Southwood Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure that nebulizer equipment was properly cleaned and stored after each use for 2 of 2 residents reviewed for oxygen and nebulizer use (Residents 12 and 63). Findings include:1. On 1/21/26 at 9:57 a.m., during an initial observation, Resident 12 was lying in bed. She indicated she had received a nebulizer treatment. A nebulizer is (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece). The nebulizer tubing and mask were lying on the bedside nightstand on top of a clear plastic bag dated 1/19/26. The medication chamber was observed to have clear liquid inside. On 1/21/26 at 10:15 a.m., the medical record of Resident 12 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included, but were not limited to, diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was provided routine dental services for 1 of 32 residents reviewed for dental services (Resident 9). Findings include:During an interview, on 1/21/26 at 9:31 a.m., Resident 9 indicated she wanted to see a dentist, but she did not think dental services had been offered to her since she was admitted to the facility. The resident indicated she had missing teeth and teeth that had fallen out that she wanted checked. Resident 9's record was reviewed on 1/22/26 at 1:33 p.m. Census information indicated the resident was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) assessment, dated 12/19/25, indicated the resident was cognitively intact. A care plan, last revised on 5/21/25, indicated the resident had the potential for oral/dental problems due to carious (cavities or tooth decay) teeth. Interventions included, but were not limited to, dental consult as needed. The resident's electronic record lacked…

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 family notification after a resident experienced a significant change in condition and subsequently received life-sustaining interventions to include a ventilator without notification to the emergency contact, for 1 of 3 residents reviewed for quality of care (Resident B). Findings include, A confidential interview during the survey indicated Resident B's emergency contact was not notified when the resident was transferred from the facility on [DATE]. Resident B's clinical record was reviewed on [DATE] at 10:47 a.m. Diagnoses on Resident B's profile included personal history of transient cerebral ischemic attack (TIA-stroke), and seizure disorder. A physician's order, dated [DATE], indicated send the resident to the hospital for evaluation and treatment. An eINTERACT SBAR Summary for Providers, dated [DATE] at 5:30 a.m., indicated the resident had a fall and was unresponsive. Resident B was found on floor in the bathroom, assessed, transferred…

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

Based on record review and interview, the facility failed to ensure a thorough investigation of abuse allegations was conducted and a record of the investigation was maintained for 3 of 3 residents reviewed for abuse (Residents H, G, and F). Findings include:1. An Indiana Department of Health (IDOH) reportable incident investigation file was reviewed on 9/3/25 at 2:31 p.m. The file included an IDOH incident report dated 6/14/25. The report indicated Residents H and G had an altercation in the dining room. Resident H pushed Resident G's wheelchair across the dining room. There was no physical touch or harm. The staff immediately separated the residents, and an investigation was initiated. The report indicated the investigation would include resident statements. The incident file included two statements from staff members who witnessed the incident and three days of psychosocial follow-up for Residents H and G. The incident file lacked documentation of resident statements, including interviews to determine if other residents had experienced negative interactions with Resident H.…

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 interviews, the facility failed to accurately document wound description upon admission to the facility for 1 of 3 residents reviewed for wounds (Resident B), and failed to ensure medications were documented according to physician orders for administration of insulin for 1 of 3 residents reviewed for medication administration (Resident D). Findings include: 1. On 9/3/25 at 11:00 a.m., the medical record of Resident B was reviewed. The resident was admitted to the facility on [DATE]. admission diagnosis included but were not limited to paraplegia (paralysis that occurs in the lower half of the body), and type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high). A physician order, dated 8/11/25, indicated to administer Medi honey Wound/Burn Dressing External Gel to coccyx wound topically every dayshift for pressure ulcer care cover with ABD pad and secure. A physician order, dated 8/10/25, indicated administer Miconazole Nitrate 2 % Cream to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure medications were administered and documented according to physician orders for administration of insulin for 4 of 4 residents reviewed for medication administration (Residents, D, F, B, and E). Findings include: 1. On 4/9/25 at 10:00 a.m., during an initial observation and interview of Residents D and E. The residents indicated they had received their insulin. They were not sure of times of administration and indicated it was administered at breakfast. On 4/9/25 at 1:40 p.m., observed Licensed Practical Nurse (LPN) 7, at the medication administration cart. The LPN indicated she was not usually late administering insulin. On 4/9/25 at 1:05 p.m. during interview with Resident D. She indicated she received her insulin around 12:30 p.m., She indicated she did not eat breakfast that a.m. but she did receive insulin. She did not know what time it was administered. She indicated she usually got her insulin before she ate but it did vary.…

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 enhanced barrier precautions were followed during a dressing change for 1 of 3 residents reviewed for pressure ulcers (Resident G). Findings include: During a continuous observation, on 4/10/25 from 9:56 a.m. to 10:16 a.m., the following was observed. Licensed Practical Nurse (LPN) 7 performed hand hygiene, donned gloves and a gown, and completed the dressing change to Resident G's sacrum (bone at the base of the spine). Near the end of the sacrum dressing change, Certified Nurse Aide (CNA) 11 entered the room to assist LPN 7. CNA 11 did not perform hand hygiene after entering the room. CNA 11 donned gloves but did not put on a gown. CNA 11 held up Resident G's left heel so LPN 7 could complete the dressing change to that area. CNA 11 removed the dressing from Resident G's left heel and continued to hold up the resident's leg. CNA 11 did not perform hand hygiene or change gloves after she removed the resident's dressing. On 4/10/25 at 10:16 a.m., the continuous observation was completed. At the same…

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 adequate nurse staffing for 5 of 6 units schedules reviewed (units 100, 200 A, 200 B, 400, and 500). Findings include: 1. During an interview, on 12/31/24 at 9:25 a.m., Resident K indicated there were sometimes when she had not been given her insulin. She understood that the nurses were human and were really busy, but she was a Registered Nurse in her career and knows that insulin needs to be given as ordered. She would never refuse any of her insulin, it was too important for her to have it. Resident K's record was reviewed on 12/31/24 at 8:29 a.m. The profile indicated the resident resided on the 400 unit of the facility. Her diagnoses included, but were not limited to, type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin [a hormone that regulates blood sugar levels] or doesn't use it properly, resulting in high blood sugar levels) with hyperglycemia (high blood sugar). A significant change Minimum Data Set (MDS) assessment, dated 10/28/24, indicated the resident 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 record reviews, and interviews, the facility failed to ensure inulin medications were administered as ordered for 3 of 3 residents reviewed for insulin medications (Residents F, K, and H). Findings include: 1. Resident F's record was reviewed on 12/30/24 at 1:10 p.m. The profile indicated the resident's diagnosis included, but were not limited to, systemic lupus erythematosus (an illness that occurs when the immune system attacks healthy tissue and organs) and diabetes mellitus (a group of diseases that result in too much sugar in the blood). A quarterly Minimum Data Set (MDS) assessment, dated 11/8/24 indicated the resident was cognitively intact and was on insulin medication. A care plan, dated 10/7/20, indicated the resident had diabetes mellitus and had potential for complications. Interventions included, but were not limited to, diabetes medication as ordered by doctor and educate regarding medications and importance of compliance. a. A physician order, dated 4/6/24, indicated to administer Fiasp…

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 handwashing during 2 of 2 dining observations and 1 of 1 kitchen observations and the facility failed to ensure adequate dishwashing temperatures were maintained for 1 of 1 kitchen observations. Findings include: 1a. During a dining observation, on 12/2/24 at 11:59 a.m., Central Supply Aide washed her hands at the sink and tore off a piece of paper towel by unraveling it from a commercial size roll that was on the counter. She left drops of water on the top of the paper towel roll from where she ripped it off with her wet hands. She dried her hands and proceeded to turn off the water faucet with the same paper towel she dried her hands with. She then went to the kitchen window and obtained a tray to serve to a resident. During a dining observation, on 12/2/24 at 12:01 p.m., Certified Nurse's Assistant (CNA) 35 washed her hands at the sink and tore off a piece of paper towel by unraveling it from a commercial size roll that was on the counter. She obtained the paper towel with wet hands 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 the code status (a medical term that indicates a patient's wishes regarding what life-saving measures should be taken if their heart stops beating or breathing stops) was documented and readily available to staff for 1 of 24 residents reviewed for advanced directives ( a written document that tells the health care providers who should speak for a resident and what medical decisions they should make if the resident becomes unable to speak for themselves) (Resident 152). Findings include: Resident 152's record was reviewed on 12/3/24 at 9:51 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atherosclerotic heart disease of the native coronary artery (a condition where plaque [a buildup of cholesterol, fat, blood cells, and other substances in the walls of the heart arteries] builds up in the coronary arteries, cardiomegaly (enlarged heart), and history of myocardial infarction (heart attack). An admission Minimum Data Set (MDS) assessment, dated 11/18/24, 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.

Based on record review and interview, the facility failed to ensure notification of a resident discharge had been reported to the Ombudsman (a person who investigates and resolves complaints and represents or protects the interests of another person or group) for 1 of 2 residents reviewed for hospitalization (Resident 6). Findings include: Resident 6's record was reviewed on 12/3/24 at 3:47 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis (hemiplegia refers to a severe or complete loss of strength, whereas hemiparesis refers to a relatively mild loss of strength) following a cerebral infarction (stroke), chronic obstructive pulmonary disease (COPD-a common lung disease that makes it difficult to breathe), and congestive heart failure (CHF-a condition where the heart is unable to pump enough blood to the body's tissues). A change of condition assessment, dated 10/1/24, indicated the resident complained of new or worsening abdominal pain, shortness of breath, and had abnormal vital signs. A transfer document, dated…

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

Based on record reviews and interviews, the facility failed to ensure Minimum Data Set (MDS) resident assessments were completed timely for 2 of 2 residents reviewed for MDS records over 120 days old (Residents 42 and 2). Findings include: 1. On 12/4/24 at 9:32 a.m., Resident 42's record was reviewed. She was discharged on 8/10/24, and the record indicated her return was not anticipated. The record lacked documentation of a discharge MDS assessment being completed. On 12/9/24 at 2:13 p.m., Resident 42's record indicated that a discharge MDS assessment had been signed and completed on 12/9/24 with an export ready status. During an interview on 12/9/24 at 2:33 p.m., Employee 19 indicated they did an audit every few months and so did the corporate office. She was not aware they had missed completing the discharge MDS assessment in a timely manner for Resident 42 until 12/9/24 when the corporate office called and let her know. The corporate office maintained an audit log, but she did not, she would just go through and check things. 2. On 12/9/24 at 2:23 p.m., Resident 2's record 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to obtain and implement treatment orders upon admission for a stage 4 pressure ulcer (full thickness tissue loss with exposed muscle and/or bone) for 1 of 1 resident reviewed for pressure ulcers (Resident K). Findings include: On 12/9/24 at 11:00 a.m., the medical record of Resident K was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to, paraplegia (paralysis that occurs in the lower half of the body), osteomyelitis (an inflammation or swelling that occurs in the bone), enterocolitis (inflammation of the colon) to clostridium (bacterial infection in the colon), and pressure ulcer (bed sore) sacral (tail bone) region stage 4 (full thickness ulcer with the involvement of the muscle or bone). A Physician order, dated 10/28/24, indicated the following wound treatment was to be applied on day shift every Monday, Wednesday, Friday, and as needed. Staff were to cleanse the wound on the sacrum with…

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

Based on record review and interview, the facility failed to ensure there was sufficient weekend staffing for 1 of 4 fiscal year quarters reported for sufficient and competent nurse staffing (4/1/24-6/30/24). Findings include: On 12/2/24 at 11:00 a.m., the staffing data report was reviewed. The facility had reported low weekend staffing for the third fiscal year quarter (4/1/24-6/30/24). During an interview on 12/4/24 at 1:43 p.m., Certified Nursing Assistant (CNA) 13 indicated staff did not have enough time to complete their daily assignments, they needed more staff, and the biggest problem at the facility was with retaining staff. The facility asked her to stay late or work overtime nearly every day, but she declined because she wanted to avoid burnout. During an interview on 12/4/24 at 2:42 p.m., Licensed Practical Nurse (LPN) 15 indicated the facility did not have enough staff to do everything that needed to be done, and the staff they did have struggled to get things done. Each CNA had up to 2 halls on day and evening shifts, and on weekend shifts they were staffed even…

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 staff was competent in completing tasks accurately for 2 of 5 residents reviewed for medication administration (Residents 51 and M). Findings include: 1a. During the medication administration observation, on 12/6/24 at 7:50 a.m., Licensed Practical Nurse (LPN) 23 obtained a glucometer machine from the top of her medication cart and wiped it with an alcohol pad from front to back, she then placed it back down on the medication cart, she grabbed a lancet (medical tool for drawing blood and a cutting instrument used in surgery), test strip (a small disposable plastic strip that measures blood sugar levels), and a alcohol pad and proceeded into Resident 51's room. Upon entering the resident's room, she set the glucometer machine on the bedside table without a barrier underneath. The nurse put on gloves. She attempted to use the glucometer machine but had an error message and was unable to use it. She exited the resident's room and obtained a second glucometer machine from a different medication cart 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 record reviews and interviews, the facility failed to ensure the correct supporting diagnosis was used to prescribe an antipsychotic for 1 of 5 residents reviewed for unnecessary medications (Resident 1), and failed to attempt a Gradual Dose Reduction (GDR) or provide evidence to support the denial of a GDR for 2 of 5 residents reviewed for unnecessary medications (Resident 48). Findings include: 1. On 12/5/24 at 9:02 a.m., Resident 1's record was reviewed for unnecessary medications. Her diagnoses included, but were not limited to, major depressive disorder (a mental health condition that can cause persistent low mood and loss of interest in activities), psychotic disorder with delusions (serious mental illness where people lose touch with reality and have abnormal thinking, and have false beliefs), agoraphobia (fear of being in places that may be difficult to escape or help would not be available) with panic disorder (anxiety that causes repeated unexpected panic attacks). On 12/5/24 at 9:36 a.m., Resident 1's pharmacy recommendations were reviewed. A pharmacy…

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 medication was labeled properly for 1 of 3 medication carts reviewed for medication storage (Resident 51). Findings include: On 12/6/24 at 8:13 a.m., the 200 B hall (front) medication cart contained an undated and opened Novolog (medication used to lower blood sugar) insulin pen. The insulin pen contained a label that indicated it was for Resident 51 and was delivered to the facility on 9/11/24. During an interview, on 12/6/24 at 8:14 a.m., Licensed Practical Nurse (LPN) 23 indicated insulin was good for 30 days once opened and she was not aware of how long the Novolog pen for Resident 51 had been opened. During an interview, on 12/6/24 at 8:16 a.m., Licensed Practical Nurse (LPN) 3 indicated insulin pens should have an open date placed on them when they are used. LPN 3 indicated insulin was good for 28 days once opened. Resident 51's record was reviewed on 12/6/24 at 9:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, type 2 diabetes mellitus (a chronic…

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 handling of the glucometer (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) meter during medication administration pass for 1 of 4 residents reviewed during medication administration (Resident 51) and the facility failed to maintain a separation of clean and dirty mechanical lift pads and mop heads supplies in the laundry room for 1 of 1 laundry room observations. Findings include: 1. During the medication administration observation, on 12/6/24 at 7:50 a.m., Licensed Practical Nurse (LPN) 23 obtained a glucometer machine from the top of her medication cart and wiped it with an alcohol pad from front to back, she then placed it back down on the medication cart, she grabbed a lancet (medical tool for drawing blood and a cutting instrument used in surgery), test strip (a small disposable plastic strip that measures blood sugar levels), and a alcohol pad and proceeded into Resident 51's room. Upon entering the resident's room, she set the glucometer…

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 supervise, monitor, and initiate interventions for a dementia resident with a known history of intrusive wandering behaviors, Resident B, which resulted in her being hit by another resident, for 1 of 3 residents reviewed for abuse (Residents B and C). Findings include: An Indiana State Department of Health (ISDH) Survey System report, dated 5/27/24 at 9:40 a.m., submitted by the facility indicated Resident B went into Resident C's room. Resident C made contact with Resident B's right side of her face. Resident B sustained a reddened area on her right temple measuring 2 centimeters (cm) by 3 cm. Resident B was one-on-one observation with staff at the time of the incident and staff had tried to redirect the resident. Resident C was trying to get Resident B out of his personal space with no intent to harm. Resident B was transferred to an inpatient psychiatric facility. The physician, the police department, and responsible parties were notified of the incident. On 6/3/24 at 10:21 a.m., Licensed Practical Nurse (LPN) 7…

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 maintain a system for the reconciliation of narcotic medications resulting in two separate occasions of drug diversion for 1 of 3 residents reviewed for medication reconciliation (Resident C). Findings include: 1. An Indiana State Department of Health (ISDH) Survey System report, dated 4/22/24 at 1:30 a.m., submitted by the facility indicated one card of Resident C's Norco (narcotic medication used to relieve moderate to severe pain) was missing. Qualified Medication Aide (QMA) 6 and Registered Nurse (RN) 5 were suspended pending investigation. The pharmacy and Police Department were notified of the missing narcotic medication. On 5/14/24 at 9:32 a.m., the Administrator (ADM) indicated the facility could not prove who took the missing narcotic medication card of Norco. On 5/14/24 at 11:55 a.m., the Director of Nursing (DON) indicated she did part of the investigation of the missing narcotic card and the Corporate Registered Nurse…

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 transferred to a doctor's appointment in a dignified manner for 1 of 3 residents reviewed for dignity concerns (Resident B). Finding includes: A confidential interview, during the survey, indicated Resident B was brought to the urology office for a scheduled appointment on 3/21/24 at 11:15 a.m. The resident was transported to the office from a local long term care facility by an ambulance service. He was brought in by stretcher wrapped in only a sheet covered in feces (poop), underneath the sheet he was wearing only an adult diaper. His catheter was falling out of his urethra (the tube that lets urine leave your bladder and your body). His colostomy bag (collection of poop) was full and leaking feces all over his body. His skin was red and excoriated (a place where your skin is scraped or abraded) by his stoma (an opening on the abdomen that can be connected to either your digestive or urinary system to allow waste to be diverted out of your body) and his back. On 4/2/24 at 11:45 a.m., Resident B's…

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

Based on record review and interview, the facility failed to ensure medical records were accurately documented for 1 of 3 residents reviewed for intravenous medication administration (Resident D). Findings include: On 4/2/24 at 11:35 a.m. Resident D's record was reviewed. His diagnoses included, but were not limited to, metabolic encephalopathy (a problem in the brain. It is caused by a chemical imbalance in the blood), acute kidney failure (kidneys suddenly stopped working properly), presence of cardiac pacemaker (a device used to control an irregular heart rhythm implanted into the heart), type 2 diabetes (blood sugar disorder), atrial fibrillation (heart rate irregularity), bacteremia (presence of bacteria in the bloodstream), bilateral sensorineural hearing loss (damage either to the tiny hair cells in your inner ear or to the nerve pathways that lead from your inner ear to the brain causing hearing loss), and congestive heart failure (the heart's capacity to pump blood cannot keep up with the body's need). A physician order, dated 1/29/24, indicated to administer cefazolin…

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 1 of 3 residents received care and services related to skin impairment (Resident D). Findings include: During an interview on [DATE] at 1:37 p.m., Resident D indicated she had gaulding (chafing or irritation) to abdominal folds. She asked the staff to clean her and apply medication. She asked the Certified Nurse Aides (CNA) to tell the nurse she needed to have treatment applied and they did not do it. She asked for pain medication yesterday and had to wait for a long time to get it. She called several times to ask for medicine and had to wait for 2.5 hours to get her pain medication. She had no nystatin powder. It happened a lot and she did not understand why she was out when they did not use it very much. The resident indicated the treatment to abdominal folds had not been administered for several days. The resident indicated she had been seen by the Nurse Practitioner on [DATE] and was given an order for Diflucan due to 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 document review, the facility failed to implement a system to monitor and reconcile narcotic medications for 1 of 3 residents reviewed for medications, and failed to ensure medications were available and administered in accordance with physician orders for 1 of 3 residents reviewed medications (Resident D). Findings include: 1. During an interview on [DATE] at 1:37 p.m., Resident D indicated, she asked for pain medication on [DATE] around 10:00 a.m. and had to wait for a long time to get it. She called several times to ask for medications and had to wait for 2.5 hours to receive pain medication. On [DATE] at 3:30 p.m., Licensed Practical Nurse (LPN) 3 and LPN 4, indicated, if they did not have a medication, they got it out of the emergency drug kit (EDK). If not available in the EDK, they call the pharmacy and order the medication. On [DATE] at 3:45 pm during interview with the DON. The DON indicated if medication was not available the nurse would obtain the medications from the EDK, if…

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

Based on observation, interview, and record review the facility failed to ensure residents had safe smoking materials provided for 1 of 1 resident reviewed for accidents (Resident 65), failed initiate fall follow-up protocols for 1 of 1 resident reviewed for accidents (Resident 25), and failed to ensure safe medication storage for 2 of 4 residents reviewed for accidents (Residents 39 and 254). Findings include: 1. On 10/03/23 at 10:51 a.m., while observing Resident 65, in the designated smoking area. The resident dropped ashes several times on her lap blanket. She indicated she had never had a smoking blanket or apron to wear when smoking and she was unable to feel sensation below her waist due to an auto accident resulting in injury to her spine. The Maintenance Technician provided one to one supervision for Resident 65 and indicated smoking blankets or aprons were not provided for the residents. Resident 154 indicated smoking blankets or apron were not available for her to use. Observation of the smoking area lacked evidence of a smoking apron or smoking blanket. On 10/5/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure expired insulin medications were disposed of properly for 2 of 3 medication carts reviewed for medication storage (Residents 57 and 79) and the facility failed to ensure insulin medication was labeled properly for 1 of 3 medications carts reviewed for medication storage (Resident 97). The facility failed to ensure proper storage of insulin medication for 2 of 3 medication carts reviewed for medication storage (Residents 57 and 88). Findings include: 1. On 10/5/23 at 9:05 a.m., the 100-hall medication cart contained 2 insulin pens (an injection device with a needle that delivers insulin into the subcutaneous [under the skin] tissue) that were expired. The pens were labeled for Residents 57 and 79. Resident 57's insulin pen had an open date of 8/24/23 and Resident 79's insulin pen had an open date of 8/30/23. During an interview, on 10/5/23 at 9:10 a.m., Licensed Practical Nurse (LPN) 4 indicated the insulin pens were good 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 observation, interview, and record review, the facility failed to ensure the cleanliness and sanitation of the kitchen and food preparation and storage areas for 2 of 2 kitchen observations. Findings include: 1. During the initial kitchen tour with the Dietary Manager (DM), on 10/2/23 at 10:20 a.m., the following was observed: a. The flooring in the dry storage room was sticky when walked upon and observed with a heavy soilage buildup and dingy with dried food particles, fresh food items, and small pieces of paper debris, including salt/pepper packets, jelly packets, bread ties, and paper towel pieces. b. The light cover above the stove and ovens was soiled with a heavy buildup of dust debris and grease. c. The stove hood filter vent was soiled with a heavy buildup of dust debris and grease. d. The conventional oven and the convection oven were soiled with burnt food debris. e. The steamer had a heavy lime buildup and soiled with burnt food debris. f. The sanitizer bucket water appeared used and soiled. The DM tested the sanitizer solution with a test strip and 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.

Based on interview and record review, the facility failed to ensure a resident was provided showers as preferred for 1 of 3 residents reviewed for choices (Resident 25). Finding includes: During an interview, on 10/3/23 at 8:58 a.m., Resident 25 indicated she had requested to receive two showers a week but there were times she would go a whole week without a shower. Resident 25's record was reviewed on 10/6/23 at 9:34 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 9/16/23, indicated the resident was cognitively intact and required a one-person physical assist with bathing. A care plan, dated 10/28/21 and revised on 2/24/23, indicated the resident had self-care performance deficit, required assistance with ADL (activities of daily living) related to shortness of breath and weakness. Intervention included, but were not limited to, resident preferred to take a shower during evening shift on Tuesday and Friday. Review of resident council minutes, dated 8/8/23, indicated the residents had concerns about not receiving their showers per residents' preferences. Review of point 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 interview and record review, the facility failed to ensure an allegation of missing money was reported and handled as an allegation of misappropriation, and failed to report the allegation to the Indiana Department of Health completed for 1 of 1 resident reviewed for missing personal property (Resident 39). Findings include: On 10/03/23 10:19 a.m., Resident 39 indicated her monthly facility payment went missing 6/25/23, in the amount of $837.00 cash. On 10/05/23 at 12:23 p.m., Resident 39 indicated when the money went missing, before she went to dialysis 6/26/23. She told an unknown male Certified Nursing Aide (CNA) and CNA 15 she believed it was another unknown CNA, who had dirty-blonde hair in a bun, that took the money. She indicated a police report was not filed, and she was not sure if anything else had been done. Record review completed on 10/04/23 at 2:03 p.m., indicated Resident 39's record lacked documentation of an investigation or outcomes. In an interview on 10/05/23 at 2:25 p.m., the Social Service Director (SSD) indicated that she had known about Resident 39's…

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

Based on interview and record review, the facility failed to assess, document, and conduct a thorough investigation after a resident alleged missing money for 1 of 1 resident reviewed for resident property (Resident 39). Findings include: On 10/03/23 10:19 a.m., Resident 39 indicated her monthly facility payment went missing 6/25/23, in the amount of $837.00 cash. On 10/05/23 at 12:23 p.m., Resident 39 indicated before she went to dialysis on 6/26/23, she told an unknown male Certified Nursing Aide (CNA) and CNA 15 that she believed another unknown CNA, with dirty-blonde hair in a bun, took the money. She indicated a police report was not filed, and she was not sure if anything else had been done. A record review, completed on 10/04/23 at 2:03 p.m., indicated Resident 39's record lacked documentation of an investigation or outcomes. In an interview on 10/05/23 at 2:25 p.m., the Social Service Director (SSD) indicated that she had known about Resident 39's missing money from the business office because the resident could not pay her bill. SSD did not have any record of an…

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

Based on observation, record review, and interview, the facility failed to ensure care plans were revised for 2 of 24 residents reviewed for care plans (Residents, 98 and 65). Findings Include: 1. On 10/03/23 at 10:51 a.m., while observing Resident 65, in the designated smoking area. The resident dropped ashes several times on her lap blanket. She indicated she had never had a smoking blanket or apron to wear when smoking and she was unable to feel sensation below her waist due to an auto accident resulting in injury to her spine. The Maintenance Technician provided one to one supervision for Resident 65 and indicated smoking blankets or aprons were not provided for the residents. Resident 154 indicated smoking blankets or apron were not available for her to use. Observation of the smoking area lacked evidence of a smoking apron or smoking blanket. On 10/5/23 at 11:15 a.m., during an interview the Regional Nurse Consultant indicated if a resident wanted to smoke, they were assessed for safe smoking and if they dropped ashes on themselves, they were to be wearing a smoking apron. 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 nail care was provided to a dependent resident for 1 of 32 residents reviewed for activities of daily living (ADL) (Resident 13). Finding includes: On 10/3/23 at 10:34 a.m., Resident 13 was observed lying in bed with long, untrimmed fingernails with dark debris underneath the fingernails on bilateral (both) hands. On 10/4/23 at 2:01 p.m., Resident 13 was observed lying in bed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 10/5/23 at 9:05 a.m., Resident 13 was observed lying in bed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 10/5/23 at 9:00 a.m., Resident 13 was observed lying in bed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. Resident 13's record was reviewed, on 10/4/23 at 2:12 p.m. The resident's diagnoses included, but were not limited…

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 hand splint intervention was provided for a resident with a hand contracture (fixed tightening of muscle, tendons, ligaments, or skin) and a compression sleeve intervention was provided for the resident with edema (swelling caused by too much fluid trapped in the body's tissues) for 1 of 1 resident reviewed for limitation in range of motion (ROM) (Resident 13). Findings include: On 10/3/23 at 10:34 a.m., Resident 13 was observed lying in bed with a contracted right hand. The right hand had long, untrimmed fingernails and was in a tightly closed fist. No compression sleeve nor a hand splint device were observed on the resident. On 10/4/23 at 2:01 p.m., Resident 13 was observed lying in bed with a contracted right hand. The right hand had long, untrimmed fingernails and was in a tightly closed fist. No compression sleeve nor a hand splint device were observed on the resident. On 10/5/23 at 9:00 a.m., Resident 13 was observed lying in bed with a contracted right hand. The right hand had long, untrimmed…

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 storage of respiratory equipment for 2 of 2 residents reviewed for respiratory care (Residents 25 and 254). Findings Include: 1. On 10/3/23 at 9:04 a.m., Resident 25's unbagged nebulizer (turns liquid medicine into a mist that can be easily inhaled) mouthpiece and tubing was observed hanging off the nebulizer machine. The resident was resting in bed. On 10/4/23 at 9:45 a.m., Resident 25 was asleep in bed and her unbagged nebulizer mouthpiece and tubing were observed hanging down the side of her bedside table almost touching the floor. On 10/5/23 at 10:03 a.m., Resident 25 was sitting up in her wheelchair and her unbagged nebulizer mouthpiece and tubing was observed sitting on top of her nebulizer machine. A clear substance was noted to be in the medication chamber of the mouthpiece. On 10/5/23 at 2:55 p.m., Resident 25's unbagged nebulizer mouthpiece and tubing were observed to be sitting on top of her nebulizer machine and a clear substance was noted to be in the medication chamber 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 record review and interview, the facility failed to ensure documented evidence of medication administration for 2 of 5 residents reviewed for unnecessary medications (Resident 33 and 60). Findings include: 1. Resident 33's record was reviewed on 10/4/23 at 1:50 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hyperlipidemia (an excess of lipids [fats] in the blood), manic episodes (a state of mind characterized by high energy, excitement, and euphoria over a sustained period of time), anxiety disorder (persistent and excessive worry that interferes with daily activities) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A significant change Minimum Data Set (MDS) assessment (a standardized assessment tool that measures health status in nursing home residents), dated 8/20/23, indicated the resident had severe cognitive deficit and received antipsychotic medication (a type of psychiatric medication which are available on prescription to treat psychosis) and antidepressant…

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 documented evidence of physician treatment orders being completed for 1 of 3 residents reviewed for nursing services (Resident B). Finding includes: During an initial observation, on 8/26/23 at 7:30 p.m., Resident B was observed in her bed watching television (TV). She was positioned on her back, facing right, with a positioning pillow under her left side. No pillow support was observed under the resident's heels or between bony prominence's (areas which are under the most pressure and are at greatest risk for developing pressure sores). During a random observation, on 8/28/23 at 9:50 a.m., Resident B was observed in her bed. The resident had a positioning pillow on her left side, but her body was not in contact with the pillow. The resident was positioned on her back. No pillow support for her heels or in between her bony prominence's were observed. During a random observation, on 8/28/23 at 12:05 p.m., Resident B was observed in her bed positioned on her back with the head of her bed elevated, eating…

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.