Aperion Care Vincennes

Based on interview, observation, and record review, the facility failed to ensure a plan was in place to control a resident's pain for 1 of 1 resident reviewed for pain management. A resident indicated his pain was not controlled, staff were not giving routine pain medication as ordered, documentation lacked pain characteristics, non pharmacological interventions were not in place, and notification to the Medical Doctor was not consistently documented. Finding includes:During an interview on 3/18/26 at 10:40 A.M., Resident 4 indicated he was having pain that was not controlled and receiving hospice services.On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified disorder of adult personality, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition.The most recent quarterly MDS assessment, dated 3/16/26, indicated Resident 4 was cognitively intact, had no behaviors, was dependent on staff for toileting, showering, transfers, and bed mobility, on a pain medication regimen, no pain within…

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 accurate documentation in resident clinical records for 2 of 2 records reviewed. A resident that was in the hospital had a progress note with vital signs documented in the clinical record. A resident had a shower documented when it was not given. (Resident D, Resident C)Findings include:1. On 3/20/26 at 9:37 A.M., Resident D's clinical records were reviewed. His diagnoses included, but were not limited to pneumonia, Type II diabetes mellitus, personal history of traumatic brain injury, tracheostomy status, and gastrostomy status. The most current admission Minimum Data Set, dated [DATE], indicated Resident D was never or rarely understood and dependent on staff for toileting, bathing, mobility and transfer. Resident D had a tracheostomy, used oxygen, suctioning, a foley catheter, and had a Stage 4 pressure ulcer present on admission. Nurses Notes: 3/24/2026 1:55 P.M.Note Text: This nurse phoned ER (Emergency Room) for update.…

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 hospice communication and documentation was occurring between the facility and the hospice company for 1 of 1 residents reviewed for hospice. The clinical record lacked hospice communication. (Resident 4)Finding includes:During an interview on 3/18/26 at 10:40 A.M., Resident 4 indicated he was receiving hospice services.On 3/24/26 at 9:55 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified disorder of adult personality, anxiety, depression, chronic pain, panic disorder, gastroparesis, and malnutrition.The most recent quarterly MDS assessment, dated 3/16/26, indicated Resident 4 was cognitively intact, had no behaviors, was dependent on staff for toileting, showering, transfers, and bed mobility, on a pain medication regimen, no non-medication interventions for pain, and received as needed (PRN) pain medication, and not receiving hospice services.Physician's Orders included, but were not limited to, the following:admitted to (Hospice Company name)…

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 residents received end of life care for 2 of 3 residents reviewed for hospice care. A collaborative plan of care was not established for residents who received hospice services and routine assessments, and physician orders were not completed. (Resident B, Resident C)1. During record review on 10/20/25 at 1:15 P.M., Resident B's diagnoses included but were not limited to chronic kidney disease and malignant cancer. Resident B's most recent Minimum Data Set (MDS) assessment, dated 9/3/25, indicated the resident had not received hospice services. Resident B's physician orders included Lorazepam 0.5 milligrams (mg) one tablet every three hours as needed for anxiety (started 10/6/25 at 8:00 P.M.) and morphine sulfate solution 20 milligrams/milliliter (mg/ml) give 0.5 ml every hour as needed for pain or shortness of breath (started 10/6/25 at 7:49 P.M.), and oxygen at 2 liters per nasal cannula continuously to keep saturation level above 90% every…

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 safe, sanitary, and homelike environment in 1 of 3 resident units observed and 1 of 2 dining rooms observed. Resident areas had missing paint on the walls, missing cove base, plywood covering a window, and a dark decolorization to dining room vaulted ceiling. (C/D halls, room [ROOM NUMBER], room [ROOM NUMBER] and C/D dining room)Finding includes:During an observation on 9/17/25 at 11:35 A.M., Resident room [ROOM NUMBER] was missing paint from the wall under the window, around the air conditioning unit, and behind the bed. The cove base behind the resident bed was missing from the wall. An observation on 9/17/25 at 11:38 A.M., Resident room [ROOM NUMBER] had a piece of plywood completely covering 1 of 2 windows in the room. An observation on 9/17/25 at 11:40 A.M., a shared restroom door near the nurse's station on the C/D hall unit had a protective door covering that had peeled away from the door, approximately 5 inches from the…

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

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment was maintained in accordance with professional standards for food services safety during 1 of 1 kitchen observations. Containers of food were stored on the dry food storage room floor and on the walk-in freezer floor, and a buildup of dust and debris was observed over the cookstove hood, on the ceiling in and around the vents above the dishwashing area, on top of the dishwasher, and along the base of the walls and floor. Finding includes:1. During an observation on 7/30/25 at 11:45 A.M., the facility kitchen' cookstove hood had a buildup of dust, the ceiling contained a buildup of dust in and around vents above the dishwashing area, the top of the dishwasher had a buildup of dust and debris, and dust and debris was built up along the base of the walls in the dishwashing area. During an interview on 7/31/25 at 1:00 P.M., Culinary Aide (CA) 4 indicated the kitchen staff had not been completing a daily cleaning task checklist and was unaware of where to find a cleaning task…

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 employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service for 1 of 1 kitchens observed. The Dietary Manager was not certified. (Dietary Manager) Finding includes: On 2/4/25 at 9:51 A.M., the Dietary Manager was asked to provide her certification certificate. At that time, she indicated she was not certified yet, but she was working on it. She indicated she started working at the facility in August of 2024 and her previous certification had expired. During an interview on 2/10/25 at 10:49 A.M., the Administrator indicated they knew the Dietary Manager needed to take her test again because she failed the first time, but the new test date was unknown. At that time, the Administrator indicated the Dietary Manager was on a 30 day Performance Improvement Plan (PIP). On 2/10/25 at 11:33 A.M., the Administrator provided the PIP on the dietary manager, dated 12/2/24 and 1/15/25, which included, but were not limited to, the following issues: Dietary Manager…

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 notice of transfer or discharge was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations and transfers. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization. (Resident D, Resident B, Resident 79, Resident 48, Resident 30) Findings include: 1. On 2/6/25 at 1:58 P.M., Resident 30's clinical record was reviewed and indicated they were admitted from the facility to the hospital on [DATE] and returned back to the facility from the hospital on [DATE]. Resident 30's clinical record lacked a notice of transfer/discharge given to the resident or a representative at the time of transfer. During an interview on 2/13/25 at 11:19 A.M., the Administrator indicated they did not have any record of Resident 30 or Resident 30's representative receiving a notice of transfer or discharge on [DATE]. At that time, she indicated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 5 of 5 residents reviewed for hospitalizations and transfers. There was no documentation of a resident or representative receiving a bed hold policy at the time of hospitalization. (Resident D, Resident B, Resident 79, Resident 48, Resident 30) Findings include: 1. On 2/6/25 at 1:58 P.M., Resident 30's clinical record was reviewed and indicated they were admitted from the facility to the hospital on [DATE] and returned back to the facility from the hospital on [DATE]. Resident 30's records lacked a bed hold policy given to the resident or a representative at the time of the transfer. During an interview on 2/13/25 at 11:19 A.M., the Administrator indicated they did not have any record of Resident 30 or Resident 30's representative receiving a bed hold policy on 11/8/24. At that time, she indicated the facility should fill out the state bed hold form. 2. On 2/10/25 at 3:00…

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 comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both the comprehensive and quarterly review assessments. Care plans weren't revised for residents that were nothing by mouth (NPO), had a bed alarm, had a catheter removed, and a decline in activities of daily living (ADLs). (Resident C, Resident 73, Resident 79, Resident 4) Findings include: 1. On 2/10/25 at 10:27 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, hemiplegia on right dominant side, and dementia with mood disturbance. The most recent Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident C's cognition was moderately impaired and totally dependent on staff for toileting and transfers, and did not have an indwelling catheter. Current Physician's Orders were reviewed and lacked an order for an indwelling catheter. Resident C's care plans were reviewed and included, but were not limited 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.

Based on observation, interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed on the dementia unit. A Certified Nurse Aide (CNA) failed to provide appropriate Activities of Daily Living (ADL) care for a resident on the dementia unit along with other concerns on the hall with 15 men. (Resident B, men's hall) Finding includes: 1. On 2/5/25 at 11:33 A.M., Resident B was observed in a wheelchair in activities. At that time, his hair was not combed. On 2/10/25 at 10:47 A.M., Resident B was observed sitting up in a wheelchair in the common area next to table, eyes closed. On 2/10/25 at 11:15 A.M. Resident B was observed awake sitting in a wheelchair in common area with a word search paper in front of him at table, making marks on paper. On 2/11/25 at 10:45 A.M., Resident B was observed sitting up in a wheelchair in common area next to table watching TV. 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 follow facility policy by ensuring safe and secure storage of medications for 5 residents during 2 random observations of the medication carts. Medications had been pre-prepared and held in medication cups in the medication cart prior to administration. (Resident B, Resident G, Resident 76, Resident 34, Resident 19) Findings include: 1. On 2/4/25 at 10:00 A.M., the medication cart on B Hall was observed. Qualified Medication Aide (QMA) 5 opened the top drawer and four medication cups were observed with pills in them. The names written on the cups were as follows: Resident G (1 pill) Resident 76 (1 pill) Resident 34 (2 pills) Resident B (1 pill) At that time, QMA 5 indicated the medication cups had been prepared for the 11:00 A.M. medication pass and she was aware they were not supposed to be in the cart pre-prepared. 2. On 2/4/25 at 10:15 A.M., medication cart on D Hall was observed. Licensed Practical Nurse (LPN) 7 opened the top drawer and a medication cup was observed with eight pills in it. Resident 19'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 ensure menus were being followed by dietary staff for 1 of 1 kitchens reviewed. (Kitchen) Finding includes: During an interview on 2/10/25 at 10:49 A.M., the Administrator indicated the Dietary Manager was on a 30 day Performance Improvement Plan (PIP). The Administrator indicated when she took over 12/9/24, it took her two days to see and know the kitchen had major concerns. The Dietary Manager was already on a 30 day PIP for not following menus at that time like they should have been but the menus have been followed since the current Administrator took over. At that time, the Administrator indicated no one held the staff accountable for what they did wrong. The turnover in Administration probably had some to do with it because the staff were on their own. They continued the PIP for another 30 days and the Dietary Manager was told she would not be able to maintain the role unless things were changed. The next PIP review date is 2/14/25. The Administrator indicated majority of the resident grievances were about dietary…

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 provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents observed for infection control. Staff did not clean the shared glucometer prior to use, staff was not using proper personal protective equipment (PPE) or signage, and hands were not sanitized between glove use. (Resident C, Resident D, Resident G, Resident H) Findings include: 1. On 2/10/25 at 10:27 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, hemiplegia on right dominant side, and dementia with mood disturbance. The most recent Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident C's cognition was moderately impaired and totally dependent on staff for toileting and transfers. On 2/11/25 at 1:16 P.M., incontinence care was observed on Resident C performed by Certified Nurse Aide (CNA) 25 and CNA 27. Staff came into the room wearing a gown and mask. CNA 27 put on gloves lowered 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 each resident was treated with respect and dignity for 2 of 3 residents reviewed for dignity concerns and one random observation. Residents felt like staff were rude and not in a hurry to provide care and staff made unkind comments about a resident within hearing distance of that resident. (Resident C, Resident E, Resident F) Findings include: 1. On 2/10/25 at 10:27 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, stroke, hemiplegia on right dominant side, and dementia with mood disturbance. The most recent Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident C's cognition was moderately impaired and totally dependent on staff for toileting and transfers. During an observation of incontinence care on 2/11/25 at 1:16 P.M., Resident C indicated night shift staff were rude to her when she asked for ice and asked to get out of bed. She indicated they wouldn't give her ice because she didn't need it and they wouldn't get her up because they…

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 timely care plan conferences with residents and/or their representatives for 3 of 7 residents reviewed for care plan conferences. Care plan conferences were not held quarterly for residents and/or their representatives to participate in planning of care. (Resident D, Resident 4, Resident 35) Findings include: 1. On 2/6/25 2:39 P.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus type II, sepsis, UTI, flaccid bladder, and dementia with behaviors. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/25/25, indicated Resident D's cognition was moderately impaired. The clinical record indicated Resident D had a care plan conference on 1/26/24, 4/26/24 and 10/4/24. During an interview on 2/11/25 at 2:27 P.M., the Social Services Director (SSD) indicated Resident D did not have any other care plan conferences in the last year. 2. On 2/11/25 at 9:26 A.M., Resident 4's clinical record was reviewed. Current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to clarify a Resident's code status for 1 of 1 residents reviewed for advanced directives. A resident's current facesheet and Physician's Order did not match the signed Indiana Physician Orders for Scope of Treatment form. (Resident B) Finding includes: On [DATE] at 3:00 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to heart failure, diabetes, dementia, anxiety, depression, and psychotic disorder. The most current Annual Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B had severe cognitive impairment, required set up or clean up (helper sets up or cleans up; resident completes activity) assistance for eating, was dependent (resident does none of the effort to complete the activity) on staff for toilet use and transfers, and required partial/moderate (helper does less than half the effort) assistance for bed mobility. Physician Orders included, but were not limited to the following: FULL CODE…

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 incident report contained an explanation of the circumstances for an alleged incident. The incident report lacked details related to the actual incident reported involving a Certified Nurse Aide (CNA) and resident. (CNA 31, Resident B) Finding includes: An Indiana Department of Health (IDOH) incident report, dated 1/22/25, indicated a staff member reported CNA 31 was providing care that did not meet company standards for Resident B. On 2/10/25 at 3:00 P.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to heart failure, diabetes, dementia, anxiety, depression, and psychotic disorder. The most current Annual Minimum Data Set (MDS) assessment, dated 1/13/25, indicated Resident B had severe cognitive impairment, required set up or clean up (helper sets up or cleans up; resident completes activity) assistance for eating, was dependent (resident does none of the effort to complete the activity) on staff for toilet use and transfers, and required partial/moderate (helper does less…

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 develop a care plan for 2 of 5 residents reviewed for Unnecessary Medications, and 1 of 1 residents reviewed for hospice services. A resident was administered an anticoagulant and an antiplatelet and did not have a care plan related to the medication. A resident received hospice services but lacked a care plan. (Resident D, Resident 79, Resident 67) Findings include: 1. On 2/10/25 at 11:53 A.M., Resident 67's clinical record was reviewed. Current diagnoses included, but was not limited to, non-traumatic brain dysfunction, anxiety, and depression. The most recent Minimum Data Set (MDS) assessment, dated 1/13/24 indicated Resident 67 is rarely/never understood, and a cognitive status could not be completed, and Resident 67 received hospice services. Current Physician's Orders included, but was not limited to, admit to hospice, dated 12/23/24. Resident 67's clinical record lacked a care plan related to hospice services. On 2/13/25 at 11:18 A.M., the [NAME] President of Operations indicated if a resident is 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 residents with indwelling urinary catheters received appropriate orders and services to prevent urinary tract infections (UTI) for 2 of 3 residents reviewed for catheter care. A resident's urinary catheter bag was not placed lower then his bladder and a resident with a urinary catheter did not have an order. (Resident D, Resident 48) Findings include: 1. On 2/5/25 at 11:01 A.M., Resident D was laying with his head of his bed and foot of the bed elevated. The resident's indwelling catheter bag was observed under the resident's left leg and there was yellow liquid in it and in the tubing. On 2/6/25 2:39 PM Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus type II, sepsis, UTI, flaccid bladder, and dementia with behaviors. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/25/25, indicated Resident D's cognition was moderately impaired, had a catheter, and was totally dependent on staff 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) met the needs of each resident for 1 of 1 residents reviewed for antibiotic use. A resident's antibiotics (taken for multiple infections) were not continued in a timely manner after discharge from the hospital. (Resident D) Finding includes: On 2/6/25 2:39 PM Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), diabetes mellitus type II, deep vein thrombosis (DVT), sepsis, urinary tract infection (UTI), flaccid bladder, and dementia with behaviors. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 1/25/25, indicated Resident D's cognition was moderately impaired and he was totally dependent on staff for toileting, transfers, and showers. An After Visit Summary, dated 1/22/25, indicated Resident D…

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

Based on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 3 residents (Residents 6, Resident D) observed during medication pass. Two medication errors were observed during 31 opportunities for error in medication administration. This resulted in a medication error rate of 6.45 percent. Findings include: 1. On 2/7/25 at 9:40 A.M., the ADON was observed to administer 16 units of Lyumjev (insulin lispro) via an insulin pen to Resident D. The ADON did not prime the pen prior to clicking it to the number of units. At that time, she questioned whether the pen needed to primed, and indicated she did not prime insulin pens, and only primed needles when drawing insulin from a vial. 2. On 2/7/25 at 9:25 A.M., the ADON was observed to prepare an insulin administration for Resident 6. At that time, the ADON indicated she could not find the resident's insulin, and would request it from the pharmacy to be delivered that afternoon. On 2/7/25 at 2:04 P.M., the ADON indicated Resident 6's insulin 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.

Based on observation, interview, and record review, the facility failed to ensure prevention of a significant medication error for 1 of 3 residents observed for medication administration. A dose of insulin was not given resulting in an increase of blood sugar. (Resident 6) Finding includes: On 2/7/25 at 9:25 A.M., the ADON was observed to prepare an insulin administration for Resident 6. At that time, the ADON indicated she could not find the resident's insulin in the medication cart or the medication storage room, and would request it from the pharmacy to be delivered that afternoon. On 2/7/25 at 2:04 P.M., the ADON indicated Resident 6's insulin had been found in another medication cart that morning, but that Resident 6 missed the 8:00 A.M. dose. On 2/13/25 at 10:57 A.M., Resident 6's clinical record was reviewed. A current order for Novolog insulin indicated to administer based on the following sliding scale: 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units Notify MD (Medical Doctor) and or NP (Nurse Practitioner) of blood…

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 smoking policies related to smoking safety were enforced for 2 of 2 random observation of smoking. (Resident K, Resident 51, Resident 20) Finding includes: During a random continuous observation on 2/5/25 from 11:05 A.M. through 11:45 A.M., the following was observed on the G/H/I Hall: 11:05 A.M. Resident K, Resident 51, and Resident 20 were observed all sitting in wheelchairs in the common area around the nurses station. Resident 51 indicated it was a usual occurrence to wait for staff to take them out to smoke. He indicated they were supposed to go out at 11:00 A.M., but since it was dietary's turn to take them, sometimes that smoke time was skipped because dietary did not have time to take them. At that time, a form was observed posted by the nurses station that indicated 11:00 A.M. smoke break with dietary beside the time. 11:08 A.M. Registered Nurse (RN) 17 called dietary and indicated they needed someone to come and take the smokers out. 11:18 A.M. Certified Nurse Aide (CNA) 27 indicated if 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 a sanitary environment was maintained in accordance with professional standards for food services safety during 2 of 2 kitchen observations. Kitchen staffs' hair was not fully contained within a hairnet, and kitchen staff failed to complete proper hand hygiene. Findings include: 1. During an observation on 12/4/24 at 12:00 P.M. the DM (Dietary Manager) was in the kitchen wearing a hairnet. The DM's hair was not fully contained by the hairnet with loose strands of hair coming out the front and back of the hairnet. During an observation on 12/5/24 at 12:00 P.M., the DM and [NAME] 4 were preparing for lunch service. During service, the DM and [NAME] 4's hair was not fully contained by their hairnet with loose strands exposed. During an interview on 12/5/24 at 3:40 P.M., the Facility Administrator indicated she had previously mentioned to the DM that her hair must be covered by the hairnet. 2. During a kitchen observation on 12/5/24 at 11:59 A.M., a printed sign above the kitchen handwashing sink indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 2 of 6 resident halls observed. Resident areas had holes in walls, floors appeared dirty and unmopped, bedpans were stored uncovered, cove base was missing from a resident restroom, a vent fan was missing a cover in a resident restroom, used Styrofoam cups were not removed from a resident's room, and resident wheelchairs had not been cleaned. (C/D Halls, Resident D, Resident F, room [ROOM NUMBER], room [ROOM NUMBER], Resident H, Resident G, Resident M) Finding includes: 1. During a review of facility grievance forms on 12/4/24 at 1:30 P.M., a concern/complaint form dated 12/1/24 indicated that a family member to a resident in room [ROOM NUMBER] made staff aware that the resident had not had any housekeeping services in days and had been out of toilet paper for days. Family indicated the room was filthy. During a review of resident council minutes on 12/4/24 at 1:40 P.M., a council…

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 resident records were accurate and complete for 1 of 3 residents reviewed for pressure wounds and 1 of 3 residents reviewed for diabetic care. Medication Administration Records (MAR) and Treatment Administration Records (TAR) were not documented completely. (Resident D) Finding includes: During record review on 12/6/24 at 10:30 P.M., Resident D's diagnoses included, but were not limited to, diabetes mellitus, morbid obesity, and chronic kidney disease. Resident D's most recent quarterly Minimum Data Set (MDS) assessment dated , 11/8/24, indicated the resident received insulin. Resident D's care plan included, but was not limited to, Resident has a left toe infection (created 9/30/24) and resident has diabetes mellitus (created 12/18/20). Resident D's physician orders included, but were not limited to, treatment to left, first toe. Cleanse area with wound cleanser or normal saline solution, pat dry. Apply Betadine twice a day and as needed, every day and night shift (started 10/17/24), and Humalog Injection (insulin)…

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 safe, sanitary, and homelike environment in 3 of 4 resident halls observed and 2 of 3 shared restrooms observed. Resident rooms were missing window trim, had stained toilet bowels, and were missing thresholds between doorways, shared shower rooms were missing light covers, cove base, corner trim, had cracked or broken tiles, had a broken switch plate, and had old screw holes in the walls, and hall floors were missing baseboard and had worn spots and paint splatters. (C/D Halls and shower rooms, GHI shower room, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings includes: 1. During an observation on 8/15/24 at 11:00 A.M., room [ROOM NUMBER]'s restroom contained a stained commode with the bowl having dark discolorization. 2. During an observation on 8/15/24 at 11:15 A.M., Hall D was observed to have white paint splatters on the hallway floor as well as what appeared to be worn spots through 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 routine catheter care and ostomy care was completed for 3 of 3 residents reviewed for catheter/ostomy care. Routine catheter and ostomy care was not provided per the residents' plan of care. (Resident C, Resident D, Resident F) Finding includes: 1. Resident C was observed up in a wheelchair in her room on 8/16/24 at 10:00 A.M A catheter drainage bag was clipped to the underside of the resident's wheelchair. Resident C indicated that she also had a colostomy and that she had recently waited through multiple shifts for nursing staff to change the colostomy bag. A record review on 8/16/24 at 10:30 A.M., indicated that Resident C's diagnoses included, but were not limited to, paraplegia, neuromuscular dysfunction of bladder, and stage 4 pressure ulcer of sacral region. Resident C's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 6/1/24, indicated the resident had no cognitive impairment, had an indwelling catheter, and an ostomy. Resident C's physician orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident was clinically appropriate to administer their own medications without supervision by qualified staff during a random observation during the survey. A resident was alone in their room with a cup of medications sitting at their bedside table. (Resident F) Finding includes: During an observation and interview on 4/19/24 at 11:40 A.M., Resident F was sitting up in their bed at a bedside table. A medication cup holding six medication tablets and/or capsules had been placed on the bedside table. Resident F indicated not knowing what the medications were and that she intended to take the medications after lunch. During record review on 4/19/24 at 12:15 P.M., Resident F's diagnoses included, but were not limited to heart failure and anxiety. Resident F's most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] included that the resident had no cognitive impairment. Resident F's physician orders 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.

Based on observation, interview, and record review, the facility failed to ensure a resident's plan of care was followed for 1 of 4 resident care plans reviewed. A resident did not receive care from at least 2 staff members according to the resident's plan of care, resulting in an allegation of staff negligence. (Resident B) Finding includes: During an observation and interview on 4/19/24 at 10:50 A.M., Resident B indicated that he had recently been hospitalized and received a feeding tube after nursing staff had administered his medications orally while Resident B was lying flat in bed, causing a medication to get stuck in the resident's throat and burn a hole in his throat. During the interview, Resident B was sitting up in a wheelchair, eating ice chips. On two occasions the resident had trouble swallowing the ice and began coughing. During record review on 4/18/24 at 11:30 A.M., Resident B's diagnoses included, but was not limited to, cerebral infarction, dysphagia, cognitive communication deficit, and hemiplegia. Resident B's most recent Quarterly MDS (Minimum Data Set)…

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 provide assistance with bathing for 2 of 3 residents reviewed for activities of daily living (ADLs). Residents did not receive assistance with ADL's (bathing) according to the plan of care and bathing schedule. (Resident B, Resident C) Findings include: 1. During an observation on 4/19/24 at 10:50 A.M., Resident B was sitting up in a wheelchair. Resident B had multiple stains on the front of his shirt. During an interview on 4/19/24 at 12:45 P.M., Resident B's family member indicated that Resident B had went 23 days while only receiving two showers. Resident B had yeast growing in the palm of his left hand. During record review on 4/18/24 at 11:30 A.M., Resident B's diagnoses included, but was not limited to, cerebral infarction, cognitive communication deficit, and hemiplegia. Resident B's most recent Quarterly MDS (Minimum Data Set) assessment, dated 3/29/24 included that the resident had moderate cognitive impairment, one sided impairment to both upper and lower extremities, and was dependent with bathing.…

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 complete and accurate facility assessment for 1 of 1 reviewed based on the resident population and identification of resources needed to provide the necessary care and services required for their residents. Finding includes: On 1/17/24 at 10:00 A.M., the Administrator provided a facility assessment form dated 1/16/24. The form listed general staff as Licensed Nurses, direct care staff, and other, but lacked specific staff titles and lacked the staffing plan to ensure sufficient staff were in the building to meet the needs of the residents. The form lacked training topics and competencies specific to the facility, and only listed those trainings and competencies included in the facility assessment template. All physical environment and building/plant needs listed were those in the template, and not specific to the facility. On 1/23/24 at 2:23 P.M., the Administrator indicated the facility assessment was completed using a template, and only those areas with blanks were filled in. She indicated she was unsure how 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, interview and record review, the facility failed to ensure each resident was treated with respect and dignity for 1 of 6 residents observed for care, and 3 of 3 random observations. A staff member was observed speaking to a resident in an undignified manner, a resident waited on a meal for over 22 minutes after other residents were served, a resident was observed wearing clothing belonging to a recently deceased resident, and staff opened a window during care against the resident's wishes. (Resident 30, Resident 55, Resident 127, Anonymous Resident) Findings include: 1. On [DATE] at 12:20 P.M., Resident 30 was observed sitting at a dining room table with three other residents. The other three residents were eating lunch with a tray in front of them. Resident 30 did not have a tray. At that time, Certified Nurse Aide (CNA) 7 indicated the kitchen had been notified a while ago that Resident 30's lunch tray had not been brought to the unit with the other trays. CNA 7 and Registered Nurse (RN)…

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 care was provided in accordance with the written plan of care for 5 of 5 residents reviewed. Care plan interventions and orders were not followed or implemented for the following: fluid restriction, skin assessment, prescribed antibiotics, hand splints, and performance of household chores. (Resident 7, Resident 45, Resident 58, Resident 60, Resident 127) Findings include: 1. On 1/18/24 at 12:37 P.M., clinical records were reviewed for Resident 58. Diagnosis included, but were not limited to, chronic kidney disease, dependence on renal dialysis, Type II diabetes mellitus with retinopathy, and cerebral palsy. The most recent quarterly MDS (Minimum Data Set) Assessment, dated 1/10/24, indicated Resident 58 was cognitively intact, required assistance of 2 for bed mobility, transfers, and toilet use, supervision and set up with eating. There were no skin issues or pressure ulcers. Current physician orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan for 2 of 5 residents reviewed for development of care plans and failed to provide care plan conferences with residents and residents' representatives for 5 of 5 residents reviewed for care plan conferences. A resident lacked a care plan for dialysis and dementia. A resident lacked a care plan for smoking. (Resident 17, Resident 24, Resident 31, Resident 57, Resident 58) Findings include: 1. On 1/22/24 at 10:20 A.M., the clinical record for Resident 24 was reviewed. Resident 24 was admitted on [DATE]. Diagnoses included, but were not limited to, hypertension, neurogenic bladder, paraplegia, anxiety, depression, and bipolar disease. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 12/14/23, indicated Resident 24 was cognitively intact and required substantial assistance for bed mobility and was totally dependent on staff for transfers, toilet use and bathing. The last care plan conference in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an ongoing program to support residents in their choice of activities for 2 of 7 halls reviewed. A and B Halls lacked activities in accordance with the activity calendar. (Locked Dementia Unit A and B Hall) Finding includes: On 1/16/24 at 12:24 P.M., Licensed Practical Nurse (LPN) 22 indicated she wished activity staff would give Resident 45 more to do to keep her occupied. She indicated Resident 45 liked to walk, and someone took her for a walk twice a day, but she needed more to do. At that time, Resident 45 was observed sitting in the common area on B Hall, then wandering from B Hall to A Hall, and back again. On 1/17/24 at 11:06 A.M., no activities were observed on A or B Halls. At that time, an activities calendar posted in the hall indicated Name 5 for the 11:00 A.M. activity. On 1/22/24 at 10:52 A.M., no activities were observed on A or B Halls. At that time, the activities calendar indicated Nailed it for the 10:00 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 observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 4 of 5 residents reviewed for accidents. A resident was found smoking several times in his room/bathroom and was still allowed to carry his smoking supplies on his person. Residents' care plan interventions were not followed and alarms were not working. (Resident 57, Resident 25, Resident 127, Resident 178) Findings include: 1. On 1/16/24 at 11:34 A.M., ashes were observed in the shared bathroom sink and a cigarette butt floated up into the sink from the drain when the water was turned on. On 1/17/24 at 11:00 A.M., Resident 57 was observed smoking a yellow colored vape in his room, a camouflage colored vape was plugged into the wall charging, and a black colored vape was laying next to it on the night stand. On 1/22/24 from 1:38 P.M.- 2:05 P.M., during a smoke break observation in an unventilated barn, the following was observed: At 1:40 P.M., Resident 57 reached into his coat pocket, pulled out a pack of cigarettes and lighter, 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 ensure sufficient and competent nursing staff was provided for 1 of 3 units reviewed, 2 of 6 resident council meetings reviewed, and 2 of 2 resident grievances reviewed. Incontinence care was not completed, hospice orders were not in place, interventions were not followed resulting in falls, notification was not completed following significant changes, and the unit was observed to not be sufficiently staffed. (A/B Unit) Findings include: 1. During the survey dates of 1/16/24 through 1/26/24, the following anonymous staff interviews were completed: a. Many days, there is a lot of charting to do after a shift due to lack of time to complete it during the shift. I have stayed 1 1/2 to 2 hours over just to chart. There is often only one nurse on A/B, and 2 aides which is not enough. We need one nurse and two aides per hall. b. There is not enough staff to properly care for the residents. Several times, what is on the staffing sheet and who is actually here working are very different. c. Not all of our tasks can…

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 all the freezers in the kitchen had thermometers in them and temperature logs filled out for 1 of 1 kitchen observations. The ice cream freezer did not have a thermometer in it and the freezer in dry storage lacked a temperature log for January 2024. (Kitchen) Findings include: On 1/16/24 at 10:02 A.M., the following was observed in the kitchen: no thermometer in the ice cream freezer no temperature log for the freezer in dry storage for January 2024 During an interview on 1/25/24 at 2:07 P.M., Kitchen Staff 27 indicated all of the freezers and refrigerators in the kitchen should have a thermometer in them, and they should all have a temperature log to write temperatures on daily. On 1/25/24 at 2:58 P.M., a current Record of Refrigeration Temperatures policy, not dated, was provided by the Administrator and indicated A daily record is to be kept of refrigerated items. The Dietary Manager is to assign an employee to daily record all refrigerator and freezer temperatures. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 5 of 9 residents during observation of perineal care. Gloves were not changed between dirty and clean tasks during peri care, staff dropped gloves on the floor and picked them up and used them to perform peri care. Staff failed to sanitize hands between dirty and clean tasks and after completing peri care (Resident 16, Resident 66, Resident B, Resident 55, Resident E) Findings include: 1. On 1/18/24 at 5:22 A.M., Certified Nurse Aide (CNA) 15 was observed to provide incontinence care for Resident B. CNA 15 washed hands with a five second lather, put gloves on, then assisted the resident to the toilet. After pulling their pants and incontinence brief off, CNA 15 assisted Resident B to get dressed using the same gloves. CNA 15 then washed hands with a nine second lather. 2. On 1/18/24 at 5:34 A.M., CNA 15 was observed to provide incontinence care for Resident 55. CNA 15 washed hands with a nine second lather, obtained clothes from the closet, then obtained 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 sanitary environment for resident rooms and halls. The outside of the building had paint peeled off the frame and window frames. The water temperature on the dementia unit was hot. (A wing, B wing, C wing, D wing, E wing, I wing) Findings include: 1. On 1/16/24 from 10:39 A.M. until 11:54 A.M., the following water temperatures were observed: B Hall shower room [ROOM NUMBER].7 degrees Fahrenheit Bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] 124.0 degrees Fahrenheit Bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] 123.1 degrees Fahrenheit A Hall shower room [ROOM NUMBER].3 degrees Fahrenheit Bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] 124.3 degrees Fahrenheit 2. On 1/16/24 at 10:57 A.M., the bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] was observed with five toothbrushes and two combs sitting behind the faucet on the sink. The resident in room [ROOM NUMBER] indicated at that time…

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 notification to a resident's healthcare provider following a significant change for 1 of 2 residents reviewed for nutrition. The Registered Dietician (RD) was not notified following a significant weight loss, and the physician was not notified of a significant weight loss or medication recommendation. (Resident 54) Finding includes: On 1/22/24 at 10:02 A.M., Resident 54's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety and depression. The most recent Annual and State Optional MDS (Minimum Data Set) Assessment, dated 11/4/23, indicated a severe cognitive impairment, no swallowing disorders, and no weight loss. Resident 54 required setup with supervision for eating. Current physician orders included, but were not limited to: Regular diet, dated 5/6/24. House shake two times a day for supplement with breakfast and supper, dated 8/6/21. A current potential for nutritional problems related to dementia care plan, initiated 5/10/21, included, but was 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 new diagnosis of schizophrenia was reviewed for appropriateness for 1 of 5 residents reviewed for unnecessary medications. (Resident 63) Finding includes: On 1/22/24 at 9:54 A.M., Resident 63's clinical record was reviewed. admission date was 5/11/23. Diagnosis included, but was not limited to, schizophrenia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 11/30/23, indicated a severe cognitive impairment, and a diagnosis of schizophrenia. Current physician orders included, but were not limited to: Risperidone extended release subcutaneous suspension prefilled syringe 125 mg (milligram)/0.35 ml (milliliter) one time a day every 28 days related to schizoaffective disorder, dated 10/29/23. An admission record, dated 5/11/23, did not indicate schizophrenia or schizoaffective disorder under diagnosis information. An admission record, dated 7/19/23, indicated schizoaffective disorder with an onset date of 8/3/23. A PASRR (preadmission screening and resident review), dated 3/13/23,…

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 provide emergency basic life support immediately when needed, including CPR (cardiopulmonary resuscitation) for 1 of 1 resident reviewed for CPR. Staff did not immediately provide services to a resident that required emergency care and CPR. (Resident 178) Finding includes: On [DATE] at 10:48 A.M., Resident 178's clinical record was reviewed. Diagnosis included, but was not limited to, dementia and traumatic brain injury. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated [DATE], indicated a severe cognitive impairment, no falls, and no swallowing disorders. Physician orders included, but were not limited to, the following: CPR - Full Code, dated [DATE]. A full code care plan was in place, dated [DATE]. Progress notes included, but were not limited to, the following: [DATE] 0 at 9:30 A.M.Resident was sent to [hospital] ER via [hospital EMS] at 9:00 am for eval [evaluation]. During breakfast resident was seating next to this…

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 limited mobility received appropriate services and assistance to prevent further decrease in range of motion for 2 of 2 residents reviewed for the restorative nursing program. (Resident 7, Resident 29) Findings include: 1. During an interview on 1/17/24 at 2:29 P.M., Resident 7 indicated he should be getting restorative therapy, but doesn't always get it. On 1/19/24 at 10:19 A.M., Resident 7's clinical record was reviewed. Diagnoses include, but were not limited to, traumatic brain injury and hemiplegia affecting right dominant side. The most recent Annual MDS Assessment, dated 11/22/23, indicated Resident 7 was cognitively intact, had impairment of both upper and both lower extremities, totally dependant on 2 staff for toileting, transfers, and bed mobility, and received restorative therapy. The following orders were included in the Point of Care nursing tab of the resident's electronic clinical record, but not limited to: NURSING REHAB: Passive ROM [range of motion]- Resident will…

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 incontinent of urine received incontinence services and assistance. Residents were observed saturated with urine at the end of night shift for 2 of 5 residents reviewed for incontinence care. (Resident B, Resident E) Findings include: 1. On 1/18/24 at 5:22 A.M., Certified Nurse Aide (CNA) 15 was observed assisting Resident B out of bed and with toileting. Resident B walked into the bathroom and CNA 15 removed the incontinence pad which was observed saturated with urine. CNA 15 then assisted the resident with a clean and dry incontinence pad. At that time, CNA 15 indicated she had been the only CNA on two halls (20 residents) and had not had time to provide incontinence care to all residents by herself. On 1/25/24 at 10:21 A.M., Resident B's clinical record was reviewed. Diagnosis included, but were not limited to, bipolar disorder and dementia. The most recent Quarterly and State optional MDS (Minimum Data Set) Assessment, dated 11/12/23, indicated a severe cognitive impairment, and extensive…

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 free of significant medication errors for 1 of 1 insulin administration. The nurse failed to prime the insulin pen before administering insulin to a resident. (Resident 60) Finding includes: On 1/18/24 at 7:11 A.M., LPN (Licensed Practical Nurse) 20 was observed administering insulin to Resident 60. LPN 20 applied the needle, dialed the Lantus SoloStar Pen to 7 units without priming the pen, put on gloves and administered the insulin into Resident 60's abdomen. LPN 20 opened another Lantus SoloStar Pen to finish the dose of medication, applied a needle, dialed the pen to 31 units without priming the pen, put on gloves and administered the insulin into Resident 60's abdomen. On 1/23/24 at 9:19 A.M., Resident 60's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II. The most recent Annual MDS (Minimum Data Set) Assessment, dated 11/4/23, indicated Resident 60's cognition was moderately impaired and the resident received insulin. Current…

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

Based on observation, interview, and record review, the facility failed to ensure complete and accurate documentation of resident records for 1 of 2 residents reviewed for nutrition, and 1 of 2 residents reviewed for restorative nursing program. (Resident 54, Resident 7) Findings include: 1. On 1/22/24 at 10:02 A.M., Resident 54's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recent Annual and State Optional MDS (Minimum Data Set) Assessment, dated 11/4/23, indicated a severe cognitive impairment, and no weight loss. Current physician orders included, but were not limited to: Monthly weight every 1st of the month, dated 7/1/21. A current potential for nutritional problems related to dementia care plan, initiated 5/10/21, indicated, but was not limited to, the following interventions: Monitor/record/report to MD as needed for signs and symptoms of emaciation . significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months, dated 11/16/21. Weights as ordered and as needed, dated 11/16/21. Weights from…

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

Based on observation, interview, and record review, the facility failed to follow 2 of 2 hospice contracts to ensure communication from the Hospice providers were available for the facility staff. Hospice diet orders were not put into place when ordered, and hospice communication was not available for review on a unit with a Hospice resident. (Resident 28, Resident 178) Findings include: 1. On 1/22/24 at 9:49 A.M., Resident 28's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, and depression. The most recent Significant Change MDS (Minimum Data Set) Assessment, dated 12/28/23, indicated a severe cognitive impairment, extensive assistance of two staff with bed mobility, transfers, and toileting, total dependence of one staff with eating, and hospice services while a resident. Current physician orders included, but were not limited to, the following: Admit to [Hospice B], dated 12/29/23 Resident 28's clinical record lacked any hospice notes or assessments. Hospice communication could not be located on the unit. On 1/22/24 at 1:06 P.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 observation, interview and record review, the facility failed to ensure the smoking policy was followed for 1 of 1 residents reviewed for smoking. A resident has been caught smoking in his room and was still considered a safe smoker and allowed to keep his smoking supplies on his person. (Resident 57) Finding includes: On 1/16/24 at 11:34 A.M., ashes were observed in the shared bathroom sink and cigarette butt floated up into the sink when the water was turned on, On 1/17/24 at 11:00 A.M., Resident 57 was observed smoking a yellow colored vape in his room. On 1/23/24 at 9:00 A.M., Resident 57's clinical record was reviewed, Diagnoses included, but were not limited to, chronic obstructive pulmonary disease. The most recent Quarterly MDS Assessment, dated 10/17/23, indicated Resident 57 was cognitively intact and supervision of staff for bed mobility, toileting, and transfers. On 1/16/24 at 10:30 A.M., a list of smokers in the facility was provided by the Administrator and indicated Resident 57 was a smoker. On 1/26/24 at 9:00 A.M., Resident 57's January 2023 through January…

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.