Brickyard Healthcare - Golden Rule Care Center

Based on interview and record review, the facility failed to obtain a Hemoglobin A1C lab, as ordered, for 1 of 5 residents reviewed for unnecessary medications. (Resident 75)Findings include:The clinical record for Resident 75 was reviewed on 9/9/25 at 12:19 p.m. Her diagnoses included, but were not limited to, type 2 diabetes mellitus. The 8/17/25 diabetes mellitus care plan indicated an intervention was to administer diabetes medication as ordered by the doctor, and to monitor/document for side effects and effectiveness. The Medications section of Physician 13's, 7/30/25, progress note indicated to give one 750 mg tablet of Metformin Extended Release one time a day related to type 2 diabetes mellitus. The Assessments and Plans section of the note indicated, Type 2 diabetes mellitus with other specified complication: Recheck hemoglobin A1c and consider changing metforminto [sic] glargine insulin. The 7/30/25 physician order indicated to obtain a Hemoglobin A1c level. There were no Hemoglobin A1c level results in the clinical record after the above 7/30/25 order. An interview 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 observation, interview, and record review, the facility failed to promote residents' dignity by not answering call lights in a timely manner resulting in incontinence (Resident M, Resident Q, and Resident U), not assisting with activities of daily living (ADLs) as preferred with showers and after toileting care (Resident J), and refusing to assist Resident M to get into their recliner from the bed at night, and refusing to heat up a resident's food when the resident reported the food was cold (Resident M) for 4 of 4 residents reviewed for dignity.Findings include: 1. The clinical record for Resident J was reviewed on 7/14/25 at 1:45 p.m. The diagnoses included, but were not limited to, fracture of right lower leg and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment, dated 5/20/25, indicated Resident J was cognitively intact, used a wheelchair for mobility, frequently incontinent of bladder and always incontinent of bowel, and required supervision or touching assistance with mobility. During an interview with Resident J’s family member on 7/15/25 at 9:50…

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 administer insulin as ordered by the physician for Resident C and Resident V, failed to complete a weekly skin assessment timely for Resident C, and failed to complete neurological checks after a fall for 2 of 4 residents reviewed for falls and for 2 of 3 residents reviewed for quality of care (Resident C, Resident V, Resident T, and Resident O).Findings include:1. During an interview with Confidential Staff 5 on 7/15/25 at 12:23 p.m., they indicated the facility was not conducting weekly skin assessments for residents and was not administering insulin as ordered by the physician. The clinical record for Resident C was reviewed on 7/15/25 at 11:00 a.m. The diagnoses included, but were not limited to, diabetes, Parkinson disease, chronic kidney disease, dementia, Alzheimer's disease, anxiety, muscle weakness, difficulty walking and morbid (severe) obesity. A physician’s order, dated July 2025, indicated the resident was ordered insulin glargine (long-acting insulin) 24 units at bedtime for diabetes. The instructions were 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.

A. Based on observation, interview, and record review, the facility failed to notify the physician of urinalysis results (Resident C), failed to implement contact isolation or enhanced barrier precautions (EBP) for a resident with multidrug-resistant organism (MDRO) (Resident C), failed to move a resident to a private room after a resident was revealed to have a MDRO (bacteria or other microorganisms that have become resistant to multiple antibiotics) (Resident C), and failed to implement EBP for Resident K for 2 of 3 residents reviewed for infection control (Resident C and Resident K).B. Based on observation and interview, the facility failed to properly store an ice scoop to ensure infection control measures for 1 of 1 random observation.Findings include: 1. During an interview with Confidential Staff 4 on 7/15/25 at 12:23 p.m., they indicated Resident C had a urinalysis completed, in December 2024, with the diagnoses of providencia stuartii (bacteria that was considered a MDRO). The facility did not implement any EBP or move the resident to a private room until April 2025. 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 2. The clinical record for Resident D was reviewed on 3/27/2025 at 1:00 p.m. The medical diagnoses included emphysema and diabetes. A Quarterly Minimum Data Set assessment, dated 2/4/2025, indicated Resident D was cognitively intact and received insulin. A diabetes management care plan, revised 3/2/2025, indicated Resident D had diabetes mellitus. Interventions included to monitor Resident D's blood glucose as well as education about compliance and to document and report noncompliance. A respiratory care plan, revised 3/2/2025, indicated Resident D had emphysema and was at risk for impaired gas exchange. Interventions included to administer medications as ordered. A physician order, started on 7/5/2024 and discontinued on 3/25/2025, indicated Resident D received sliding scale insulin based upon the blood glucose reading. The order stated to inject as per sliding scale: if blood glucose was 150 - 200 to administer four units; if blood glucose was 201 - 250 to administer eight units; if blood glucose was 251 - 300…

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 residents with their preference to have the capability to open their bedroom window to get fresh air for 4 of 5 residents reviewed for accommodation of needs/preferences (Resident C, Resident E, Resident F, and Resident B). Findings include: 1. Review of the clinical record of Resident C, on 3/17/25 at 12:25 p.m., indicated the resident's diagnoses included, but were not limited to, respiratory failure, chronic respiratory failure with hypoxia, morbid (severe) obesity, diabetes, age related debility. The admission Minimum Data Set (MDS) assessment for Resident C, dated 1/15/25, indicated the resident was cognitively intact for daily decision making. The resident had no behavior consisting of wandering. It was important to the resident to get fresh air when the weather was good. During an interview with Resident C's family member on 3/17/25 at 2:07 p.m., they indicated the resident was hot one day and requested for the family member to open their window to get some fresh air. Resident C's window 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 provide showers and/or baths to prevent body odor and failed to provide incontinent care timely to a resident to promote dignified care for 1 of 3 residents reviewed for activities of daily living (Resident C). Findings include: The clinical record for Resident C was reviewed on 3/17/25 at 12:25 p.m. The diagnoses included, but were not limited to, respiratory failure, chronic respiratory failure with hypoxia, morbid (severe) obesity, diabetes, age related debility. The admission Minimum Data Set (MDS) assessment for Resident C, dated 1/15/25, indicated the resident was cognitively intact for daily decision making. The resident was dependent for showers/bathing, substantial/maximal assistance for upper dressing, and dependent for lower body dressing. The resident had no behavior consisting of rejection of care. The resident was frequently incontinent of their bowels and bladder. During an interview with Resident C's family member on 3/17/25 at 2:07 p.m., they indicated the facility was not providing the resident with…

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

Based on interview and record review, the facility failed to notify a resident when they had outside physician appointments for 1 of 3 residents reviewed for notification of appointments (Resident E). Findings include: During an interview with Resident E on 3/17/25 at 1:40 p.m., they indicated they had several outside doctor appointments, and the resident was never notified about them. The resident indicated the man that drove the bus to appointments would show up at their door and say, let's go, you have an appointment. The resident indicated this happened at least four times and maybe even more than that. The resident indicated they were an early riser, so they were thankful they were always dressed and ready. The resident indicated they did not want to cause any trouble or get anyone in trouble, they just felt it was courteous to let them know they had an appointment. During an interview with Licensed Practical Nurse (LPN) 1 on 3/17/25 at 1:45 p.m., they verified Resident E had five outside doctor appointments in January 2025, February 2025, and March 2025. There was no…

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 develop and implement a comprehensive care plan for 1 of 5 residents reviewed for infections. (Resident B) Findings include: The clinical record of Resident B was reviewed on 3-17-25 at 11:45 a.m. Her diagnoses included, but were not limited to, diabetes with neuropathy and abnormal gait and mobility. Her most recent Minimum Data Set assessment, dated 1-30-25, indicated she was cognitively intact and required the use of a wheelchair for mobility. It indicated she had a foot infection, was receiving an antibiotic, and received dressing changes to her feet. A review of a note from a podiatrist, dated 1-14-25, indicated she had started on an antibiotic for one week for cellulitis to the second toe of her left foot. A follow-up visit note, dated 1-28-25, indicated her affected toe still showed signs of cellulitis and a second round of antibiotics was ordered for another seven days. A care plan was not located in Resident B's clinical record related to the cellulitis of the left second toe. In an interview with the facility's…

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

Based on interview and record review, the facility failed to follow and institute their antibiotic stewardship policies and protocols for 1 of 5 residents reviewed for infections, related to cellulitis. (Resident B) Findings include: The clinical record of Resident B was reviewed on 3-17-25 at 11:45 a.m. Her diagnoses included, but were not limited to, diabetes with neuropathy and abnormal gait and mobility. Her most recent Minimum Data Set assessment, dated 1-30-25, indicated she was cognitively intact and required the use of a wheelchair for mobility. It indicated she had a foot infection, was receiving an antibiotic, and received dressing changes to her feet. A review of a note from a podiatrist, dated 1-14-25, indicated she had started on an antibiotic for one week for cellulitis to the second toe of her left foot. A follow-up visit note dated, 1-28-25, indicated her affected toe still showed signs of cellulitis and a second round of antibiotics was ordered for another seven days. In an interview on 3-17-25 at 12:58 p.m., with the facility's Infection Preventionist, she…

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

Based on observation, interview and record review, the facility failed to notify the Administrator immediately of allegations of sexual abuse on the Alzheimer's Care Unit of the facility for 3 of 18 residents on the Alzheimer's Care Unit. (Residents 50, 56, and 74) Findings include: 1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and insomnia. The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short and long-term memory problems. She did not know the current season or that she was in a nursing home. Her cognitive skills for daily decision making were severely impaired, in that she rarely/never made decisions. It indicated she had physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during one to three days 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 implement residents' behavior care plans and provide adequate monitoring and supervision to timely address residents' behaviors for 6 of 18 residents on the Alzheimer's Care Unit. (Residents 11, 14, 50, 51, 56, 57, 67, and 74) Findings include: 1. The clinical record for Resident 50 was reviewed on 6/17/24 at 1:10 p.m. Her diagnoses included, but were not limited to: Alzheimer's disease, anxiety, and insomnia. The 5/15/24 Quarterly MDS (Minimum Data Set) assessment indicated the BIMS (brief interview for mental status) was not conducted, as she was rarely/never understood. The staff assessment for mental status indicated she had short term and long-term memory problems. She did not know the current season or that she was in a nursing home. Her cognitive skills for daily decision making were severely impaired, in that she rarely/never made decisions. It indicated she had physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually…

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 services were provided to preserve the dignity of a dependent resident who required the assistance of staff for activities of eating and dressing by removing food debris from the resident's clothing after a meal and provide incontinent care in a timely manner for a resident dependent on staff assistance with toileting for 2 of 5 residents reviewed for dignity. (Resident 2 and confidential resident) Findings include: 1. The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure. A baseline activities of daily living care plan, dated 5/28/2024, indicated to assist Resident 2 with eating as needed. This care plan did not indicate the amount of assistance, or the number of staff needed. An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired, independent with eating, and needed substantial to maximum assistance with dressing. An observation and interview, on 6/14/2024 at 11:30 a.m., with…

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

Based on observation, interview, and record review, the facility failed to promote a clean environment for Resident 2 by having dried debris built up on her recliner, thick dust built up on a box fan utilized by Resident 17, and by having dust built up on an open ledge under the seat and food debris on the footboard of Resident 46's motorized scooter for 3 of 3 residents reviewed for a clean environment. Findings include: 1. The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure. An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired. An observation and interview, on 6/14/2024 at 11:30 a.m., with Family Member 12 indicated that Resident 2 had declined since she was admitted to the facility at the end of May. Family Member 12 tried to come every day and spend time with her mother usually between 11:00 and 11:30 a.m. Resident 2 needed assistance with eating and there had been multiple times that Resident 2 would be found covered in food on her clothing, have food…

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 accurately encode minimum data set assessments for Resident 17's prognosis of six months or less and for Resident 54's utilization of hospice services for 2 of 2 residents reviewed for minimum data set assessment hospice accuracy. Findings include: 1. The clinical record for Resident 17 was reviewed on 6/18/2024 at 1:22 p.m. The medical diagnosis included respiratory failure. An Annual Minimum Data Set Assessment, dated 3/28/2024, indicated Resident 17 was cognitively impaired, did not have a life expectancy of six months or less, but utilized hospice services. A physician order, dated 3/21/2023, indicated for Resident 17 to receive hospice services. A hospice standing order, dated 12/31/2023, located inside of Resident 17's hospice binder at the nurses' station. The order indicated that Resident 17 had a terminal illness with a life expectancy of six months or less. 2. The clinical record for Resident 54 was reviewed on 6/17/2024 at 11:05 a.m. The medical diagnosis included diabetes with neuropathy. A Significant Change…

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 assist a resident with eating (Resident 2) and a dependent resident with shaving to their preference (Resident 54) for 2 of 4 residents reviewed for activities of daily living. Findings include: 1. The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure. A baseline activities of daily living care plan, dated 5/28/2024, indicated to assist Resident 2 with eating as needed. This care plan did not indicate the amount of assistance, or the number of staff needed. An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired, independent with eating, and needed substantial to maximum assistance with dressing. An observation and interview, on 6/14/2024 at 11:30 a.m., with Family Member 12 indicated that Resident 2 had an overall decline in their condition since they were admitted to the facility at the end of May. Family Member 12 tried to come every day to spend time with her mother. She usually arrived…

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 change the humidification for Resident 2's oxygen concentrator for 1 of 2 residents reviewed for respiratory care needs. Findings include: The clinical record for Resident 2 was reviewed on 6/18/2024 at 11:10 a.m. The medical diagnosis included heart failure. An admission Minimum Data Set Assessment, dated 5/30/2024, indicated that Resident 2 was cognitively impaired. A physician order for Resident 2, dated 5/24/2024, indicated to change prefilled bottles on her oxygen concentrator and humifaction weekly and as needed. An observation conducted, on 6/13/2024 at 11:45 a.m., noted Resident 2 sitting in her BRODA chair with her daughter sitting next to her. Resident 12 was utilizing oxygen via nasal cannula with the humidification bottle empty and labelled 6/6/2024. An observation conducted, on 6/14/2024 at 11:30 a.m., noted Resident 2 sitting in her BRODA chair with her daughter sitting next to her. Resident 12 was utilizing oxygen via nasal cannula with the humidification bottle empty and labelled 6/6/2024. An…

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

Based on record review and interview, the facility failed to ensure a staff member working in the capacity of a licensed nurse had a current license to practice in Indiana who had the ability to care for 84 or 84 residents. Findings include: The employee records were reviewed on 4/4/2023 at 1:30 p.m. The nursing license for LPN 1 was indicated as Pending Application. An interview Professional Licensing Agency Representative on 4/5/2023 at 11:21 a.m., indicated LPN 1 does not have a compact nursing license, but had an application for Indiana licensure based on endorsement (reciprocity) that was received in January 2023. As of 4/5/23, the application for Indiana licensure is still pending and LPN 1 is not able to work independently in Indiana at this time. An interview with the Administrator on 4/5/2023 at 12:45 p.m., indicated that LPN 1 was pending license for reciprocity and the facility was under the impression she could work as a nurse while her application was pending. The facility does not have a policy for staff licensure, but they follow the State guidelines to employ staff…

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 timely notification of the physician and/or resident representative for cognitively impaired residents of a skin-related issues of a pressure area, bruise and redness and of a significant weight loss for 2 of 3 residents reviewed for notification of a change in condition. (Residents B and N) Findings include: 1. The clinical record for Resident N was reviewed on 4-4-23 at 10:45 a.m. His diagnoses included, but were not limited to, chronic ischemic heart disease, hypertension and occlusion, history of falls, epilepsy and stenosis of unspecified carotid artery. His most recent Minimum Data Set (MDS) assessment, dated 1-12-23, indicated he was moderately cognitively impaired, was at risk for skin pressure ulcers, but had no pressure ulcers or other skin issues. A review of Resident N's progress notes, dated 4-2-23 at 10:29 a.m., an unidentified staff CNA had reported to the licensed nurse redness to resident sacral area, resident had several loose stools, barrier cream applied after incontinence care. Bruising to left…

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 record review, the facility failed to complete an investigation and report an allegation of misappropriation of property for 1 of 5 residents reviewed for missing personal property. (Resident 78) Findings include: During an interview, on 3/29/23 at 1:50 p.m., Resident 78 indicated she had a cell phone stolen in December and the facility hasn't done anything to find it. She said she reported it to a nurse but couldn't remember her name. Resident 78 indicated she had left the cell phone in her room when she went to therapy, and it was gone when she returned. She talked to several people and was told RN 8 would investigate. RN 8 had asked her if she had a 'find my phone app' and she did not. Resident 78 told her she didn't have service on it that day. Resident 78 said she bought a new phone and nothing else was done. No one has ever gotten back with her or said they were looking for the phone. Resident 78 indicated she was still paying on the phone. Resident 78's record was reviewed, on 3/31/23 at 1:33 p.m., and indicated diagnoses that 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.

Based on interview and record review, the facility failed to ensure the appropriate transfer and discharge paperwork provided to a resident upon transfer to an area hospital was included in the resident's clinical record for 1 of 2 residents reviewed for hospitalization. (Resident 11) Findings include: The clinical record for Resident 11 was reviewed on 4-5-23 at 10:40 a.m. It indicated her diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetic polyneuropathy. A progress note of a telehealth visit by a nurse practitioner (NP), dated 2-7-23, indicated Resident 11 had a cough and shortness of breath of one week duration. She ordered for the resident to have a chest xray and to start routine breathing treatments with plans to follow clinically. A progress note, change of condition notation, dated 1-7-23 at 9:59 p.m., indicated the chest xray results indicated a right basilar pneumonia and effusion and the results had been sent to the NP on call. The NP ordered for an oral antibiotic to be started. The resident requested to be sent to a local…

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 accurately code MDS (Minimum Data Set) assessments for Resident C and Resident F for 2 of 14 residents reviewed for MDS accuracy. Findings include: 1. The clinical record for Resident C was reviewed on 4/3/2023 at 1:05 p.m. The medical diagnoses included chronic obstructive pulmonary disease and Alzheimer's disease. A 5-day MDS Assessment, dated 3/15/2023, indicated that Resident C had an ostomy. A Significant Change of Condition MDS Assessment, dated 3/29/2023, indicated that Resident C was receiving hospice care but did not have a life expectancy prognosis of 6 months or less. An interview with MDS Nurse on 4/3/2023 at 2:40 p.m. indicated that Resident C did not have an ostomy for the 3/15/2023 assessment and should have been coded for 6 months or less prognosis for the 3/29/2023 assessment. A physician statement, dated 3/25/2023, indicated that Resident C had a 6 months or less life expectancy if disease processes ran their normal courses. 2. 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 interview and record review, the facility failed to ensure care plans were developed for the use of medications for hypothyroidism, hypertension and anti-platelets medications for 2 of 25 residents reviewed for care plans. (Residents F and N) Findings include: 1. The clinical record for Resident N was reviewed on 4-4-23 at 10:45 a.m. His diagnoses included, but were not limited to, chronic ischemic heart disease, hypertension and occlusion and stenosis of unspecified carotid artery. A review of his current medications indicated he was physician ordered for the use of Plavix Tablet, an anti-platelet medication, 75 milligrams (mg) once daily related to his diagnosis of chronic ischemic heart disease. This medication was last ordered on 12-14-22. In an interview on 4-5-23 at 11:22 a.m., she indicated she was unable to locate a care plan for the use of Plavix. She indicated she ensured a care plan was developed today for its use. I don't know how we missed this because we had corporate do an audit on care…

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

Based on observation, interview and record review the facility failed to provide hair care and nail care for 2 of 3 residents reviewed for Activities Of Daily Living (ADL) (Resident J and Resident H). Findings include: 1.) During an observation on 3/29/23 at 1:43 p.m., Resident H was sitting in a geriatric chair in the common area with greasy, dirty and uncombed hair. Review of the record Resident H on 3/31/23 at 10:10 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, fracture of shaft of left femur, dehydration, rhabdomyolysis, anxiety, hypertension, dementia and history of falling. The Quarterly Minimum Data Set (MDS) assessment for Resident 53, dated 3/13/23, indicated the resident was severely impaired for daily decision making. The resident was totally dependent of two people to transfer and did not ambulate. The resident required extensive assistance of two people for personal hygiene and totally dependent of two people for bathing. The plan of care for Resident H, dated 3/15/23, indicated the resident had physical functioning…

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 administer subcutaneous fluids as ordered by a provider for 1 of 4 residents reviewed for medication compliance. (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19. A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired and was not dehydrated. A comprehensive metabolic panel, dated 7/28/2022, indicated that Resident B had an elevated blood urea nitrogen (BUN) of 71 mm/dl. A normal range was listed as 7-25. An elevated BUN can indicate changes with the kidneys and hydration status. A nurse practitioner's note for Resident B, dated 7/27/2022, contained an addendum on 8/2/2022 that stated .BUN 71, creatinine 1.0. Verbal order given to nurse for 500ml [milliliter] bolus of 0.9% NS SQ [normal saline subcutaneously] . An interview with DON on 4/4/2022 at 2:45 p.m. indicated she could not find the order for fluids on Resident B's medical record nor where he 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 timely initiate treatment as ordered to a pressure area to the right heel and failed to follow up on a pressure area to the left heel for 1 of 3 residents reviewed for pressure areas (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19. A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired, was at risk for developoing pressure areas, and had three stage two pressure areas. A wound nurse note, dated 7/20/2023, indicated Resident B had a pressure area to the right lateral heel with a dressing of skin prep twice a day. The medication administration record for Resident B indicated skin prep to the right lateral heel was not stated until 7/28/2023. A nursing progress note, dated 7/21/2022, indicated Resident B had a pressure are of stage two to the left heel with measurements of 3.8 x 2.78 x 0 centimeters (cm). A weekly skin assessment, dated 7/25/2022,…

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 maintain oxygen at the physician's ordered flow rate, and failed to date the oxygen tubing. This affected 1 of 1 resident reviewed for respiratory care. (Resident 34) Findings include: On 3/29/23 at 12:24 p.m., Resident 34 was seated in her recliner, her oxygen concentrator was set on 1 and 1/2 liters per minute and her oxygen tubing was not dated. On 3/31/23 at 11:21 a.m., LPN 1 checked for a date on the oxygen tubing and said it was dated 3/20/23. She asked Resident 34 if they had changed the tubing when they changed the water bottle, and the resident said no. LPN 1 told the resident she would get get new tubing because it should have been changed a few days ago, and she got new tubing and replaced it. Resident 34's record was reviewed on 3/31/23 at 11:35 a.m. and indicated diagnoses that included, but were not limited to, chronic obstructive pulmonary disease, acute and chronic respiratory failure with low blood oxygen, atrial fibrillation, hypertensive heart disease with heart failure, congestive heart…

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 have a CMS-approved (Centers for Medicare and Medicaid) indication for the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medication use. (Resident 55) Findings include: The clinical record of Resident 55 was reviewed on 3-31-23 at 10:50 a.m. His diagnoses included, but were not limited to, other specified depressive episodes, generalized anxiety, other Alzheimer's disease and dementia in other diseases classified elsewhere with behavioral disturbance. It indicated he was admitted to the facility less than 6 months ago and was admitted into the facility's secured memory care unit. His admission Minimum Data Set (MDS) assessment, dated 1-23-23, indicated he was severely cognitively impaired. It indicated he was admitted to the facility and received anti-psychotic medications 7 of 7 days each week. His admission medication orders indicated he was prescribed Zyprexa, an anti-psychotic medication, 7.5 milligrams (mg) twice daily for behavioral disturbance. Behavioral documentation, 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 record review and interview, the facility failed to timely report out of range lab results to the medical provider for 1 of 3 residents reviewed for laboratory services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 4/3/2023 at 10:10 a.m. The medical diagnoses included white matter disease and covid-19. A Minimum Data Set Assessment, dated 7/25/2022, indicated that Resident B was severely cognitively impaired. A comprehensive metabolic panel, dated 7/28/2022, indicated that Resident B had an elevated blood urea nitrogen (BUN) of 71 mm/dl. A normal range was listed as 7-25. An elevated BUN can indicate changes with the kidneys and hydration status. The laboratory report was indicated as reviewed on 8/1/2022. A nurse practitioner's note for Resident B, dated 7/27/2022, contained an addendum on 8/2/2022 that stating intervention for elevated BUN. An interview with the DON on 4/4/2023 at 2:45 p.m. indicated she could not find where the physician was notified of the laboratory results from 7/28/2022 prior to addendum dated for 8/2/2022. 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, observation, and record review, the facility failed to follow up on a recommendation for a dental consultation for a Resident F for 1 of 4 residents reviewed for dental services. Findings include: The clinical record for Resident F was reviewed on 4/3/2023 at 10:55 a.m. The medical diagnoses included dementia and stroke. A Significant Change of Condition Minimum Data Set, dated [DATE], indicated that Resident F was cognitively impaired. A nutrition at risk progress note, dated 1/5/2023, indicated a recommendation for a dental consult. An interview with the DON on 4/4/2023 at 2:15 p.m. indicated that the recommendation was never conveyed to the social service director or family in January, but Resident F's family declined dental services on 3/31/2023. A policy entitled, Dental Services, was provided by the Administrator on 4/5/2023 at 2:05 p.m. The policy indicated, .It is the policy of the facility to assist residents in obtaining routine (to the extent covered under the State plan) 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 provide routine dental services for for 2 of 5 residents reviewed for dental services (Resident H and Resident 11). Findings include: 1.) During an observation on 3/29/23 at 1:43 p.m., Resident H was sitting in the common area, the resident had visible teeth. Review of the record Resident H on 3/31/23 at 10:10 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinson's disease, fracture of shaft of left femur, dehydration, rhabdomyolysis, anxiety, hypertension, dementia and history of falling. The plan of care for Resident H, dated 11/22/22, indicated the resident was at risk for dental problems related to some or all natural. The interventions included, but were not limited to, refer for dental services as needed. The nutritional assessment for Resident H, dated 3/13/23, indicated the resident was at risk for malnutrition. The resident had dental problems and received a puree diet. Resident follows a Puree diet related to dentition & dysphagia diagnosis. The assessment was signed by…

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