Majestic Care Of South Bend

Based on observation, interview and record review the facility failed store and prepare food in a sanitary manner related to labeling and dating of opened food in the walk-in cooler and disposing of expired spices in 1 of 1 kitchens observed. This had the potential to effect 72 of 74 residents who received their meals from the kitchen. Finding includes: 1. During the initial kitchen tour with the DM (Dietary Manager) on 9/30/2024 at 9:44 A.M., the following food items were observed in the walk-in cooler: -Eight single serve cheese cups did not have a made on or use by date. -Half a bag of salad mix was open but did not have an opened on or use by date. -A bag of celery was open and did not have an opened on or use by date. -7 bowls of salad with clear cellophane wrap did not have a made on or use by date. 2. During the initial kitchen tour with the DM on 9/30/2024 at 9:52 A.M., the following food items were observed in the dry storage areas: - Whole celery seed was opened 7/7/23 and had an expiration date of 1/30/24. - Poultry seasoning was opened but had no opened on date and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record review, the facility failed to provide a dependent resident an assistive device for 1 of 1 residents reviewed for accommodation of needs. (Resident 3) Finding includes: During a family interview on 9/30/2024 at 2:25 P.M., the responsible party for Resident 3 indicated he was concerned Resident 3 did not have a wheelchair to get out of bed. The family member indicated Resident 3 was always in bed when he visited and did not see a wheelchair in his room. Resident 3's family member indicated he would like him to get out of the bed. During an observation on 10/1/2024 at 9:53 A.M., 10/2/2024 at 9:45 A.M., 10/2/2024 at 2:24 P.M., 10/3/2024 at 9:09 A.M., 10/3/2024 at 11:57 A.M., and 10/4/2024 at 1:29 P.M. Resident 7 was in bed and no wheelchair was in the room. A record review was completed on 10/2/2024 at 1:37 P.M., for Resident 3. Diagnoses included, but not limited to: hemiplegia, unspecified affecting left dominant side, vascular dementia, unspecified severity, with other behavioral…

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 SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) Form was provided following the end of Medicare skilled services for 1 of 1 resident who discharged from Medicare services and remained in the facility. (Resident 45) Finding includes: During a review of Beneficiary Notification forms, conducted on 10/4/2024 at 8:45 A.M., a Notice of Medicare Non-Coverage (NOMNC) form had been provided to Resident 45 on 6/26/2024 and indicated the resident's Medicare coverage was ending on 6/28/2024. There was no SNF-ABN (a form that informs a beneficiary that medicare may not pay for a service or item they intend to receive) provided to Resident 45. During an interview on 1/4/2024 at 8:54 A.M., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed. The form was blank in response to whether Resident 45 received the SNF-ABN form. Resident 45 was provided a Notice of Medicare Non-Coverage (NOMNC) Form which indicated Resident 45's Medicare coverage would end on 6/28/2024. 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 interview and record review, the facility failed to provide the resident, or the resident's representative, with a notice of transfer form for 2 of 2 residents reviewed for hospitalization. (Residents 8 and 59) Findings include: 1. A record review was completed on 10/3/2024 at 2:47 A.M. for Resident 8. Diagnoses included type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact. During an interview on 9/30/2024 at 2:30 P.M., Resident 8 indicated he had been hospitalized a few months ago but did not remember the specific date. Resident 8 had been sent to the emergency room and was admitted to the hospital on the following dates: -2/21/2024. -3/11/2024. -8/12/2024. The record lacked documentation the facility had provided Resident 8 a Notice of Transfer/Discharge for any of the hospitalizations. During an interview on 10/3/2024 at 2:35 P.M., the Executive Director (ED) indicated there was no documentation the Notice of Transfer/Discharge form was…

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

Based on interview and record review, the facility failed to provide the resident, or the resident's representative, with a copy of the Bed Hold Policy when sent to the hospital for 2 of 2 residents reviewed for hospitalization. (Residents 8 and 59) Findings include: 1. A record review was completed on 10/3/2024 at 2:47 A.M. for Resident 8. Diagnoses included type 2 diabetes mellitus with neuropathy, bladder cancer, anxiety and depression. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact. During an interview on 9/30/2024 at 2:30 P.M., Resident 8 indicated he had been hospitalized a few months ago but did not remember the specific date. Resident 8 was sent to the emergency room and admitted to the hospital on the following dates: -2/21/2024. -3/11/2024. -8/12/2024. The record lacked documentation the facility provided Resident 8 a copy of the Bed Hold Policy for any of the hospitalizations. During an interview on 10/3/2024 at 2:35 P.M., the Executive Director (ED) indicated there was no documentation a copy of 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 interview and record review, the facility failed to develop a person-centered care plan regarding fluid needs for 1 of 18 residents whose care plans were reviewed. (Resident 8) Finding includes: A record review was completed on 10/01/2024 at 2:25 P.M. for Resident 8. Diagnoses included type 2 diabetes mellitus with neuropathy and congestive heart failure. A Quarterly Minimum Data Set (MDS) assessment, dated 7/10/2024, indicated Resident 8's cognition was intact. Physician's Orders for Resident 8 included, but were not limited to: -6/28/2024 2000 milliliter (ml) daily fluid restriction for edema and congestive heart failure. -4/3/2024 Furosemide 40 milligrams (mg) by mouth two times a day related to hypertensive heart disease and congestive heart failure. A current Care Plan, initiated on 9/12/2022, indicated Resident 8 was at risk for a fluid imbalance related to acute kidney failure and diuretic use. Interventions included, but were not limited to: staff was to educate the resident and family on the importance of the fluid restriction, as well as the risks and 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 resident were assisted with personal hygiene and showers for 3 of 4 records reviewed for Activities of Daily Living (ADL). (Resident 3 & 24) Findings include: 1. During a family interview on 9/30/2024 at 3:08 P.M., the responsible party indicated he did not think Resident 3 had been getting up out of bed to be given a shower. During an observation on 10/1/2024 at 9:53 A.M., 10/3/2024 at 9:09 A.M. and on 10/4/2024 at 9:03 A.M., Resident 3 had long finger nails with a brown substance under them. A record review was completed on 10/2/2024 at 1:37 P.M., for Resident 3. Diagnoses were included, but not limited to: hemiplegia, unspecified affecting left dominant side, vascular dementia, unspecified severity, with other behavioral disturbance and acquired absence of right leg below knee. A Quarterly Minimum Data Set (MDS) assessment, dated 9/25/2024, indicated Resident 3 had severe cognitive impairment, had limited range of motion to one side of his body and bathing and personal hygiene needs were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to follow the Physician's orders related to flushing a G-tube (gastrointestinal tube) and changing the tubing for 2 of 2 residents who were reviewed for a G-tube. (Resident 222 & 7) Findings include: 1. During an interview on 10/1/2024 at 9:57 A.M., Resident 222 indicated his G-tube was not being used for nutrition or medications but it was supposed to be flushed twice a day. He indicated his G-tube had only been flushed once since his admission on [DATE]. During an interview on 10/2/2024 at 10:40 A.M., Resident 222 indicated his G-tube had not been flushed the last two days. During an observation on 10/2/2024 at 10:41 A.M., no medical equipment for flushing a G-tube was located in the residents room, bathroom or trash can. Resident 222's record review was completed on 10/2/2024 at 11:45 A.M. Diagnoses included, but were not limited to: paraplegia, fusion of lumbar spine, neurogenic bowel and neuromuscular dysfunction of bladder. A current…

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

Based on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 4 residents (Resident 28 & 35) observed during medication pass. There were 25 opportunities observed with 2 medication errors, resulting in a medication error rate of 8 percent. Findings include: 1. During an observation and interview on 10/2/2024 at 9:15 A.M., RN 11 did not have Resident 28's fluticasone propionate available to administer and indicated she would call the pharmacy. A record review was completed on 10/2/2024 at 10:00 A.M., for Resident 28. Diagnoses included but were not limited to: chronic pain syndrome and allergies. A Physician's Order, dated 3/28/2024, indicated Fluticasone Propionate suspension 50 micrograms (MCG) one spray in each nostril one time a day for allergies. 2. During an observation and interview on 10/2/2024 at 10:11 A.M., for Resident 35, RN 11 indicated she did not know why there were two inhalers in the opened bag in the medication drawer. She indicated neither inhaler had an opened date 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 infection control practices were carried out appropriately for the storage of respiratory equipment, catheter care, blood sugar monitoring and cleaning of a glucometer for 3 of 3 residents observed for infection control. (Resident 13, 21 & 26) Findings include: 1. During an observation on 10/1/2024 at 11:14 A.M., QMA 14 cleaned Resident 26's finger with an alcohol wipe then fanned the area with her hand. When she returned to the medication cart, she placed the unsanitized glucometer in a basket on top of supplies used for blood sugar monitoring and walked away. During an interview on 10/1/2024 at 11:18 A.M., QMA 14 indicated she was not sure if she could wave her hand over the finger and cleaning of the glucometer with a bleach wipe should have occurred after returning to the cart. 2. On 10/3/2024 at 9:05 A.M., a record review was completed for Resident 13. Diagnoses included, but were not limited to: urinary tract infection, human immunodeficiency virus, and obstructive reflux uropathy. A review of 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 maintain a safe and sanitary environment related to monitoring personal refrigerator temperatures and disposing of expired food in personal refrigerators for 3 of 3 residents who used personal refrigerators. (Residents 21, 44 & 45) Findings include: 1. During an observation on 9/30/2024 at 10:13 A.M., Resident 21's personal refrigerator had a temperature log form with the month labeled as August and no temperatures were recorded for any of the dates. During an observation on 9/30/2024 at 2:00 P.M., Resident 44's personal refrigerator had a temperature log form with the month labeled as August and no temperatures were recorded for any of the dates. During an observation on 9/30/2024 at 2:19 P.M., Resident 45's personal refrigerator had a temperature log form with the month labeled as July and had temperatures recorded only on 7/5/2024, 7/6/2024, 7/8/2024, 7/9/2024 and 7/10/2024. 2. During an observation on 9/30/2024 at 2:19 P.M., Resident 45's personal refrigerator contained the following expired food: - 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 a Licensed Nurse followed standards of practice, during a medication administration, related to observation of mediation consumption for 1 of 1 residents observed during a random observation. (Resident Q) Finding includes: During a random observation and interview, on 8/20/2024 at 11:25 A.M., Resident Q had a breakfast tray and a small clear cup of containing multiple medications on his bedside table, approximately five feet from his bed. He indicated he did not know the medications were on the table and stated it was not unusual for them to be left in the room. Resident Q indicated his medications often ended up on the floor because it was not communicated to him that his medications had been left on the bedside table. On 8/20/24 at 11:39 A.M., LPN 11, an agency staffing nurse, summoned to Resident Q's room to verify the cup of medications observed were Resident Q's medications. LPN 11 indicated the medications were Resident Q's medications and asked had asked the resident if he was ready to take them,…

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 3 of 3 residents reviewed for facility initiated transfers to a local hospital for dialysis treatments, received documentation including a statement of notification of the transfer, appeal rights, a copy of the bed hold policy and the Ombudsman's information. (Resident E, D and F) Findings include: 1. During an interview, on 8/19/24 at 1:05 P.M., Resident E's sister indicated Resident E was unable to breath, on 8/14/24, and had been transferred to a local emergency room (ER) where she required an immediate dialysis treatment. On 8/20/24 at 2:50 P.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but were not limited to, End Stage Renal Disease (ESRD), dependence on renal dialysis, congestive heart failure and respiratory failure. Nursing Progress Notes were reviewed from 8/12/24 through 8/14/24 and there were no nursing assessments documented for Resident E, who had not received her regularly…

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 there were a sufficient number of licensed nurses (RN/LPN) to provide care and services to 1 of 2 nursing units (Skilled/Rehabilitation Unit.) This directly affected 5 of 10 residents reviewed for care needs. (Resident D, B, H, L, and K) See F678 for additional information regarding Resident D. See F755 for additional information regarding Residents B, L, K and D Finding includes: On [DATE] at 11:13 A.M., a review of the clinical record for Resident D was conducted. The resident's diagnoses included, but were not limited to: necrotizing fasciitis (flesh eating disease) to a sacral wound, insulin dependent diabetic, End Stage Renal Disease with hemodialysis and history of a cardiac arrest. A Care Plan, dated [DATE], indicated the resident was at risk for complications, related to medical conditions, medications and treatments. The interventions included, but were not limited to, observe for signs/symptoms of complications 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 and interview, the facility failed to ensure 1 of 3 shower rooms were cleansed after use. This had the potential to affect all 55 residents residing on the South unit, Finding includes: On 7/9/24 at 10:52 A.M., the following was observed in shower room A, on the South Unit: -An opened package of wipes on the sink. -Brief packages lying on top of a dresser/drawer. -A moderate size smear of a brown substance in front of toilet. -A smear of white substance on left assist bar, for the toilet. -Used towels on a cart. -A large chair with a wet sheet on it. -Trash in bags on floor near the door. During an observation of the South shower room A on 7/9/24 at 2:21 P.M., with Unit Manger the following was observed: -An opened package of wipes on the sink. -Brief packages lying on top of a dresser/drawer. - A moderate size smear of a brown substance in front of toilet. -A smear of white substance on left assist bar, for the toilet. -Used towels on a cart. -A large chair with a wet sheet on it. -Trash in bags on floor near the door. During an interview on 7/9/24 at 2:26…

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 residents received medications and treatments in accordance with physician orders and per facility policy for 4 of 6 residents reviewed for nursing services, (Residents B, L, K & D). Findings Include: 1. A record review was completed for Resident B on 7/11/24 at 12:28 P.M. The diagnoses included, but were not limited to, cellulitis of right lower limb, type 2 diabetes, chronic obstructive pulmonary disease, atrial fibrillation, heart failure, stage 2 pressure ulcer. An admission Minimum Data Set (MDS) assessment, dated 5/22/24, indicated Resident B was cognitively intact, was admitted with one stage 2 pressure area and one stage 4 pressure area.and received 7 days of insulin injections in the previous 7 days of the assessment period. The current Physician's Orders included: -Accu Check 3 times daily before meals and at bedtime related to diabetes, ordered 5/17/24 with no end date. -Insulin Aspart Injection solution 100 unit/ml per sliding scale 3 times daily, ordered 5/16/24 with no end date.…

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 report an allegation of resident to resident abuse to local law enforcement within 24 hours as directed by the facility's policy, when 2 residents were allegedly involved in a physical altercation, resulting in forehead bruising to both residents, (Resident B and Resident C). Findings include: On 2/19/24 at 11:35 A.M., Indiana State Department of Heath Survey Report System, Incident Number 346, indicated, on 1/27/24 at 10:40 A.M., it was reported that Resident B made contact with Resident C and hit him in the face in the hallway while waiting to smoke. The residents were immediately separated, head to toe assessments were completed to note reddened areas to the foreheads of both residents. The report indicated the physician, administrator, and family were notified, Resident B was placed on 15 minute safety checks, and the residents would be separated during activities. On 2/19/24 at 1:35 P.M., during an interview with the Administrator, she indicated the incident was not reported to local law enforcement because neither…

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 thoroughly investigate an allegation of resident to resident abuse when 2 residents were allegedly involved in a physical altercation resulting in forehead bruising to both residents, (Resident B and Resident C). Findings include: On 2/19/24 at 11:35 A.M., Indiana State Department of Heath Survey Report System, Incident Number 346, indicated on 1/27/24 at 10:40 A.M., it was reported that Resident B made contact with Resident C and hit him in the face in the hallway while waiting to smoke. The residents were immediately separated, head to toe assessments were completed to note reddened areas to the foreheads of both residents. The report indicated the physician, administrator, and family were notified, Resident B was placed on 15 minute safety checks, and the residents would be separated during activities. 2/19/24 at 1:35 P.M., during an interview with the Administrator, she indicated she felt the facility's investigation was thorough. She indicated there were no staff statements taken because Registered Nurse (RN) 9…

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 representative was notified timely, when there was an acute change in the resident's condition. (Resident F) Finding includes: On 1/8/24 at 11:10 A.M., a review of the clinical record for Resident F was conducted. The resident's diagnoses were dementia and non-traumatic brain dysfunction. A Care Plan, dated 9/15/23, indicated the resident had advance directives and wished to be a full code. The interventions included but were not limited to: support resident/family with ongoing decisions, notify physician and representative of changes in the resident's condition. A Change of Condition Assessment form, dated 1/3/24 at 7:30 A.M., indicated at the time of the evaluation the resident's vital signs were: blood pressure 72/51, pulse 90, respirations 24 and temperature was 98.0. The resident's pulse oximetry was 98% on room air. The resident was a full code, however the resident had not been able to swallow, had labored/rapid breathing, had abnormal vital signs and had been lethargic. The recommendations…

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 1 of 3 residents reviewed received appropriate interventions when there had been an acute change of condition. (Resident F) Finding includes: On 1/8/24 at 11:10 A.M., a review of the clinical record for Resident F was conducted. The resident's diagnoses were dementia and non-traumatic brain dysfunction. A Care Plan, dated 9/15/23, indicated the resident had advance directives and wished to be a full code. The interventions included but were not limited to: support resident/family with ongoing decisions, notify physician and representative of changes in the resident's condition. A Progress Note, dated 1/3/24 at 6:30 A.M., indicated .Resident calmly resting in bed, R 24; T 98.0; P 90; B/P 72/51; O2 Sat 98% on room air. Resident is responsive to touch, only moans when being turned and repositioned. House NP (Nurse Practitioner) and DON (Director of Nursing) updated on resident's current condition. Will continue to monitor This Progress Note had been documented by LPN 2 A Change of Condition Assessment form, completed…

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 medications were labeled and dated in 1 of 2 medication storage rooms and 1 of 2 medications carts. Findings include: 1. During an observation of the South Medication Room, on 8/23/2023 at 3:08 P.M., with the North Unit Manager, an opened bottle of Konvomep insulin for Resident 137 was located in the refrigerator. The North Unit Manager confirmed there was no open date and indicated there should have been. 2. During an observation of the North Medication Cart, on 8/24/2023 at 2:30 P.M., with QMA 11, the following medications were noted to be labeled and opened but had no date to indicate when they had been opened: A bottle of Lispro insulin for Resident 138. A tube of Mupiricon ointment for Resident 46. A Trilegy inhaler for Resident 46. A Flutiicasaline aerosol vial for Resident 46. An albuterol inhaler for Resident 41. A large container of Peg 3350 powder for Resident 12. A large container of Peg 3350 powder for Resident 34. A large bottle of Milk of Magnesia for Resident 12. A large bottle 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 items and drinks were covered when transporting 15 trays to residents who resided on the North hallway who received a meal tray on 8/21/23. Finding includes: During an interview, on 8/21/23 at 11:59 A.M., Resident C indicated he eats in his room, receives a tray of food and the only thing covered is the main dish. The rest of the meal had no lids, to cover the food. Resident indicated this morning his oatmeal had no cover on it and he won't eat anything that doesn't have a lid on it. He indicated he doesn't know if someone coughed over it or what. On 8/21/23 at 12:14 P.M., the Resident C's meal tray arrived to the room and was observed to have no lid or covering over his coffee, water, fruit or vegetable. On 8/21/23 at 12:18 P.M., Resident 140's meal tray was observed being transported down the hallway to his room. The tray was observed to have coffee, fruit and water, uncovered, on the tray. The staff member carrying the tray down the hallway indicated she transports the meal trays from the…

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

Based on observation, interview and record review, the facility failed to ensure the north shower room had shower drains without debris covering them, this had the potential to effect 20 of 20 residents who used the shower room. Finding includes: On 8/20/23 at 5:58 P.M., the north shower room was observed to have 3 shower heads and drains. The drain the farthest from the entry door had half the drain covered over with hair. The middle drain had a wet empty sugar packet covering 1/4 of the drain. On 8/25/23 at 2:22 P.M., the north shower room was observed and the drain furthest from the entry door had half the drain covered with hair. The middle drain had a piece of the sugar packet lying inside the drain. During a tour of the north shower room, on 8/25/23 at 3:05 P.M., with the Housekeeping Director and the Corporate Administrator from a sister facility, the entry door was observed to have a notice on the door indicating Floor Wet. The Housekeeping Director indicated the shower room had just been cleaned. The drain furthest from the door was observed with hair covering half 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, record review and interviews, the facility failed to ensure 28 residents with resident trust accounts had access to more than $50.00 of their funds on a daily basis and had reasonable access after hours and on weekends. Finding includes: During an interview with alert and oriented, Resident 15, on 8/22/2023 at 11:34 A.M., she indicated she could not access her resident fund money after 5:00 P.M.on Fridays. During an interview with alert and oriented, Resident 41, on 8/21/2023 at 2:09 P.M., he indicated resident fund money was only available if the Business Office Manager was in the building. During a review of the resident trust accounts and interview with the Business Office Manager, on 8/25/2023 at 9:30 A.M., she indicated residents only had access to $50.00 of their resident funds per day during the front receptionist hours. The Business Office Manager indicated $50.00 was the daily limit per the company policy. She indicated there was no system to allow residents to access more than $50.00 per day. On the weekend, the facility had recently started…

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 there was documentation 1 of 28 residents with a resident trust account exceeding the Medicaid allowable limit was notified of the regulation. (Resident 71) Finding includes: During a review of the facility Resident Trust Accounts, on 8/25/2023 at 9:30 A.M., with the Business Office Manager, she disclosed Resident 71, a Medicaid funded resident's Resident Trust Account exceeded the allowable Medicaid limit. Review of the account ledger for Resident 71's Resident Trust Account, the resident had $4, 614.73 on 5/30/2023. The resident's current account balance, on 8/16/2023, was $3, 404.95. During an interview with the Business Office Manager, on 8/25/2023 at 9:30 A.M., she indicated she had verbally spoken with Resident 71 regarding her account balance. There was no documentation regarding the conversation, the Business Office Manager was unable to give a date she had spoken with the resident and although the resident's trust fund account balance was lower, it still exceeded the Medicaid limitation. 3.1-6(h)

Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents interviewed were free of verbal abuse. (Resident E) Finding includes: On 8/23/23 at 10:22 A.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but was not limited to: End Stage Renal Disease (ESRD), heart failure, diabetic, dependent on dialysis, respiratory failure-dependent on supplemental oxygen and morbid obesity. A Progress Note, dated 8/5/23 at 2:46 P.M., written by RN 5 indicated the resident had a behavior that morning. The Note indicated the resident had waited awhile for CNA 6 and when she arrived, to the room, the resident had taken her own brief off and had thrown it on the floor. RN 5 talked to the resident concerning her behavior with CNA 6. A Progress Note, dated 8/9/2023 at 2:08 P.M., indicated the Interdisciplinary Team (IDT) met with Resident E's sister regarding the incident on 8/5/23. The sister was informed the incident was reported to the Indiana Department of Health and CNA 6 was suspended pending an investigation.…

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 that notification of the Ombudsman was made in a timely manner of resident's discharge from the facility for 1 of 1 resident reviewed for notification of discharge. (Resident 86) Finding includes: A clinical record review was completed on, 8/23/2023 3:17 P.M., diagnoses for Resident 86 included, but were not limited to: systemic lupus erythematosus, Human Immunodeficiency Virus, bipolar disorder manic with psychotic features, anxiety disorder, schizoaffective disorder. An MDS (Minimum Data Set) assessment was initiated on 6/16/2023 and not completed. Resident 86 was admitted [DATE] and sent to the hospital on 6/17/2023. Resident 86 returned to facility 6/20/2023 and sent to the hospital on 6/21/2023 with discharge not anticipated. A Progress Note, dated 6/17/2023 at 9:21 P.M., indicated .stated that she is hearing voices in her mind and was put on fifteen minutes checks A Progress Note, dated 6/17/2023 at 9:30 P.M., indicated .trying to put 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, record review and interview, the facility failed to ensure care plans were developed for 1 of 28 residents reviewed. (Resident 11) Finding includes: A record review for Resident 11 was completed on 8/22/2023 at 3:22 P.M. Diagnoses included, but were not limited to: type 2 diabetes, moderate protein-calorie malnutrition, acquired total absence of pancreas, and chronic pain syndrome. During an interview, on 8/20/2023 at 4:37 P.M., Resident 11 was concerned with going blind in his left eye. He was seen by the facility eye doctor and he was told of a cataract in his left eye that needed to be removed. A Quarterly Minimum Data Set (MDS) assessment, dated 11/3/2022, indicated he had impaired vision. A Progress Note, dated 10/31/2022, from the (name of provider)indicated that the patient wants to proceed with surgery. Cataract surgery recommended, ophthalmology consult with follow up in 4-5 months. A Progress Note, dated 4/19/2023, from the (name of provider) indicated patient wanted to proceed with surgery, cataract surgery recommended and ophthalmology consult for…

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

Based on interview, observation and record review, the facility failed to ensure the care plan was revised and residents were invited to care plan meetings for 1 of 29 residents whose care plans were reviewed. (Resident 26 ). Finding includes: During an interview, on 8/21/23 9:59 A.M., Resident 26 indicated that he had not been invited routinely or included in care plan meetings. He indicated he was his own representative. During an interview, on 8/25/2023 at 10:01 A.M., with the MDS (Minimum Data Set) nurse, she indicated the Care Plan review pops up every quarter with the MDS assessment reminder and both the assessment and care plan were revised at the same time. She indicated the care plan invitations came from the social services department and the new social worker had just started that week. During an interview, on 8/25/2023 at 2:38 P.M., the Regional Nurse indicated there was no documentation the resident had been invited, notified or included in the care plan meetings. 3.1-35(c)(2)

Based on observations, record reviews, and interviews, the facility failed to provide shaving for 2 of 3 residents reviewed (Residents 7 and 41) and nail care for 1 of 3 residents reviewed (Resident 41) who were unable to perform these tasks. Findings include: 1. During an observation and interview, on 8/21/2023 at 2:21 P.M., Resident 41 had not been shaved and his fingernails were long with dark brown matter under them. The resident indicated that he would like to be shaved but it is not done, even when he asks. The same problem occurred with his fingernails. A record review, conducted on 8/23/2023 at 11:31 A.M., indicated Resident 41's diagnoses included, but were not limited to: Parkinson's disease and chronic obstructive pulmonary disease. A Quarterly MDS (Minimum Data Set) assessment, dated 7/28/2023, indicated Resident 41 had no cognitive deficits. He required extensive assist of 1 staff for bed mobility, transfers, and toileting. He needed limited assist of 1 for dressing and eating. A Care Plan dated 11/21/2022, reviewed/revised 11/22/2022, included, but was not limited 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.

Based on observation, interview, and record review the facility failed to arrange an ophthalmology follow up appointment for 1 of 1 resident reviewed for vision and hearing. (Resident 11) Finding includes: A record review for Resident 11 was completed on 8/22/2023 at 3:22 P.M. Diagnoses included, but were not limited to: type 2 diabetes, moderate protein-calorie malnutrition, acquired total absence of pancreas, and chronic pain syndrome. During an interview on 8/20/2023 at 4:37 P.M., Resident 11 was concerned with going blind in his left eye. He was seen by the facility eye doctor and he was told of a cataract in his left eye that needed to be removed. A Quarterly Minimum Data Set (MDS) assessment, dated 11/3/2022, indicated he had impaired vision. A Progress Note, dated 10/31/2022, from the [name of provider] indicated that the patient wanted to proceed with surgery. Cataract surgery was recommended, ophthalmology consult with follow up in 4-5 months. A Progress Note, dated 4/19/2023, from the [name of provider] indicated the patient wanted to proceed with surgery. Cataract surgery…

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 with significant weight loss received fortified pudding as ordered for 1 out of 4 reviewed for nutrition. (Resident 13) Finding includes: The record review for Resident 13 was completed on 8/23/2023 at 10:00 A.M. Diagnoses included, but not limited to: anorexia, dementia without behavioral disturbances and chronic kidney disease stage 2. A Quarterly Minimum Data Set (MDS) assessment, dated 6/27/2023, indicated a weight loss. A Nutrition/Dietary Note, dated 7/13/2023, indicated Resident 13 triggered at 180 days significant weight loss of 11 pounds which is 9.8 % on 7/3/2023. Weight taken on 7/11 indicated an additional 9 pound weight loss in one week. Changed appetite stimulant the previous week. The current diet was continued, ice cream was discontinued at lunch and dinner and fortified pudding for lunch and dinner were started. A Physician Order, dated 4/7/2023, indicated Regular diet Dys Adv texture, Regular (None/Thin) consistency, fortified pudding with lunch and dinner. A Care Plan,…

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 oxygen and respiratory equipment use was ordered and care planned for 2 of 28 residents reviewed for respiratory needs. (Resident 28 and 41) Findings include: The clinical record for Resident 28 was reviewed on 8/23/2023 at 2:21 P.M. Resident 28 was admitted to the facility on [DATE] with diagnoses included, but not limited to: s/p cerebral vascular disease, hypertensive heart disease, atherosclerotic heart disease, type 2 diabetes mellitus, osteoarthritis left knee and hip, chronic gout, hyperlipidemia, dysphagia following cerebral vascular accident and sleep disorder. The most recent Minimum Data Set (MDS) assessment for Resident 28, completed on 8/8/2023 indicated the resident was moderately cognitively impaired,, had not exhibited any behaviors, and required extensive staff assistance of one staff for bed mobility, wheelchair locomotion, dressing and personal hygiene and required the staff assistance of two staff for transfers…

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 a plan was in place to provide trauma-informed care for 1 of 1 residents reviewed for Post Traumatic Stress Disorder. (Resident 44) Finding includes: 1. The record for Resident 44 was reviewed on 8/22/2023 at 2:44 P.M. Resident 44 was admitted to the facility with diagnosis, including but not limited to: type 1 diabetes mellitus, proliferate diabetic retinopathy without macular edema, legal blindness, post traumatic stress disorder (PTSD)\, bipolar disorder and schizoaffective disorder, bipolar type. The following diagnosis were added on 7/7/2023: intermittent explosive disorder and mild cognitive impairment of uncertain or unknown etiology, other problems elated to housing an economic circumstances and problems related to other legal circumstances. The resident was sent for an in patient psychiatric stay on 7/3/2023 and was readmitted to the facility on [DATE]. The initial MDS assessment, completed for the admission assessment, 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 interview and record review, the facility failed to ensure medication was available for administration in 2 of 3 residents reviewed who received anxiolytic (anti-anxiety) medication. (Resident C and G) Finding includes: During an interview, on 8/21/23 at 1:45 P.M., Resident C indicated he was supposed to take 3 medications in a certain time frame, like Valium but with a different name, to keep his leg from spasming. He doesn't believe there is a back up pharmacy and the back up medications in the facility isn't kept full and runs out often. On 8/26/23 at 10:12 A.M., a review of the clinical record for Resident C was conducted. The resident's diagnoses included, but was not limited to: nontraumatic compartment syndrome of left lower extremity, epilepsy, schizoaffective disorder-bipolar, cognitive communication deficit, anxiety and muscle weakness/spasms. A copy of the hand written prescription, dated 5/2/23, indicated .Diazepam 2.5 mg [milligrams] PO [by mouth] in the afternoon A copy of the handwritten prescription, dated 5/2/23, indicated .Diazepam 5 mg [milligrams] PO [by…

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

Based on observation, record review, and interview, the facility failed to ensure a pharmacy recommendation for a PRN medication was re-evaluated and signed by a physician for 1 out of 5 residents reviewed for unnecessary medication. (Resident 11) Finding includes: A record review for Resident 11 was completed on 8/22/2023 at 3:22 P.M. Diagnoses included, but were not limited to: type 2 diabetes, moderate protein-calorie malnutrition, acquired total absence of pancreas, and chronic pain syndrome. A Pharmacy Recommendation, created between 4/1/2023 and 4/5/2023, for Resident 11, indicated .This resident has a PRN order for Compazine. Compazine or prochlorperazine is considered an anti-psychotic though it can be used to treat nausea and vomiting. Therefore, according to federal requirement, a PRN order for Compazine is limited to 14 days. A new PRN order cannot be renewed unless the attending physician or prescribing practitioner first evaluates the resident to determine if entering a new order for the PRN medication is appropriate. If Compazine is being used to treat nausea 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 interviews, the facility failed to ensure insulin was administered at the correct time for 1 of 2 residents reviewed for insulin administration. (Resident 2) Finding includes: On 8/23/2023 at 10:15 A.M., LPN 5 was notified of the need to observe blood glucose assessments and insulin administration prior to the noon meal. LPN 5 indicated she had three residents on her cart for whom she checked blood sugar levels and administered insulin. LPN indicated she usually completed the assessment between 11:00 - 11: 30 A.M. On 8/23/2023 at 11:15 A.M., LPN 5 was not observed on her nursing unit. She returned to the nursing unit at 11:40 A.M. and indicated she had already assessed blood sugar levels and administered her insulin for the noon meal. Review of the medication administration record for Resident 2, on 8/23/2023 at 3:00 P.M., indicated LPN 5 had administered 3 units of Humalog insulin at 10:45 A.M. Resident 2 was observed lying in his bed awake on 8/23/2023 at 11:30 A.M. He did not have any food and/or drinks other than water on his overbed tray.…

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 it was free of a medication error rate of greater than 5% for 3 of 9 residents observed during medication pass. Five medication errors were observed during 39 opportunities. This resulted in a medication error rate of 12.82 percent. (Resident 141, 140, and 83 ) Finding includes: 1. During an observation of a medication administration pass, conducted on 8/22/2023 at 11:01 A.M., QMA 13 removed two Lidocaine 4% patches from a box, dated and signed the patches and administered the patches to the right thigh and right buttocks of Resident 141. Review of the Physician's order for the Resident 141's Lidocaine 4% patches, indicated they were to be applied to the resident's right shoulder and right thigh. 2. During an observation of a medication administration pass, conducted on 8/23/23 at 9:25 A.M., QMA 14 prepared and administered the following medications to Resident 140: Aspirin 81 mg (milligram) one tablet. Daily vitamin, one tablet. Vitamin b1 100 mg. One tablet, Eliquis 5 mg tablet. Folic Acid 1 mg one…

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 1 of 3 residents reviewed for dental services had a dental examination completed (Resident 28) and 2 of 3 residents reviewed for dental needs had dental recommendations completed timely for outside referrals. (Resident 72 and 11) Findings include: 1. The clinical record for Resident 28 was reviewed on 8/23/2023 at 2:21 P.M. Resident 28 was admitted to the facility on [DATE] with diagnoses included, but not limited to: status post cerebral vascular disease, hypertensive heart disease, atherosclerotic heart disease, type 2 diabetes mellitus, osteoarthritis left knee and hip and age related debility. The most recent Minimum Data Set (MDS) assessment for Resident 28, completed on 8/8/2023 indicated the resident was moderately cognitively impaired,required extensive staff assistance of one staff for personal hygiene and required the staff assistance of two staff for transfers and was totally dependent of one staff for bathing needs. 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, record review and interview, the facility failed to ensure 1 of 3 nursing staff passing medications followed manufacturer's recommendations for the cleaning of a glucometer. Finding includes: During an observation of a medication pass, conducted on 8/24/2023 at 7:30 A.M., RN 10 washed her hands, took a basket with a glucometer, alcohol swabs, test strips and lancets into Resident 11's room. RN 10 utilized the glucometer to check Resident 11's blood sugar level. After obtaining the resident's blood sugar, the nurse placed the used glucometer back on top of alcohol pads and lancets and placed the basket on top of the medication cart and then placed the whole basket into the medication cart. RN 10 explained she was going to wait until the resident's breakfast tray was delivered before she gave the resident insulin. On 8/24/2023 at 8:00 A.M., RN 10 was observed to sanitize her hands, pull the plastic basket with the used glucometer, alcohol pads and lancets out of her medication cart drawer. She then drew up the dose of insulin for Resident 11. After administering…

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.