Waters Of Tipton Skilled Nursing Facility, The

Based on interview and record review, the facility failed to ensure a bed hold policy was provided to the resident or resident's representative at the time of transfer for 1 of 2 residents reviewed for hospitalization. (Resident 78)Findings include:The clinical record for Resident 78 was reviewed on 3/24/26 at 2:34 p.m. The diagnoses included, but were not limited to, repeated falls, history of falling, and dementia.A progress note, dated 6/25/25, indicated Resident 78 was noted to be on the floor and complained of back pain. The resident was transferred by Emergency Medical Services (EMS) to the hospital.The clinical record did not indicate the bed hold policy was provided to the resident or resident's representative at the time of transfer.During an interview, on 3/26/26 at 9:56 a.m., Social Services14 indicated the staff should document when the bed hold policy was provided to the resident or resident's representative when a resident was transferred to the hospital.During an interview, on 3/26/26 at 10:12 a.m., Social Services14 indicated she found the note about the transfer,…

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 mental health services were provided for a resident with several mental health disorders for 1 of 4 residents reviewed for mood and behavior. (Resident 12)Findings include:During an observation and interview, on 3/19/26 at 10:37 a.m., Resident 12 was in bed and indicated she did not receive mental health services but would like to attend therapy sessions.During an observation and interview, on 3/25/26 at 1:57 p.m., Resident 12 was in bed and was thinking about going to the ice cream bar activity downstairs. She indicated staff had not asked if she would like to attend therapy and wished staff would because she could use it.The clinical record for Resident 12 was reviewed on 3/23/26 at 12:36 p.m. The diagnoses included, but were not limited to, bipolar disorder, conversion disorder, anxiety disorder, post-traumatic stress disorder, panic disorder, delusional disorder, and dementia.Resident 12 was admitted to the facility, on 9/5/25, after an extended in-patient stay at a psychiatric hospital.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 observation, interview and record review, the facility failed to ensure staff followed enhanced barrier precautions and wore personal protective equipment which included a gown during catheter care for 1 of 1 resident randomly observed for infection control. (Resident 93)Findings include:During an observation of catheter care, on 3/24/26 at 11:05 a.m., CNA 13 and Unit Manager 7 were in the room for Resident 93's catheter care. CNA 13 performed catheter care and did not wear a gown during the process.The clinical record for Resident 93 was reviewed on 3/24/26 at 3:26 p.m. The diagnoses included, but were not limited to, benign neoplasm of the bladder, neuromuscular dysfunction of the bladder, and a stroke affecting the left non-dominant side.A physician's order, dated 12/17/25, indicated enhanced barrier precautions every shift for the indwelling catheter.During an interview, on 3/24/26 at 11:16 a.m., Unit Manager 7 indicated a gown should be worn when performing catheter care.During an interview, on…

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

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 4 residents reviewed for dignity. (Resident B and C)Findings include:1. During an observation, on 11/11/25 at 3:12 p.m., Resident B had a healed scar from a laceration above her right eyebrow.The clinical record for Resident B was reviewed on 11/11/25 at 10:25 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, generalized anxiety disorder, mood disorder, cognitive communication deficit, major depressive disorder, altered mental status, and dementia.A quarterly minimum data set (MDS) assessment, dated 8/10/25, indicated Resident B had a severe cognitive impairment. The resident required maximal assistance to maintain personal hygiene which included combing hair, shaving, applying makeup, and washing/drying face and hands.A care plan, dated 10/13/25, indicated the resident was at risk of psychosocial distress. Interventions included, but were not limited to, offer reassurance she was safe in the facility.In a facility witness statement,…

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 person-centered care plan was developed with individualized interventions and reviewed and revised to accommodate the resident's care needs prior to initiating a medication to control behaviors for 1 of 1 resident reviewed for dementia care. (Resident C)Findings include:The clinical record for Resident C was reviewed on 7/17/25 at 10:06 am. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and muscle weakness. A handwritten document, titled Behavior Sheet, dated 6/17/25, indicated Resident C had a sexually inappropriate behavior when he grabbed CNA 1's butt with both his hands. She was standing him up to move him to his wheelchair when he touched her. The CNA provided the resident with instructions or redirected him, which improved the behavior immediately.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/21/25, indicated Resident C inappropriately…

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 assessment which included prior interventions, risks and benefits, and the clinical rationale for the initiation of a medication to control behaviors was completed and documented for 1 of 3 residents reviewed for unnecessary medications. (Resident C)Findings include:The clinical record for Resident C was reviewed on 7/17/25 at 10:06 am. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and muscle weakness. A handwritten document, titled Behavior Sheet, dated 6/17/25, indicated Resident C had a sexually inappropriate behavior when he grabbed CNA 1's butt with both his hands. She was standing him up to move him to his wheelchair when he touched her. The CNA provided the resident with instructions or redirected him, which improved the behavior immediately.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/21/25, indicated Resident C inappropriately…

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

Based on interview and record review, the facility failed to ensure a resident's behaviors were documented in the electronic medical record for 1 of 3 residents reviewed for a complete and accurate clinical record. (Resident C)Findings include:The clinical record for Resident C was reviewed on 7/17/25 at 10:06 am. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, and muscle weakness. The following were provided by the Executive Director, on 7/18/25 at 11:00 a.m.:A handwritten document, titled Behavior Sheet, dated 6/17/25, indicated Resident C had a sexually inappropriate behavior when he grabbed CNA 1's butt with both his hands. She was standing him up to move him to his wheelchair when he touched her. The CNA provided the resident with instructions or redirected him, which improved the behavior immediately.The handwritten note was provided after the start of the survey and was not located in Resident C's medical record. A handwritten document, titled Behavior Sheet, dated 6/21/25, indicated Resident C inappropriately physically touched CNA…

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 notify the physician when a resident sustained an injury during a transfer for 1 of 3 residents reviewed for notification of change. (Resident B) Findings include: During a telephone interview, on 6/16/25 at 9:43 a.m., Resident B's family member indicated Resident B had to be sent to the emergency room. The facility reported the resident had a skin tear, but it was a laceration which required seven staples. The family was not notified until Resident B was sent to the hospital. During an observation, on 6/16/25 at 9:27 a.m., Resident B had a wound on the outer aspect of her lower left leg. The wound was approximately two centimeters long and closed with six staples. It was bruised around the area. The clinical record for Resident B was reviewed on 6/16/25 at 9:40 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, unsteadiness on feet, and muscle weakness. A facility document, titled Skin Tear, dated 6/10/25 at 9:50 p.m., LPN 3 notified the on-call physician on 6/10/25 at 10:14 p.m. A 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 observation, interview and record review, the facility failed to ensure a resident was kept safe during a transfer for 1 of 1 resident reviewed for accidents. (Resident B) Findings include: During a telephone interview, on 6/16/25 at 9:43 a.m., Resident B's family member indicated Resident B had to be sent to the emergency room. The facility reported the resident had a skin tear, but it was a laceration which required seven staples. During an observation, on 6/16/25 at 9:27 a.m., Resident B had a wound on the outer aspect of her lower left leg. The wound was approximately two centimeters long and closed with six staples. It was bruised around the area. During an observation, on 6/17/25 at 10:33 a.m., with LPN 6, the bed frame was observed to be covered with sheep skin. The edges under the sheep skin covering felt rounded along the frame and at the joints where the frame connected. The underside was found to have metal bolts, but they did not stick out and were inside of the bed frame. There was no area on the bed frame found sticking out. The bed frame had no sharp edges. 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 observation, interview and record review, the facility failed to ensure a sufficient number of staff were available to provide residents nursing care and other related services to the residents. (Resident 187, 56, 34, 20, 73, 30 and 66) This deficient practice had the potential to affect 88 of 88 residents. Findings include: A Payroll Based Journal (PBJ) for the 1st quarter of 2025 indicated the facility scored a 1-star staffing rating. 1. During an observation, on 3/12/25 at 9:31 a.m., Qualified Medication Aide (QMA) 17 answered the call light for Resident 187. The family had pushed the call light and asked QMA 17 if they could take the resident to the bathroom. QMA 17 indicated they would, but they would have to wait for another aide to be available since the resident was a 2 person assist, and the other aide was busy. During an interview, on 3/12/25 at 10:10 a.m., QMA 17 indicated this hall was staffed fine but Terrace Hall needs more staffing. It can take longer than they want to get their work done…

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 used adequate testing equipment, such as a working thermometer, to ensure adequate washing of the dishware in the high temperature dishwasher. This deficient practice had the potential to affect 88 of 88 residents who received food from the kitchen. Findings include: During an observation and interview, on 3/11/25 at 9:50 a.m., the wash cycle thermometer on the dishwasher was not working. [NAME] 21 indicated the dishwasher was a high temperature dishwasher. She was not sure why the thermometer gauge was not working or what they were using to gauge the temperature. During an observation and interview, on 3/11/25 at 9:50 a.m., [NAME] 23 was running the dishes through the dishwasher. He indicated he was not sure why the thermometer was not working and was not sure how the temperature was gauged before washing the dishes. During an interview, on 3/11/25 at 10:23 a.m., Maintenance 24 indicated the gauge had been broken. He was not sure how they were gauging the temperature. During an interview, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was given notification of the resident's transfer and discharge to the hospital for 4 of 4 residents reviewed for transfer and discharge. (Resident 2, 12, 74 and 237) Findings include: 1. The clinical record for Resident 2 was reviewed on 3/11/25 at 4:16 p.m. The diagnoses included, but were not limited to, fever, respiratory infection, and hallucinations/delusions. The resident was transferred out of the facility and to the hospital on [DATE] for fever and respiratory infection and 1/24/25 for new/worsening hallucinations/delusions. The facility was unable to provide notification to the Ombudsman of the transfer. 2. The clinical record for Resident 12 was reviewed on 3/11/25 at 4:11 p.m. The diagnoses included, but were not limited to, dementia, type 2 diabetes, and muscle weakness. The resident was transferred out of the facility and to the hospital due to hallucinations and aggressive behavior…

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.

A current facility policy, titled Catheters, undated and received from the Clinical Support Nurse on 3/14/25 at 1:30 p.m., indicated .Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and facility protocol and procedure with adherence to infection prevention and control techniques A current facility policy, titled Hand Hygiene, undated and received from Corporate Support Nurse on 3/17/25 at 10:40 a.m., indicated .If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations. Some of these situations included .before putting on and taking off gloves A current facility policy, titled GUIDELINES FOR INFECTION CONTROL/ISOLATION, dated as reviewed 2/2023 and received from the Director of Nursing on 3/17/25 at 1:48 p.m., did not cover walking in halls/common areas in PPE. Donning and Doffing PPE: Proper Wearing, Removal and Disposal (reviewed October 3, 2022) was retrieved on 3/19/25 from the Centers of Disease Control (CDC) website. The guidance included the need…

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 need for a bed and chair alarm was re-evaluated and on-going monitoring was documented for 1 of 1 resident reviewed for physical restraints. (Resident 49) Findings include: During an observation, on 3/13/25 at 9:49 a.m., Resident 49 had a bed alarm and a chair alarm. The clinical record for Resident 49 was reviewed on 3/13/25 at 9:48 a.m. The diagnoses included, but were not limited to, dementia, cognitive communication deficit, mild cognitive impairment, and abnormalities of mobility. A physician's order, with a start date of 7/1/23, indicated to use a bed sensor alarm while the resident was in bed every shift for falls. A physician's order, with a start date of 3/29/24, indicated to place a chair sensor in the resident's chair while she was in her room every shift for falls. A fall risk review assessment, dated 1/14/25, indicated the resident did not have a history of falling within the past 3 months. The last documented fall in the Electronic Health Record (EHR) was 9/17/24. There was no…

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 care plan meetings were held quarterly and timely upon admission for 2 of 2 residents reviewed for care plan meetings. (Resident 12 and 30) Findings include: 1. The clinical record for Resident 12 was reviewed on 3/11/24 at 4:16 p.m. The diagnoses included, but were not limited to, type 2 diabetes, dementia, and muscle weakness. A care plan note was documented for September 2024 and March 2025. There were no notes found to show a care plan meeting had been held after September and prior to March. During an interview, on 3/13/25 at 9:57 a.m., the Social Service Designee indicated she was not able to find documentation for a care plan meeting between 9/24 and 3/25. She indicated care plan meetings were to be completed quarterly. 2. During an interview, on 3/12/25 at 9:30 a.m., Resident 30 indicated she did not have a care plan meeting until 3/11/25. The clinical record for Resident 30 was reviewed on 3/17/25 at 3:43 p.m. The diagnoses included,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) care were assisted to the bathroom timely, and staff followed a physician's order related to footwear during a transfer for 2 of 2 dependent residents reviewed for ADL care. (Resident 187) Findings include: 1. During an observation, on 3/12/25 at 9:31 a.m., Qualified Medication Aide (QMA) 17 answered the call light for Resident 187. The family had pushed the call light and asked QMA 17 if they could take the resident to the bathroom. QMA 17 indicated they would, but they would have to wait for another aide to be available since the resident was a 2 person assist, and the other aide was busy. During an observation, on 3/12/25 at 10:28 a.m., QMA 17 and another staff member went into the room to take Resident 187 to the bathroom. Resident 187 waited 57 minutes to be taken to the bathroom. During an interview, on 3/12/25 at 10:45 a.m., QMA 17 indicated the resident…

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

Based on observation, interview and record review, the facility failed to ensure residents with catheters had physician's orders in place for 3 of 4 residents reviewed for catheters. (Resident 59, 56 and 10) Findings include: 1. During an observation, on 3/11/25 at 12:03 p.m., Resident 59 was observed sitting in his recliner. A catheter bag was noted to be draining to gravity. The clinical record for Resident 59 was reviewed on 3/13/25 at 11:01 a.m. The diagnoses included, but were not limited to, fall, acute kidney failure, and hypertension. The resident did not have a physician's order for an indwelling catheter. During an interview, on 3/13/25 at 11:12 a.m., LPN 6 indicated a resident needed to have a physician's order for a catheter. She indicated Resident 59 did not have an order for the catheter. 2. During an observation, on 3/11/25 at 11:00 a.m., Resident 56 was sitting on his recliner. A urinary catheter was attached to the side of the recliner. The clinical record for Resident 56 was reviewed on 3/13/25 at 8:08 a.m. The diagnoses included, but were not limited to, 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 label an oxygen line with the date it was put into use, to store an oxygen line in a bag when not in use, to ensure oxygen orders were in place, and to discard a nebulizer mask and tubing which was no longer in use for 3 of 3 residents reviewed for respiratory care. (Resident 59, 140 and 71) Findings include: 1. During an observation, on 3/12/25 at 10:12 a.m., Resident 59 had an oxygen concentrator with the oxygen line and nasal cannula attached. The line was found to be missing the date it was initiated. During an interview, on 3/12/25 at 10:22 a.m., LPN 6 was observed to write a date on the tubing for 3/12/25. She indicated the line should have been changed on the night shift but was not documented and she would have to call the nurse and check. During an observation, on 3/13/25 at 10:26 a.m., the oxygen line for Resident 59 was observed to be wrapped up and laying on top of the oxygen concentrator and not in a bag. The line was dated for 3/12/25. During an interview, on 3/13/25 at 10:29 a.m., QMA 3…

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 Registered Nurse coverage was provided for at least 8 consecutive hours in a 24-hour day for 1 of 14 days reviewed for RN coverage. (3/2/25) Findings include: The Payroll Based Journal (PBJ) was reviewed and indicated the facility received a 1-star staffing rating for the first quarter of 2025. The daily nursing staff schedule, dated 3/2/25, indicated there was not a Registered Nurse (RN) in the facility for 8 consecutive hours that day. During an interview, on 3/18/25 at 2:06 p.m., the Director of Nursing (DON) indicated the facility did not currently have a staffing scheduler, so she had been responsible for the nursing schedule. She indicated there was not a Registered Nurse scheduled to be in the facility for any shift on the date of 3/2/25. The weekend option RN who normally worked was on vacation and when the open shift was filled, it was overlooked. There should be an RN in the building covering at least an 8-hour shift in a 24-hour period. A current facility policy, titled Registered Nurse Coverage, undated…

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 the pharmacy received a medication authorization and a resident did not have to provide their personal home supply until the medication was authorized for 1 of 1 resident reviewed for pharmacy services (Resident 71) and failed to ensure narcotic count sheets were signed by the in-coming and out-going staff for 4 of 4 narcotic log books reviewed. Findings include: 1. During an interview, on 3/11/25 at 10:26 a.m., Resident 71 indicated she was not getting her Creon (a medication which replenished enzymes for digestion of food) and it was to be given with meals. A care plan, dated 2/25/25, indicated the resident was at risk for weight loss, pain, fatigue and other complications related to a cancer diagnosis and to administer medications as ordered. The clinical record for Resident 71 was reviewed on 3/13/25 at 11:47 a.m. The diagnoses included, but were not limited to, pancreatic cancer, diabetes mellitus, and myasthenia gravis (an auto-immune disorder). A physician's order, dated 2/20/25, indicated to give 2 capsules…

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 monitoring for potential side effects of psychotropic medications were in place for 1 of 5 residents reviewed for unnecessary medications. (Resident 73) Findings include: The clinical record for Resident 73 was reviewed on 3/17/25 at 2:08 p.m. The diagnoses included, but were not limited to, delusional disorder, visual hallucinations, depression, and neurocognitive disorder with Lewy Bodies. 1. A physician's order, dated 3/12/25, indicated Resident 73 was to take Depakote Sprinkles (a medication commonly used for bipolar disorder symptoms), two times a day, for delusional disorder. A physician's order, dated 3/10/25, indicated Resident 73 was to take haloperidol (an antipsychotic medication), as needed (PRN), for delusions and agitation. A physician's order, dated 3/10/25, indicated Resident 73 was to take Risperdal (an antipsychotic medication), two times a day, for delusional disorder. A physician's order, dated 8/24/24 and discontinued on…

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

Based on observation, interview and record review, the facility failed to ensure food was served at palatable and appetizing temperatures for 1 of 1 room tray observed. (the terrace unit) Findings include: During an interview, on 3/12/25 at 9:48 a.m., Resident 66 indicated the food was sometimes served cold. During an interview, on 3/12/25 at 11:13 a.m., Resident 10 indicated the food was served cold. During an observation and interview, on 3/14/25 at 1:09 p.m., Kitchen Manager 16 took a temperature of a room tray which was about to be delivered on the Terrace unit. The chili dog temperature was 110 degrees, and the corn was 85 degrees. Kitchen Manager 16 indicated both items should have temped at 145 degrees. The resident council meeting minutes were reviewed on 3/13/25 at 10:32 a.m., and indicated: a. March 2024, the old business indicated the food was still cold. b. January 2025, the new business indicated the serving time of the food could be better and they needed more nursing staff. During a meeting with the resident council, on 3/13/25 at 1:56 p.m., the 2 residents 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 interview and record review, the facility failed to ensure unlicensed staff notified a licensed staff member when a resident was found to have discolored areas located on both shoulders for 1 of 1 resident reviewed for an injury of unknown origin. (Resident 2) Finding includes: The clinical record for Resident 2 was reviewed on 12/30/24 at 11:30 a.m. The diagnoses included, but were not limited to, cognitive communication deficient, atrial fibrillation, and dementia. A facility shower sheet, dated 6/26/24 and signed by a QMA on the nurse signature line, indicated .red bruising was found on both shoulders. On the same document, dated 6/28/24, the resident was given a bed bath. There was no note of bruising on the sheet. The next entry on the same document, dated 7/5/24, indicated the resident had a shower. Faded bruising was noted at the area of both shoulders and the upper chest area. A facility document, titled SHOWER SHEET:SKIN CHECKS, dated 6/29/24 and provided by the Director of Nursing on 12/31/24 at 9:06 a.m., indicated the resident had .bruising near collarbone 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 The facility failed to ensure dietary employees had competency and skills in the operation of the dishwasher. This deficient practice had the potential to impact 93 of 93 residents who consumed meals prepared by the facility kitchen. Findings include: During an interview on 3/8/23 at 10:51 a.m., the DON indicated all 93 of the facility's residents consumed foods orally. During an observation of the dishwasher operation on 3/8/24 at 9:17 a.m., Dietary Aide 6 sprayed dishes and placed them on a tray/rack to go into the dishwasher. During an interview on 3/8/24 at 9:17 a.m., Dietary Aide 6 indicated he was a new employee and this was his first time operating the dishwasher. He was being trained, however no one was with him at the moment because staffing was short. He did not know what temperature the dishwasher was supposed to reach during the washing or rinsing process. He did not know anywhere in the kitchen where this information was listed. He would need to ask for assistance. During an observation and…

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

Based on observation, interview, and record review, the facility failed to obtain a physician's order, complete assessments, document care plans, and complete daily function testing for residents wearing personal body alarms. (Residents 20 and 43) Findings include: 1. During an observation on 3/8/24 at 2:12 p.m., Resident 20 was seated in her recliner with a pull tab alarm clipped to her left shoulder. The resident was sleeping. Resident 20's clinical record was reviewed 3/8/24 at 2:15 p.m. Her diagnosis included unspecified dementia, history of falling, and cognitive communication deficits. A 1/4/24 Fall Risk care plan indicated interventions included the following: 1/2 side rails to bed to provide assist with mobility and positioning, monitor for changes in gait/positioning, and an alarm x 30 days. The clinical record lacked a physician's order for a personal body alarm. The clinical record lacked assessment related to the use of an alarm for fall risk prevention by the Interdisciplinary Team (IDT). The clinical record lacked documentation Resident 20's family or representative…

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 notify a resident's responsible party of an allegation of abuse, in accordance with facility policy, for 1 of 3 residents reviewed for the implementation of the abuse protocol (Resident B). Findings include: Review of a 2/8/24 facility self reported incident indicated a coworker alleged CNA 100 had spoken to Resident B in an upset tone. A 2/8/24 Confidential Witness Statement indicated CNA 100 pointed her finger at Resident B and spoke to him in an upset tone because the resident was in the hallway yelling about the noise from the dining cart. During an interview, on 3/5/24 at 11:51 a.m., with Resident B's representative, she indicated she had not been informed of an employee speaking to the resident in an unkind manner. Resident B's clinical record was reviewed on 3/5/24 at 2:39 p.m. Current diagnoses included Alzheimer's disease, vascular dementia, anxiety, and depression. A 1/18/24, quarterly, Minimum Data Set assessment indicated the resident was severely cognitively impaired, understood others, and did not display any…

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

Based on observation, interview, and record review, the facility failed to assess a resident for pain, address her concerns and distress, and notify the physician of resident pain and distress for 1 of 2 resident's reviewed for pain management. (Resident 197) Findings include: During a random observation on 3/4/24 at 10:00 a.m., Resident 197 was observed in her room in bed, positioned on her back. She was moaning loudly and indicated she felt cold. The resident was observed to have a sheet and a blanket over her body. She indicated several times, Why is it so cold, I just keep shaking. Several staff members were observed walking past the resident's room and not addressing the resident's concerns. At 10:33 a.m., QMA 9 was seated at a small desk in the hallway, entering information into a computer. The resident continually moaned and indicated she was cold and requesting someone to help her get warm. At 10:58 a.m., a staff member was observed in her room putting clothes away. The resident was heard calling for her Mother and for help. The staff member indicated to the resident to stop…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to discard an expired insulin pen and to indicate a date opened on another insulin pen, and label over-the-counter medications with resident identifiers for 2 of 3 medication carts observed for medication storage. (Orchard Hall and Garden Hall medication carts) Findings include: 1. During observation of the Orchard Hall medication cart on [DATE] at 10:17 a.m., accompanied by QMA 9, the following was observed: A Lantus Solostar insulin pen (to treat diabetes) without an opened date. QMA 9 indicated the pen contained 240 units. A Humalog QuikPen (to treat diabetes) with a do not use after date of [DATE]. QMA 9 indicated the pen should have been discarded. Two unopened bottles of Daily Multivitamin Men's Health (a supplement) without a resident's identifiers. An unopened box of NightTime Cold and Flu (to treat cold or flu) without a resident's identifiers. 2. During an observation of the Garden Hall medication cart on [DATE] at 10:31 a.m., accompanied by LPN…

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

Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 4 residents being reviewed for respect and dignity. (Residents B and F) Findings include: A document, titled Indiana State Department of Health Survey Report System, dated 10/24/23, indicated Resident B voiced concerns regarding care provided to her by CNA 1 on 10/23/23. The five-day follow-up indicated the facility suspended CNA 1 while the investigation was being completed, but was unable to substantiate the specific incident, which occurred on 10/23/23. However, during the investigation, the facility discovered negative findings regarding CNA 1 and chose to move forward with her termination. During an interview, on 10/24/23 at 3:15 p.m., the Executive Director (ED) indicated CNA 1 was terminated for customer service after her investigation was completed. She had received more complaints regarding this staff member's customer service during the investigation and she thought it was best to terminate her. 1. During an interview, on 10/25/23 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 interview and record review, the facility failed to ensure a chest X-ray was completed for 1 of 3 residents being reviewed for diagnostic services. (Resident E) Finding includes: An Intake Information indicated Resident E had a raspy sore throat and a cough. An order was written for a chest X-ray. The resident was told the X-ray company was coming the evening of 10/9/23. The X-ray company called on 10/9/23 around 9 p.m., indicating the staff members car broke down and someone would be at the facility on Tuesday (10/10/23). The X-ray company did not come to do the chest X-ray until the morning of 10/13/23 and the resident had been sent to the hospital. During an interview, on 10/23/23 at 12:15 p.m., the Interim Director of Nursing (DON) indicated Resident E was admitted to the hospital on [DATE], for signs and symptoms of pneumonia. They received a phone call from the hospital, on 10/13/23, Resident E had Legionella. The record for Resident E was reviewed on 10/24/23 at 2:15 p.m. Diagnoses 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.