Life Care Center Of The Willows

Based on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration for 2 of 4 residents reviewed for respiratory care. (Residents 51 and 74) Findings include:1.On 1/21/26 at 9:23 a.m., Resident 51 was observed in bed. She had a nasal cannula sitting next to her head. She had indicated she was not feeling well at the time and was coughing. The concentrator was set to 4 liters per minute. On 1/21/26 at 2:50 p.m., Resident 51 was observed in bed with no nasal cannula in place. On 1/22/26 at 9:53 a.m., Resident 51 was observed sitting in bed with no nasal cannula in place. On 1/23/26 at 10:12 a.m., Resident 51 was observed in bed with no nasal cannula in place. Resident 51's record was reviewed on 1/22/26 at 2:25 p.m. Diagnoses included, but were not limited to, heart failure, dementia, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, indicated the resident was cognitively intact. A Physician's Order, dated 1/17/26, indicated oxygen at 4 liters per…

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 weights were being checked and monitored for a resident who received medications for heart failure and failed to ensure medication was not administered in an excessive dose for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for pain. (Residents 48 and 75)Findings include:1. Record review for Resident 48 was completed on 1/22/2 at 9:38 a.m. Diagnoses included, but were not limited to, insomnia, anemia, heart failure, end stage renal disease, and respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 10/29/25, indicated the resident was moderately cognitively impaired. The resident received diuretic medication. A Care Plan, dated 10/29/25, indicated the resident had fluid overload or potential fluid volume overload related to chronic heart failure. Interventions included administer medications as ordered, observe and report sudden weight gain, and to weigh at the same time of day as ordered by the physician. The January 2026 Physician's Order Summary (POS)…

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

Based on observation and interview, the facility failed to ensure infection control practices were in place and implemented related to lack of glove changes and performing hand hygiene during wound care for 1 of 3 wound care treatments observed. (Resident 64) Finding includes:On 1/23/26 at 11:30 a.m., the Wound Nurse was observed performing dressing changes for Resident 64. The resident had a pressure ulcer to the medial side and lateral side of the left foot. The Wound Nurse washed her hands and then donned a gown and gloves. She removed the dressing to the lateral side of the foot. There was a small pressure area that she cleaned with saline and applied skin prep (provides protective film over skin). She then removed the old dressing to the medial foot, without changing gloves or performing hand hygiene. She cleansed the area with saline and applied skin prep. She removed her gloves and donned new gloves, without performing hand hygiene. She removed a dressing from the coccyx. There was a small open wound with slough observed. She washed the wound with saline, removed her gloves…

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 promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy to reduce antibiotic resistance related to ordering an antibiotic for prophylactic (preventative) use in a resident with COPD (Chronic Obstructive Pulmonary Disease) for 1 of 1 resident reviewed for antibiotic use. (Resident 5)Finding includes:During interview on 1/20/26 at 2:46 p.m., Resident 5 indicated that he had been taking an antibiotic three times per week to keep his Chronic Obstructive Pulmonary Disease (COPD) from getting bad. Resident 5 record was reviewed on 1/23/2026 at 9:27 a.m. Diagnoses included, but were not limited to, Atherosclerotic Heart Disease, automatic implantable cardiac defibrillator, Chronic Obstructive Pulmonary Disease (COPD), peripheral vascular disease (PVD), hypertension, Diabetes Mellitus type 2, and paroxysmal atrial fibrillation. The Quarterly Minimum Data Set assessment, dated 12/24/25, indicated the resident was moderately cognitively impaired. The Physician's Order Summary, dated 1/2026, 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 observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to improper use of personal protective equipment (PPE) prior to entering and leaving a droplet precautions room and staff not knowing why a resident was in isolation for 1 of 3 residents reviewed for infection control. (Resident B) Finding includes:During a random observation on 12/4/25 at 10:01 a.m., the signage on the outside of Resident B's door indicated the resident was in enhanced barrier precautions (EBP) and droplet precautions. The wound nurse was observed inside Resident B's room providing care. She had a gown and gloves on but was not wearing a mask.During a wound observation with CNA 1 and the Wound Nurse on 12/4/25 at 10:19 a.m., both wore gowns and gloves but neither staff member wore a mask.During an interview at time, the Wound Nurse indicated Resident B was in contact isolation not droplet isolation, and she was unsure why that signage was on the door. She looked at the outside of the door and confirmed the droplet…

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 ensure the residents' environment was clean and in good repair related to dirty and discolored vents, exposed electrical wiring, and a broken baseboard heating cover for 3 of 3 units and the dining room. (East Hall, Center Hall, [NAME] Hall, and Dining Room) Findings include: During an Environmental Tour on 9/29/25 at 8:55 a.m., the following was observed: 1. East Halla. The ceiling vents were dirty and discolored throughout the hallway. 2. Center Hall a. The ceiling vents were dirty and discolored throughout the hallway.b. There was exposed electrical wiring in the hallway across from room [ROOM NUMBER].c. There were exposed electrical wiring hanging from a ceiling tile in the center hallway. 3. [NAME] Halla. The ceiling vents were dirty and discolored throughout the hallway. 4. Dining Room a. The vents in the dining room were dirty and discolored.b. The baseboard heating unit cover was not attached. During an interview on 9/29/25 at 9:49 a.m., 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 maintain clinical records that were complete and accurately documented, related to incontinence care documentation for 3 of 3 residents reviewed for activities of daily living (ADL) care. (Residents B, C, and D) Findings include:1. Resident B's record was reviewed on 9/29/25 at 10:09 a.m. Diagnoses included, but were not limited to, high blood pressure, adult failure to thrive, and mild cognitive impairment. The admission Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident was cognitively intact, required substantial to maximal assistance with toileting, bed mobility, and was dependent for transfers. The resident was frequently incontinent of bowel and bladder. A Care Plan, dated 8/18/25, indicated the resident had urinary incontinence. Interventions included, but were not limited to, assist with toileting and pericare as needed. The CNA (Certified Nursing Assistant) Task, B&B - Bowel and Bladder Elimination, indicated CNAs were to document at least every shift (3 times a day) incontinence care…

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

Based on observation and interview, the facility failed to ensure resident's privacy was maintained related to the electronic medication record left open and unlocked in the hallway during medication pass for 2 of 5 residents observed during medication pass. (Residents 113 and 6) Finding includes: On 11/8/24 at 8:15 a.m., LPN 1 was observed passing medications to Resident 113. She prepared the medications in the hallway on the East Hall cart using the electronic medication record on the computer. She then took the medications to the resident in his room. The computer screen was left open and on, leaving the residents medications and personal information available to view. At 8:25 a.m., LPN 1 returned to the East Hall cart and prepared medications for Resident 6. She then took the medications to the resident in his room and again left the computer screen open and unlocked with personal information available to view in the hallway. During an interview on 11/8/24 at 8:37 a.m., LPN 1 indicated she should have locked the screen but didn't know how to unlock it. 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 record review and interview, the facility failed to ensure care plans were implemented for 1 of 19 resident care plans reviewed. (Resident 9) Finding includes: Resident 9's record was reviewed on 11/8/24 at 10:20 a.m. Diagnoses included, but were not limited to, senile degeneration of the brain and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was severely cognitively impaired for daily decision making. She required maximal to total dependence on staff for activities of daily living (ADL) care. She received antipsychotic, anti-anxiety, antidepressant, and opioid medications. She was on hospice care. The November 2024 Physician Order Summary indicated Resident 9 received morphine sulfate (opioid pain medication) 20 milligram/milliliter (mg/ml), 5 mg by mouth every two hours as needed. The resident was to be observed for opioid medication side effects every shift. There were no care plans related to pain and opioid use. During an interview on 11/12/24 at 3:50 p.m., the Director of Nursing indicated there were no care plans…

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

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a treatment not provided as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident 39) Finding includes: On 11/8/24 at 10:40 a.m., wound care for Resident 39 was observed with the Infection Prevention (IP) Nurse. The resident had a stage 4 pressure ulcer to her sacrum. She was in bed and turned onto her right side. The nurse removed the old dressing and cleansed the wound with wound wash, patted the area dry and checked measurements. She then applied skin prep to the skin surrounding the wound and applied an antimicrobial gel to the wound bed. She then packed the wound with calcium alginate and covered the area with an island border dressing. The resident's record was reviewed on 11/7/24 at 3:31 p.m. Diagnoses included, but were not limited to, diabetes mellitus, adult failure to thrive, and a stage 4 pressure ulcer to sacral region. The Quarterly Minimum Data Set assessment, 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 observation, record review, and interview, the facility failed to ensure a nutritional supplement was offered during meal service and food consumption logs were completed for a resident with a history of weight loss for 1 of 2 residents reviewed for nutrition. (Resident 5) Finding includes: On 11/13/24 at 1:07 p.m., Resident 5 was seated at a table in a wheelchair in the Assisted Dining Area. The resident had a meal tray in front of her which included mashed potatoes, ground meatballs with gravy, vegetables, and ice cream. There was no bowl of soup observed. The resident's meal ticket had Super Soup written on the ticket. Record review for Resident 5 was completed on 11/12/24 at 10:45 a.m. Diagnoses included, but were not limited to, stroke, diabetes mellitus, hypertension, dementia, and end stage renal disease. The Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated the resident was cognitively impaired. The resident had an impairment on one side of her upper and lower extremities for a functional limitation in range of motion. The resident required a…

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

Based on observation, record review, and interview, the facility failed to ensure infection control measures were implemented related to hand hygiene during medication pass for 2 of 5 residents observed during medication pass. (Residents 113 and 6, and LPN 1) Finding includes: On 11/8/24 at 8:15 a.m., LPN 1 was observed passing medications to Resident 113. There was no hand hygiene observed prior to medication preparation. She gave the medications to the resident in his room and returned to the medication cart to prepare medications for Resident 6. There was no hand hygiene observed. After the medications had been poured into the medication cup, she used hand sanitizer. The nurse then took the medications to Resident 6 in his room. She returned to the medication cart and did not perform hand hygiene. During an interview on 11/8/24 at 8:37 a.m., LPN 1 indicated she thought she only had to wash her hands after every third resident. During an interview on 11/8/24 at 8:44 a.m., the Director of Nursing indicated the nurses had hand sanitizer that should be used and they should wash their…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to not following up on urine culture results in a timely manner for 1 of 2 residents reviewed for urinary tract infections. (Resident 40) Finding includes: Resident 40's record was reviewed on 11/12/24 at 1:11 p.m. Diagnoses included, but were not limited to, vascular dementia, major depression, and a history of urinary tract infections (UTIs). The Quarterly Minimum Data Set assessment, dated 9/23/24, indicated the resident was cognitively intact and was dependent on staff for toileting assistance. The resident had been on antibiotics during the assessment period. A Health Status Note, dated 10/14/24, indicated the resident was sent to the hospital to be evaluated for vaginal bleeding. The resident returned to the facility later that day with an order for an antibiotic related to a UTI. A Physician's Order, dated 10/14/24,…

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 abuse was reported to the Indiana Department of Health (IDOH), for 1 of 3 residents reviewed for abuse. (Resident B) Finding includes: The record for Resident B was reviewed on 3/15/24 at 9:15 a.m. Diagnoses included, but were not limited to, hypertension and type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 1/24/24, indicated the resident was cognitively intact. A written summary of an interview between Resident B and Social Services (SS), dated 2/22/24 at 2:30 p.m., indicated Resident B had reported that during night shift at 5 a.m., the resident had woken up with a CNA stripping her clothes off and then sitting her in her wheelchair, saying, you're going to be punished. The resident indicated she felt the CNA had said that maybe because she had put her call light on a lot that night due to being in pain. Resident B had asked the CNA what her name was, and the CNA told her she didn't have a name. The CNA had continued to dress her and placed her in the empty dining…

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 ensure the residents' environment was in good repair related to marred walls, a cracked toilet base, marred doors, chipped paint, dirty floors, and missing pieces of baseboard for 2 of 2 units. (East and West) Findings include: During the Environmental tour with the Director of Maintenance and the Director of Housekeeping on 1/3/24 at 1:38 p.m., the following was observed: 1. East Unit: In room [ROOM NUMBER], the floors were dirty, the walls were marred and paint was chipped on the side of bed 2. There were missing pieces of the baseboard next to the restroom. One resident resided in the room. 2. [NAME] Unit: a. In room [ROOM NUMBER], the base of the toilet was cracked. Two residents resided in the room. b. In room [ROOM NUMBER], the walls were marred, and paint was chipped. The baseboard in the restroom was marred. Two residents resided in the room. Interview with the Director of Maintenance on 1/3/24 at 1:40 p.m., indicated the areas were in need of…

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

Based on observation, record review, and interview, the facility failed to honor a resident's preference related to dressing for 1 of 1 residents reviewed for choices. (Resident 21) Finding includes: During an interview on 12/27/23 at 10:37 a.m., Resident 21 indicated he would like to wear regular day clothes and not a hospital gown. The record for Resident 21 was reviewed on 12/28/23 at 2:37 p.m. Diagnoses included, but were not limited to, paranoid personality disorder, adult failure to thrive, and bipolar disorder. A Significant Change in Status Minimum Data Set (MDS) assessment, dated 8/1/23, indicated the resident was moderately impaired for daily decision making. He required extensive assistance with two persons physical assist for dressing. The daily and activity preferences section indicated it was very important to the resident to choose what clothes to wear. A Care Plan, dated 12/28/22, indicated he liked to wear a facility/hospital gown for comfort and ease. Interventions included, but were not limited to, staff will dress the resident in accordance with his preferences.…

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 develop an initial plan of care within 48 hours of admission related to Activities of Daily Living (ADL) for 1 of 19 residents whose care plans were reviewed. (Resident B). Finding includes: The record for Resident B was reviewed on 3/26/19 at 9:03 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to bipolar disorder, respiratory failure, and dementia. The baseline care plan was initiated on 3/13/23 which included ADL status, discharge plan, pain, skin integrity, and risk for change in mood or behavior due to a medical condition. During an interview on 1/2/24 at 3:45 p.m., the Assistant Director of Nursing indicated the baseline care plan should have been created within 48 hours after admission regarding his ADL status. 3.1-30(a)

Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed and in place for a resident with a history of dehydration for 1 of 19 resident care plans reviewed. (Resident G) Finding includes: On 12/27/23 at 9:26 a.m. the Resident G was observed in her bed. The side rails were up, there was a mat on the floor. There was no beverage to drink in the room. The resident was observed again on 12/28/23 at 9:56 a.m., and 12:59 p.m., and 1/2/24 at 8:15 a.m. in bed with no beverage in the room. On 12/29/23 at 9:32 a.m., staff was observed removing the resident's breakfast tray from her room. The beverage was on the tray, full with a lid on it. The food had been untouched. There was no beverage in the room. On 12/29/23 at 12:15 p.m. and 2:35 p.m., the resident was in bed with the side rails up and a mat on the floor. There was a beverage on the overbed table that was located out of reach beyond the foot of the bed. On 1/2/24 at 8:57 a.m., the resident was up in a Broda chair in the dining room. There was no beverage on the table. 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, record review, and interview, the facility failed to ensure residents received the necessary care for activities of daily living care (ADL) related to not receiving bathing after admission and twice weekly, dirty fingernails, and the lack of shaving a beard for 3 of 3 residents reviewed for ADL care. (Residents D, B, and C) Findings include: 1. On 12/27/23 at 10:23 a.m., Resident D was observed lying in bed. The resident's fingernails had visible debris underneath them. The resident indicated she had not received any bathing at the facility since she was admitted . Record review for Resident D was completed on 12/28/23 at 11:14 a.m. Diagnoses included, but were not limited to, vertebral fracture, anxiety, and depression. The resident was admitted to the facility on [DATE]. The Bathing Task record indicated the resident had 1 shower on 12/27/23. The record lacked any documentation the resident had a shower prior to 12/27/23 since she was admitted on [DATE]. During an interview on 12/28/23 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, record review, and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of a Physician's Order for a neck brace, the lack of monitoring and assessments of skin discolorations, and skin treatments not signed out as ordered for 1 of 2 residents reviewed for positioning and limited range of motion and 2 of 4 residents reviewed for non-pressure skin conditions. (Residents D, 36, and 19) Findings include: 1. On 12/27/23 at 10:23 a.m., Resident D was observed lying in bed watching television. The resident had a neck brace in place. She indicated sometimes the staff would help her put it on and take it off. She did not like to wear it when she was lying down. On 12/28/23 at 11:13 a.m., Resident D was observed sitting in the front lobby with other residents. The resident had a neck brace in place. Record review for Resident D was completed on 12/28/23 at 11:14 a.m. Diagnoses included, but were not limited to, vertebral fracture,…

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

Based on observation, record review, and interview, the facility failed to ensure a resident received the necessary treatment to prevent a decrease in range of motion related to a hand splint not in place as ordered for 1 of 1 residents reviewed for positioning and mobility. (Resident 1) Finding includes: On 12/27/23 at 11:02 a.m., and 12/28/23 at 11:04 a.m., Resident 1 was observed in bed. Her eyes were closed and her hands were under the covers. There was a hand splint on her night stand. On 12/28/23 at 1:01 p.m., the resident was observed in bed. There was no splint on her hand and a splint was observed on her night stand. The resident's record was reviewed on 12/28/23 at 2:55 p.m. Diagnoses included, but were not limited to, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a cerebral vascular event and vascular dementia. The Quarterly Minimum Data Set assessment, dated 11/21/23, indicated the resident had severe cognitive impairment, and was dependent on staff for bed mobility, transfers, toileting and eating. A Physician's Order, dated 8/25/22,…

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 safety measures were in place to prevent accidents related to seizure precautions not in use, fall precautions not implemented, and a post-op helmet not in use as ordered for 3 of 3 residents reviewed for accidents. (Residents G, F and E) Findings include: 1. On 12/27/23 at 9:26 a.m., Resident G was observed in her bed. She was moaning and complaining her stomach hurt. She was not wearing a post-op helmet. There were full length bed rails on her bed with no seizure pads in place and a mat on the floor. On 12/28/23 at 9:56 a.m. and 12:59 p.m., the resident was observed in bed, there were no seizure pads on the bed and the resident was not wearing a post-op helmet. A helmet was observed on a cabinet next to the bed. The resident's record was reviewed on 12/28/23 at 1:02 p.m. Diagnoses included, but were not limited to, metabolic encephalopathy, muscle weakness, unspecified convulsions and diabetes mellitus. The Significant Change…

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 residents' hydration and nutritional needs were met related to providing fluids to a dependent resident and weights being monitored for a resident with weight loss for 2 of 6 residents reviewed for hydration and nutrition. (Residents G and 37) Findings include: 1. On 12/27/23 at 9:26 a.m. the Resident G was observed in her bed. The side rails were up, there was a mat on the floor. There was no beverage to drink in the room. The resident was observed again on 12/28/23 at 9:56 a.m., and 12:59 p.m., and 1/2/24 at 8:15 a.m. in bed with no beverage in the room. On 12/29/23 at 9:32 a.m., staff was observed removing the resident's breakfast tray from her room. The beverage was on the tray, full with a lid on it. The food had been untouched. There was no beverage in the room. On 12/29/23 at 12:15 p.m. and 2:35 p.m., the resident was in bed with the side rails up and a mat on the floor. There was a beverage on the overbed table that was located out of reach beyond the foot of the bed. On 1/2/24 at 8:57 a.m.,…

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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being related to non-pharmacological interventions provided prior to administering pain medications and not following Pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents 4 and 48) and 1 of 1 residents reviewed for pain. (Resident 105) Findings include: 1. Resident 4's record was reviewed on 12/29/23 at 1:12 p.m. Diagnoses included, but were not limited to bipolar disorder, depression and polyneuropathy. The Quarterly Minimum Data Set assessment, dated 10/24/23, indicated the resident had mild cognitive deficits and took opioid pain medications. The December 2023 Physician's Order Summary (POS) indicated the resident took acetaminophen, 650 milligrams (mg) every 8 hours as needed for mild pain. The resident also took hydrocodone/ acetaminophen (opioid pain medication) 5/325 mg every 12 hours as needed for severe pain.…

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 gradual dose reduction (GDR) was attempted for 1 of 5 residents reviewed for unnecessary medications. (Resident E) Finding includes: The record for Resident E was reviewed on 12/28/23 at 11:06 a.m. Diagnoses included, but were not limited to, intracranial injury, dementia, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 10/2/23, indicated the resident was severely cognitively impaired for daily decision making. He received an antidepressant and antipsychotic medication on a routine basis only. A Physician Order, dated 11/7/22, indicated seroquel (an antipsychotic medication) 25 milligram (mg), give 1.5 tablet by mouth in the morning and 2.5 tablets by mouth at bedtime. A Care Plan, dated 9/26/22, indicated the resident used a psychotropic medication related to behavior management and was at risk for side effects. Interventions included, but were not limited to, consult with pharmacy and the Physician to consider dosage reduction when clinically appropriate, at least quarterly. A…

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

Based on record review and interview, the facility failed to ensure an ordered urine culture was obtained and sent to the laboratory timely for 1 of 5 residents reviewed for unnecessary medications(Resident E). Finding includes: The record for Resident E was reviewed on 12/28/23 at 11:06 a.m. Diagnoses included, but were not limited to, intracranial injury, dementia, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 10/2/23, indicated the resident was severely cognitively impaired for daily decision making. A Physician's Order, dated 5/6/23, indicated to obtain a urinalysis, culture and sensitivity (UA C&S). A Nurses' Progress Note, dated 5/5/23 at 11:00 p.m., indicated the resident was noted to have dark brown tinged urine with a fever of 102 degrees Fahrenheit and noted congestion with 90% oxygen saturation on room air. New orders were received from the Physician for a chest x-ray, UA C&S, oxygen as needed, and Rocephin (an antibiotic) 1 gram intramuscularly injection for 7 days. A Nurses' Progress Note, dated 5/6/23 at 3:00 a.m., indicated the urine…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to a physician prescribing antibiotics for a urinary tract infection without a urinalysis and culture completed for 1 of 5 residents reviewed for unnecessary medications. (Resident E). Finding includes: The record for Resident E was reviewed on 12/28/23 at 11:06 a.m. Diagnoses included, but were not limited to, intracranial injury, dementia, and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) assessment, dated 10/2/23, indicated the resident was severely cognitively impaired for daily decision making. A Physician's Order, dated 5/6/23, indicated to obtain a urinalysis, culture and sensitivity (UA C&S). A Physician's Order, dated 5/6/23, indicated ceftriaxone sodium injection solution reconstituted (Rocephin) 1 gram, inject intramuscularly one time a day. A Nurses' Progress Note, dated 5/5/23 at 11:00 p.m., indicated the resident was noted to have dark brown tinged urine with a fever of 102…

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.