Waldron Rehabilitation And Healthcare Center

Based on observation, interview, and record review, the facility failed to have knowledgeable dietary staff regarding a chemical dishwasher for 6 of 6 dietary employees reviewed for kitchen. (Dietary Manager, [NAME] 4, [NAME] 5, Dietary Aid 6, Dietary Aid 7, and Dietary Aid 8) A tour of the kitchen was conducted with [NAME] 4 on 10/3/24 at 11:15 a.m. [NAME] 4 indicated she was not sure what the dishwasher strip testing should read. It was observed [NAME] 4 was using the wrong testing strips to test the chemical dishwasher. She also was unsure of proper temperatures that should be recorded. [NAME] 4 did not know what the temperatures or readings should be for chemical sanitization parts per million (ppm). During an observation of the chemical dishwasher with the Dietary Manager (DM) on 10/3/24 at 12:00 p.m., she was using the wrong chemical testing strips to test the chemical dishwasher. An incorrect reading was being read and the DM did not know why. During an interview with the DM on 10/3/24 at 12:23 p.m., they indicated high temperature logs were being kept for the chemical…

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 promote residents' dignity by ensuring privacy for a resident during toileting and providing incontinent care in a timely manner for 2 of 2 residents reviewed for dignity. (Resident 23 and Confidential Resident) Findings include: 1. During an observation on 10/8/24 at 12:13 p.m., Qualified Medication Aide (QMA) 1 and Certified Nurse Aide (CNA) 2 assisted Resident 23 to the toilet in the shower room. QMA 1 and CNA 2 indicated they left Resident 23 in the bathroom alone, because the resident preferred privacy. The shower room had hooks for a privacy curtain, but did not have a privacy curtain hanging to provide privacy to the hallway. QMA 1 and CNA 2 did not know what happened to the privacy curtain. The shower room door was opened four times while the resident was using the restroom, exposing the resident to the hallway. During an interview with the Maintenance Director on 10/8/24 at 12:26 p.m., they indicated it was laundry staff's responsibility to ensure the privacy curtains were in place. During an…

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

Based on interview and record review, the facility failed to hold quarterly care plan meetings for 1 of 3 residents reviewed for care plans. (Resident 8) The clinical record for Resident 8 was reviewed on 10/7/24 at 10:35 a.m. The diagnoses included, but were not limited to, chronic kidney disease, heart failure, and generalized anxiety disorder. During an interview with Resident 8 on 10/4/24 at 11:00 a.m., they indicated they did not have regular care plan meetings. A Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated Resident 8 was cognitively intact for daily decision making. The electronic health record (EHR) indicated Resident 8 had a quarterly care plan meeting, on 8/4/23, a quarterly care plan meeting, on 2/5/24, and another quarterly care plan meeting, on 7/9/24; indicating no care plan meetings were done for six months, then not again for another five months. During an interview with the Social Service Director (SSD) on 10/7/24 at 1:31 p.m., they indicated care plan meetings were to be held quarterly, and she did not know how the quarterly meetings got…

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 utilize an assistive device of a gait belt during a transfer resulting in a fall for 1 of 2 residents reviewed for accidents. (Resident 23) Findings include: During an interview with the Director of Nursing (DON) on 10/8/24 at 11:45 a.m., they indicated Resident 23 was an extensive assist of two people for transfers, on 9/20/24, when she fell. The staff were not utilizing a gait belt during the transfer and the resident did not have any medical condition that would prevent a gait belt being used. During an observation on 10/8/24 at 12:13 p.m., Qualified Medication Aide (QMA) 1 and Certified Nurse Aide (CNA) 2 assisted Resident 23 from her wheelchair to the toilet utilizing a gait belt. The resident was totally dependent of the two staff and gait belt for the transfer and the resident was bent over at the waist. During an interview with the Therapy Manager on 10/8/24 at 12:34 p.m., they indicated gait belts should be used during transfer and ambulation for all residents unless the resident was independent with…

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

Based on interview and record review, the facility failed to ensure 2 of 2 residents reviewed for misappropriation of property were not subjected to missing narcotic medications. (Residents B and C) The deficient practice was corrected on 4-4-24, prior to the start of the survey, and was therefore past noncompliance. The facility had immediately began an investigation upon learning of the missing narcotic medication and associated paperwork and begin staff education regarding the correct means to conduct controlled substance counts. Based on resident assessments and interviews, there was not a negative impact to the comfort level of either resident identified as being affected by this deficient practice. Findings include: In an interview with the Executive Director (ED) 5-21-24 at 11:22 a.m., she indicated the facility recently had an issue with diversion of narcotics. She indicated the concern was reported to the Indiana Department of Health's Long Care Division on 3-28-24, the date it was identified, and investigation has continued since that date. In another interview on 5-21-24…

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 implement policies and procedures related to misappropriation of resident property for 2 of 2 residents reviewed for misappropriation of property related to drug diversion. (Residents B and C) The deficient practice was corrected on 4-4-24, prior to the start of the survey, and was therefore past noncompliance. The facility had immediately began an investigation upon learning of the missing narcotic medication and associated paperwork and begin staff education regarding the correct means to conduct controlled substance counts. Based on resident assessments and interviews, there was not a negative impact to the comfort level of either resident identified as being affected by this deficient practice. Findings include: In an interview with the Executive Director (ED) 5-21-24 at 11:22 a.m., she indicated the facility recently had an issue with diversion of narcotics. She indicated the concern was reported to the Indiana Department of Health's Long Care Division on 3-28-24, the date it was identified, and investigation has…

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 maintain a safe, clean, sanitary and comfortable environment for a resident shower room and a resident's recliner was observed with a dried brown substance present. These deficient practices have the ability to adversely affect any residents who utilize the shower room and Resident F. (Resident F) Findings include: 1. During an observation of the shower room, located across from the Rehab Hall's Nurse's Station on 1-16-24 at 7:20 p.m., with LPN 3, the tile floor of the shower appeared discolored with brown and tan stains, one wet wash cloth was observed in left back corner of the shower. Behind and adjacent to the wall of the toilet were two balled-up pieces of tissue paper located on the floor. LPN 3 indicated she had heard the facility is planning to be replace the shower floor tile soon, but was unsure of a date. LPN 3 indicated she had noticed the discoloration of the tile and it did not look appealing to her. I don't know that I would want to walk on that shower floor barefoot. LPN 3 indicated she has…

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, observation, and record review, the facility failed to ensure resident specific fall interventions of antiroll back brakes and bright color tape were applied to wheelchair brakes 1 of 3 residents reviewed for falls. (Resident G) Findings include: The clinical record for Resident G was reviewed on 1/17/2024 at 2:51 p.m. The medical diagnosis included Alzheimer's disease. A Quarterly Minimum Data Set Assessment, dated 11/10/2023, indicated that Resident G had multiple falls and was cognitively impaired. A fall care plan for Resident G indicated interventions of anti-roll back to wheelchair, dated 3/7/2023, and bright colored tape to the wheelchair brakes, dated 12/18/2023. An observation on 1/17/2024 at 2:49 p.m. indicated Resident G was laying in bed at this time. She had a wheelchair next to her bed that did not have antiroll back brakes nor had color tape to the wheelchair brakes. An observation and interview on 1/17/2024 at 3:00 p.m. indicated CNA 2 came to Resident G's room. She confirmed that no antiroll back brakes or color tape to her wheelchair brakes. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 5 residents reviewed for nutrition had an admission weight obtained in less than 14 days from time of admission. (Resident B) Findings include: The clinical record of Resident B was reviewed on 1-16-24 at 4:06 p.m. It indicated he admitted to the facility on [DATE] with diagnoses that included, but were not to, a recent left femur fracture, muscle wasting and atrophy, cognitive communication deficit, dementia, paranoid schizophrenia and prostate cancer. An admission nursing assessment, dated 12-2-23, indicated his admission weight, dated 5-1-2021, was 175.4 pounds (#). This resident had previously been a resident from 1-29-2021 to 5-10-2021. Current weights for Resident B were documented as 150 # on 12-13-23, and 148.5 # on 1-4-24. A nutrition assessment, dated 12-4-23, 76 yo [years old] M [male] readmit with fracture of L. [left]femur and dx [diagnosis] of cancer of bone, ARF, [acute renal/kidney failure] and anemia. Monthly wt [weight]…

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 observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 for 4 of 40 residents observed during a random observation. (Residents 14, 31, 35, and 29). Findings include: The clinical record for Resident 14 was reviewed on 12/8/23 at 11:54 a.m. indicated, the resident tested positive for COVID-19 on 12/7/23 and was on contact droplet isolation for 10 days. The clinical record for Resident 31 was reviewed on 12/8/23 at 11:58 a.m. indicated, the resident tested positive for COVID-19 on 12/7/23 and was on contact droplet isolation for 10 days. Resident 14 and Resident 31 were roommates. The clinical record for Resident 35 was reviewed on 12/8/23 and was on strict isolation for contact droplet isolation related to a positive COVID-19 status. Resident 35 was roommates with Resident 29. An interview with ED (Executive Director) conducted on 12/8/23 at 12:25 p.m. indicated, Resident 35 had tested positive for COVID-19 on 12/4/23. She further indicated, Resident 29 had tested negative for COVID-19 on 12/4/23, but refused to leave his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident's money was secure and accounted for while it was being stored by a staff person for 1 of 3 residents reviewed for misappropriation of a resident's property. (Resident C) Findings include: The clinical record for Resident C was reviewed on 10/23/23 at 11:00 a.m. The resident's diagnosis included, but was not limited to, Parkinson's Disease. The 7/29/23 Quarterly MDS (Minimum Data Set) assessment indicated Resident C was cognitively intact. A reportable incident to the Indiana Department of Health on 10/20/23 indicated an incident had occurred on 10/16/23 of an allegation of misappropriation of funds. The immediate action that was taken was the MDS Coordinator was suspended, police were notified and an investigation was started. A follow up of the investigation dated 10/20/23 indicated The facility DON [Director of Nursing] received an email from [Resident C's Power of Attorney] alleging that [MDS Coordinator] took [Resident C] out on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely report an allegation of misappropriation to the IDOH (Indiana Department of Health) per policy for 1 of 4 residents reviewed for misappropriation. (Resident E) Findings include: The clinical record for Resident E was reviewed on 10/24/23 at 10:02 a.m. His diagnoses included, but were not limited to, end stage renal disease, heart failure, and serous retinal detachment. The 7/26/23 Quarterly MDS (Minimum Data Set) assessment indicated he had a BIMS (brief interview for mental status score) of 15, indicating he was cognitively intact. An interview was conducted with Resident E on 10/24/23 at 10:40 a.m. He indicated prior to going to the hospital on [DATE], about $500, probably more, went missing from his wallet. He could tell it was $500 by the thickness of his wallet, as he couldn't see well, due to having degenerative eye disease. CNA 9 took it, and he knew it was her. He went outside to smoke, and when he came back to his room, his door wasn't…

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 thorough investigation was conducted for 1 of 3 residents reviewed for misappropriation of a resident's property. (Resident C) Findings include: The clinical record for Resident C was reviewed on 10/23/23 at 11:00 a.m. The resident's diagnosis included, but was not limited to, Parkinson's Disease. The 7/29/23 Quarterly MDS (Minimum Data Set) assessment indicated Resident C was cognitively intact. A reportable incident to the Indiana Department of Health on 10/20/23 indicated an incident had occurred on 10/16/23 of an allegation of misappropriation of funds. The immediate action that was taken was the MDS Coordinator was suspended, police were notified and an investigation was started. A follow up of the investigation dated 10/20/23 indicated The facility DON [Director of Nursing] received an email from [Resident C's Power of Attorney] alleging that [MDS Coordinator] took [Resident C] out on LOA (leave of absence) August 18, 2023. [Resident C'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 timely obtain a urinalysis as ordered and to ensure post fall occurrence follow-up assessments were completed at least once per shift for 72 hours following a fall for 2 of 3 residents reviewed for falls. (Resident C and F) Findings include: 1. The clinical record for Resident C was reviewed on 10/23/23 at 11:00 a.m. The resident's diagnosis included, but was not limited to, Parkinson's Disease. The 7/29/23 Quarterly MDS (Minimum Data Set) assessment indicated Resident C was cognitively intact. A care plan for the resident's refusals of care dated 6/8/23 indicated the staff was to reapproach the resident at a later time if he refuses. A physician order for Resident C dated 10/18/23 indicated the staff was to obtain a urine culture. A nursing progress note dated 10/19/23 indicated the resident refused to obtain a urine culture. He indicated the urine culture should have been collected at night. The resident's medical chart did not include documentation the staff reattempt later in the day as per the resident requested. An…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide fresh water and failed to keep water within reach for 10 of 10 residents reviewed for hydration (Resident 21, Resident 39, Resident 48, Resident 14, Resident 41, Resident 51, Resident 7, Resident 8, Resident 50 and Resident 26). Findings include: 1.) During an observation and interview with Resident 21's family member on 7/10/23 at 2:13 p.m., the resident had a styrofoam cup on his bedside table with warm fluid in it, the cup was dated 7/9/23 third shift. Resident 21's family member indicated the resident frequently did not have fresh water and it was important for him to receive fresh water. The family member indicated the family often had to go get the resident fresh water when they visited daily. Review of the record of Resident 21 on 7/17/23 at 12:15 p.m., indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, anxiety, dementia, major depressive disorder and constipation. 2.) During an…

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

Based on observation, interview and record review the facility failed to provide an ongoing activity program for the memory care unit for 4 of 4 residents reviewed for activities (Resident 48, Resident 42, Resident 51 and Resident 157). Findings include: During an observation of the memory care unit on 7/10/23 at 11:46 a.m., residents sitting in the dining room, living room, resident rooms and residents wandering up and down the hallway going in and out of other resident rooms. There were no activities occurring on the memory care unit. The activity calendar, dated July 2023, provided by the Administrator on 7/17/23 at 12:05 p.m., indicated there was an activity of makin/bakin scheduled for 11:00 a.m. During an observation on the memory care unit on 7/10/23 at 2:04 p.m., there were no activities occurring on the memory care unit. The activity calendar, dated July 2023, provided by the Administrator on 7/17/23 at 12:05 p.m., indicated there was an activity of models scheduled for 1:30 p.m. During an observation and interview with CNA 10 on 7/10/23 at 2:47 p.m., there were no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement fall interventions and failed to keep walk ways free of clutter for 4 of 7 residents reviewed for falls (Resident 51, Resident 50, Resident 19 and Resident 20). Findings include: 1.) Review of the record of Resident 51 on 7/13/23 at 12:40 p.m., indicated the resident's diagnoses included, but were not limited to, unsteady on feet, weakness, diabetes, hypertension, anxiety, major depressive disorder, dementia , psychotic disturbance, arthritis and Parkinson's disease. The plan of care for Resident 51, dated 4/14/23, indicated the resident was at risk for falls and injury and has had an actual falls relate to dementia, history of falls, Parkinson's disease, poor safety awareness, unsteady gait, visual impairment and weakness. The interventions included, but were not limited to, bright colored tape on call light, non-skid footwear, urinal within reach, soft touch call light and bedside commode beside bed. The Quarterly Minimum Data…

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 have adequate staffing on the memory care unit to provide care, monitor, intervene and provide services in a safe manner for 4 of 4 random resident observations. (Resident 151, Resident 52, Resident 48 and Resident 21). Finding include: During an observation on 7/10/23 at 12:54 p.m., Resident 151 was wandering up and down the hallway, entering other resident rooms. During an observation on 7/10/23 at 12:54 p.m., Resident 151 was wandering up and down the hallway, entering other resident rooms. During an observation on 7/11/23 at 10:58 a.m., there were 5 residents sitting in the dining room there were no staff present. Resident 52 stood up from his geriatric chair and indicated he was leaving the resident was unstable on his feet and pulling his catheter tubing as he was moving away from his geriatric chair. The resident was half way over his arm rest of the chair. Was unable to locate staff on the memory care unit, except for housekeeper 11. Housekeeper 11 indicated she was not trained to assist residents, 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 implement an specialized memory care unit activity program and failed to implement individualized interventions for residents with dementia for 5 of 5 residents reviewed for dementia (Resident 48, Resident 42, Resident 51, Resident 157 and Resident 21). Findings include: During an observation of the memory care unit on 7/10/23 at 11:53 a.m., residents were sitting in the dining room, bedroom, living room and wandering up and down the hallway going in other resident rooms. There were no activities on the unit. There was no staff intervention. During an observation on 7/10/23 at 2:04 p.m., residents were sitting in the dining room, bedroom, living room and wandering up and down the hallway going in and out of other resident rooms. There were no activities on the unit. There were no staff intervention. During an observation on 7/10/23 at 12:51 p.m., Resident 48 was sitting was sitting at the door crying and attempting to leave the memory care unit when staff opened the door. The resident was yelling and screaming…

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 cover a foley catheter drainage bag, to provide dignity for a resident with a foley catheter for 1 of 4 residents reviewed for catheters. (Resident 8) Findings include: On 7/10/23 at 1:15 p.m., Resident 8's foley catheter drainage bag was observed hung on the open side of the bed and was uncovered. Resident 8's record was reviewed on 7/11/23 at 3:03 p.m. The record indicated resident 8 had diagnoses that included, but were not limited to, chronic kidney disease stage 3, history of urinary tract infections, kidney cyst, chronic obstructive pulmonary disease, paraplegia, neuromuscular dysfunction of the bladder, and difficulty swallowing. A Significant Change Minimum Data Set assessment, dated 5/13/23, indicated Resident 8 was cognitively intact, has had no dehydration, had an indwelling catheter, had a urinary tract infection, required extensive assistance of 2 for activities of daily living, and had limitation in range of motion in lower extremities. 07/17/23 12:58 PM., the DON said she is responsible 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.

Based on interview and record review, the facility failed to have documentation that a Notice of Medicare Non-Coverage (NOMNOC) or Advanced Beneficiary Notice (ABN) was provided to Resident 50 for 1 of 3 residents reviewed for beneficiary notices. Findings include: The clinical record for Resident 50 was reviewed on 7/14/2023 at 2:59 p.m. The medical diagnoses included abnormal electrolytes, weakness, and metabolic encephalopathy. A Quarterly Minimum Date Set (MDS) Assessment, dated 4/13/2023, indicated resident 50 was cognitively intact. A completed Beneficiary Protection Notification Review was provided by the facility on 7/14/2023 at 2:05 p.m. by the Executive Director that indicated Resident 50 had a Medicare Part A stay from 3/31/2023 through 5/26/2023 with no supporting documentation, such as a NOMNOC or ABN. During an interview on 07/17/23 at 12:06 p.m. the Executive Director verified the facility could not find any supporting documentation of ABN or NOMNOC for Resident 50. A policy entitled, SNF NOTICE FOR MEDICARE/MEDICARE ADVANTAGE/Medicaid MCO ADMISSIONS, was provided by…

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, observation, and record review, the facility failed to promote a clean homelike environment for 1 of 4 residents reviewed for room cleanliness. (Resident 210) Findings include: The clinical record for Resident 210 was reviewed on 7/17/2023 at 11:45 a.m. The medical diagnoses included muscle wasting and lymphedema. An admission Minimum Data Set Assessment, dated for 6/17/2023, indicated Resident 210 was mildly cognitively impaired. Resident 210 needed extensive assistance of two or more staff for transferring and toileting activities of daily living. During an observation and interview with Resident 210 on 7/10/2023 at 11:55 a.m. he was sitting in his recliner at that time, eating his lunch. He had a bedside commode with no lid immediately next to him that had dried feces on it. He indicated he wished the staff would clean the besdide commode better after it was used. During an observation on 7/12/2023 at 4:30 p.m. the bedside commode was sitting in his room next to his dining table and continued to have the dried fecal matter on it. A policy entitled, Safe…

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, observation, and record review, the facility failed to timely complete a grievance for missing items reported verbally to a staff member for 1 of 2 residents reviewed for missing items. (Resident 46) Findings include: The clinical record for Resident 46 was reviewed on 7/14/2023 at 1:45 p.m. The medical diagnoses included cerebral infarct. An Annual Minimum Data Set Assessment, dated for 4/8/2023, indicated Resident 46 was cognitively intact. During an interview and observation on 7/10/2023 at 12:03 p.m. Resident 46 had indicated she had a pair of pink checkered shorts missing as well as two blankets that she had told multiple staff members, including direct care staff and the laundry staff, of over the last few weeks. During this interview, Housekeeper 4 came in with Resident 46's pink shorts and stated she was still looking for the blankets. Resident 46 reiterated the description of the blankets to Housekeeper 4 and Housekeeper 4 said she would keep an eye out for them. During an interview with Social Services Director on 7/11/2023 at 1:45 p.m. she verified she…

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 assist dependent residents with Activities of Daily living (ADL) for 3 of 6 residents reviewed for ADL assistance (Resident 21, Resident 51 and Resident 27) Findings include: 1.) During an observation on 7/10/23 at 11:46 a.m., Resident 21 was walking down the hallway with a walker. The resident's hair was disheveled and uncombed and there was a black substance underneath the resident's finger nails. During an observation and interview with Resident 21's family member indicated the family visited the resident daily and most the time the family had to change his incontinent brief because it [NAME] be full of bowel movement and soiled. The resident member indicated the facility did not comb his hair or clean his dentures. Observation at this time Resident 21 had a strong urine smell, dirty dentures, hair uncombed and disheveled and black substance underneath his fingernails. The family member indicated he often smelled strong of urine. Review…

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 record review, the facility failed to ensure the urinary catheter drainage bag was free of contact with the floor for 1 of 3 residents reviewed for urinary catheter. (Resident 50) Findings include: The clinical record for Resident 50 was reviewed on 7/14/2023 at 2:59 p.m. The medical diagnoses included abnormal electrolytes, weakness, and metabolic encephalopathy. A Quarterly Minimum Date Set Assessment, dated 4/13/2023, indicated resident 50 was cognitively intact and used an indwelling urinary catheter. During an interview and observation on 7/11/2023 at 11:06 a.m. Resident 50 was in bed at this time with her urinary catheter drainage bag off to the left side of the bed. The drainage bag had been placed in a urinary hat that was tipped over and causing the bag to be laying on the floor with a moderate amount of dark urine in the collection system. During an observation on 7/12/2023 at 3:30 p.m. Resident 50 was laying in bed with her urinary catheter bag hanging off the right side of her bed. Her bed was placed so the right side of her bed was contacting…

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 oxygen tubing was dated for 2 of 3 residents reviewed for oxygen therapy. (Resident 210 and Resident 20) Findings include: 1. The clinical record for Resident 210 was reviewed on 7/17/2023 at 11:45 a.m. The medical diagnoses included muscle wasting and obstructive sleep apnea. An admission Minimum Data Set Assessment, dated for 6/17/2023, indicated Resident 210 was mildly cognitively impaired. Resident 210 utilized oxygen therapy and BiPAP/CPAP. During an observation and interview with Resident 210 on 7/10/2023 at 11:55 a.m. he was sitting in his recliner at this time, eating his lunch. He had an oxygen cannula in place connected to an oxygen concentrator. No date was on the tube or the storage bag for his nasal cannula. Resident 210 was not sure when the tubing was last changed. During an observation on 7/11/2023 at 2:55 p.m. Resident 210 continued to use his nasal cannula with no date indicated on either the tubing or storage bag. 2. The clinical record for Resident 20 was reviewed on 7/13/2023 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.

Based on observation, interview and record review the facility failed to assess a new onset of pain, treat a new onset of pain and failed to notify the physician of a resident experiencing an new onset of pain for 1 of 4 resident's reviewed for pain (Resident 42) Finding include: During an observation on 7/10/23 at 11:51 a.m., Resident 42 was standing in the hallway with her left hand clenched in a tight ball. CNA 6 asked the resident if she had something in her hand and attempted to open the resident's left hand, the resident yelled that hurts, QMA 7 was standing there and indicated the resident had been doing that for awhile with her left hand. The resident was moaning and refused to open her left hand. During an observation on 7/11/23 at 11:09 a.m., Resident 42 was sitting in the dining room and was clenching her left hand in a tight ball, the left hand was swollen and bruised and the resident was crying. The resident was guarding her left hand with her right hand. During an observation on 7/12/23 at 2:30 p.m., Resident 42 sitting in the dining room with left hand clinched, 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 interview and record review, the facility failed to provide eight hours of RN coverage for 2 of 6 days triggered reviewed in Quarter 2 of Fiscal Year 2023 and 1 of 1 days randomly selected for Quarter 2 of Fiscal Year 2023. Findings include: A Payroll Based Journal (PBJ) report, compiled on 7/5/202, indicated no RN hours were reported for six days, including 1/22/2023 and 1/29/2023. Timecards were reviewed for 1/22/2023 and 1/29/2023 on 7/17/2023 at 11:45 a.m. to indicate no RN hours for these aforementioned day. Timecards for a randomly selected day, 1/28/2023, was reviewed by surveyor on 7/17/2023 at 11:45 a.m. to indicate only 5 hours and 9 minutes of RN coverage on that day. During an interview with the Executive Director on 7/17/2023 1:45 p.m. she indicated that there were no RN hours for 1/22/2023 and 1/29/2023. She stated the RN on call was not in the building at that time due to kids and she was unsure why there were incomplete RN hours on 1/28/2023, but it would have fallen under the same weekend as 1/29/2023. It was the expectation of the facility to follow 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 interview and record review, the facility failed to complete an inventory sheet and failed to have staff or resident/resident's representative sign the inventory sheet upon discharge. Findings include: On 7/14/23 at 9:38 a.m., an interview with a family member for Resident 156 was completed. The family member indicated Resident 156 had been discharged the day before, and all his things he brought here; his phone, clothes, etc., were packed in boxes by her and removed from the facility. The family member indicated she didn't fill out any kind of an inventory sheet when he was admitted , and no one filled out or had her sign one when she removed his clothing and other items from the facility. Resident 156's record was reviewed on 7/14/23 at 12:46 p.m. The record indicated Resident 156 had diagnoses that included, but were not limited to, cognitive communication deficit, cancer in the abdominal cavity, seizure disorder, high blood pressure, and muscle wasting. On 7/14/23 at 2:38 p.m., the [NAME] President of Leadership Development provided a copy of Resident 156's personal…

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 accurately report the RN coverage hours for 4 of 6 days triggered on a Payroll Based Journal Report for Fiscal Year 2023 Quarter 2. Findings include: A Payroll Based Journal (PBJ) report, compiled on 7/5/2023, indicated no RN hours were reported for six days, including 1/8/2023, 2/2/2023, 2/26/2023, and 3/26/2023. During an interview with the Executive Director on 7/17/2023 1:45 p.m. she indicated that a previous Director of Nursing (DON 6) had been in the building for eight consecutive hours on 1/8/2023 and the current Director of Nursing (DON) had completed the eight consecutive hours of RN coverage for 2/2/2023, 2/26/2023, and 3/26/2023. She was unsure why these hours were not captured on the PBJ report and was still waiting to hear from their reporting partners. The facility's expectation was that all nursing hours are reported accurately to the PBJ.