 residents reviewed for accidents (Resident M).Findings include:During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m., she visited her husband on the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. She had not received a call from the facility regarding his injury. It worried her that the staff was so dismissive about his injury. She had made arrangements for him to be discharged on 1/16/26 to another facility due to her fear for his safety and the lack of concern from the staff. There was another resident that resided at the facility who had been a boxer prior to being admitted to the memory care unit and was known to be violent. That resident made her feel unsafe when she visited. The staff also indicated they had not planned for any type…

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 staff failed to implement policies and procedures to immediately report an injury of unknown origin to the Administrator or Director of Nursing for 1 of 11 residents reviewed for abuse and neglect (Residents M). Findings include:During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m. she visited her husband on the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. The staff also indicated they had not planned for any type of Xray or test to fully assess his injury. It worried her that the staff was so dismissive about his injury. She had made arrangements for him to be discharged on 1/16/26 to another facility due to her fear for his safety and the lack of concern from the staff. On 1/15/26 at 3:10 p.m., Resident M was observed seated in the common area at a table with another male resident talking. His left eye was observed to be swollen and…

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

Based on observation, interview, and record review, the facility failed to investigate an injury of unknown origin following observation of a resident with swelling and discoloration of his left eye for 1 of 11 residents reviewed for abuse and neglect (Resident M).Findings include:During an interview on 1/15/26 at 2:53 p.m., Resident M's wife indicated on 1/10/26 at around 12:00 p.m., she visited her husband on the memory care unit. She found that he had a swollen, darkly bruised left eye. When she asked staff what had happened, they indicated to her they had no idea why he had a black eye. The staff also indicated they had not planned for any type of Xray or test to fully assess his injury. It worried her that the staff was so dismissive about his injury. She had made arrangements for him to be discharged on 1/16/26 to another facility due to her fear for his safety and the lack of concern from the staff. On 1/15/26 at 3:10 p.m., Resident M was observed seated in the common area at a table with another male resident talking. His left eye was observed to be swollen and discolored…

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

A. Based on record review and interview, the facility failed to follow physician ordered parameters regarding medication administration of blood pressure medication for 2 of 11 residents reviewed for abuse and neglect (Residents E and L). B. Based on observation, interview, and record review, the facility failed to perform assessments following observation of a resident with swelling and discoloration of his left eye for 1 of 11 residents reviewed for abuse and neglect (Resident M). Findings include:A. 1. The clinical record for Resident E was completed on 1/15/26 at 11:12 a.m. Diagnoses included type two diabetes mellitus, stage three chronic kidney disease, heart failure, edema, and presence of a cardiac pacemaker. A current physician's order, dated 3/18/25, indicated to check heart rate daily and monitor for signs and symptoms of altered cardiac output or pacemaker malfunction. The resident's clinical record lacked a recorded heart rate for the reviewed months of November 2025, December 2025, and January 2026. During an interview on 1/15/26 at 12:42, the Regional Reimbursement…

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 an Interdisciplinary Team (IDT) post fall assessment and implement post fall interventions for 3 of 3 residents reviewed for accidents. (Resident B, E, and F) Findings include:1. The clinical record for Resident B was reviewed on 11/6/25 at 10:21 a.m. Diagnoses included history of stroke affecting left side, epilepsy, and dementia with behavioral disturbance.A health care plan, dated 6/22/25, indicated the resident was a high risk for falls related to confusion, incontinence and poor comprehension/communication.Resident B's progress notes lacked documentation of an IDT review of falls on 8/13/25, 8/17/25, 8/21/25, 8/22/25, and 8/23/25. The resident's care plan lacked an added intervention for the fall on 8/23/25.2. The clinical record for Resident E was reviewed on 11/6/25 at 12:05 p.m. Diagnoses included senile degeneration of the brain, convulsions, dementia, and difficulty walking.A health care plan, revised on 9/5/25, indicated the resident was a high risk for falls related to gait/balance problems,…

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 physician ordered weekly skin assessments or document the resident's refusal for 2 of 4 residents reviewed for quality of care. (Resident B and E)Findings include:1. A clinical record review for Resident B was completed on 10/14/25 at 12:02 p.m. Diagnoses included rhabdomyolysis (a condition characterized by the breakdown of skeletal muscle tissue, leading to release of harmful substances into the bloodstream), type II diabetes mellitus, history of coccyx fracture, and morbid (severe) obesity.A current physician's order, dated 12/26/24, indicated to complete a weekly skin assessment every evening shift on Mondays for weekly skin assessments.The resident's clinical record lacked an ordered skin assessment for 6/2/25, 6/23/25, 6/30/25, 7/7/25, 7/28/25, 8/4/25, 8/11/25, 9/1/25, 9/15/25, 9/22/25, and 9/29/25.A health care plan, dated 5/9/24, indicated the Resident B would refuse care. Interventions included, to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons…

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 contact the physician for blood sugar values outside the ordered parameters for 1 of 4 residents reviewed for quality of care (Resident B). Findings include:The clinical record for Resident B was completed on 9/10/25 at 11:19 a.m. Diagnoses included diabetes mellitus type II, dementia, exocrine pancreatic insufficiency, and need for assistance with personal care. A health care plan, revised on 4/5/25, indicated the resident had diabetes mellitus related to pancreatogenesis diabetes and received insulin. Interventions included: administer diabetes medication as ordered by physician. A physician's order, dated 6/3/25, indicated to administer Admelog SoloStar (insulin to treat diabetes mellitus), inject six units before meals. Hold for blood sugar less than 110 and call for blood sugar less than 70 or greater than 400. A health care plan, revised on 4/5/25, indicated the resident had diabetes mellitus related to pancreatogenesis diabetes and received insulin. Interventions included: administer diabetes medication as ordered…

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

Based on interview and record review, the facility failed to complete ordered skin assessments for 1 of 4 residents reviewed for quality of care (Resident D). Findings include:The clinical record for Resident D was completed 9/10/25 at 12:12 p.m. Diagnoses included Alzheimer's disease, diabetes mellitus type II, and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment, dated 8/13/25, indicated the resident had severe cognitive impairment, used a wheelchair for mobility, and was dependent on staff for all activities of daily living. A physician's order, dated 11/14/24, indicated to complete weekly skin assessments every Friday. A review of Resident D's Assessment record on 9/15/25 indicated the most recent skin assessment was 8/22/25. The record lacked assessment on 8/29/25, 9/5/25, and 9/12/25. During an interview on 9/15/25 at 3:00 p.m., the Corporate Nurse Consultant indicated all ordered skin assessments were to be completed and documented on the day the assessment was due, weekly. The missing assessments should have been completed and documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a sufficient amount of staff to provide nursing activities of daily living (ADL) care and laundry services so that residents received ADL care and did not have to wait a long time for assistance. This deficient practice had the potential to effect 114 of 114 residents who received nursing care. Findings include: During an interview on 4/1/25 at 11:43 a.m., Resident 12 indicated, there were not enough aides and he often had to wait a long time for assistance especially on the weekends. Sometimes, staff would tell him to do what he could on his own until they could come and help him, but that made him frustrated because he wouldn't be in the facility if he didn't need help. When he had to wait too long, it would often cause him to have accidents. On 4/1/25 at 1:30 p.m., the call light for room [ROOM NUMBER] was observed to be illuminated. At 1:32 p.m., Licensed Practical Nurse (LPN) 13 opened the door and asked the resident from 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, interview, and record review, the facility failed to ensure residents' grievances had follow ups that provided adequate/effective interventions to address and prevent reoccurring concerns related to staff interactions towards a dependent resident (Resident 9) and nursing staff call light response. This deficient practice had the potential to effect 4 of 4 residents from Resident Council who communicated facility concerns on behalf of all residents who resided in the facility (Residents 9, 21, 35, 26 and 70). Findings include: On 4/4/25 at 11:30 a.m., a Resident Council meeting was held with 4 residents present, Residents 21, 35, 26 and 70) The residents indicated there were not enough aides to help get to all the residents without having to wait a long time. All 4 residents agreed that the facility needed more nursing staff and laundry staff. The residents indicated, night shift was the worst because they could never find any staff to help, or if they put the light on they would have 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to date insulin pens, and an insulin bottle was expired for 1 of 3 medication carts reviewed and 1 of 2 medication rooms reviewed. Findings include: 1. Resident 41 had a pen of insulin lispro not dated for 3 of 3 pens in the 500-hall medication cart. 2. Resident 96 had a pen of admelog insulin not dated and a insulin pen of lispro not dated in the 500-hall medication cart. 3. Resident 27 ad a vial of insulin lispro 100u/ml dated [DATE] in the Caring Heart medication room. The vial was expired. On [DATE] at 1:45 p.m., RN 5 indicated there were too many nurses working on 500 hall to keep up. A policy titled, Medication Storage in the Facility revised 2024 was provided by the Minimum Data Set (MDS) Consultant. It indicated, .Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, 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 interview and record review, the facility failed to notify the ombudsman of a transfer/discharge to the hospital for 1 of 2 residents reviewed for transfer/discharge notification (Resident 27). Findings include: On 4/4/25 at 9:27 a.m. Resident 27's medical record was reviewed. He was a long-term care resident who resided in the memory care unit. His diagnoses included, but were not limited to, acute kidney failure and obstructive uropathy (a blockage in the urinary tract). A progress note, dated 1/15/2025, indicated Resident 27 had complained of chest pain and was sent to the hospital. During an interview on 4/4/25 at 1:45 p.m. the Regional Director of Clinical Services (RDCS) indicated Resident 27 did not have an appointed guardian at the time and they had just gotten a new social worker who was unfamiliar with the long-term care practice of notifying the ombudsman of discharges, so they did not notify them of the transfer/discharge to the hospital. On 4/4/25 at 1:50 p.m. the RDCS provided a copy of a current facility policy titled, Transfer and Discharge dated 6/2020. 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 notify the resident or resident representative of the bed hold policy for 1 of 2 residents (Resident 27) reviewed for bed hold policy notification. Findings include: On 4/4/25 at 9:27 a.m. Resident 27's medical record was reviewed. He was a long-term care resident who resided in the memory care unit. His diagnoses included but were not limited to, acute kidney failure and obstructive uropathy (a blockage in the urinary tract). A progress note, dated 1/15/2025, indicated Resident 27 had complained of chest pain and was sent to the hospital. During an interview, on 4/4/25 at 1:45 p.m., the Regional Director of Clinical Services (RDCS) indicated Resident 27 did not have an appointed guardian at the time and Resident 27 was not cognitively aware so they did not notify anyone of the bed hold policy. On 4/4/25 at 1:50 p.m. the RDCS provided a copy of a current facility policy titled, Transfer and Discharge dated 6/2020. The policy indicated .VII. Bed Hold A. Before the facility transfers a Resident to a hospital or allows a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded to reflect residents' conditions and/or services for 6 of 23 residents reviewed (Residents 2, 35, 36, 39, 46, and 47). Findings include: 1. On 4/2/25 at 10:26 a.m., the most recent comprehensive MDS assessments were reviewed for Residents 2, 35, 36, 39, 46, and 47. a. Resident 2 was a long-term care resident with a diagnosis which included, but was not limited to, bipolar disorder. She had a Pre-admission Screen and Record Review (PASARR), dated 1/3/23, which indicated she was considered by the state to have a major mental illness (MMI). Resident 2's most recent comprehensive MDS assessment, dated 2/10/24, did not code her PASARR Level II status. b. Resident 35 was a long-term care resident with a diagnosis which included, but was not limited to, bipolar disorder. There was no PASARR level I or II on file. Cross reference F645. Resident 35's admission MDS assessment, dated 9/11/24, did…

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 (Resident 35) who had a diagnosis of a major mental illness received and/or maintained on file a copy of her Pre-admission Screen and Resident Review (PASARR) Level I & II for 1 of 5 residents reviewed for PASARR. Findings include: On 4/3/25 at 10:29 a.m., Resident 35's medical record was reviewed. She was a long-term care resident with a diagnosis which included, but was not limited to, bipolar disorder. There was no PASARR level I or II on file. On 4/3/25 at 11:09 a.m., the regional Minimum Data Set (MDS) Consultant (MDSC) accessed Resident 35's PASARR online and indicated she had a level II completed which approved her for long-term care without specialized services indefinitely. The level of care PASARRs had been completed at her previous facility and were on file online, but it appeared that in between the facility's change in Social Service Directors, no one followed up on Resident 35's PASARR to ensure it transferred to her record on file at her current facility. This would also have triggered her…

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 update a resident's care plan when a change had been made to his medications for 1 of 4 residents reviewed for care plan revision (Resident 28). Findings include: On 4/3/24 at 10:32 a.m., a record review was completed for Resident 28. He had the following diagnoses which included, but were not limited to, Alzheimer's disease, dementia, anxiety, hypertension, and reduced mobility. Resident 28's medication regimen did not include an antidepressant. Resident 28 had a care plan that indicated he required antidepressant medication for the diagnosis of depression date 11/7/24. The goal indicated he would be free from discomfort or adverse reactions to the antidepressant medication. During an interview with the Regional Nurse Consultant (RNC) on 4/7/25 at 11:15 a.m., he indicated Resident 28 went out to the hospital and his medications were changed and his care plan did not get updated with the changes. A policy titled, Care Plans was provided by the Minimum Data Set (MDS) consultant. It indicated, .Changes may be made to 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 observations, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for 2 of 2 dependent residents reviewed for ADLs (Resident 14 and 74). Findings include: 1. During the survey, Resident 14 was observed at several intervals throughout the week. On 4/2/25 at 10:44 a.m. and 3:00 p.m., she was observed in bed, flat on her back. She wore a hospital gown, her nails were long with dark debris under them, her hair was greasy and matted at the back of her head. Resident 14 had a g-tube feeding, (a gastrostomy tube feeding, is a method of providing nutrition directly to the stomach through a tube inserted into the abdomen) and did not receive food/drink via mouth, and her lips were dry, her teeth and gums appeared tacky and her breath had a foul odor. On 4/3/25 at 10:53 a.m., 11:47 a.m. and 1:05 p.m., she remained the same as above. On 4/4/25 at 8:38 a.m., 12:01 p.m., and 2:00 p.m., she remained the same as above. On 4/7/25 at 9:33 a.m., Resident 14 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who was occasionally incontinent of bowel received appropriate treatment to restore as much normal bowel function as possible for 1 of 1 resident reviewed for bowel incontinence. Findings include: During an observation and interview on 4/2/25 at 11:21a.m., Resident 366 indicated that the antibiotics were causing him to be incontinent of bowel. He had not been incontinent of bowel prior to all the antibiotics he took, and he knew it was related to the antibiotics. The CNAs put him into a brief as a prevention, which he understood. But the CNAs would tell him just to use the brief instead of the bed pan. This caused the wound vacuum on his sacrum to get dirty and then it had to be changed which was very painful. He wanted to use the bed pan if possible. Resident 366's record was reviewed on 4/3/25 at 11:06 a.m. Resident 366 had diagnoses to include, but not limited to, complete traumatic amputation at level between…

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 that a resident was vaccinated against COVID for 1 of 5 residents reviewed for vaccinations (Resident 55). Findings include: On 4/4/25 at 12:47 p.m., a record review was completed for Resident 55. She had the following diagnoses which included but were not limited to migraines, muscle weakness, chronic pain syndrome, and acute respiratory failure. Resident 55's record lacked documentation of the COVID vaccination. On 4/7/25 at 11:15 a.m., during an interview with the Minimum Data Set (MDS) consultant, she indicated she looked in the system for the vaccination and for a vaccination declination and she could not find either one. A policy titled, Infection Prevention and Control Program COVID was provided by the Regional Nurse Consultant (RCS) on 4/4/25 at 9:17 a.m. It indicated, .The facility will follow centers for Medicare and Medicaid services (CMS) and centers for disease control and prevention (CDC) as well as state and local government guidance to mitigate the spread of COVID-19 and manage outbreaks 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of property (Resident B). The deficient practice was corrected on 12/19/24, prior to the start of the survey, and was therefore past noncompliance. Findings includes: A facility reported incident (FRI) report, dated 12/17/24 at 2:01 p.m., indicated the local police had entered the building at the request of Resident B's sister to investigate potential fraudulent charges on Resident B's account. The facility immediately opened an investigation into this concern along with a review of previous involvement in concerns with Resident B's bank account. On October 28, 2024, Resident B received her bank statement and noticed that there were charges on her account that she did not recognize. She went to the Business Office Manager (BOM) who helped her call the bank to make a report of possible fraudulent charges 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 implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 of 3 residents reviewed for misappropriation (Residents B). Findings includes: During an interview on 2/14/25 at 11:01a.m., a family member indicated she had been informed by Resident B around September or October 2024 that she had concerns about her debit card being used for purchases without her knowledge. Resident B had indicated that the SSA who had been shopping for her had quit without telling anyone, did not return the resident's debit card, and had taken all the evidence of the resident's records with her. The facility was made aware, along with the local police and the Ombudsman. Resident B had indicated when she received her October bank statement, she was missing over $4000. The resident indicated there were charges such as door dash, bath and body works, withdrawals from automated teller…

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 thoroughly investigate an allegation of the misappropriation of property for 1 of 3 residents reviewed for misappropriation of property (Resident B). Findings include: During an interview on 2/20/25 at 9:59 a.m., the ADM indicated she found out in October 2024 that Resident B had given her debit card to the SSA to use to help with shopping for the resident. The BOM had not seen Resident B's bank statements until October when the resident had asked her for help with her debit card. The SSD had contacted the SSA in October about suspicious charges, and the SSA had denied knowledge of the suspicious charges. The SSA had possession of Resident B's debit card for 38 days after she left employment with the facility. The debit card had been deactivated after being returned to the facility on [DATE], and the unusual charges that had been occurring for the past 3 months had stopped appearing on the bank statements. The ADM indicated she had not done an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from significant medication errors related to administration of transdermal patches (a medication patch applied to the skin) for 1 of 1 resident reviewed for medication errors (Resident Q). Findings include: During an interview on 1/30/25 at 11:25 a.m., Resident Q's wife indicated that on 12/25/24 when she arrived to take Resident Q home, he had two Exalon patches (a medication patch applied to the skin for treatment of dementia). Resident Q was discharged form the hospital and admitted to the facility on [DATE] for rehab. On 1/1/25, when she went to visit him, she again discovered that he had two Exalon patches on, so she called the nurse down to witness. The Administrator (ADM), Director of Nursing Services (DNS), and the nurse all told her it was not a medication error to have two Exalon patches on. On 2/17/25 at 11:00 a.m., Resident Q's record was reviewed. His diagnoses included, but were not limited to, neurocognitive…

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 an admission inventory was completed, and failed to ensure discharge medications were counted and documented for 1 of 1 resident reviewed for medication disposition (Resident Q). Findings include: During an interview on 1/30/25 at 11:25 a.m., Resident Q's wife indicated that when she took him out of the facility on 1/1/25, they had at first refused to send them home with his medications, many of which they had brought from home, but the physician eventually ordered the medications to be released. The wife indicated she felt he was not being given the correct medication. On 2/17/25 at 11:00 a.m., Resident Q's record was reviewed. His diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (a progressive brain disorder that causes a decline in thinking and reasoning), dementia (a group of conditions that cause a person to lose the ability to think, remember, and reason), disorientation (feeling confused…

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 resident's representative was notified of a left hip wound for 1 of 3 residents reviewed for wounds (Resident C). Findings include: Resident C's record was reviewed on 10/23/24 at 10:05 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 10/9/24, indicated the resident had a severe cognitive impairment and had an arterial ulcer (a sore caused by poor perfusion [delivery of nutrient-rich blood] to the lower extremities). Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, generalized anxiety disorder (persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events), and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked which can lead to reduced blood flow and potential tissue…

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

A. Based on record review and interview, the facility failed to implement care plan interventions to prevent further development of wounds for 1 of 3 residents reviewed for wounds (Resident C). Findings include: Resident C's record was reviewed on 10/23/24 at 10:05 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 10/9/24, indicated the resident had a severe cognitive impairment and had an arterial ulcer (a sore caused by poor perfusion [delivery of nutrient-rich blood] to the lower extremities). Diagnoses on the resident's profile included, but were not limited to, unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, generalized anxiety disorder (persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events), and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked which can lead to reduced blood flow 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 and interview, the facility failed to ensure a resident who fell was not moved before seeking treatment, and was subsequently diagnosed with a hip fracture for 1 of 3 residents reviewed for accidents (Resident B). Findings include: An Indiana State Department of Health Survey Report System report, dated 10/12/24 at 2:01pm, indicated Resident B was in the main dining room having lunch when he stood up and tripped on the chair leg and fell to his right. Nursing immediately assessed the resident who complained of lower extremity pain and was unable to bend his leg. Pain medication was given, and the Physician (MD) was notified and gave an order to send to the emergency room (ER) for evaluation and treatment. Resident B was diagnosed with a left femur fracture and the femur was surgically repaired. Resident B's record was reviewed on 10/23/24 at 10:04 a.m. Diagnoses on Resident B's profiled included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions, memory loss and confusion being 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 notify the responsible party of a change in condition of 1 of 1 resident reviewed for change of condition and notification (Resident B). Findings include: On 9/5/24 at 11:56 p.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. admission Diagnosis included but were not limited to, acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues), pneumonitis (Pneumonia, a bacterial infection of the lungs) due to inhalation of food and vomit. Physician Order, dated 8/15/24, indicated to administer 10 milliliters (ml) of Amoxicillin suspension (liquid) 250/5 ml via G-tube (a tube that is surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine) every 12 hours for pneumonia for 7 days. Physician order, dated 8/16/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure respiratory services order was obtained and entered into the medical record for 1 of 1 resident reviewed for respiratory services (Resident B). Findings include: On 9/5/24 at 11:56 p.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. admission Diagnosis included but were not limited to, acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues), pneumonitis (pneumonia, a bacterial infection of the lungs) due to inhalation of food and vomit. Physician order, dated 8/13/2024, indicated to administer albuterol nebulizer 0.083% 2.5 mg (milligrams) inhale orally via nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) two times a day for SOB…

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 medications were provided as ordered by the physician for 1 of 3 residents reviewed for medication administration (Resident B). Findings include: On 9/5/24 at 11:56 p.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. admission Diagnosis included but were not limited to, acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient) with hypoxia (low levels of oxygen in your body tissues), pneumonitis (pneumonia, a bacterial infection of the lungs) due to inhalation of food and vomit. Physician order, dated 8/13/24, indicated to administer albuterol nebulizer 0.083% 2.5 mg inhale orally via nebulizer (typically consist of a main nebulization unit, a reservoir for holding the liquid for nebulization, and a mouthpiece through which drug aerosol is inhaled) two times a day for SOB (shortness of breath). Physician…

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 the pest control program, throughout the building, was effective for 3 of 3 days of observation which had the potential to affect 100 of 100 residents residing in the building. Findings include: During a conversation, on 7/17/24 at 11:58 a.m., the Maintenance Supervisor (MS) indicated he had used Drop Dead insect spray on the baseboards and in the air. Also, he used chemicals used to treat the drains in the kitchen, resident restrooms, and pantries. The facility used a local pest company. He would provide the pest control company documents, his efforts to control the pests, and the Material Safety Data Sheets for the chemicals he used in this building. During a conversation, on 7/17/24 at 1:49 p.m., the Administrator (Admin) indicated the facility did have gnats. On 7/17/24 at 9:50 a.m., the first wooden door in the dining room was opened, the door was used for window food service access, and at least a dozen flying insects were observed flying together in the air (swarming). The Assistant Dietary…

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 services for effective assessment, skin care, and monitoring were provided in a timely manner to a resident that complained of not feeling well for 1 of 3 residents reviewed for quality of care. (Resident G) Findings include: On 7/18/24 at 10:25 a.m., Resident G's medical record was reviewed. She was admitted on [DATE] for Rehab with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) exacerbation, and on 2/21/24 she was moved to Long-Term Care (LTC). Resident G's nursing progress notes were reviewed and lacked documentation of any new areas to her abdomen, back, thighs and/or peri-area. The progress notes lacked documentation of any refusals to be cleaned, bathed or repositioned. The progress notes lacked documentation of any behaviors for picking at, removing, or refusing care for her ileostomy. The progress notes lacked documentation of any behaviors for making false allegations, delusion and/or incompetency in her…

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 supervision for a resident while taking a shower resulting in a fall for 1 of 3 residents reviewed for falls (Resident C). Findings include: On 7/17/24 at 10:32 a.m., a record review was completed for Resident C. He had the following diagnoses which included but were not limited to C2-C7 cervical fracture, essential hypertension, Alzheimer's disease, cardiomegaly (enlarged heart), type 2 diabetes mellitus, unspecified dementia, chronic embolism and thrombosis of unspecified deep veins of left lower extremity (blood clots in the left lower leg), muscle weakness, repeated falls, need for assistance with personal care, and adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol). Resident C admitted to the facility on [DATE]. He was prescribed a blood thinner called Eliquis 5 mg…

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 a resident's elopement incident was accurately reported after the resident exited an open window on the second floor sunroom and the resident sustained injuries for 1 of 3 incidents reviewed for accuracy (Resident B). Findings include: An Indiana State Department of Health Survey System report, dated 3/16/24 at 8:40 p.m., submitted by the facility indicated Resident B had exited the second story of the facility through a window. Resident B unlocked the safety latch of the window and utilized a gait belt tied/anchored to a sitting chair to lower herself to the ground. Resident B was observed in the parking lot by Licensed Practical Nurse (LPN) 5. LPN 5 informed onsite staff and initiated the elopement protocol; visual line of sight was never broken. The resident had refused an assessment and treatment by facility staff and was extremely combative. Resident B made multiple attempts at physical contact towards staff. The resident was transferred…

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 not left in resident's room without proper supervision and/or a medication self-administration assessment for 3 of 9 residents reviewed for accidents (Residents 76, 79 and 17). Findings include: 1. On 2/8/24 at 2:55 p.m., a Breo inhaler was observed on Resident 76's over the bed table. She indicated the nurse left it there. Resident 76's medical record was reviewed on 2/9/24 at 11:43 a.m. Her diagnoses included, but were not limited to, coronary artery disease (heart disease), heart failure, and anxiety disorder. A physician order indicated Breo Ellipta, inhale one puff by mouth once daily. On 2/12/24 at 1:34 p.m., the Director of Nursing (DON) indicated Resident 76 did not have a self-administration assessment for medications. 2. On 2/8/24 at 10:37 a.m., a tube of Calmoseptine was observed on top of Resident 79's book shelf. Resident 79's medical record was reviewed on 2/15/24 at 11:12 a.m. Her diagnoses included, but were not limited to, diabetes mellitus (blood sugar disorder) 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 2. On [DATE] at 12:02 p.m., Resident 39's record was reviewed. He was admitted on [DATE]. His diagnoses included, but were not limited to, traumatic subdural hemorrhage (bleeding in the brain), cerebral infarction (stroke), and diabetes mellitus (blood sugar disorder). His physician order, dated [DATE], indicated his code status was a full code. His care plans were reviewed. He did not have a care plan for his code status. On [DATE] at 1:35 p.m., the Director of Nursing (DON) provided Resident 39's POST (Physician Orders for Scope of Treatment) form. It indicated he wanted to be a full code. A care plan was added on [DATE], it indicating Resident 39 had a full code status. Interventions included start CPR (cardio-pulmonary resuscitation) and call 911 (emergency services) and review quarterly and as needed for any change in code status. On [DATE] at 3:01 p.m., the DON indicated Resident 39 should have had a code care plan. Based on interview and record review, the facility failed to ensure comprehensive care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure meaningful activities were provided and implemented as scheduled, failed to invite additional residents to activities, and failed to document the participation/engagement in activities of the attending residents. This deficient practice had the potential to affect 39 of 39 residents who resided on the secured memory care unit. Findings include: During an interview on 2/12/24 at 1:25 p.m., Resident 63's family member indicated, she wished there were more meaningful activities for Resident 63 to attend because she had a higher functional ability than many of the other residents. The family member indicated there only seemed to be a lot of coloring and snacks. The family member indicated she wished there could be more live music, or old-time music, volunteer pet visits, volunteer multi-generational visits, maybe even some musical circles that the residents could get into and play. The family member indicated it seemed like a lot of…

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

Based on observation, interview, and record review, the facility failed to prevent the potential for accidents by effectively monitoring and maintaining the anti-roll back brake systems on wheelchairs for residents who required them for 3 of 9 residents reviewed for accidents (Residents 63, 85 and 255). Findings include: 1. On 2/8/24 at 12:54 p.m., Resident 63 was observed as she attempted to stand up from her wheelchair as she ate lunch in the secured memory care dining room. Each time she attempted to stand, her anti-roll back brakes did not engage on her wheelchair. On 2/12/24 at 9:58 a.m., a record review was completed for Resident 63. She had the following diagnoses, which included, but were not limited to dementia, psychotic disturbance, anxiety, and history of falling. She had a comprehensive care plan which was initiated on 8/7/23, and indicated she was at risk for falls related to cognitive deficits, poor safety awareness, medications, history of falls, unsteady balance, assistance with transfers, weakness, and new environment. She had an intervention, dated 10/23/24, 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 the staff providing assistance with eating followed infection control guidelines for 2 of 2 residents observed for residents needing assistance with eating (Resident 41 and 75), and the facility failed to ensure all foods were dated in the kitchen for 1 of 2 observations of the kitchen. Findings include: 1 On 2/8/24 at 12:20 p.m., Qualified Medical Aide (QMA) 17 was observed assisting Resident 75 with eating. She used both hands to pull the front of her shirt down. QMA 17 did not hand wash or use hand sanitizer before returning to assist the resident with eating. On 2/8/24 at 12:28 p.m., QMA 17 reached into her pocket to retrieve her medication cart keys to give to the pharmacist. She did not wash her hands or use hand sanitizer before continuing to assist Resident 75 with eating. On 2/8/24 at 12:47 p.m., QMA 17 was observed to refill Resident 75's drinking cup. She touched the handle of the drink dispenser and did not hand wash or use hand sanitizer before continuing to assist Resident 75 with eating.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident (Resident 72) had the right to privacy during a wound dressing treatment for 1 of 1 resident reviewed for privacy. Findings include: On 2/8/24 at 11:46 a.m., Resident 72 indicated she had a pressure ulcer on her tailbone and the facility staff changed the dressing three times a week. On 2/13/24 at 10:03 a.m., Licensed Practical Nurse (LPN) 12 was observed completing Resident 72's dressing change with LPN 19 assisting. On 2/13/24 at 10:06 a.m., an unidentified lab phlebotomist (draws blood from residents for diagnostic testing) opened Resident 72's door without knocking. LPN 12 and LPN 19 indicated the resident was receiving care. The phlebotomist did not close the door, but continued to try and convince them she did not need blood from their resident, but her roommate. They indicated to come back in 5 minutes. She indicated she did not have 5 minutes. Resident 72's privacy curtain was not used to provide privacy during…

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 Foley (urinary containment device) catheters were not on the floor and a Foley bag had a dignity cover for 2 of 3 residents observed for urinary collection devices (Resident 72 and 79). Findings including: 1 On 2/9/24 at 2:26 p.m., Resident 94's foley bag was observed from the open door of his room, the bag was on the floor and there was not a dignity bag to preserved his dignity. His diagnoses included, but were not limited to, urinary tract infection, chronic kidney disease, and acute (sudden onset) kidney failure. A care plan, dated 11/28/23, indicated Resident 94 was at risk for urinary tract infections (UTI) related to his history of UTIs. The care plan goal was for the resident would have no active UTIs. 2. On 2/8/24 at 11:46 a.m., Resident 72's small catheter bag was hanging on the side of her bed visible to the hallway passersby, there was no dignity bag on it. Her diagnoses included, but were not limited to, kidney insufficiency and diabetes mellitus (blood sugar disorder). Her care plan, 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 enteral nutrition formula was correctly labeled for 1 of 1 resident reviewed for tube feeding management according to policy (Resident 25). Findings included: On 2/9/24 at 2:23 p.m., observed the enteral feeding for Resident 25, the pump was running, and the 1000 milliliter (ml) bottle of Jevity 1.5 formula (fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) was initialed and labeled with the date 2/8/24 at 5:00 a.m. Measurements on the bottle indicated that there was under 200 ml left inside the container. The pump display screen indicated it was pumping at a rate of 55 ml per hour and the amount that had been fed was 1972 ml. A new and unopened container of Jevity was observed sitting on the resident's bedside table located behind the pump. A record review for Resident 25 was conducted on 2/12/24 at 1:54 p.m. The profile indicated the residents' diagnoses included, but were not limited to, moderate protein-calorie malnutrition (does…

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.