Healthwin Health & Rehabilitation

Based on interview and record review, the facility failed to ensure a comprehensive plan of care including a plan for type 2 diabetes, wound care and colostomy care was created for 1 of 3 residents reviewed for care plans. (Resident B) Finding includes: On 3/27/25 at 11:30 A.M., a clinical record review was completed for Resident B's. Diagnoses included, but were not limited to, paraplegea, type 2 diabetes, osteomylitis of the left femur that required surgical intervention and the application of wound vac placement, colostomy status, and pressure ulcers. The Annual Minimum Data Set (MDS) assessment,dated 2/21/25, indicated Resident B was fully cognitively intact, required extensive assistance for bed mobility, transferring, bathing, dressing, and personal hygiene. The resident was assessed to have had two stage 2 pressure ulcers, one unstageable pressure ulcer, and a surgical wound. In addition, Resident B was receiving insulin for diabetes and had received 5 injections in the previous 7 days. Physician's orders included the following: -Lantus Subcutaneous Solution to inject 10…

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 physician orders were in place for the treatment of low blood glucose, and failed to ensure the documentation was completed for wound care treatment according to physician orders, for 1 of 3 residents reviewed for diabetic management and wound treatment, (Resident B). Finding includes: On 3/27/25 at 11:30 A.M., a clinical record review was completed for Resident B's. Diagnoses included paraplegia, type 2 diabetes, osteomylitis of the left femur, seizure disorder, history of stroke, colostomy status, neurogenic bladder requiring a catheter, resistance to multiple antibiotics, tachycardia, and pressure ulcers. The Annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B was fully cognitively intact, required extensive assistance for bed mobility, transferring, bathing, dressing, and personal hygiene. The resident was assessed to have had two stage 2 pressure ulcers, one unstageable pressure ulcer, and a surgical wound. 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 ensure there was a sufficient number of nursing staff to provide care to residents on all nursing units. This deficient practice had the potential to affect of residents. See F677 for additional information regarding Residents B, M, D, E, and 55 Findings include: During a Resident/surveyor group meeting, conducted on 2/13/2025 at 1:41 P.M., 22 of 22 residents attending complained about untimely response to call lights, not receiving at least two showers a week and not receiving medications timely and/or not receiving all of their medications. During a Family meeting with the new corporate representatives and the Director of Nursing, conducted on 2/12/2024 at 2 PM, several resident representatives complained about the lack of staffing to provide care, especially at night and residents not receiving timely showers or medications. The family representatives queried the new corporate staff and DON about reducing the number of staff and firing the QMAs (Qualified Medication Aides) and shower aides. The Director 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.

2. Resident M's record review was completed on 2/18/2025 at 11:13 A.M. Diagnoses included, but were not limited to: paraplegia, sacral osteomyelitis, neuromuscular dysfunction of bladder and epilepsy. A current Physician's order dated, 2/11/2025, indicated Resident M was to receive one gram ertapeneum (antibiotic) intravenously one time a day for sacral osteomyelitis from 2/11/2025 to 2/17/2025. A February 2025 Medication Administration Record (MAR) indicated Resident M had not received her dose of ertapeneum on 2/13 and 2/16/2025. Resident M's record lacked the documentation she had refused her medication or a Physician had been notified that she had missed two doses of her medication. During an interview on 2/18/2025 at 2:15 P.M., the Director of Nursing indicated she was not sure why Resident M had missed two doses of ertapeneum, but Resident M should have received a dose of ertapeneum on 2/13 and 2/16/2025. 3. Resident L's record review was completed on 2/18/2025 at 1:05 P.M. Diagnoses included but were not limited to: spinal stenosis, chronic obstructive pulmonary disease,…

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, observation and record review, the facility failed to ensure dependent residents received showers or complete bed baths as scheduled for 5 of 8 residents who were reviewed for showers or complete bed baths. (Residents B, M, D, E, and 55) Findings include: 1. During an interview on 2/11/2025 at 9:48 A.M., Resident B indicated she was scheduled to receive three showers a week, but had not received a shower for over two weeks. She indicated there was not enough staff to give her a shower, but she had had a couple of bed baths over the last two weeks. During an interview on 2/12/2025 at 9:55 A.M., Resident B's family member indicated the resident had not had a shower in over two weeks and she had called and left multiple messages for the Administrator, but had not received a call back. During an interview on 2/12/2025 at 10:05 A.M., Resident B's family member indicated the resident was alert and oriented and the resident had been upset about not receiving any showers for over two weeks. Resident B's record review was completed on 2/12/2025 at 11:13 A.M. Diagnoses…

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 follow Physician orders related to tubi grips, and to failed to assess and treat an area of impaired skin for 2 of 12 residents reviewed for quality of care. (Residents J & 67) 1. During an interview on 2/11/2025 at 10:41 A.M., Resident J indicated she wore Tubi-grips to help with the swelling in her lower legs and feet. She indicated she could not put the Tubi-grips on by herself and staff had not regularly placed the Tubi-grips on her legs. During observations of Resident J, the resident was not wearing Tubi-grips (compression socks) on either leg and her right lower leg and foot were swollen: -2/11/2025 10:41 A.M. -2/12/2025 at 9:05 A.M. -2/13/2025 at 3:37 P.M. -2/14/2025 at 12:05 P.M. -2/17/2025 09:06 A.M. -2/17/25 2:01 P.M. Resident J's record review was completed on 2/17/2025 at 9:34 A.M. Diagnoses included, but were not limited to: post polio syndrome, hemiplegia and hemiparesis, Parkinson's disease and anxiety. A Quarterly Minimum Data Set (MDS) assessment, dated 1/24/2025, indicated Resident J 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 observation, interview and record review, the facility failed to ensure a resident was free from verbal abuse for 1 of 1 residents reviewed. (Resident 51) Finding includes: During an observation and interview, on 2/12/2025 at 11:17 A.M., Resident 51 indicated there was an agency nurse on the evening shift that had yelled at her during her shifts at the facility. The resident was unable to recall the staff member's name. Resident 51 indicated the last incident where this staff yelled at her happened approximately two to three weeks ago. Resident 51 indicated the last incident had occurred when she was lying in bed, felt unwell and did not want to attend meal service in the dining room. The resident indicated the nurse raised her voice and demanded the resident get out of her bed and go to the dining room for her meal. Resident 51 was tearful during the re-telling of this occurrence. Resident 51 said, I feel like I'm going to die here. Resident 51 indicated she had reported the incident to the Director of Nursing (DON) the day after the incident had occurred. The resident…

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

Based on observation, interview and record review, the facility failed to ensure a resident from free from a physical restraint for 1 of 1 residents reviewed for restraints. (Resident 67) Finding includes: During an observation on 2/11/2025 at 10:52 A.M., Resident 67 was seated in the dining room in a wheelchair being fed his breakfast by the CNA 11. There was a fastened seat belt noted to be across the resident's lap. During an observation and interview on 2/11/2025 at 11:00 A.M., Resident 67 was had finished his breakfast and w the resident was asked to release his button seat belt. Resident 67 was unable to release the button clasp. During an observation on 2/12/2025 at 11:29 A.M., Resident 67 was seated in his wheelchair in the hallway with the seat belt fastened. During an observation on 2/17/2025 at 3:12 P.M., Resident 67 was seated in his wheelchair with the seat belt fastened. A record review was completed on 2/11/2025 at 2:00 P.M. for Resident 67. Diagnoses included but not limited to: osteoarthritis of right hand, localized swelling, mass and lump right upper limb,…

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 allegation of verbal abuse was reported timely after an allegation was made to the Indiana Department of Health for 1 of 1 resident reviewed for abuse. (Resident 51) Finding included: During an observation and interview, on 2/12/2025 at 11:17 A.M., Resident 51 indicated there was an agency nurse on the evening shift that had yelled at her during her shifts at the facility. The resident was unable to recall the staff member's name. Resident 51 indicated the last incident where this staff yelled at her had occurred approximately two to three weeks ago. Resident 51 indicated this last incident occurred when she was lying in bed, felt unwell and did not want to attend meal service in the dining room. The resident indicated the nurse raised her voice and demanded the resident get out of her bed and go to the dining room for her meal. Resident 51 was tearful during the re-telling of this occurrence. Resident 51 said, I feel like I'm going to die here. Resident 51 indicated she reported the…

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

Based on interview and record review, the facility failed to ensure a comprehensive plan of care included a plan to address an osteomyelitis diagnosis and the use of an indwelling catheter for 1 of 24 residents reviewed for comprehensive care plans. (Resident Q) Findings include: A record review for Resident Q was completed on 2/18/2025 at 9:00 A.M. Diagnosis included, but were not limited to osteomyelitis right foot/ankle, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3. A Physician's order dated 2/7/2025 indicated, an order for the medication, ceftazidime 1.25 grams (gm) intravenously (IV) for osteomyelitis, A History and Physical evaluation, dated 1/3/2025 by the attending Physician, indicated an X-ray of Resident Q's foot had shown chronic osteomyelitis and the resident was started on IV antibiotics. A Nursing Progress note, dated 2/7/2025, indicated Resident Q was admitted from the hospital due to a diagnosis of osteomyelitis. Resident Q's record did not include a plan of care for osteomyelitis. In addition, there was 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.

Based on observation, interview and record review, the facility failed to ensure residents were provided with activities designed to meet their interest and their physical, mental, psychosocial well-being for 2 of 2 resident reviewed for activities. (Resident 55 and 83) Findings include: 1. During an observation, on 2/12/2025 at 2:37 P.M., Resident 55 was observed seated in her room while reclined in a Broda chair with a television playing. During an observation, on 2/13/2025 at 11:03 A.M., Resident 55 was observed in a Broda chair in her room with her eyes open and looking at the floor. The television was tuned to a game show. During an observation, on 2/14/2025 at 2:04 P.M., Resident 55 was observed lying in her bed on her right side with her eyes closed. The February activity calendar indicated Valentine Bingo was scheduled at this time. The clinical record of Resident 55 was reviewed on 2/17/2025 at 8:46 A.M. The resident's diagnoses included, but were not limited to: Alzheimer's disease, dementia, peripheral vascular disease, depression, anxiety, unspecified convulsions and…

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

Based on interview and record review, the facility failed to ensure there were clinical indications to support the continued use of an indwelling catheter for 1 of 3 residents reviewed for catheters. (Resident Q) Findings include: A record review for Resident Q was completed on 2/18/2025 at 9:00 A.M. Diagnosis included, but were not limited to osteomyelitis right foot/ankle, diabetes mellitus type 2, anxiety, depression, hypertension, and chronic kidney disease stage 3. A Physician's order, dated 2/7/2025, included the following: Foley (urinary) catheter, size 18 french, 10 milliliter balloon. A Physician's progress note,dated 2/8/2025, indicated Resident Q had a Foley (urinary) catheter. There was no documentation of why the resident required the use of an indwelling urinary catheter. A Nurse Practitioner (NP) note, dated 2/20/2025, indicated Resident Q had redness to her buttocks and a Foley urinary catheter was in place for wound healing. However, there was no documentation of any current open wounds for Resident Q that could have been contaminated by urine. During an interview…

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 follow Physician's orders related to enteral feedings for 1 of 1 resident reviewed for a gastronomy tube (G-tube) (Resident 46). Finding includes: During an observation on 2/11/2025 at 2:53 P.M., a bottle of Osmolite 1.5 (enteral tube feeding) was disconnected from Resident 46 and hanging on an intravenous line (IV) pole. The bottle of Osmolite was not dated and had approximately 200 milliliters (mLs) left in the bottle. During an observation on 2/12/2025 at 10:40 A.M., a bottle of Osmolite 1.5 was disconnected from Resident 46 and hanging on an IV pole. The bottle of Osmolite was dated 2/11/2024 and had approximately 300 mLs remaining in the bottle. During an observations on 2/13/2025 at 1:36 P.M., a bottle of Osmolite 1.5 was disconnected from Resident 46 and was hanging on an IV pole with approximately 200 mLs still remaining in the bottle. The date on the bottle was 2/12/2024. Resident 46's record review was completed on 2/13/2025 at…

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

Based on observation, interview, and record review, the facility failed to assist a resident with a fractured arm apply her continuous positive airway pressure (CPAP) and clean the equipment after use for 1 of 1 residents reviewed for respiratory care. (Resident 23) Finding includes: During an observation and interview on 2/11/2025 at 10:49 A.M., Resident 23's CPAP mask and tubing were lying uncovered on an opened SoClean machine on the right side of the resident's bed. Resident 23 had a splinted right arm propped up on a pillow. During an observation and interview on 2/11/2025 at 2:40 P.M., Resident 23 indicated no one ever cleaned her CPAP, and she did not always wear her CPAP because it was too hard for her to put on by herself with a broken arm. Resident 23 indicated no one had helped her the previous night. During an observation on 2/12/2025 at 2:22 P.M., Resident 23's CPAP mask and tubing was still lying uncovered on an opened SoClean machine. During an observation and interview on 2/13/2025 at 11:15 A.M., Resident 23 indicated she did not wear her CPAP the previous night…

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 follow standards of practice for infection control for 3 of 4 residents who received supplemental oxygen or wore a CPAP (continuous positive airway pressure) machine at night. (Residents 27, 95 and 11) Findings include: 1. During the following observations, Resident 27's CPAP mask was in a SoClean (automated CPAP equipment cleaner and sanitizer) machine. The SoClean machine was not on, did not have a lid and the inside of the machine contained dust. -2/11/2025 at 10:25 A.M. -2/12/2025 at 11:56 A.M. -2/14/2025 at 2:10 P.M. -2/18/2025 at 1:54 P.M. Resident 27's record review was completed on 2/17/2025 at 3:30 P.M. Diagnoses included but were not limited to: Parkinson's disease, sleep apnea, anxiety and dysphagia. A current Physician's order dated, 4/9/2024, indicated Resident 27's CPAP mask was to be placed in the SoClean machine with the tubing intact after it was removed from the resident. A current Care Plan dated, 3/17/2023, indicated Resident 27 had altered respiratory status related to sleep apnea. 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 a Hoyer Lift (a mechanical lift device) was used safely, by staff, for 1 of 3 residents reviewed for accidents. (Resident D) Finding includes: On 9/20/24 at 11:04 A.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to: non-traumatic brain injury, insulin dependent diabetic, seizure disorder and aphasia. A Fall Risk assessment, dated 7/9/24, indicated the resident was a high risk for falls. A Quarterly MDS (Minimum Data Set) assessment, dated 7/11/24, indicated the resident was non-verbal, dependent (helper does all of effort) with all transfers, had no falls and weighed 155 pounds. A Fall Care Plan, initiated on 6/7/23 and revised on 2/2/24, indicated the resident was at risk for an injury related to seizure activity, immobility and increased tone due to a brain injury. The interventions included, but were not limited to: obtain labs as ordered, keep physician informed 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 ensure food was handled appropriately, foods were sealed appropriately, and foods were dated when opened. This had the potential to affect the 120 residents who receive meals from the kitchen. Findings include: 1. During a meal observation , on 3/11/2024 at 12:18 P.M., CNA 8 approached a resident and picked up the residents roll with a bare hand and buttered the roll. The CNA then approached another resident, and with bare hands, picked up the resident's roll and buttered it. CNA 8 approached a third resident and asked about needing a roll buttered. The third resident replied yes, and the CNA picked up the roll with a bare hand and buttered the roll. During an interview, on 3/11/2024 at 12:24 P.M., CNA 8 indicated she should not have touched the food with her bare hands. 2. During a walk-through observation of the main kitchen, on 3/11/2024 at 9:40 A.M., with dietary staff 7, the following was observed in the walk-in freezer: an open, unsealed bag of chicken tenders without a label or date, an open 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 develop a person-centered care plan for 1 of 26 residents whose care plans were reviewed. (Resident 45) Finding includes: During an observation, on 3/12/2024 at 10:17 A.M., a black, scabbed, lesion was noted to the right side of Resident 45's jaw. The resident indicated it kept bleeding and the doctor had not looked at it. A record review was conducted on 3/13/2024 at 1:23 P.M. Diagnoses for Resident 45 included, but were not limited to, metabolic encephalopathy, collapsed vertebrae in thoracic region, and pain in thoracic spine. An Annual Minimum Data Set (MDS) assessment, dated 1/15/2024, indicated Resident 45's cognition was intact. She was at risk for pressure ulcers, but none were noted. No other skin problems were noted. The record lacked any physician orders or a care plan related to the skin lesion on her jaw. During an interview, on 3/14/2024 at 10:31 A.M., LPN 5 indicated the Nurse Practitioner (NP) looked at it last year and thought a referral was made to a dermatologist, but couldn't be sure.…

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 update a fall care plan with new interventions after a fall, for 1 of 3 residents reviewed for falls. (Resident 111) Finding includes: During an interview, on 3/11/2024 at 2:47 P.M., Resident 111 indicated he had a recent fall, but was unsure when. A record review was completed on 3/13/2024 at 1:22 P.M. The resident had intact cognition, with diagnoses including, but not limited to: type two diabetes, concussion without loss of consciousness, history of transient ischemic attack and cerebral infarction. An admission Minimum Data Set (MDS) assessment, dated 2/6/2024, indicated the resident required extensive assistance with the assist of one person for bed mobility, transferring and toileting and supervision with the assist of setup help for eating. An Interdisciplinary Team Note, dated 2/20/2024, indicated the resident had slid out of his wheelchair and the intervention included therapy assessment of cushion with anti-slip device placement. An Interdisciplinary Team Note, dated 3/6/2024, indicated the resident had fallen…

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 administer a PRN (as needed) diuretic medication per Physician's Orders, for 1 of 5 residents whose medication orders were reviewed. (Resident 174) Finding includes: During an interview, on 3/11/2024 at 2:37 P.M., Resident 174 was observed to have edema (swelling) to bilateral (both) feet. A record review was completed on 3/14/2024 at 10:41 A.M. Resident 174's diagnoses included, but were not limited to chronic congestive heart failure, chronic kidney disease, pacemaker, and a cardiac defibrillator. Current Physician Orders included: Daily Weights: See PRN (as needed) medication order for weight gain of 2 lbs. (pounds) or greater in 24 hour in the morning. Lasix (diuretic) 20 mg (milligram) give 1 tablet by mouth every 24 hours as needed for CHF (Congestive Heart Failure) for weight gain of 2 lbs. or greater in 24 hours. Resident 174's current weights were as follows: 3/7/2024--245 lbs. 3/8/2024--245 3/10/2024--238 3/11/2024---247 (gain of 9 lbs.) 3/12/2024--248 3/13/2024--250 3/14/2024--251 The March 2024…

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 oxygen equipment was stored appropriately and cleaned, for 2 of 3 residents reviewed for oxygen use. (Residents 8 & 83) Findings include: 1. During an observation, on 3/11/2024 at 2:33 P.M., Resident 8's CPAP mask was lying on top of the bedside dresser, not placed in the SloClean machine and without a storage bag. During an observation, on 3/12/2024 at 8:57 A.M. the resident's CPAP mask was lying on top of the bedside dresser, not placed in the SloClean machine and without a storage bag. During an observation, on 3/13/2024 at 9:50 A.M., the resident's CPAP mask was lying on top of bedside dresser, not placed in the SloClean machine and without a storage bag. During an observation, on 3/14/2024 at 1:34 P.M., Resident 8's CPAP mask was not bagged and was lying on top of the dresser, not in the SloClean machine and without a storage bag. During an interview, on 3/14/2024 at 1:30 P.M., the Director of Nursing indicated CPAP masks should be kept in the SloClean Machine for cleaning purposes while not 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 a resident received person centered dementia care for 1 of 1 residents reviewed for dementia care. (Resident 6) Finding includes: A random observation was completed on 3/13/2024 at 9:53 A.M. Resident 6 was in the restroom yelling out she was going to sue the facility because she did not want the help from the two CNAs trying to help her. CNA 8 was heard telling the resident she was going to get the paperwork and a pen so the resident could sue the facility. An interview with CNA 8 was completed on 3/13/2024 at 9:55 A.M. CNA 8 indicated there were no excuses for what she said to Resident 6, and she should not have told Resident 6 that she was going to get paperwork and a pen to sue the facility. A record review was completed on 3/13/2024 at 2:15 P.M. Resident 6's diagnoses included, but were not limited to: dementia, pseudobulbar affect, traumatic brain injury, anxiety disorder, major depressive disorder, and obsessive-compulsive disorder. A Quarterly MDS (Minimum Data Set) assessment, dated 2/7/2024,…

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.

Bases on observation, interview, and record review, the facility failed to properly label medications with the patient identification and date the medication was opened, for 3 medications found in 2 of 6 medication carts. (Northwest Cart 1 & East cart 1). The facility also failed to maintain a clean and sanitaty environment for medication storage to preserve medication integrity, for 1 of 6 medication carts observed. (Riverlane Cart) Findings include: 1. During an observation of the Northwest Cart 1 with RN 4, on 3/14/2024 at 9:15 A.M., a bottle of Flonase was found open, but no open date was noted. During an interview, on 3/14/2024 at 9:15 A.M., RN 4 indicated the Flonase should have had an open date on the box. 2. During an observation of the East Cart 1 medication cart with LPN 13, on 3/14/2024 at 2:54 P.M., 2 sealed bottles of nitroglycerin tablets were in the drawer, with no label or patient identifier information. During an interview, on 3/14/2024 at 2:54 P.M., LPN 13 indicated she did not know to whom the nitroglycerin belonged, and they should be labeled. A current policy…

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.