Waters Of Scottsburg, The

Based on interview and record review, the facility failed to ensure blood pressure medication was not administered to a resident (Resident K) outside of prescribed parameter blood pressure for 1 of 4 residents reviewed for quality of care. Findings include:1. The clinical record for Resident K was reviewed on 3/17/26 at 11:15 a.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure). The physician's order, dated 2/14/26, indicated the resident was to receive Midodrine 10 mg, via gastrostomy tube, three times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. for hypotension. The medication was to be held (not administered) for a systolic blood pressure (SBP) greater than 110. Review of the February 2026 medication administration record indicated the medication was administered on the following dates and times:-On 2/16/26 at 10:00 p.m., when the resident's SBP was 122,-On 2/17/26 at 6:00 a.m., when the resident's SBP was 126,-On 2/17/26 at 10:00 p.m., when the resident's SBP was 119, and-On 2/19/26 at 6:00 a.m., when the resident's SBP was 119. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure the hall meal service food was held at an appropriate temperature for 2 of 2 observations; failed to ensure the food was not overcooked for 1 of 2 meal service observations; and failed to ensure residents received adequate portions for 7 of 10 residents reviewed for dietary services. This deficient practice had the potential to affect 73 of 78 residents residing in the facility. Findings include:During a kitchen food service observation, on 3/15/26 at 12:25 p.m., the following was observed:-The meatloaf was observed with blackened areas across the top and along the edges in the pan.-The serving portion of the meatloaf provided to the residents measured 3 inches in length, one inch in width with a depth of one inch. During an interview, on 3/15/26 at 1:20 p.m., the Executive Director indicated she was going to have the outsourced Dietary Manager re-educate the kitchen staff on portion sizes. During an interview, on 3/16/26 at 11:40…

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

Based on observation, interview and record review, the facility failed to ensure a variety of snacks and snacks with nutritional value were available for the residents for 4 of 7 residents reviewed for dietary services. This deficient practice had the potential to affect 73 of 78 residents residing in the facility. Findings include:During an observation of the snack pantry on 3/15/26 at 11:00 a.m., the following was observed:-One jar of peanut butter on the counter next to the refrigerator-There was no bread in the pantry-A tray with 4 peanut butter sandwiches and 2 peanut butter and jelly sandwiches in baggies. The crust of the bread was hard. There were no other snacks observed in the pantry for the residents except what the residents had purchased for themselves. On 3/15/26 at 11:05 a.m., small bags of cheez-its were the only snacks observed on the snack cart. During an interview, on 3/16/26 at 10:35 a.m., Resident N indicated they don't have snacks all the time and sometimes don't get offered snacks at night because the staff do not have anything to give them. They had peanut…

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 E) was informed of a decrease in pain medication; failed to ensure a resident's (Resident M) representative was notified of the discontinuation of therapy services; and failed to ensure a resident's (Resident E) follow-up appointment for suture removal status post amputation was set-up for 2 of 3 residents reviewed for resident rights. Findings include:1 The clinical record for Resident E was reviewed on 3/15/26 at 2:27 a.m. The resident's diagnoses included, but were not limited to, orthopedic after care following surgical amputation, diabetes, chronic pain, depression, acquired absence of left leg above knee and myalgia (pain). The admission MDS (Minimum Data Set) assessment, dated 2/2/26, indicated Resident E's cognition was intact. The hospital history and physical note, dated 1/29/26, indicated Resident E had a left above knee amputation on 1/16/26. The hospital discharge orders, dated 1/29/26, indicated the resident had a follow-up appointment with the vascular nurse practitioner on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure complete and accurate information was provided to the abuse coordinator for an allegation of resident-to-resident abuse; failed to ensure an allegation of resident-to-resident abuse was reported to the abuse coordinator; and failed to ensure an allegation of verbal abuse was reported, in a timely manner, for 3 of 4 residents reviewed for abuse. (Resident B, Resident C and Resident D) Findings include:1.On 3/15/26 at 12:00 p.m., Staff Member 8 indicated on 3/12/26 in the late afternoon/early evening, Staff Member 8 overheard Resident B tell Resident C he was going to kill her if Resident C came in his room. Staff Member 8 reported the incident to the Director of Nursing who then told Staff Member 8 to inform Social Services. When Staff Member 8 reported the incident to Social Services, Social Services asked Staff Member 8 what do you want me to do about it. On 3/15/25 at 12:05 p.m., Staff Member 9 indicated on 3/13/26 at around 1:00 p.m.,…

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 monitoring was in place for a resident (Residents E, G and K) on anticoagulant therapy and monitoring was in place for a resident (Resident E and Resident F) on insulin 4 of 4 residents reviewed for pharmacy procedures. Findings include:1. The clinical record for Resident E was reviewed on 3/15/26 at 2:47 p.m. The resident's diagnoses included, but were not limited to, diabetes (persistently high blood sugar levels) and status post left above knee amputation. The admission order, dated 1/29/26, indicated the resident was to receive the following medications:-Aspirin (blood thinner) 81 mg (milligrams) daily-Insulin Lispro (long-acting insulin) 5 units subcutaneously with meals-Xarelto (blood thinner) 20 mg daily with breakfast Review of the resident's January, February, and March 2026 medication administrations lacked documentation of nursing staff monitoring the resident for signs/symptoms of bleeding for the blood thinners and for signs/symptoms of hypoglycemia/hyperglycemia for the insulin. 2. The clinical record…

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 walls in the closet in a resident's (Resident B) room were clean and free of debris and failed to ensure the closet door was safely intact for 1 of 3 residents reviewed for environment. Findings include:The clinical record for Resident B was reviewed on 3/15/26 at 2:04 p.m. The resident's diagnosis included, but was not limited to, chronic obstructive pulmonary disease (a progressive chronic inflammatory lung disease that causes obstructed airflow, making it difficult to breath). On 3/17/26 at 10:20 a.m., the following observations were made in Resident B's room:-The sliding door to the closet was observed off the track and leaning up against the right side of the closet. Standing inside the closet looking out towards the room the right upper wall in the closet was observed with multiple gray/black spotted areas that extended across the width of the wall and extended 10 inches downward. The interior wall, above the closet entrance, had a large area, from top to bottom, of gray/black spotted areas.…

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 (Resident B) medication administration record reflected the administration of narcotic medication; and failed to ensure physician visits for residents' (Resident B, Resident D, Resident E and Resident F) were uploaded, in a timely manner for 4 of 5 residents reviewed for medical records. Findings include:1.The clinical record for Resident B was reviewed on 1/23/26 at 11:07 a.m. The resident's diagnoses included, but were not limited to, subarachnoid hemorrhage with loss of consciousness, paraplegic (Paralysis affecting the lower half of the body), and traumatic brain injury (brain dysfunction). The physician's order, dated 10/9/25, indicated the resident was to receive Modafinil (medication to improve wakefulness) 100 mg (milligrams) daily at 8:00 a.m.Review of the November 2025 medication administration (MAR) and the November 2025 controlled substance record indicated the following:-On 11/04/25 the MAR reflected the administration…

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

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident F) dignity was maintained for 1 of 3 residents reviewed for resident rights.Findings include:The clinical record for Resident F was reviewed on 1/28/26 at 3:20 p.m. The resident's diagnoses included, but were not limited to, depression and anxiety. The quarterly MDS (Minimum Data Set) assessment, dated 12/23/25, indicated the resident's cognition was intact.The incident report, dated 1/28/26 at 1:10 p.m., indicated Resident F reported that the Social Services Designee (SSD) came into her room with Resident G, and pulled Resident F's privacy curtain open hastily. The SSD then stated to Resident G, see, she [Resident F] is a woman. SSD then told Resident F that she needed to shave her face. Resident F told the SSD not to pull open her privacy curtain without asking.During an interview, on 1/28/26 at 1:30 p.m., Resident F indicated a few days ago that a new roommate (Resident G) moved into the room with her. After a short time, Resident F introduced herself to Resident G. A few hours…

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's (Resident B) blood pressure medication was not administered, as ordered by the physician when out of parameters, for 1 of 3 residents reviewed for quality of care. Findings include:The clinical record for Resident B was reviewed on 1/23/26 at 11:07 a.m. The resident's diagnosis included, but was not limited to, atrial fibrillation.The physician's order, dated 10/9/25, indicated the resident was to receive Propranolol (medication used for an irregular heartbeat) HCL (hydrochloride), 20 mg (milligrams) three times a day at 8:00 a.m., 12:00 p.m. and 5:00 p.m. The medication was to be held if the resident's systolic (top) blood pressure (SBP) was less than 110.Review of the November 2025, December 2025 and January 2026 indicated the resident was administered the Propranolol medication when parameter readings were out of the range to administer on the following dates and times:-On 11/17/25 at 8:00 a.m., when the resident's SBP was 106.-On 11/17/25 at 12:00 p.m., when the resident's SBP was 106.-On 11/17/25…

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

Based on observation and interview, the facility failed to ensure a resident's room was adequately equipped with an individual call system device to allow the resident to call for assistance if needed for 1 of 3 residents call systems reviewed. (Resident C)Findings include:The clinical record for Resident C was reviewed on 1/23/26 at 1:52 p.m. The resident's diagnoses included, but were not limited to, anoxic brain injury (the brain was completely deprived of oxygen, causing cells to die), acute respiratory failure with hypoxia (life-threatening condition where the lungs fail to oxygenate the blood) and hypercapnia 9the buildup of too much carbon dioxide in the bloodstream) and anxiety.The care plan, dated 1/13/26, indicated the resident was at risk for falls and to place the resident's call light within reach.During an observation, on 1/28/26 at 1:26 p.m., Resident C was observed resting in bed with eyes closed. Resident C did not have his call light in place. A single call cord was observed in the room with the only call cord in place for the resident's roommate.During 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 observation, interview and record review, the facility failed to ensure the resident was evolved in aspects of his care related to a room change, and the temporary removal of his cell phone, from his possession without his consent, for 1 of 3 residents reviewed for the right to make treatment decisions. (Resident B) Findings include:The clinical record for Resident B was reviewed on 1/8/26 at 2:28 p.m. The resident's diagnoses included, but were not limited to, end stage renal disease, major depressive disorder, bipolar and anxiety. The 11/25/25 quarterly MDS (Minimum Data Set) assessment indicated Resident B had intact cognition. The care plan, dated 5/20/25, indicated Resident B enjoyed independent activities, walking and being outdoors. The care plan, dated 8/30/25, indicated Resident B resided on the secured unit related to dementia and exit seeking behaviors. The physician's order, dated 5/17/25, indicated staff were to monitor behaviors every shift for anxiety and depression. On 1/8/26 at 1:16 p.m., the resident was observed sitting on his bed in his room in the…

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

Based on interview and record review, the facility failed to implement, in a timely manner, a plan of care for a resident (Resident B) on the memory care unit for 1 of 3 residents reviewed for care plans. Findings include:The clinical record for Resident B was reviewed on 1/8/26 at 2:28 p.m. The resident's diagnoses included, but were not limited to, bipolar disease and major depressive disorder. The room change notice, dated 7/18/25, indicated Resident B was moved to the memory care unit. The care plan, dated 8/30/25, indicated the resident resided on a secure unit due to dementia and exit seeking. The clinical record lacked documentation of a secured unit base line care plan until 8/30/25 (two weeks after the resident's room change). During an interview, on 1/9/26 at 3:28 p.m., the Director of Nursing indicated Resident B's care plan for the secured unit should have been initiated at the time of the move. On 1/9/26 at 12:27 p.m., the Administrator provided a current copy of the document titled Baseline Care Plan Assessment/Comprehensive Care Plans dated 3/23/21. It included, but…

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 B) placed on the memory care unit had the appropriate diagnosis for placement for 1 of 3 residents reviewed for dementia care. Findings include:The clinical record for Resident B was reviewed on 1/8/26 at 2:28 p.m. The resident's diagnoses included, but was not limited to, diabetes, end-stage renal disease, major depressive disorder, anxiety and bipolar disorder. The physician's order, dated 7/18/25, indicated the resident may reside on the secured unit. The care plan, dated 8/30/25, indicated the resident resided on the secured unit related to dementia and exit seeking. The interventions included activities per schedule, secured unit per physician order and to review and assess appropriate placement. The clinical record lacked documentation for a diagnosis of dementia, Alzheimer's or the clinical need for the secured unit. On 1/9/26 at 12:11 p.m., Resident B's former primary care physician at the facility, indicated the resident did not have a dementia diagnosis and he would not have initiated…

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 a clean and sanitary kitchen for 2 of 2 kitchen observations and failed to store foods appropriately related to snack refrigerators for 2 of 2 snack refrigerators reviewed. This deficient practice had the potential to affect 69 of 70 residents that received foods from the kitchen. Findings include: 1.During an initial tour of the kitchen and the Main Hallway Nourishment Room, on 09/10/25 between 9:35 and 9:50 A.M, with the Dietary Manager (DM) the following was observed:-The main door to the kitchen from the dining room was propped wide open, -A rolling door in front of the steam table was open, and no staff were present serving food, -The floors were scattered with crumbs, under the tables and around the walls, -A plastic spoon and a small butter packet were under the steam table with crumb buildup on floor by the wall, -A serving plate holder had buildup of an unknown substance spilled on the back side of it, and-A plastic cart that held serving lid covers was covered with a layer of crumbs on 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 record review and interview, the facility failed to ensure a resident was free from physical restraint for the purpose of convenience for 1 of 3 residents reviewed for restraints. (Resident B)Findings include:The record for Resident B was reviewed on 7/31/25 at 9:48 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, asthma, alcohol abuse with alcohol induced mood disorder, muscle weakness, abnormalities of gait and mobility, and anxiety disorder.The care plan, dated 7/8/25 and revised on 7/28/25, indicated Resident B was at risk for falls due to and a history of falls, weakness, impaired mobility, and restlessness. The interventions included, but were not limited to, a high back wheelchair for comfort and positioning as tolerated, staff were to keep the resident's call light in reach, and staff were to keep the resident within sight of staff when he was up in his wheelchair.The incident report, dated 7/28/25, indicated Certified Nursing Aide (CNA) 3 reported to oncoming staff that staff had to use a gait belt in the…

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

Based on observation, interview and record review, the facility failed to ensure snacks were provided and were available for residents for 6 of 6 residents reviewed for dietary services (Residents E, F, G, H, K and L). This deficient practice had the potential to affect 63 of 63 residents who consume food from the facility. Findings include: During an anonymous interview, from 6/16/25 to 6/17/25, Staff Member 5 indicated last week she bought coffee, doughnuts and a gallon of milk because the facility was out of snacks. It happened all the time. The nursing staff were always buying snacks because the dietary department would not provide food or drink items, half of the time; and the residents wanted snacks. During an anonymous interview, from 6/16/25 to 6/17/25, Staff Member 7 indicated it was normal for staff to purchase snacks for the residents as dietary almost never has any for them. During an interview with the Dietary Manager, on 6/16/25 at 10:15 a.m., she indicated they had been unable to get pasteurized eggs for the past four weeks due to a shortage. It was a first come,…

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 the physicians' orders related to medication hold parameters for 2 of 3 residents reviewed for Quality of Care. (Resident B and Resident D). Findings include: 1. The clinical record for Resident B was reviewed on 6/16/25 at 11:11 a.m. The resident's diagnosis included, but was not limited to, hypertension. The physician's order, dated 3/8/25, indicated the resident was to receive atenolol 25 mg (milligrams) daily at 8:00 a.m. for hypertension. The resident's medication was to be held for SBP (systolic blood pressure) less than 120. The April 2025 medication administration record (EMAR) indicated the resident received the atenolol when their SBP was less than 120 on the following dates: - On 4/06/25, the resident's SBP was 112. - On 4/07/25, the resident's SBP was 118. - On 4/11/25, the resident's SBP was 118. - On 4/13/25, the resident's SBP was 109. - On 4/14/25, the resident's SBP was 115. - On 4/24/15, the resident's SBP was 102. - On 4/30/25, the resident's SBP was 89. The May 2025 EMAR indicated the resident…

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

Based on interview and record review, the facility failed to ensure a physician's order was in place for the administration of an additional dose related to anxiety medication for 1 of 3 resident's reviewed for pharmacy services. (Resident E) Findings include: The clinical record for Resident E was reviewed on 6/17/25 at 1:30 p.m. The resident's diagnosis included, but was not limited to, generalized anxiety. The care plan, dated 1/14/25, indicated the resident was at risk for anxiousness and to administer medications as ordered by the physician. The physician's order, dated 2/10/25, indicated the resident was to receive Lorazepam, 0.5 mg (milligrams) by mouth daily at bedtime (8:00 p.m.). Review of the May 2025 and June 2025 controlled drug records indicated the Lorazepam was administered on the following dates and times: - On 5/05/25 at 8:00 a.m. and 8:00 p.m., the controlled drug records indicated the resident received the Lorazepam twice a day (BID). - On 5/06/25 at 8:00 a.m. and 8:00 p.m., the controlled drug records indicated the resident received the Lorazepam BID. - On…

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

Based on observation, interview and record review, the facility failed to ensure a resident (Resident E) received double portions, per the meal tickets, for 1 of 3 residents reviewed for dietary services. Findings include: The clinical record for Resident E was reviewed on 6/16/25 at 2:20 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease and malignant neoplasm of the prostate. The physician's order, dated 10/10/24, indicated the resident was to receive double portions at all meals. During an observation of the lunch meal service, on 6/17/25 at 12:15 p.m., Resident E did not receive double portions. The resident's meal ticket/card, dated 6/17/25, indicated the resident was to receive double portions, in all capital letters, at the top of the ticket. During an interview, on 6/17/25 at 12:30 p.m., the Dietary Manager indicated the dietary staff should follow the meal tickets when serving meals. On 6/17/25 at 2:00 p.m., the Clinical Support provided a current, undated copy of the document titled Accuracy of Quality of Tray Line Service. It included,…

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 appropriate assistive device related to a lip plate was in place, per the resident's plan of care, for 1 of 3 residents reviewed for assistive devices. Findings include: The clinical record for Resident B was reviewed on 6/16/25 at 11:11 a.m. The resident's diagnoses included, but were not limited to, vascular dementia and severe intellectual disorder. The physician's order, dated 3/8/25, indicated the resident was to received an pureed consistent carbohydrate diet and to provide an inner lip plate (divided plate) at meals. The care plan, dated 4/16/23, indicated the resident was on a consistent carbohydrate pureed diet and to provide an inner lip plate for meals. During an observation, on 6/17/25 at 12:25 p.m., the resident was served his lunch meal in individual bowls. The resident's lunch meal ticket, dated 6/17/25, indicated the resident was to have an inner lip plate at meals. During an interview, on 6/17/25 at 12:30 p.m., the Dietary Manager indicated the dietary staff should have followed 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 record review and interview, the facility failed to schedule 8-hour consecutive RN coverage for 6 of 6 months reviewed. (July, August, September, October, November, and December 2024). This had the potential to affect all 60 residents currently residing in the facility. Findings include: The review of the July through December 2024 Licensed Nursing schedule indicated the following days were short of 8 consecutive hours of RN coverage: - On July 6, 2024, there were only 6 hours of consecutive RN coverage. - On July 7, 2024, there were only 6 hours of consecutive RN coverage. - On July 20, 2024, there were only 6 hours of consecutive RN coverage. - On July 21, 2024, there were only 6 hours of consecutive RN coverage. - On August 3, 2024, there were only 6 hours of consecutive RN coverage. - On August 4, 2024, there were only 6 hours of consecutive RN coverage. - On August 17, 2024, there were only 6 hours of consecutive RN coverage. - On August 18, 2024, there were only 6 hours of consecutive RN coverage. - On August 31, 2024, there were only 6 hours of consecutive RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure narcotic medication counts were properly documented at the time of administration and expired insulins were removed for 3 of 5 medication carts reviewed. ([NAME] Drive medication cart 1, [NAME] Avenue medication cart 1 and Memory Care medication cart 1). Findings include: 1. During an observation on [DATE] at 10:08 a.m., of the [NAME] Drive Medication Cart 1, the following concerns were identified in the narcotic drawer: a. The Controlled Drug Receipt Record/Disposition sheet indicated that Resident 53 had 3 tablets of the Tramadol left on the sheet. The Tramadol medication card had 2 tablets left. The record for Resident 53 was reviewed on [DATE] at 8:21 a.m. The diagnoses included, but were not limited to, nondisplaced fracture of the right radius of the neck, hereditary and idiopathic neuropathy, gout, diverticulosis, abdominal pain, and irritable bowel syndrome. The physician's order, dated [DATE], indicated to administer 50 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.

Based on record review and interview, the facility failed to adequately secure residents in the facility van when transporting 1 of 3 residents reviewed for accidents (Resident 66) Findings include: The clinical record for Resident 66 was reviewed on 2/19/25 at 1:30 p.m. The resident's diagnoses included, but were not limited to, chronic osteomyelitis with draining sinus to the left radius and ulna, muscle weakness, difficulty in walking, unsteadiness on feet, radiculopathy, lumbosacral region intervertebral disc disorders with radiculopathy, and lack of coordination. The baseline care plan completed on admission to the facility, dated 1/15/25, indicated the resident had no previous history of falls. The Minimum Data Set (MDS) assessment, dated 1/21/25, indicated the resident was cognitively intact. The resident required extensive assistance with two staff members to complete her Activities of Daily Living (ADL's). The ADL care plan, dated 2/7/25, indicated Resident 66 had a risk for falls due to weakness, impaired mobility, lumbosacral radiculopathy, and sacroiliitis. 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 record review and interview, the facility failed to ensure dialysis site monitoring and assessments were completed for 1 of 3 residents reviewed for dialysis. (Resident 24) Findings include: The record for Resident 24 was reviewed on 2/19/25 at 10:15 p.m. The resident's diagnoses included, but were not limited to, dependence on renal dialysis, end stage renal disease, and diabetes mellitus The physician's order, dated 5/13/24, indicated staff were to monitor the resident's AV (arterial vascular) fistula for signs and symptoms of infection, bleeding, bruit/thrill every shift. The order was discontinued on 12/29/24 related to the resident being sent to the hospital. The Quarterly Minimum Data Set (MDS) assessment, dated 9/26/24, indicated the resident's cognition was moderately impaired. The resident required substantial or maximal staff assistance with his Activities of Daily Living (ADL's). The care plan, dated 6/20/23, indicated Resident 24 had end stage renal disease with the need for dialysis. The interventions included, but were not limited to, dialysis per dialysis…

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 store and dispose of discontinued insulin pens appropriately for 1 of 5 medication carts reviewed for medication storage. (Eagle Court Hall Medication Cart) Findings include: 1.a. During an observation on 2/18/25 at 10:35 a.m. of the Eagle Court Hall Medication Cart, Resident 18's Humalog kwikpen was lying freely in the drawer without a pharmacy label, but had a sticker on the kwikpen with the resident's name. The Humalog had an open date of 2/17/25. The record for Resident 18 was reviewed on 2/18/25 at 10:40 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetic mellitus with diabetic neuropathy. The physician's order, dated 1/8/25, indicated staff were to administer Lispro (Humalog) subcutaneously, four times daily for diabetes, per sliding scale: if 150 to 199 mg/dL ( milligrams per deciliter) give 4 units ; 200 to 249 mg/dL give 8 units; 250 to 299 mg/dL give 12 units; 300 to 349 mg/dL give 16 units for blood sugar greater than 350 mg/dL give 20 units and notify the physician. 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 snacks were provided and available for residents for 8 of 10 residents reviewed for dietary services (Residents B, N, O, H, R, P, Q, and S). This deficient practice had the potential to affect 61 of 62 residents who consume food from the faciliy. Findings include: During an interview, on 2/5/25 at 12:50 p.m., Resident B indicated she and her roommate buy their own snacks, and the kitchen never had any to provide. During an interview, on 2/5/25 at 1:05 p.m., Resident N indicated the kitchen never had any snacks to offer so she had purchased her own. During an interview, on 2/6/25 at 9:28 a.m., Resident O indicated the kitchen always was out of orange juice, grape juice, apple juice as well as milk. There were never snacks passed out at night. On 2/6/25 at 9:30 a.m., Certified Nurse Aide (CNA) 9 was observed passing snacks and drinks on the [NAME] Hallway. CNA 9 indicated she had purchased all the snacks on the snack cart because…

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 B) was informed, in a timely manner, of the cancellation of an appointment for 1 of 3 residents reviewed for resident rights. Findings include: The clinical record for Resident B was reviewed on 2/5/25 at 2:11 p.m. The resident's diagnoses included, but were not limited to, end stage heart failure and anxiety. The progress note, dated 1/29/25 at 8:39 a.m., indicated the resident was upset and angry. She had an appointment with pain management and the appointment was canceled. An attempt was made to explain to the resident that once she was picked up by hospice services, hospice would take over her care and manage her pain which was why the appointment was canceled. The clinical record lacked documentation that the resident was notified of the cancellation of the appointment prior to the day of the appointment on 1/29/25. During an interview on 2/5/25 at 12:50 p.m., the resident indicated she had an appointment with pain management on 1/29/25. It was canceled sometime in January by Licensed…

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 residents' right to be free from verbal abuse by a staff member for 2 of 4 residents reviewed for abuse. (Resident D and Resident L) Findings include: 1. The clinical record for Resident D was reviewed on 2/6/25 at 11:22 a.m. The resident's diagnoses included, but were not limited to, schizoaffective disorder, psychotic disorder with delusions and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment, dated 11/1/24, indicated Resident D was alert and oriented. The incident report, dated 1/16/25, indicated Resident D reported concerns with her care provided by Licensed Practical Nurse (LPN) 14. The follow up report, dated 1/23/25, indicated after an investigation was completed related to concerns with care, the facility was unable to substantiate any allegations of abuse. During an interview on 2/5/25 at 1:25 p.m., Resident D indicated LPN 14 was always argumentative. She had a snotty attitude; the LPN's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1150B of the Act for 2 of 4 residents reviewed for reporting abuse allegations. (Resident D and Resident L) Findings include: The incident report, dated 1/16/25, indicated Resident D reported concerns with her care provided by Licensed Practical Nurse (LPN) 14. The follow up report, dated 1/23/25, indicated after an investigation was completed, the facility was unable to substantiate any allegations of abuse. 1. The clinical record for Resident D was reviewed on 2/6/25 at 11:22 a.m. The resident's diagnoses included, but were not limited to, schizoaffective disorder, psychotic disorder with delusions and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment, dated 11/1/24, indicated Resident D was alert and oriented. During a telephone interview on 2/7/25 at 2:30 p.m., RN 15 indicated on 1/14/25, after she clocked in…

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

Based on observation, interview and record review, the facility failed to implement a plan of care for a resident (Resident B) after all the resident's teeth were extracted for 1 of 3 residents reviewed for care plans. Finding includes: The clinical record for Resident B was reviewed on 2/5/25 at 2:11 p.m. The resident's diagnoses included, but were not limited to, end stage heart failure and anxiety. On 2/5/25 at 12:50 p.m., the resident was observed without teeth. The resident indicated she was going to be fitted for dentures since she had all of her teeth pulled on 1/10/25. The progress note, dated 1/10/25 at 2:47 p.m., indicated the residents' mouth was packed with gauze. The resident had some bleeding at that time. The physician's order, dated 1/31/25, indicated the resident may have per resident preference: Chicken noodle soup, ice cream, or pudding, related to having all her teeth pulled on 1/10/25. The clinical record lacked documentation of the implementation a plan of care related to the extraction of all the resident's teeth. During an interview, on 2/6/25 at 10:15 a.m.,…

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's (Resident B) diet was changed and implemented in a timely manner for 1 of 3 residents reviewed for dietary. Findings include: The clinical record for Resident B was reviewed on 2/5/25 at 2:11 p.m. The resident's diagnoses included, but was not limited to, hypertension and end stage heart disease. During an interview, on 2/5/25 at 12:50 p.m., Resident B indicated on 1/10/25, she had all of her teeth extracted so she could be fitted for dentures. The progress note, dated 1/10/25 at 2:47 p.m., indicated the resident's mouth was packed with gauze there was some bleeding observed. The physician's order, dated 1/14/25, indicated the resident was to have chicken noodle soup, ice cream, pudding and milk for meals due to having all her teeth pulled on 1/10/25. The clinical record lacked documentation of a change in the resident's ability to eat on 1/10/25 until 1/14/25. During an interview, on 2/6/25 at 10:15 a.m., the Director of Nursing indicated to her knowledge, the resident did not come back with any…

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 reviewed, the facility failed to ensure a resident's (Resident H) therapeutic diet was followed for 1 of 3 residents reviewed for resident meals. Findings include: The clinical record for Resident H was reviewed on 2/7/25 at 11:44 a.m. The resident's diagnoses included, but were not limited to, diabetes, anxiety and major depressive disorder. The physician's order, dated 3/12/24, indicated the resident was to receive prune juice with her lunch every day. During an interview on 2/6/25 at 1:40 p.m., Resident H indicated she had an order from the doctor to have prune juice every day with her lunch. She had never received the prune juice with her lunch tray. During an interview on 2/6/25 at 2:38 p.m., the Regional Director of the dietary service indicated she would have to go out a purchase some prune juice since the facility currently had no prune juice available. The partial contract for dietary management contract was provided by the Regional Director of Operations on 2/27/25 at 5:48 p.m. It included, but was not limited to, Dining Services…

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 dressing changes on residents' (Resident B and Resident D) peripherally inserted central catheter line were completed as ordered for 2 of 2 residents reviewed for quality of care. Findings include: 1. The clinical record for Resident B was reviewed on 11/2/24 at 5:56 p.m. The resident's diagnosis included, but was not limited to, acute osteomyelitis of the right foot and ankle. The physician's order, dated 10/5/24, indicated to change the peripherally inserted central catheter (PICC) line dressing weekly and as needed. The care plan, dated 10/24/24, indicated the resident had a PICC line to the right upper extremity and to change the dressing per order. During an observation on 11/1/24 at 1:12 p.m., Resident B's PICC line dressing to the right upper extremity was dated 10/24/24. During an observation on 11/2/24 at 4:53 p.m., Resident B's PICC line dressing to the right upper extremity was dated 10/24/24. The November 2024 medication administration record indicated the treatment was completed on 11/1/24.…

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

Based on interview and record review, the facility failed to ensure a resident's (Resident E) routine Lorazepam (narcotic antianxiety medication) was administered, as ordered by the physician, for 1 of 3 residents reviewed for pharmaceutical services. Findings include: The clinical record for Resident E was reviewed on 11/4/24 at 9:45 a.m. The resident's diagnoses included, but was not limited to, anxiety and chronic obstructive pulmonary disease. During an interview on 11/2/24 at 6:24 p.m., Resident E indicated her anxiety medications were frequently late and sometimes she did not get it at all. The care plan, dated 5/17/24, indicated the resident was at increased risk for anxiousness due to anxiety and to administer the anxiety medication as ordered. The physicians's order, dated 7/26/24, indicated the resident was to receive Lorazepam 1 mg (milligram) routinely at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The October 2024 medication administration record indicated the resident received the Lorazepam 1 mg on the following dates and times: -10/04/24 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 observation, interview and record review, the facility failed to ensure food was served at appropriate temperatures for 1 of 1 observations of food temperatures. ([NAME] Hall) Findings include: On 11/1/24 at 12:00 p.m., upon entrance to the dining room, a meal time sign was observed to be posted which included the following meal times for [NAME] Hall: Lunch - 12:15 p.m. Dinner - 5:20 p.m. Review of the September 2024 resident council minutes, dated 9/19/24 at 2:00 p.m., indicated the residents had concerns of breakfast food being served cold and dinner being served late. Review of the October 2024 resident council minutes, dated 10/24/24 at 2:00 p.m., indicated the residents had concerns of the breakfast food being served cold and dinner was late. On 11/1/24 at 12:58 p.m., the lunch trays were brought to the [NAME] Hall at 12:58 p.m. On 11/1/24 at 1:08 p.m., with the Dietary Manager, the following food temperatures were observed: -Cheesy grits with shrimp - 145 degrees -Collard greens - 126 degrees…

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

Based on interview and record review, the facility failed to ensure as resident's (Resident E) medication administration record accurately reflected the administration of as needed narcotic pain medication for 1 of 3 residents reviewed for medical records. Findings include: The clinical record for Resident E was reviewed on 11/4/24 at 9:45 a.m. The resident's diagnoses included, but were not limited to, end stage heart failure, anxiety and chronic obstructive pulmonary disease. The physician's order, dated 8/2/24, indicated the resident was to receive Morphine Sulfate (narcotic pain medication), 0.75 mg (milligrams) every 2 hours as needed for pain. The October 2024 controlled drug record indicated the resident received the medication on the following dates and times: -10/3/24 at 12:02 a.m., 5:30 a.m., 7:30 a.m., 9:30 a.m., 11:30 a.m., 1:30 p.m., 3:30 p.m., 5:30 p.m. and 7:30 p.m. -10/4/24 at 5:00 a.m., 7:45 p.m., and 9:45 a.m. -10/5/24 at 4:00 a.m., 6:00 a.m., 8:00 p.m. and 10:00 p.m. -10/6/24 at 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m. and 8:15 p.m. -10/8/24 at 8:30 a.m., 10:35…

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 act upon resident concerns of food temperatures, taste of food, no activities on the weekend, drinks not being passed at night, staff completed the menus instead of asking the residents for 5 of 13 months of Resident Council meetings (May, July, September, November 2023; and January 2024). This deficient practice had the potential to affect the 67 residents currently residing in the facility. Findings include: 1. The Resident Council Meetings, dated 5/23/23, indicated the residents' concerns were not acted upon or resolved related to Cold food, quality of the food, cheese not melted on burgers, kitchen not following the menus, not getting snacks after 6:00 p.m., not getting milk when requested on ticket, not getting correct eggs being put on tray, more snack choices for the nutrition room, orange juice watered down, and not getting Ensure. The response dated 5/26/23, from the Activity Director, indicated she responded that as of right now, there was an activity aide on Sundays from 8:00 a.m. to 4:30 p.m. The activities…

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 individualized resident activities were conducted for residents with dementia related to aggressive behaviors, resident to resident altercation, accidents, and inappropriate sexual behaviors for 6 of 19 residents reviewed for dementia care. (Residents C, E, F, G, B, and H) Findings include: 1. The record for Resident C was reviewed on 1/31/23 at 2:21 p.m. The diagnoses included but were not limited to, Alzheimer's disease, dementia with other behavioral disturbances, senile degeneration of the brain, alcohol abuse, major depressive disorder, anxiety disorder, insomnia, and delusional disorder. The Quarterly MDS (Minimal Data Set) assessment, dated 12/20/23, indicated the resident was severely cognitively impaired and was never or rarely understood and did not exhibit any behaviors. The care plan, dated 1/30/23, indicated the resident was at risk for behavioral disturbances related to dementia with behavioral disturbances. He was hard of hearing, had agitation, verbal and physical aggression, toileted in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure appropriate psychosocial follow-up by social services, related to aggressive behaviors, resident to resident altercations, accidents, and inappropriate sexual behaviors for 4 of 19 residents reviewed for social services. (Residents 61, C, E, and F) Findings include: 1. During an interview on 1/30/24 at 10:25 a.m., Resident 61 indicated she had depression and complicated life circumstances. The facility was aware of it. She had no one to talk to. The record for Resident 61 was reviewed on 1/31/24 at 8:21 a.m. The diagnoses included, but were not limited to, alcoholic cirrhosis of liver with ascites, depression, alcohol abuse, and suicidal ideations. The PASRR (Pre-admission Screening and Resident Review) Level 2 outcome, dated 7/27/23, indicated the resident had been hospitalized on [DATE] because she said she wanted to hurt herself. She had a personal history that was significant for alcohol dependence which had resulted in…

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

Based on observation, record review, and interview, the facility failed to ensure appropriate staffing to maintain the kitchen. This deficient practice had the potential to affect all 67 residents currently residing in the facility. Findings include: During tours of the kitchen on 1/29/24 at 9:14 a.m., 1/29/24 at 10:16 a.m., 1/31/24 at 1:16 p.m., and 2/1/24 at 10:03 a.m., multiple concerns were observed with the kitchen cleanliness. The kitchen was observed to pans with food debris in them used for multiple meal service times, dirty equipment, utensils, floors, and appliances throughout multiple observations and during non-meal service times throughout the survey. Cross Reference: F812 During an interview on 1/29/24 at 9:30 a.m., Dietary [NAME] 3 indicated they didn't have a dietary manager. They had several staff members quit and it was down to just her and two other staff members for a while. During an interview on 1/30/24 at 1:16 p.m., Dietary [NAME] 5 indicated they didn't have a manager right now and only had three core staff working for a while. Himself, Dietary [NAME] 3 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, record review, and interview, the facility failed to ensure staff followed menus and recipes for meal services for 3 of 3 random observations of meal service. This deficient practice had the potential to affect 65 of the 67 residents currently residing at the facility. Findings include: 1. During an observation on 1/29/24 at 11:35 a.m., Dietary [NAME] 3 poured potato flakes into a pot of boiling water. She did not measure anything and kept adding potatoes until it was thickened. She then temped the foods on the tray service line. She indicated she did not have peppers and onions to temp. They were in the steak. The steak had very few, small green specks which the cook indicated were peppers. Onions could not be distinguished from the rest of the patty if they were present. At 12:05 p.m., a resident came to the kitchen window and asked what was for lunch. Dietary [NAME] 3 told him it was Salisbury steaks and mashed potatoes and that was all they were having. She didn't have a vegetable prepared. The cook began serving. The plates were served with 1 beef patty…

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

Based on record review, observation, and interview, the facility failed to ensure residents were offered a nourishing snack at night between dinner and breakfast for 6 of 21 residents related to snacks. This deficient practice had the potential to affect the 65 of the 67 residents currently residing in the facility. Findings include: The review of the 9/21/23 Resident Council meeting, the following concern was identified: - Residents said they were being told by night shift there were no snacks available for them in the nutrition room. They were also requesting oranges and bananas to be available in the nutrition room. On 9/21/23, the Dietary Manager indicated she was stocking the nutrition room daily with bread, peanut butter, jelly, bologna, cheese, applesauce, pudding, and cottage cheese. There were crackers, jello and oatmeal also available. Oranges and bananas would be ordered. During the Resident Council meeting on 1/31/24 at 1:00 p.m. with 9 residents whom the Activities Director indicated were alert and oriented, Residents 9, 5, 54, 32, 50,and 19 indicated the snacks 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, record review, and interview, the facility failed to ensure cleanliness of the kitchen and appropriate food preparation related to the steam table, handwashing sink, storage containers, preparation counter, storage cabinet, food processor, and kitchen appliances for 3 of 3 random observations of the kitchen. Findings include: 1. During the initial tour of the kitchen on 1/29/24 at 9:14 a.m., the following concerns were observed: -The handwashing sink had no paper towels or trashcan within reach. - The steam table had brown grime streaking down the front and staining the bottom rack of the table's stainless steel. - Storage containers underneath a preparation counter with packets of ketchup, creamer, salt, and pepper were dirty with food particles and grime. - The cabinet above the preparation counter storing plates and bowls had food particles and crumbs littering the cabinet. - The second preparation counter had food grime caked in the corners and streaking down the front. -The outside of the food processor was coated in food particles and grime. -There 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 observation, record review, and interview, the facility failed to ensure resident preferences with meals were honored for 2 of 25 residents reviewed for choices. (Resident B and 275) Findings include: 1. The record for Resident B was reviewed on 2/1/24 at 1:00 p.m. The diagnosis included, but was not limited to, dysphasia. The care plan, dated 8/22/22, indicated the resident had allergies to tomato and tomato products. The interventions included, but were not limited to, do not provide allergen. The nutritional assessment, dated 7/7/22, indicated the resident's food allergies included tomatoes. The resident's meal tray card indicated her allergies included tomatoes and tomato products. During an observation on 2/1/24 at 12:31 p.m., Resident B's tray was uncovered. She was served the main dish, including the beef mostaccioli which had tomato based sauce. The review of her tray card indicated she was allergic to tomatoes and she had selected to have a hamburger for lunch. During an interview on 2/1/24 at 12:32 p.m., CNA (Certified Nurse Aide) 8 indicated she would need 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 revise a resident's care plan from being at-risk for skin issues to actual skin impairment when the resident developed a rash and wound to the right ankle and leg for 1 of 19 residents whose care plans were reviewed. (Resident 13) Findings include: The record for Resident 13 was reviewed on 1/29/24 at 1:19 p.m., The diagnoses included, but were not limited to, end stage renal disease with dialysis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus, heart failure, and vascular dementia. moderate, without behavioral, psychotic, or mood disturbance, and anxiety. The Interim Payment Minimum Data Set (MDS) assessment, dated 11/20/23, indicated the resident had moderate cognitive impairment, occasionally felt down/depressed, had no behavior issues, required partial to moderate assistance for bed mobility, was dependent for transfers, was non-ambulatory, and had impairment in functional range of motion on one side of his lower extremity. A Skin/Wound note, dated…

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

Based on observation, record review, and interview, the facility failed to ensure appropriate emergency supplies for tracheostomy care were at the bedside for 1 of 1 residents reviewed for tracheostomy care. (Resident 25) Findings include: During an observation on 1/30/24 at 8:57 a.m., Resident 25 was resting in bed. She had a tracheostomy and was breathing room air. There was no ambu bag (mechanical resuscitation device) or emergency oxygen supply at the bedside or in the room. During an interview on 1/30/24 at 8:59 a.m., LPN (Licensed Practical Nurse) 6 indicated there was not an ambu bag in the resident's room. The closest ambu bag she had access to was at her crash cart. The nurse searched the room and verified there was no ambu bag in the room. To her knowledge they did not keep them in the room for their tracheostomy patients. During an observation on 1/30/24 at 9:02 a.m., LPN 6 walked to the crash cart which was approximately fifteen to twenty feet down hall at the nurse's station. She removed the seal from the crash cart but could not get it open. She tried multiple times 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 record review and interview, the facility failed to ensure appropriate behavioral health services were obtained for 1 of 12 residents reviewed for behavioral health services. (Resident 61) Findings include: During an interview on 1/30/24 at 10:25 a.m., Resident 61 indicated she had depression and complicated life circumstances. The facility was well aware of it. Someone came and saw her a month or so ago and was supposed to come back every Thursday, but they hadn't come back yet, and it was over a month ago. She believed she would benefit from therapy. She had no one to talk to. The record for Resident 61 was reviewed on 1/31/24 at 8:21 a.m. The diagnoses included, but were not limited to, alcoholic cirrhosis of liver with ascites, depression, alcohol abuse, and suicidal ideations. The PASRR (Pre-admission Screening and Resident Review) Level 2 outcome, dated 7/27/23, indicated the resident had been hospitalized on [DATE] because she said she wanted to hurt herself. She had personal history that 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 ensure adequate supervision to prevent falls, wandering and inappropriate behaviors for 5 of 19 residents observed. This deficient practice had the potential to affect 19 residents residing on the dementia unit. (Residents G, B, C, E, and F) Findings include: 1. The record for Resident G was reviewed on 1/30/24 at 2:45 p.m. The diagnoses included, but were not limited to, cerebral infarction, altered mental status, mild cognitive impairment, aphasia, cognitive communication deficit, polyneuropathy, dementia, lack of coordination, weakness, difficulty walking, disorientation, major depression, affective mood disorder, bipolar disorder, and peripheral vascular disease. The Quarterly MDS assessment, dated 12/3/23, indicated the resident was severely cognitively impaired. The IDT (Interdisciplinary Team) note, dated 3/22/23 at 7:18 a.m., indicated the resident's notes were reviewed, and on 3/21/23 the resident was exit-seeking, pacing, and becoming aggressive with staff when redirecting. The behavior note, dated…

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

Based on observation, record review, and interview, the facility failed to obtain routine dental services for 1 of 2 residents reviewed for dental services. (Resident 39) Findings include: During an observation on 1/29/24 at 10:10 a.m., Resident 39 had broken and discolored teeth. Some of the edges of her teeth were jagged. The record for Resident 39 was reviewed on 1/31/24 at 11:14 a.m. The diagnoses included, but were not limited to, aphasia, dementia, and dysphagia. The Quarterly MDS (Minimum Data Set) assessment, dated 11/24/23, indicated the resident was cognitively intact. The physician's order, dated 12/11/23, indicated the resident may be seen by the dentist. During an observation on 2/1/24 at 2:42 p.m., Resident 39 was in bed. Her teeth were stained brown and observed with multiple fractures, darkened areas, and jagged, sharp looking broken edges. During an interview on 2/1/24 at 2:44 p.m., LPN (Licensed Practical Nurse) 13 indicated the resident's teeth were not the greatest. She didn't think the resident had seen a dentist since she'd been working there. She did have…

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 identify an unresolved quality deficiency which had been cited on a previous survey, and ensure actions were developed and implemented to attempt to correct the deficiency through the quality assessment and assurance (QAA) process, as evidenced by a repeated deficiency for elopements. This deficient practice had the potential to affect 10 of 10 residents residing in the facility who are at a risk for elopement. Finding includes: The Quality Assurance and Performance Improvement (QAPI) plan was a general outline of how to set up a QAPI committee and what the committee should do. The QAPI plan was a data driven, proactive approach for improving the quality of life, care and services in long term care. The activities of QAPI involved members at all levels of the organization to identify opportunities for improvement, address gaps in systems or processes, develop and implement and improvement or corrective plan and continuous monitoring of interventions. The following deficiency was cited on this survey at Immediate Jeopardy…

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

Based on observation, interview and record review, the facility failed to ensure a staff member did not post photos of a resident on their personal social media account for 1 of 3 residents reviewed for resident rights. Findings include: The clinical record for Resident B was reviewed on 12/8/23 at 9:56 a.m. The diagnoses included, but were not limited to, dementia and cognitive communication deficit. The quarterly MDS (Minimum Data Set) assessment indicated the resident's cognition was severely impaired. Review of Resident B's guardianship paperwork indicated the guardian was appointed for the resident on 7/24/15. On 12/8//23 at 10:00 a.m., seven pictures of Resident B were observed on the Dietary Manager's personal social media page with a posted date of 10/26/23. The pictures were of the resident inside the facility, throughout her time at the facility. The resident's clinical record lacked documentation of consent from Resident B's guardian to post picture on social media. During an interview on 12/8/23 at 10:25 a.m., the Executive Director (ED) indicated per the facility…

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

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident C) fall intervention was in place, per the resident's plan of care, for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident C was reviewed on 12/8/23 at 12:06 p.m. The diagnosis included, but was not limited to, history of falls. The care plan, dated 4/13/21, indicated the resident was at risk for falls. The interventions included, but were not limited to, non-skid strips to the bathroom floor. During an observation on 12/8/23 at 2:01 p.m., Resident C's bathroom floor did not have non-skid strips in place. During an interview on 12/8/23 at 2:04 p.m., the Director of Nursing indicated they would ensure non-skid strips were placed to the bathroom floor. During an interview on 12/11/23 at 10:05 a.m., the Executive Director indicated the non-skid strips were put down on Friday. She believed that the old strips were scraped up by housekeeping and the maintenance department was not informed to replace them. This Citation relates to Complaint…

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 management failed to report incidents to the Indiana Department of Health when a resident (Resident F ) exited the facility grounds, without supervision, and when a staff member reported an allegation of abuse (Resident C) for 2 of 3 residents reviewed for reportable incidents. Findings include: 1. The clinical record for Resident F was reviewed on 9/25/23 at 3:00 p.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance and cognitive communication deficit. The annual MDS (Minimum Data Set) assessment, dated 8/13/23, indicated the resident's cognition was moderate impaired. The progress note, dated 9/4/23 at 1:20 p.m., indicated Staff Member 2 informed Staff Member 3 that Resident F was seen walking south on the highway towards a liquor store. The police were notified of a resident that had eloped from the facility. Staff Member 2 left the facility to find the resident. The resident was cooperative and brought back to the facility by the police. The resident was assessed and offered fluids. A wander…

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 adequate supervision was in place when a resident (Resident F), with impaired cognition, did not exit the facility grounds and ambulated down the highway six tenths of a mile, without supervision, for 1 of 3 residents reviewed for accidents/supervision. Findings include: On 9/25/23 at 2:36 p.m., Resident F was observed in the dining room participating in an activity. He had a wander guard to his right wrist. The clinical record for Resident F was reviewed on 9/25/23 at 3:00 p.m. The diagnoses included, but were not limited to, dementia with behavioral disturbance and cognitive communication deficit. The annual MDS (Minimum Data Set) assessment, dated 8/13/23, indicated the resident's cognition was moderate impaired. The care plan, dated 10/18/23, indicated the Care plan date was 10/18/22, Resident F's history included, but was not limited to, impaired cognition, poor insight and lack of awareness. The elopement assessment, dated 7/26/23, indicated the resident was not at risk for elopement. The progress…

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.