Mason Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications were administered according to physician's orders and professional standards for 5 of 30 opportunities, resulting in a medication administration error rate of 16.67%. (Resident 73 and 9) During an observation, on [DATE] at 9:02 A.M., RN 2 was administrating medications to Resident 73. RN 2 indicated he had 11 pills in the medication cup. The medication administered to Resident 73's were: Cymbalta 20 milligrams (mg), one tablet for depression Finasteride 5 mg, one tablet for benign prostatic hypertrophyFloranex probiotic one tabletPlavix 75 mg, one tablet for prophylaxis of blood clotsFerrous Sulfate 325 mg, one tablet for iron supplementationMetformin 500 mg, one tablet for diabetesMetoprolol Tartrate 25 mg, give 0.5 tablet for hypertensionTylenol 650 mg, one tablet for painVascepa 1 gram, give 2 tablets for hypertriglyceridemia Vitamin C 500 mg, one tablet for vitamin supplementation During a record review, on [DATE] at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to secure and destroy discontinued controlled medications and properly dispose of expired medications on 1 of 2 medication carts and in 1 of 1 medication storage room observed. (Medication cart 100 hallway and Medication storage room [ROOM NUMBER]-400 hallway)Findings include:During an observation, on 8/22/2025 at 10:20 A.M., in the top drawer of the 100 hall medication cart, two Lorazepam 0.5 mg tablets medication cards for Resident 66 that had been discontinued on 8/4/2025 were found. One card contained 10 Lorazepam 0.5 mg tablets and one card contained 60 Lorazepam 0.5 mg tablets. During an interview, on 8/22/25 at 10:20 A.M., RN 5 indicated she had discovered the discontinued medication during the morning narcotic count and had removed the cards from the narcotic drawer of the medication cart. RN 5 indicated she intended to have the medications destroyed but was interrupted before she could take them to the appropriate area for disposal.…

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 staff followed infection control practices during a skin treatment for 1 of 1 skin treatments observed. (LPN 4) Finding includes: During an observation, on 8/18/2025 at 11:36 A.M., LPN 4 completed a wound treatment. LPN 4 placed her treatment supplies, including a pair of bandage scissors, directly onto the residents' table without placing a barrier down between the table and the supplies. LPN 4 then removed the residents' sock, the elastic bandage and then the gauze from the resident's right lower leg and removed the dressing to the heel and placed them in the trash can. LPN 4 then removed her gloves and applied hand sanitizer on both hands. She then, with opened hands, used a fanning motion to dry her hands and then applied new gloves. During an interview, on 8/18/2025 at 11:53 A.M., LPN 4 indicated she should have not fanned her hands and should have placed a barrier on the table. On 8/25/2025 at 4:30 P.M., the Corporate Nurse provided the policy titled, Hand Hygiene, dated 5/29/2024, and indicated…

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

Based on record review and interview, the facility failed to ensure appropriate feeding tube care was provided regarding water flushes before and after medication administration and insertion site care for 1 of 3 residents reviewed for tube feeding. (Resident F) Finding includes: A complaint to the Indiana Department of Health (IDOH) was received on 6/11/2025 at 9:48 A.M. The complaint included, but was not limited to: .cleaning had not been performed around the feeding tube and only a gauze pad had been placed A closed record review for Resident F was completed on 6/16/2025 at 10:48 A.M. Diagnoses included, but were not limited to: cerebral infarction (stroke), dysphagia (difficulty swallowing), severe protein-calorie malnutrition and adult failure to thrive. An admission Minimum Data Set (MDS) assessment, dated 4/7/2025, indicated Resident F was cognitively intact and received artificial nutrition and hydration via a feeding tube. A Care Plan, initiated on 4/24/2025, indicated Resident F had a gastronomy tube (a tube surgically inserted through the abdominal wall directly into 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, record review and interview, the facility failed to provide scheduled pain medication in a timely manner for 1 of 3 residents reviewed for pharmaceutical services. (Resident B) Finding includes: During an interview, on 3/5/2025 at 9:28 A.M., Resident B indicated RN 2 was not allowed to provide medical services for her, including medication administration. This decision was made due to a prior incident of RN 2 scaring her during a night shift medication administration. She indicated RN 2 had been informed the other evening and night shift nurses were to administer her pain medications when needed at 4:00 P.M., 8:00P.M., 12:00 A.M. and 4:00 A.M. when RN 2 was scheduled to work A record review for Resident B was completed on 3/5/2025 at 10:32 A.M. Diagnoses included, but were not limited to: leukemia, anemia and anxiety disorder. A Quarterly Minimum Data Set assessment, completed 2/13/2025, indicated Resident B was cognitively intact and received opioid pain medication. She had medically complex conditions including a diagnosis of cancer. A Physician's Order, dated…

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

Based on observation, interview and record review, the facility failed to store, prepare and serve food in a sanitary manner in 1 of 1 kitchens observed and 2 of 2 nutrition pantries observed. This deficient practice had the potential to affect 72 of 72 who consumed food from the kitchen and nutrition pantries. Findings include: 1. During an initial tour of the kitchen, on 8/26/2024 at 11:59 A.M., with the Dietary Manager, the following was observed: - black specs of a substance on a shelf in the walk-in cooler. - an opened, undated bag of tater tots not sealed in the freezer. - an opened bag of diced pepperoni with a used by date of 7/4/2024 in the freezer. During an interview, on 8/26/2024 at 12:10 P.M., the Dietary manager indicated the shelf should have been cleaned, the tater tots should have been dated and sealed and the pepperoni should have been removed. 2. During a meal observation, on 8/26/2024 from 12:40 P.M., to 12:46 P.M., the following was observed: -at 12:43 P.M. CNA 5 passed a lunch tray with her finger extending over the rim of the plate. -at 12:46 P.M. CNA 4 passed…

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

Based on record review and interview, the facility failed to ensure a care plan regarding activities was revised and updated for 1 of 21 residents reviewed for care plans (Resident 6). Finding includes: The record for Resident 6 was reviewed on 8/29/2024 at 9:45 A.M. Diagnoses, included but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, gastrostomy status, liver disease, diabetes mellitus with neuropathy, bipolar disorder, contracture, depression, anxiety and chronic kidney disease. An annual Minimum Data Set (MDS) assessment,, dated 3/27/24, indicated it was very important for Resident 6 to listen to music, be around pets, do favorite activities, go outside, and participate in religious activities. Resident 6 indicated it is not very important to do things with groups, keep up with news, and have magazines to read. An activity care plan, dated 7/13/2023, indicated Resident 6 benefited from individualized programming, enjoyed music like the Beatles, and enjoyed visits from her Jehovah Witness church.…

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 provide appropriate communication devices for a Spanish speaking resident for 1 of 1 resident reviewed for communication. (Resident 29) Finding includes: During an interview with Resident 29's son, on 8/26/2024 at 3:21 P.M., he indicated Resident 29 could not speak English, and Spanish was her normal launguage for communication. A record review for Resident 29 was completed, on 8/28/2024 at 10:01 A.M. Diagnoses included, but were not limited to: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, dysphagia, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/19/2024, indicated Resident 29 had moderate cognitive deficit and could make herself understood, and understood others. A Care Plan, dated 4/26/2024, and revised on 6/27/2024, indicated Resident 29 had a cognitive deficit related to a diagnosis of altered mental status, and her primary language was Spanish, which may required a translator at times. Interventions…

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 respiratory equipment was changed per Physician orders for 1 of 1 resident reviewed for oxygen use. (Resident 14) Finding includes: During an observation, on 8/26/2024 at 2:38 P.M., Resident 14's oxygen tubing was dated 8/18/2024. The humidification bottle, dated 8/18/2024, was empty. During an observation, on 8/28/2024 at 10:25 A.M., Resident 14's water bottle was dated 8/18/2024, and remained empty. The 02 tubing was dated 8/18/2024. During an observation, on 8/29/2024 at 8:40 A.M., Resident 14's oxygen humidification water bottle, dated 8/18/2024, was empty and the 02 tubing was dated 8/18/2024. The record for Resident 14 was reviewed on 8/28/2024 at 9:38 A.M. Diagnoses included, but were not limited to: paraplegia, malnutrition, depression, asthma. A Quarterly Minimum Data Set (MDS) assessment, dated 6/6/2024, indicated the resident used oxygen. Current Physician Orders, dated 10/18/2023, indicated Resident 14 received oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary…

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 medication storage carts were locked when not in use; failed to store medications appropriately; failed to ensure expired medications were removed from medication carts; and failed to ensure the freezer section of a medication refrigerator was free from ice build up for 4 of 4 medication storage areas observed. (400 hall Medication Cart, 300 hall Medication Cart, 100 hall Medication Cart, and 100 hall Medication room) Findings include: 1. At 2:50 P.M., QMA 8 walked away from the 400 hall medication cart and went down the hall. The medication cart was unlocked. During an observation, on 8/26/2024 at 2:56 P.M., LPN 11 walked by the 400 hall medication cart twice. During an interview, on 8/26/2024 at 3:00 P.M, QMA 8 indicated the medication cart should not have been left unlocked. 2. During a medication storage observation on the 300 hall medication cart, on 8/27/2024 at 2:30 P.M., with RN 9 the following was observed: - A bottle of shampoo was in with the liquid medications in the bottom drawer. - A…

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

Based on observation, record review and interview, the facility failed to ensure staff used appropriate PPE (Personal Protective Equipment) when emptying a Foley catheter drainage bag for 1 of 1 resident reviewed for catheters. (Resident 14) Finding includes: During an observation, on 8/26/2024 at 2:31 P.M., Resident 14's Foley urine catheter drainage tubing had a large amount of sediment. The record for Resident 14 was reviewed on 8/28/2024 at 9:38 A.M. Diagnoses included, but were not limited to paraplegia, malnutrition, depression, and neuromuscular dysfunction of bladder. Current Physician Orders, dated 4/17/2024, indicated Resident 14 was on enhanced barrier precautions related to an: extended -spectrum beta-lactamase (ESBL (an enzyme found in some bacteria that can cause serious urinary tract infections) in the urine. A current Care Plan, dated 8/14/2024, indicated the resident had an indwelling catheter related to a neurogenic bladder. Interventions included the following: Staff will care for my catheter and personal hygiene needs, proper positioning of the drainage bag 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 observation, interview, and record review, the facility failed to have a process of accountability for medications awaiting final disposition for 4 of 8 residents whose medications were reviewed for disposition. (Resident H, Resident J, Resident K, and Resident L). Findings include: On 12/28/2023 at 10:40 A.M., an observation of the medication storage room on the front hall with the Director of Nursing (DON) was completed. A yellow bin identified as the medication disposition bin by the DON contained packets of medication that were not labeled for disposition. The following single dose medication packets were observed in the yellow bin without a disposition reason: a. A packet with a dexamethasone pill, dated 12/8/2023, a packet with a sodium chloride pill, dated 12/22/2023, and a packet with a sucralfate pill, dated 12/17/2023, all labeled for Resident H. b. Packets with magnesium oxide pills, dated 11/3/2023, 12/4/2023, and 12/5/2023, all labeled for Resident J. c. A packet with an omeprazole pill, dated 12/22/2023, labeled for Resident K. d. A packet with a furosemide…

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

Based on record review and interview, the facility failed to ensure through investigations were completed for misappropriation of resident property for 2 of 2 allegations of misappropriation of resident property reviewed. (Residents B & F) Findings include: 1. A State Reportable Form was provided on 12/27/2023 at 12:10 P.M. Under the Brief Description of Incident, the following was documented: 11/30/2023 Resident B reported she was missing $27.00 from her coin purse. The resident noticed the money missing on 11/29/2023 while out at dialysis. Resident B was unable to identify when she last saw the money. The HFA (Health Facility Administrator) initiated an internal investigation. Immediate action taken documented was a lock box provided. Follow up documentation included: HFA completed the investigation. Investigation concluded the resident noticed the $27.00 missing on 11/28/2023. HFA reviewed the camera and was unable to determine if the money was stolen. A Misappropriation of Resident Funds or Property Form indicted the following: Date/Time of Incident/Discovery: 11/28/2023.…

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 kitchen sanitation for 76 of 79 residents currently residing in the facility who consume food prepared in the kitchen. Findings include: During a kitchen observation, with the Dietary Manager (DM) on 9/18/23 at 9:52 AM, two baking pans were observed with several 3-5 centimeter-sized brown debris stuck to the inner walls of each pan. Two additional pans were observed with liquid dripping from the inside of the pan upon separation. The DM indicated pans should be checked for cleanliness and moisture prior to stacking and storing. Multiple pencil eraser-sized tan and brown spots were observed throughout the cabinetry of the kitchen. Brown, white, and black pieces of debris were visible on the floors throughout the kitchen and walk in cooler. The debris ranged from pencil lead-sized to quarter-sized. A whole mushroom, a blue ring from a milk jug, and a plastic bread bag closure were on the floor of the kitchen. The DM indicated the debris on the floor was generated in more than just the last day. 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 dignity was maintained during the dining experience for 3 of 8 residents in the assisted dining room (Resident 27, Resident 28, and Resident 31). Findings include: During an observation on 9/19/23 at 8:48 AM, eight residents were seated in the assisted dining room, with meals placed in front of them. Qualified Medication Aide (QMA) 5 was the only staff member in the room. QMA 5 stood next to, and leaned over, Resident 27 and picked up a cup she was holding and assisted her to drink. QMA 5 then picked up silverware belonging to Resident 28 and assisted her to take a bite of food. QMA 5 walked across the room to Resident 31, stood next to her, leaned over her, picked up her silverware and assisted her to take a bite of food. Resident 27's record was reviewed on 9/22/23 at 10:14 AM. Diagnoses included unspecified dementia, moderate, with anxiety, type 2 diabetes mellitus without complications, and cognitive communication deficit. 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 privacy for 3 of 24 residents reviewed during random observations. (Resident 17, Resident 63, and Resident 135) Findings include: 1. During an observation on 9/19/23 at 8:33 AM, the 100 hall a computer screen placed on top of the medication cart was visible with Resident 135's name, picture, medication list and other personal information visible. No staff member was in attendance of the cart. Resident 135's record was reviewed on 9/22/23 at 12:37 PM. Diagnoses included spinal stenosis, chronic obstructive pulmonary disease, unspecified, and dysphagia. A review of Resident 135's current admission Minimum Data Set (MDS) dated [DATE] indicated her Basic Interview for Mental Status (BIMS) score was 13 (cognitively intact). During an interview on 9/19/23 at 3:03 PM, the Director of Nursing indicated computer screens should be closed when not directly attended to ensure privacy. 2. During an observation on 9/20/23 at 12:06 PM the 100 hall…

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 an allegation of abuse was reported to the State Agency and investigated for 2 of 24 residents reviewed for abuse (Resident 9, and Resident 11). Findings include: During an observation on 9/18/23 at 11:50 AM in the dining room, Resident 9 was observed holding a two handled, lidded cup. Resident 11 grabbed the cup and tried to pull it away. Each resident held a handle of the cup and pulled it back and forth. Resident 11 grabbed Resident 9's fingers and tried to pry her fingers from the cup. Resident 9 began screaming when Resident 11 grabbed her fingers. Four staff members came in the room, including the Director of Nursing, who assisted in separating the residents. Resident 9's record was reviewed on 9/22/23 at 12:07 PM. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, and anemia. Resident 11's record was reviewed on 9/21/23 at 1:16 PM. Diagnoses included type 2 diabetes mellitus without complications, hypertension, and cognitive communication deficit. In an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to respond to a request with positioning and personal care for 1 of 7 residents reviewed for ADLs. (Resident 134) Findings include: On 9/18/23 at 3:47 PM, Resident 134 was observed lying in bed wearing a pink shirt with long sleeves. Resident 134's record was reviewed on 9/20/23 at 9:07 AM. Diagnoses included right lower leg fracture, torn cartilage of the right knee, emphysema and urinary tract infection. Resident 134 was admitted to the facility on [DATE]. Resident 134's most recent discharge Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (no cognitive deficit). The MDS indicated the resident required extensive assistance with bed mobility, personal hygiene and dressing. The MDS indicated the resident required supervision with eating. Resident 134's current care plan for Activities of Daily Living (ADLs) dated 9/13/23 with a goal date of 12/12/23 indicated the resident required 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 develop and implement preventative foot care interventions to prevent toenail injury and infection for 1 or 1 residents reviewed for foot care (Resident 19). Findings include: On 9/19/23 at 11:45 A.M., Resident 19's record was reviewed. Diagnoses included diabetes with diabetic peripheral angiopathy (narrowing of arteries), peripheral vascular disease, and long term use of insulin. An annual MDS (Minimum Data Set) assessment, dated 8/8/23, indicated the resident had no cognitive impairment. He was dependent on 2 staff members for bathing and had no foot issues were observed at the time of assessment. Care plans were as follows: 8/11/21: At risk for blood sugars to fluctuate. Interventions included: report and observe for changes in skin and sensation. 7/12/23: At risk for developing pressure ulcers related to impaired mobility and disease process. Interventions included: observe resident's skin weekly. 8/24/23: The resident was prescribed an antibiotic. Interventions included: therapeutic goals for 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 individualized contracture management interventions were in place for a resident with a decline in range of motion for 1 of 1 residents reviewed for range of motion (Resident 3). Findings include: On 9/19/23 at 11:20 A.M., Resident 3's record was reviewed. Diagnoses include dementia without behavioral disturbance, stroke with hemiplegia and hemiparesis of left non-dominant side, contracture of left wrist and diabetes. An annual MDS (Minimum Data Set) assessment, dated 4/4/23, indicated the resident has severely impaired cognition. He was dependent on staff for all ADL care and had range of motion impairment to both upper and lower extremities. A care plan, revised on 7/24/19, indicated the resident had hemiplegia/hemiparesis on the left side due to a stroke. The goal was for his care plan interventions to minimize his risk for worsening contractures with a target date of 10/15/23. Interventions included: provide needed assistance with ADL's and provide assistance to resident with his restorative nursing…

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 intravenous (IV) therapy was maintained and discontinued for 1 of 3 residents reviewed. (Resident 134) Findings include: On 9/20/23 at 9:04 AM Resident 134 was observed wearing a pink shirt with long sleeves. An IV site was observed to he lower arm. The resident indicated she had been waiting for the IV to be removed. There was no IV administration set observed in the resident's room. Resident 134's record was reviewed on 9/20/23 at 9:07 AM. Diagnoses included right lower leg fracture, torn cartilage of the right knee, emphysema and urinary tract infection (UTI). Resident 134's most recent discharge Minimum Data Set (MDS) dated [DATE] indicated their Basic Interview for Mental Status (BIMS) score was 15 (no cognitive deficit). A physician order dated 9/12/23 indicated Resident 134 was to have an IV placed for antibiotic (ATB) therapy to treat a UTI. Resident 134's current physician orders did not include a prescribed ATB. Resident…

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

Based on observation, interview and record review, the facility failed to maintain adequate staffing levels to provide assistance with repositioning and personal care needs for 2 of 3 residents reviewed (Resident A and Resident B). Findings include: An anonymous complaint to the Indiana Department of Health indicated there was a concern the facility did not have enough staff to care for the residents. On 9/20/23 at 10:00 AM, Resident B's room mate was heard yelling for help. Resident B was observed with her lower body off the bed. On 9/20/23 at 10:04 AM, an unknown CNA inside Resident B's room was observed telling Resident B there was not enough staff. The CNA told Resident B they should have gotten up earlier in the day when other staff was available to assist. In an interview on 9/22/23 at 10:56 AM, Resident B indicated on 9/20/22 at 10:00 AM, they were trying to reposition to sit on the edge of the bed to relieve back pain, when they were unable to get back onto the bed and nearly fell. Resident B indicated the call light had been on awhile. Resident B's room mate indicated 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.