Signature Healthcare Of Terre Haute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified of high blood sugars for 1 of 5 residents reviewed for unnecessary medications (Resident 6). Findings include:On 9/17/25 at 11:04 a.m., during an initial observation and interview, Resident 6 indicated he had elevated blood sugar (BS) levels due to infections and repeated urinary tract infections. On 9/22/25 at 2:30 p.m., during an interview, the Director of Nursing (DNS) indicated prior to 8/24/25 the parameter for notification for Resident 6 was to notify the physician of a BS over 400. She provided a copy of the physician order, dated 10/30/23, indicating to notify the physician of BS over 400. The DON acknowledged the order had not been brought forward under the physician's orders. The DON acknowledged a BS reading above 400 or a BS reading of HI should be reported to the physician immediately. The article, Diabetes, dated 5/15/24, was retrieved on 9/22/25 from the Centers of Disease Control (CDC) website at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor for side effects for residents who received antipsychotic medications for 3 of 5 residents reviewed for unnecessary medications (Resident 8, 5, and 99). The deficient practice was corrected on 8/8/25, prior to the start of the survey, and was therefore past noncompliance Findings include: 1. Resident 8's record was reviewed on 9/18/25 at 11:48 a.m. Census information indicated the resident was admitted to the facility on [DATE]. Diagnoses on the resident's profile included, but were not limited to, bipolar disorder (mental health condition causing extreme shifts in mood, energy, and activity levels, characterized by periods of mania and depression) unspecified. A quarterly Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident had a moderate cognitive impairment and received an antipsychotic (treats psychosis) medication during the look-back period. An admission observation, dated 2/22/25, indicated the resident had 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 record review and interview, the facility failed to ensure pharmacy review of resident medications were completed quarterly and failed to ensure the physician was notified of recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident 5). Findings include:On 9/19/25 at 10:16 a.m., the medical record of Resident 5 was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included, but not limited to, depression (an illness characterized by persistent sadness and a loss of interest in activities that you normally enjoy, accompanied by an inability to carry out daily activities, for at least two weeks), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). On 5/12/25 a pharmacy recommendation suggested the following labs for medication monitoring:…

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 3 of 6 residents (Resident 26, 3, and 152) observed during the medication pass. There were 27 opportunities for error observed with 3 medication errors, resulting in a medication error rate of 11.1 percent. Findings include:1. On 9/18/25 at 9:24 a.m., Registered Nurse (RN) 7 prepared and administered medication to Resident 26. The medication included propranolol (treats high blood pressure) 10 milligrams (mg) 1 tablet by mouth. Resident 26's record was reviewed on 9/22/25 at 10:04 a.m. Diagnoses on the resident's profile included, but were not limited to, essential, primary hypertension (high blood pressure). A physician's order, dated 8/28/25 and discontinued on 9/15/25, indicated propranolol 20 mg, give 1 tablet by mouth twice daily for coronary artery disease. A physician's order, dated 9/15/25, indicated propranolol 10 mg, give 2 tablets by mouth twice daily coronary artery disease. On 9/19/25 at 10:25 a.m., the Regional Clinical…

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 A. Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during direct patient care services for 3 of 3 random resident observations. (Residents 1,102, and 8). B. Based on observation, record review, and interview, the facility failed to ensure a urinary catheter (a flexible tube inserted into the bladder to drain urine) tubing was kept off the floor for 1 of 2 reviewed for catheter use (Resident 14). Findings include:A1. On 9/23/25 at 11:57 a.m., observed Registered Nurse (RN) 10 washing her hands. The RN turned off the faucet with her bare hand and then dried her hands on a paper towel. The nurse then donned (put on) gloves and picked up the glucometer device from the resident's dresser. On 9/23/25 at 11:59 a.m., observed RN 10 lay glucometer device (a small, portable device that measures the amount of glucose (sugar) in your blood) on the bed of Resident 1. After completing the procedure, she laid the glucometer on the resident's dresser.…

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, a facility dietary staff member failed to don gloves prior to handling sandwich bread during preparation of sandwiches during an initial tour of the kitchen. This deficient practice had the potential to affect 10 of 10 residents consuming the prepared sandwiches. Findings include: An observation of the facility's kitchen was completed on 8/4/25 at 10:10 a.m., accompanied by the Dietary Manager. Dietary Aide 2 was observed standing at a preparation table with bread laid out in a row. He held one piece of bread in a bare hand and had a knife with peanut butter in the other. He began to spread peanut butter onto the piece of bread. Dietary Aide 2 indicated he was preparing peanut butter and jelly sandwiches for lunch service and for snacks during the day. He indicated he should be wearing gloves and not touching food with his bare hands. He began to don gloves, when he was stopped by the Dietary Manager and asked to perform hand hygiene prior to donning the gloves.During an interview on 8/6/25 at 11:03 a.m., the Dietary Manager indicated the kitchen…

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 staff failed to administer scheduled doses of comfort medication per physician order without nursing assessment and physician notification for 1 of 8 resident reviewed for quality of care (Resident B). The deficient practice was corrected by 6/5/25 prior to the start of the survey and was therefore Past Noncompliance. Findings include: During a telephone interview on 6/12/25 at 3:20 p.m., Resident B's family member indicated the staff were not able to explain needs or symptoms that would be managed with the hospice ordered medications. They appeared confused about the administration of the medications and when they were to be given. The residents breathing would become rapid at times and he would begin to move his shoulders and grunt as if he were uncomfortable. When the medications were given, he seemed more comfortable and seemed to breath easier. One Qualified Medication aide (QMA) had entered the room and attempted to administer his medications, but indicated he was clenching his teeth and she was not able to administer 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 timely report an allegation of suspected resident-to-resident abuse for 1 of 7 residents reviewed for resident abuse (Resident F). Findings include: A facility reportable incident (FRI), dated [DATE] at 11:51 a.m., indicated Resident F was attempting to ambulate in her room in the memory care and fell. Resident F complained of right shoulder and bilateral lower extremities pain. The resident was transported by ambulance to the emergency room (ER) where she was diagnosed with a non-displaced acute distal right clavicle fracture, diffuse osteopenia, and a subdural hematoma with mild midline shift. A confidential concern during the survey indicated that local police responded to a nearby hospital to speak with Resident F who was being treated for injuries that occurred at the nursing home. The resident died on [DATE]. There was concern that the deceased resident had been beaten by another resident. A concern from a local hospital employee, dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to issue a 30-day notice of discharge prior to the planned date of a facility-initiated discharge for 1 of 3 residents reviewed for discharges (Resident B). Findings include: During an interview, on 3/14/25 at 9:30 a.m., Qualified Medication Aide (QMA) 5 indicated she was working the unit Resident B resided on. He was discharging from the facility today, but she was not sure what time. QMA 5 indicated she was not sure where the resident planned to discharge, but the Social Services Director (SSD) should know. During an observation, on 3/14/25 at 9:33 a.m., Resident B was lying in bed with 3.5 liters (L) of oxygen via nasal cannula, and a catheter drainage bag was hanging on the side of the bed. At the same time, the resident indicated they have something planned but was unable to say what when asked if he planned to discharge from the facility that day. The resident did not know the year or who the president was. The resident's facial hair…

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 plan for, and ensure the resident was prepared for, a safe and orderly discharge from the facility for a resident with significant clinical needs including catheter care, oxygen use, and wound care for 1 of 3 residents reviewed for discharges (Resident B). Findings include: During an interview, on 3/14/25 at 9:30 a.m., Qualified Medication Aide (QMA) 5 indicated she was working the unit Resident B resided on. He was discharging from the facility today, but she was not sure what time. QMA 5 indicated she was not sure where the resident planned to discharge, but the Social Services Director (SSD) should know. During an observation, on 3/14/25 at 9:33 a.m., Resident B was lying in bed with 3.5 liters (L) of oxygen via nasal cannula, and a catheter drainage bag was hanging on the side of the bed. At the same time, the resident indicated they have something planned but was unable to say what when asked if he planned to discharge 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 record review and interview, the facility failed to protect the resident's right to be free from verbal abuse when a resident was called a derogatory name by a staff member for 1 of 6 residents reviewed for abuse (Resident E). The deficient practice was corrected on 12/28/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: An Indiana Department of Health (IDOH) Incident Report was dated 12/27/24 at 4:33 a.m. The report indicated the staff called the Administrator and alleged verbal abuse by contract staff Licensed Practical Nurse (LPN) 4 towards Resident E. LPN 4 and Resident E exchanged inappropriate remarks. Immediate actions included resident separated from LPN 4 and taken to her room with another staff member, another staff nurse notified, Administrator notified, Administrator suspended LPN 4 via phone, LPN 4 left the facility without incident, the resident's physician, responsible party, and Director of Nursing (DON) were notified. The facility's incident investigation file included the following witness statements. A witness…

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 an incident of verbal abuse from a nurse to a resident was reported to the Indiana Department of Health (IDOH) accurately for 1 of 6 residents reviewed for abuse (Resident E). Findings include: An Indiana Department of Health (IDOH) Incident Report was dated 12/27/24 at 4:33 a.m. The report indicated the staff called the Administrator and alleged verbal abuse by contract staff Licensed Practical Nurse (LPN) 4 towards Resident E. LPN 4 and Resident E exchanged inappropriate remarks. Immediate actions included resident separated from LPN 4 and taken to her room with another staff member, another staff nurse notified, Administrator notified, Administrator suspended LPN 4 via phone, LPN 4 left the facility without incident, the resident's physician, responsible party, and Director of Nursing (DON) were notified. The follow-up, dated 1/2/25, indicated upon investigation the abuse allegation was unsubstantiated. The facility's incident investigation file included the following witness statements. A witness statement from…

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 the Notice of Transfer/Discharge forms were completed and provided to residents and/or their representatives for 4 of 4 residents reviewed for hospitalization (Residents 18, 165, 138, and 54). Findings include: 1. Resident 18's record was reviewed on [DATE] at 2:25 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a brain disorder that slowly damages memory and thinking skills, eventually leading to dementia). A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive deficit and had exhibited behavioral symptoms directed towards others. A discharge, return anticipated MDS, dated [DATE], indicated the resident had been discharged to an inpatient psychiatric hospital. The census indicated that the resident had been hospitalized from [DATE] through [DATE]. A progress note, dated [DATE] at 10:46 a.m., indicated the resident had been diagnosed with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure bed hold forms were completed and provided to residents and/or their representatives for 3 of 4 residents reviewed for hospitalization (Residents 18, 165, and 138). Findings include: 1. Resident 18's record was reviewed on [DATE] at 2:25 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a brain disorder that slowly damages memory and thinking skills, eventually leading to dementia). A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive deficit and had exhibited behavioral symptoms directed towards others. A discharge, return anticipated MDS, dated [DATE], indicated the resident had been discharged to an inpatient psychiatric hospital. The census indicated that the resident had been hospitalized from [DATE] through [DATE]. A progress note, dated [DATE] at 10:46 a.m., indicated the resident had been diagnosed with a urinary tract infection…

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 notify the physician of not administering medications as ordered for 2 of 5 Residents reviewed for unnecessary medications (Residents 76 and 74). Findings include: 1. On 1/23/25 at 10:00 a.m., the medical record of Resident 76 was reviewed. Diagnoses included but not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), dilated cardiomyopathy (disease of the heart muscle), heart failure (a condition in which your heart's main pumping chamber becomes stiff and unable to fill properly), hypertension (high blood pressure), anxiety disorder (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress), schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), major depressive disorder (an illness characterized by persistent sadness and a loss of interest in activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Ombudsman (a person who serves as an advocate for patients and consumers) had been notified of resident transfers from the facility, in the month of [DATE], for 3 of 4 residents reviewed for hospitalization (Residents 18, 165, and 138). Findings include: 1. Resident 18's record was reviewed on [DATE] at 2:25 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease (a brain disorder that slowly damages memory and thinking skills, eventually leading to dementia). The census indicated that the resident had been hospitalized from [DATE] through [DATE]. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated the resident had no cognitive deficit and had exhibited behavioral symptoms directed towards others. A discharge, return anticipated MDS, dated [DATE], indicated the resident had been discharged to an inpatient psychiatric hospital. The record lacked documentation that the…

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

Based on record review and interview, the facility failed to ensure the QMAs (qualified medication aides) followed proper standards of practice for 1 of 28 residents reviewed (Resident 92). Findings include: Resident 92's record was reviewed, on 1/23/25 at 11:06 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), pressure ulcer (injury to skin an underlying tissue resulting from prolonged pressure on skin) of right buttock, sacral region, left buttock, stage 3, and skin tear/laceration to left heel. An annual Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident had severe cognitive impairment and had 3 stage 3 pressure ulcers. A care plan, dated 8/1/22, indicated…

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 prevent new pressure wounds on 1 of 4 residents reviewed for pressure wounds (Resident 131). Findings include: On 1/21/25 at 3:13 p.m., during an initial observation Resident 131 was lying in bed on the right side on a low air loss mattress. No off-loading heel boots were observed on bilateral feet. On 1/22/25 at 9:48 a.m., during a routine observation the resident was lying in bed on her right side on a low air loss mattress. No offloading boots were observed. Boots were in the wheelchair next to the bed. On 1/23/25 at 11:00 a.m., the resident was observed lying in bed on her right side on a low air loss mattress. No offloading boots were observed on bilateral feet. On 1/24/25 at 11:30 a.m., the resident was observed lying in bed on her right side. No offloading boots to bilateral feet observed. Boots were in the wheelchair next to the bed. On 1/24/25 at 12:10 p.m., the medical record of Resident 131 was reviewed. Diagnosis included but…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide adequate hydration for 2 of 32 residents reviewed for hydration and nutrition (Residents 131 and 109). Findings include: 1. On 1/21/25 at 3:14 p.m., during an initial observation, Resident 131 was lying in bed on her right side. Skin and mouth were observed dry. A styrofoam cup with a small amount of brown liquid was observed inside on the overbed table next to the wall, which was outside of the resident's reach. On 1/22/25 at 9:48 a.m., during a routine observation, Resident 131 was lying in bed on her right side. An empty styrofoam cup was on the bedside overbed table. Resident tried to drink from the cup. On 1/24/25 at 2:00 p.m., during a general observation, Resident 131 was lying in bed on her right side. A partially melted cup of ice cream and a styrofoam cup with a small amount of water were on the overbed table. On 1/27/25 at 3:17 p.m., Resident 131 was lying in bed. Overbed table was next to the wall on the far side 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, record review, and interview, the facility failed to ensure oxygen tubing was dated when changed and was maintained and stored in a sanitary manner for 1 of 3 residents reviewed for respiratory (Resident 26). Findings include: During an observation, on 1/22/25 at 9:36 a.m., Resident 26 was asleep in his bed. His oxygen concentrator (a medical device that separates nitrogen from the air to provide oxygen-enriched air for breathing) was on, and his nasal cannula (a medical device that supplies oxygen to a patient through their nose) was in his nose. The resident's oxygen tubing was undated, and no storage bag was observed. During an observation, on 1/23/25 at 2:17 p.m., the resident was sleeping in his bed. The oxygen concentrator was running, and his nasal cannula was observed out of his nose, un-bagged, and laying inside of his trash can next to his bed. There was visible trash items in the trash can along with his nasal cannula. His oxygen tubing was undated, and no storage bag was observed. During an observation, on 1/24/25 at 10:02 a.m., the resident was 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 record review and interview, the facility failed to ensure AIMS (abnormal involuntary movement scale) assessments were completed for 1 of 5 residents were reviewed for unnecessary medications (Resident 92). Findings include: Resident 92's record was reviewed, on 1/23/25 at 11:06 a.m. The profile indicated the resident's diagnosis included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety disorder (a mental health disorder characterizer by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood). An annual Minimum Data Set (MDS) assessment, dated 12/20/24, indicated the resident had severe cognitive impairment and was on anti-psychotic and anti- depressant medication. A care plan, dated 8/15/22, indicated the resident had a diagnosis of insomnia and anxiety and is at risk for drug related symptoms due to use of psychotropic medication.…

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 dated with the date medications were opened and stored in 4 of 5 medication administration carts observed for medication storage and labeling. Findings include: 1. On 1/27/25 at 9:00 a.m., an observation of the medication administration cart on 400 hall with QMA 18. The following was observed. Resident 66 had a physician order, dated 10/18/24, for Admelog U-100 Insulin lispro (insulin lispro) solution; 100 unit/mL (milliliter) administer injection per sliding scale before meals and at bedtime for diagnosis of diabetes. Multi dose insulin vial was opened and undated. 2. On 1/27/25 at 9:10 a.m., the 300-hall medication administration cart was observed with the Director of Nursing (DNS). Resident 2 had a physician order, dated 12/30/24, for Basaglar KwikPen U-100 Insulin (insulin glargine) administer 30 units subcutaneous (under the skin) once daily for diagnosis of diabetes. Basaglar insulin pen was opened and undated. Resident 111 had a physician order, dated 1/8/25, for Lantus SoloStar…

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 post fall assessmetns and vitals were completed for 72 hours post fall for 1 of 3 residents reviewed for accidents (Resident P). Findings include: On 11/13/24 at 1:00 p.m., the facility list of falls was reviewed, it was noted Resident P slid from his wheelchair in his room resulting in the resident being found on the floor next to his wheelchair on 9/3/24. A progress note, dated 9/3/24 at 3:19 p.m., indicated Resident P was observed to be on the floor on the left side of his wheelchair. The resident was found to be incontinent of urine. No injuries noted after skin sweep (skin assessment). Vital signs were obtained, and the resident was lifted off the floor with the assistance of 3 staff. The note indicated that family and doctor were notified. An IDT (interdisciplinary team) note, dated 9/4/24 at 9:56 a.m., indicated they had discussed Resident P's fall and the root cause was determined to be urinary incontinence and an intervention to toilet…

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 assist the resident in transportation from the facility to a physician office appointment for 1 of 1 resident reviewed for transportation (Resident C). Findings include: On 11/12/24 at 11:00 a.m., the medical record of Resident C was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), osteomyelitis (a painful bone infection that causes inflammation and swelling in the bone) of bilateral heels (both heels), hypertension (high blood pressure), functional quadriplegia (a condition that causes a person to be completely unable to move due to a severe disability or frailty from another medical condition). An admission Minimum Data Set (MDS) assessment, dated 10/16/24, indicated the resident was cognitively intact and the resident required maximum assistance for daily care needs including physical…

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 allegations of resident abuse were reported immediately to the Administrator and/or designee and to the Indiana Department of Health for 2 of 3 residents reviewed for reporting allegations of abuse (Resident B and C). Findings include: On 9/24/24 at 10:29 a.m., the Director of Nursing (DON) provided the Indiana Department of Health (IDOH) help desk email correspondence with the DON, dated 9/19/24, 9/23/24, and 9/24/24. The DON indicated she had an abuse incident about Resident B and Resident C that she was trying to input into the Indiana Department of Health (IDOH) facility reported incident record (FRI) system but kept getting an error message. She had emailed the IDOH help desk, on 9/19/24 and emailed the help desk again on 9/24/24 at 10:05 a.m., and indicated in the email, .My updates from last 3 reportables and reportable from Sunday (9/22/24) is not even on my list today to follow up on. When I sent my reply, I thought they were complete…

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 an allegation of resident abuse was investigated for 2 of 3 residents reviewed for investigating abuse allegations (Resident B and C). Findings include: During an interview, on 9/24/24 at 10:29 a.m., the Director of Nursing (DON) indicated she had an incident that she was trying to input into the Indiana Department of Health (IDOH) facility reported incident record (FRI) system about Resident B and Resident C. Resident B was going around and leading Resident C by the hand. Resident C had on a gold belt buckle that Resident B kept trying to touch the buckle. Certified Nursing Aide (CNA) 5 and CNA 6, thought Resident B was being inappropriate with Resident C and Resident B was touching Resident C's private area. DON contacted the Administrator (ADM), Social Services (SS), and the behavioral health services. The behavioral health services staff called back and changed Resident B's medication order for Xanax (medication used to treat anxiety and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide personalized care and interventions for a resident (Resident F) with the diagnoses of schizophrenia (serious mental health condition that affects how people think, feel and behave) and behaviors for 1 of 5 residents reviewed for behavior management which resulted in Resident F having resident to resident altercations with 4 cognitively impaired residents residing on the same locked unit (Residents B, G, H, and J). Findings include: During the survey a document titled, All About Me, undated, was observed in Resident F's room. The document described the resident's likes and dislikes, such as her favorite hobbies, food, movies, snacks, etc. Her dislikes included when people touched her without letting her know and when people tried to make her eat when she didn't want to eat. The clinical record for Resident F was reviewed on 7/30/24 at 1:43 p.m. Resident F was [AGE] years old and resided in the facility's secured behavioral unit. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure oxygen nebulizer tubing, and equipment were dated, timed, and signed for 1of 3 residents reviewed for respiratory care (Resident F). Findings include: On 4/3/24 at 1:50 p.m., during a routine room observation, Resident F's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask and tubing were unbagged. Tubing was dated 1/25/24 and a clear liquid was within the nebulizer medication cup. On 4/3/24 at 1:55 p.m., during an interview, Resident F indicated he used half of the solution and leaves the other half for later. He used the nebulizer treatment a few times a week. On 4/3/24 at 2:00 p.m., during an interview, Registered Nurse (RN) 4 indicated the nebulizer treatment order had been discontinued on March 6th. On 4/4/24 at 11:00 a.m., during a routine room observation, Resident F indicated the nebulizer machine had been removed. The resident indicated the nurse removed it…

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

Based on observation, interview, and record review, the facility failed to ensure medications were administered per physician order and failed to notify physician of medications not being available to administer for 1 of 3 residents reviewed for medication administration. (Resident F). Findings include: On 4/3/24 at 11:31 a.m., during an observation and interview, Resident E indicated a nurse gave her 28 units of Trojeo insulin on 4/2/24. She only took 20 units because if she took the full dose her blood sugars bottomed out later in the day and early evening. She indicated she told the nurses she took 20 units, and the nurses reduced the dose to 20 units. On 4/3/24 at 12:00 p.m., the medical record for Resident E was reviewed. Diagnoses included but were not limited to, end stage renal disease (kidney failure) dated 2/14/2024, anemia in chronic kidney disease (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) dated 2/14/2024, atrial fibrillation an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your…

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

Based on observation, interview, and record review, the facility failed to ensure medications were available and provided to1 of 3 residents reviewed for medication administration, (Resident E). Findings include: On 4/3/24 at 11:31 a.m., during an observation and interview, Resident E indicated her medications and insulin were often late. She could not recall if insulin had been administered. On 4/3/24 at 12:00 p.m., the medical record for Resident E was reviewed. Diagnoses included but were not limited to, end stage renal disease (kidney failure) dated 2/14/2024, anemia in chronic kidney disease (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) dated 2/14/2024, atrial fibrillation an irregular heart rhythm (arrhythmia) that begins in the upper (atria) of your heart) dated 2/14/2024, type 2 diabetes mellitus without complications (a disease that occurs when your blood glucose, also called blood sugar, is too high) dated 2/14/2024, and essential (primary) hypertension (high blood pressure) dated 2/14/24. Physician Orders…

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 dishware and silverware had adequate sanitation and did not have a hard water buildup during 1 of 2 kitchen observations, and failed to ensure hand hygiene was completed by staff when assisting two residents with eating during 1 of 2 dining observations (Residents 60 and 78). Findings include: 1. During the initial kitchen tour with the Dietary Manager (DM), on 12/11/23 at 10:00 a.m., a thick white cloudy substance was observed on multiple dishware of pellet bases, plate covers to the pellet bases, and silverware. The DM observed the white, cloudy substance and indicated, the dishware and silverware had a heavy lime buildup from the city water. The dishware needed to be run through the dishwasher again and the silverware needed to be soaked in the delime solution to help remove the lime buildup. On 12/14/23 at 10:40 a.m., the DM indicated, the dietary staff got the silverware cleaned by descaling in the power solution and the appliance and chemical maintenance company got the dishwasher and water…

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 was provided showers as preferred for 1 of 5 residents reviewed for choices (Resident C). Findings include: During an interview, on 12/12/23 at 9:35 a.m., Resident C indicated she was not receiving showers regularly. Resident C's record was reviewed on 12/15/23 at 2:00 p.m. The resident's diagnosis included, but was not limited to, spina bifida (a congenital defect of the spine in which part of the spinal cord and its meninges are exposed through a gap in the backbone, often causing paralysis of the lower limbs). An annual Minimum Data Set (MDS) assessment, dated 10/20/23, indicated the resident was cognitively intact and required substantial to maximal assistance for bathing and personal hygiene. A care plan, dated 8/11/22 and edited 10/25/23, indicated the resident was limited in mobility/functional status and required the use of a right sided enabler to aide in repositioning, transfers, and bed mobility. An intervention of the care plan included, but was not limited to, the resident required assistance…

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 prevent a resident from exiting the facility unattended and crossing the street to a nearby house for 1 of 1 resident reviewed for elopement (when a resident leaves a healthcare facility against medical advice) (Resident B). The deficient practice was corrected on 11/7/23, prior to the start of the survey, and was therefore, past noncompliance. Finding includes: Resident B's record was reviewed on 12/15/23 at 11:14 a.m. The profile indicated the resident's diagnoses included, but were not limited to, symptoms and signs involving cognitive functions and awareness (problems with memory, language or judgment), encephalopathy (damage or disease that affects the brain), and sequelae of cerebral infarction (residual effects or conditions produced after the acute phase of an illness or injury has ended). An admission Minimum Data Set (MDS), dated [DATE], indicated the resident had severe cognitive deficit and experienced behaviors of rejection of care. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure initial wound assessment documentation was completed in a timely manner for 2 of 3 residents reviewed for wound documentation (Residents E and L). Findings include: 1. Resident E's record was reviewed on 8/1/23 at 9:08 a.m. The profile indicated the resident's diagnoses included, but were not limited to, quadriplegia (paralysis below the neck that affects all of a person's limbs). The census indicated the resident was hospitalized on [DATE] and returned to the facility on 5/26/23. A care plan, dated 5/25/23, indicated the resident was at risk for the development of pressure ulcers (an injury that breaks down the skin and underlying tissue). A 5-day Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 5/30/23, indicated the resident had a stage 2 pressure ulcer (partial thickness loss of the middle layer of skin of the body presenting as a shallow open ulcer with a red or…

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 medications were available from the Pharmacy for administration for 2 of 3 residents reviewed for available medications (Resident B and K). Findings include: 1. During a telephone interview with Resident B's family member, on 8/2/23 at 1:40 p.m., they indicated there had been many instances where the resident's medications had not been available to be administered, since his admission in January. The family would take the resident out of the facility for visits and had been told by the nursing staff that some of his medications were not available to send home with him. They had spoken to the previous Director of Nursing (DON) about this situation and how the resident could have behavior events if he did not receive the medication as ordered. On 7/17/23, they were told that he had been out of his mirtazapine (an antidepressant medication) for 3 days. The family had planned to take the resident out on this date, (8/2/23), and was told that he was out of his Clariton (a medication that relieves symptoms of sneezing,…

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 proper hand hygiene and equipment sanitation was completed during medication administration for 3 of 4 residents observed during medication administration (Resident H, M, and N). Findings include: On 8/1/23 at 12:10 p.m., Licensed Practical Nurse (LPN) 7 was observed entering Resident H's room to obtain the resident's blood glucose (the main sugar found in blood) reading. The resident was in contact isolation precautions (precautions to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient) due to methicillin-resistant Staphylococcus aureus (MRSA-a germ that does not get better with the type of antibiotics that usually cure staph infections) in a wound. A sign on the door to the room indicated a gown, gloves and mask were to be put on prior to entering the room for any contact with the resident. The nurse put on gloves and a face mask before entering the room. The nurse placed the glucometer (a device used to measure the amount of glucose in the…

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