Hillside Manor Nursing Home

Based on interview and record review, the facility failed to ensure diets were provided that met nutritional and special dietary needs for 12 of 35 residents that ate facility provided meals. All residents were served a regular diet despite other therapeutic diet orders. (Resident 4, Resident 9, Resident 11, Resident 13, Resident 20, Resident 3, Resident 29, Resident 8, Resident 30, Resident 22, Anonymous Resident A, Anonymous Resident B)Findings include:During the survey, two anonymous residents indicated the facility did not provide a diabetic menu. One resident indicated their blood sugars had been three times higher than they needed to be since a diabetic meal was not provided. The other resident indicated it was up to the residents to know what they could and couldn't have from their meals and to not eat the items that were contraindicated with their diet. On 12/8/25 at 1:04 P.M., the Kitchen Manager indicated although several residents did have therapeutic diet orders, there were no alternative meals or selections for any diets other than regular that were provided. 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 interview and record review, the facility failed to ensure residents had a diet ordered by a prescribing practitioner for 3 of 15 residents reviewed for diet orders. The resident orders did not include an order for a diet. (Resident 7, Resident 23, Resident 10)Findings include:1. On 2/5/25 at 1:17 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, Parkinson's disease, hypertension, and cancer of kidney and prostate. Resident 7 was admitted [DATE]. The most recent admission MDS assessment, dated 9/15/25, indicated the resident's cognition was severely impaired. Current Physician's Orders lacked a diet order. A current Nutritional Care Plan, last revised 9/8/25, included, but was not limited to, an intervention to provide and serve diet as ordered. 2. On 12/4/25 at 1:00 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, hypertension, anxiety, and depression. Resident 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.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 2 of 2 observations of the basement and laundry room. The basement floor was full of dirt and debris, vent covers were caked with dust, and the laundry room had debris and dust. (Basement, Laundry Room)Findings include:1. On 12/1/25 at 10:00 A.M., the basement was observed with dirt and debris on the floor in the area where the refrigerators and freezers for the kitchen were stored. Two of two vent covers in the hallway from that room to the ice machine room were observed with a thick layer of dust between the vent slats. On 12/8/25 at 1:06 P.M., the same was observed. 2. On 12/8/25 at 10:05 A.M., the laundry room area had debris scattered throughout the floor where clean clothing was kept. Multiple pieces of debris accumulated where the wall and floor meet. There was multiple wires exposed on the ceiling with a thick layer of dust caked on the wires. The electrical panel box lacked a door to cover it, and had exposed wires caked with dust. A window air condition…

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 resident was informed in advance by the prescribing practitioner of the risks and benefits of proposed treatment and treatment alternatives for 1 of 6 residents reviewed for unnecessary medications. A prescribing practitioner ordered an antipsychotic for a resident they had not seen and the clinical record lacked documentation of education provided to the resident prior to the medication being given. (Resident 23)Finding includes:During an interview on 12/3/25 at 10:23 A.M., Resident 23 indicated that before she came, she was not on any medications, and now she was on several, but she didn't know why. At that time, the resident was observed in the dining room walking with her hand along the wall and shuffling her gait. The resident indicated she thought it was from the different medications. On 12/4/25 at 1:00 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without…

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 accurate representation of advanced directive status for 1 of 2 residents reviewed for advance directives. A resident's actual code status was not reflected accurately in all documentation. (Resident 32)Finding includes:On 12/4/25 at 10:43 A.M., Resident 32's clinical record was reviewed. Diagnosis included, but was not limited to, anxiety.The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/27/25, indicated a moderate cognitive impairment.Current physician orders included, but were not limited to:Full code, dated 5/2/25.A POST (physician order for scope of treatment) form, dated 12/10/24, indicated Resident 32 had a DNR (do not resuscitate) code status. On 12/5/25 at 1:35 P.M., Registered Nurse (RN) 3 indicated all resident's code status were located in a binder at the nurses station. At that time, the binder was observed with Resident 32's face sheet. At the top of the face sheet, DNR was written. RN 3 indicated in the event of a code situation, Resident 32 would not be resuscitated due to the DNR…

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 was discharged with sufficient preparation for 1 of 1 closed records reviewed. A discharged resident was not educated to follow up with a specialist as needed, and a current list of medications was not provided. (Resident 38)Finding includes: On 12/8/25 at 9:45 A.M., Resident 38's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension.Resident 38 was admitted to the facility on [DATE] and discharged to home on 9/25/25.An admission minimum data set (MDS), dated [DATE], indicated a moderate cognitive impairment.Physician orders included, but were not limited to:Losartan Potassium-HCTZ (hydrochlorothiazide) oral tablet 100-12.5mg (milligram), give one tablet a day for hypertension, dated 6/21/25.Progress notes lacked information related to Resident 38's discharge.Resident 38's clinical record lacked any discharge assessments.Resident 38's clinical record lacked a referral or any other information related…

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 an accurate Minimum Data Set (MDS) Assessment was completed for 3 of 12 residents reviewed for MDS Assessments. Residents taking anticonvulsant medications, antianxiety, and hypoglycemic medications were not marked as administered. (Resident 3, Resident 8, Resident 2)Findings include:1. On 12/4/25 at 12:59 P.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/28/25, indicated no cognitive impairment and no use of a hypoglycemic medication. Current physician orders included, but were not limited to: Jardiance (a hypoglycemic) oral tablet, one daily, related to diabetes mellitus, dated 9/23/25. Humalog (insulin), inject 12 units with meals related to diabetes mellitus, dated 6/10/25. Tresiba FlexTouch (insulin) 50 units once daily related to diabetes mellitus, dated 6/4/25. Resident 2's medication administration record…

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 the appropriate care and services for a suprapubic catheter were given for 1 of 2 residents reviewed for catheter care. Staff was not measuring output and not cleaning the insertion site of a resident with a suprapubic catheter. (Resident 7)Finding includes: During an interview on 12/1/25 at 2:17 P.M., Resident 7's wife indicated the doctor did not want the facility to change his catheter, he wanted to do it in his office. She was not sure what care the staff performed with the catheter. During an observation on 12/4/25 at 10:05 A.M., Resident 7's catheter bag and tubing were dragging on the hallway on floor while he was walking from his room to nurse's station, Qualified Medication Aide (QMA) 55 picked it up and hung it back on his pant's pocket. On 12/4/25 at 10:45 A.M., Resident 7's catheter site was observed in his room with small amount of yellow drainage, slight redness/irritation, no odor, and brownish crust around it. There…

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 receive registry verification before filling the role of a Certified Nurse Aide (CNA) for 1 of 5 CNA licenses reviewed. An employee was working as a CNA without the facility verifying registration. (CNA 24)Finding includes:On 12/8/25 at 1:00 P.M., the employee records were reviewed. There was not a license found on CNA 24. She was hired 8/28/24 and her 120 days would have been up 12/26/24.During an interview on 12/9/25 at 9:50 A.M., the Administrator provided a certificate of completion for the 105 hour nurse aide training from the Indiana State Department of Health and said that was what was provided to them. She wanted to double check with the employee to see if she was under a different name because she was working as a CNA in the facility.During a 12/9/25 at 2:45 P.M., the Administrator indicated she was not aware that CNA 24 was not licensed. The license was not verified upon hire. She usually worked eight hours on night shift and had 35 shifts working alone as a CNA since September of 2025.On 12/10/25 at 8:31 A.M., 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 person-centered dementia treatment and services were provided for 1 of 2 residents reviewed for dementia care. (Resident 7)Finding includes:During an observation on 12/3/25 at 9:30 A.M., Resident 7 was sitting by the front door asking to play Connect Four. Staff told the resident his wife would be here soon to play. During an observation on 12/4/25 at 10:09 A.M., Resident 7 came out of room and asked the nurse when his wife would be here. She indicated Anytime. Why don't you wait in your room for her.On 12/5/25 at 1:17 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, Parkinson's disease, hypertension, and cancer of kidney and prostate. Resident 7 was admitted [DATE].The most recent admission MDS assessment, dated 9/15/25, indicated the resident's cognition was severely impaired.The clinical record lacked an activities care plan about likes, dislikes, 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 interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents reviewed for urinary tract infections (UTI). A resident was given medications that caused severe sedation when taken together resulting in unresponsiveness and a subsequent hospitalization. (Resident 6)Finding includes:On 12/5/25 at 9:40 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, paraplegia, polyneuropathy, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/25/25, indicated a moderate cognitive impairment, no behaviors, and use of an indwelling urinary catheter. Resident 6 was dependent on staff for toileting and bathing. Physician orders included, but were not limited to:Cipro (an antibiotic) oral tablet 500mg (milligrams), give 2 tablets a day, started 11/17/25 and ended 11/21/25. tizanidine 2mg three times a day for muscle spasm, give with 4mg tablet totaling 6mg, dated 5/5/25 and current. tizanidine 4mg three times a day for muscle spasm, give…

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, observation, and record review, the facility failed to ensure accurate documentation for 3 of 6 residents reviewed for unnecessary medications. Resident's Medication Administration Record (MAR) lacked documentation of medications and treatments that were received. (Resident 3, Resident 7, Resident 23)Findings include:1. On 12/5/2025 at 11:17 A.M., Resident 3's clinical record was reviewed. Diagnoses included, but was not limited to, diabetes mellitus, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and stroke. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 11/5/25 indicated Resident 3 had severe cognitive impairment. Current Physician's Orders included, but were not limited to the following: Baclofen tablet 10 milligrams (mg), 1 tablet by mouth 1 time a day for muscle spasms. Baclofen tablet 20 mg, 1 tablet by mouth in the evening for muscle spasms. Oxybutynin Chloride extended-release tablet 5 mg, 1 tablet by mouth in the evening for neuromuscular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Residents were not placed on Enhanced Barrier Precautions (EBP) when indicated for 1 of 1 resident reviewed for catheter care. (Resident 6)Findings include: On 12/4/25 at 10:45 A.M., Resident 7's catheter site was observed in his room with small amount of yellow drainage, slight redness/irritation, no odor, and brownish crust around it. There was no signage for Enhanced Barrier Precautions (EBP) observed.On 12/5/25 at 1:17 P.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, dementia with behaviors, Parkinson's disease, hypertension, and cancer of kidney and prostate. Resident 7 was admitted [DATE] with a suprapubic catheter.The most recent admission MDS assessment, dated 9/15/25, indicated the resident's cognition was severely impaired, he took a diuretic, had 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 ensure an antibiotic stewardship program was used to monitor appropriate use of antibiotics for 2 of 2 residents reviewed for antibiotic use. Resident antibiotic orders were not followed. (Resident 6, Resident 7)Findings include: 1. On 12/5/25 at 9:40 A.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, paraplegia, polyneuropathy, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 9/25/25, indicated a moderate cognitive impairment, no behaviors, and use of an indwelling urinary catheter. Resident 6 was dependent on staff for toileting and bathing. Physician orders included, but were not limited to: Cipro (an antibiotic) oral tablet 500mg (milligrams), give 2 tablets a day, started 11/17/25 and ended 11/21/25 (resident was admitted to the hospital on [DATE]). Macrobid (an antibiotic) oral capsule (nitrofurantoin monohyd macro), give 100mg twice a day, started…

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 safe, sanitary, and homelike environment in 1 of 2 resident shower rooms, 1 of 2 dining rooms, and 1 of 2 halls observed and clean linens were not covered during transport in resident halls. Overhead air vents contained a build up of dust in and around the vent, a dining room floor was uneven and flooring was raised or warped, and a shared shower room contained multiple broken floor tiles, appeared unclean, and contained a small swarm of gnats and flies near the commode. (North Unit, South Unit, North Unit dining room, and Middle-hall shower room, Resident D)Findings include:1. During an observation on 9/3/25 at 3:25 P.M., the North Unit dining room had a towel draped on the floor under an in-wall air conditioning unit. The flooring between the air conditioning unit and the entrance to the dining room was uneven, warped, and cracked. During an observation on 9/8/25 at 10:10 A.M., the North Unit dining room flooring between the air conditioning unit and the entrance to the dining room was uneven,…

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 adequate pharmaceutical services were available to provide physician prescribed routine medications to 1 of 3 residents reviewed for pharmacy services. Following a change in a resident's routine medications, the facility failed to obtain an ordered routine medication which resulted in multiple missed doses of the medication. (Resident C) Finding includes:During record review on 9/3/25 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia. Resident C's most recent annual MDS (Minimum Data Set) assessment, dated 6/20/25, indicated the resident was rarely to never understood. The resident had moderately impaired cognitive skills related to daily function. The resident received antipsychotic medication routinely. Resident B's physician orders included, but were not limited to, Geodon oral capsule 40 milligrams (MG), give 40 mg by mouth two times a day related to schizophrenia and anxiety (continued 8/13/25). Resident B'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.

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 2 resident rooms observed for water temperatures and 1 of 2 resident shower rooms observed for water temperatures, for 1 of 2 dining rooms observed for air temperatures and disrepair, and 2 of 4 resident room observed for disrepair. A shared resident restroom's water temperature reached 140 degrees Fahrenheit (F), a shared resident shower room's water temperature reached 140 degrees F, the North Unit Dining room reached 89 degrees F, floors were uneven and wet from a leaking air conditioning (AC) unit, two resident rooms' flooring was in disrepair, and one resident room's ceiling contained water damage. (Resident B, Resident C, Resident D, Resident F, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER],. North Unit dining room, North Unit shower room) Findings includes: 1. During an interview on 6/24/25 at 10:10 A.M. Resident B indicated that the air…

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 based on the resident population and identification of resources needed to provide the necessary care and services required for their residents. Finding includes: On 8/30/24 at 9:50 A.M., the Administrator provided a facility assessment form revised 1/17/24. The form listed facility personnel but lacked a staffing plan to ensure sufficient staff were in the building to meet the needs of the residents, such as number of each staff. The form lacked training topics and competencies specific to the facility, transportation information including use of a facility van, Enhanced Barrier Precautions, resident equipment, use of oxygen therapy, pharmacy information, and the facility's plan for communication related to residents and staff with communication barriers. On 9/4/24 at 10:18 A.M., the Administrator indicated she was unaware that the facility assessment could have specific detailed information about the facility. She indicated a template was used to fill out the 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 interview and record review, the facility failed to ensure designation of a certified Infection Preventionist (IP). The IP had not received specialized training in infection prevention and control, and did not currently dedicate at least part time to the role of IP for 1 of 1 staff members reviewed for IP. Finding includes: On 9/4/24 at 12:10 P.M. LPN 13 indicated that she was the current IP and responsible for the infection prevention and control program in the facility. She indicated she did not have any specialized training or certification for the role, and was able to dedicate approximately 3-4 hours per week on the infection control program. On 9/4/24 at 12:34 P.M., the facility's Administrator (via the Activity Director) indicated there was no policy or job description for the Infection Preventionist, that someone was just assigned to the role.

Based on observation, interview, and record review, the facility failed to ensure the residents right to participate in the development and implementation of his or her person-centered plan of care for 10 of 32 residents reviewed for narcotic use. The facility had implemented a facility-wide rule to crush all narcotics for every resident without resident input or obtaining a physician order to do so. (Resident 2, Resident 21, Resident 3, Resident 13, Resident 4, Resident 15, Resident 29, Resident 5, Resident 17, Resident 11) Findings include: On 8/27/24 at 2:40 P.M., Resident 5 complained of pain beyond a level of 10 on a 1-10 pain scale in her knees and back, and indicated no pain medications were currently ordered because she couldn't take it crushed in applesauce so it was discontinued. On 9/4/24 at 11:30 A.M., Resident 5's clinical record was reviewed. Diagnosis included, but was not limited to, pain. A nurse's note dated 2/19/24 at 9:00 P.M. indicated Resident 5 was yelling and screaming at staff due to having to crush her narcotics. Resident indicated she should not be…

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 accurate Minimum Data Set (MDS) Assessment was completed for 5 of 14 residents reviewed for MDS Assessments. Residents taking antiplatelet medication, diuretics, and oxygen were not marked as administered. (Resident 16, Resident 15, Resident 7, Resident 25, and Resident 6). Findings included: 1. On 8/28/24 at 10:54 AM, Resident 16's clinical record was reviewed. Resident had diagnoses that included, but was not limited to, COPD (Chronic Obstructive Pulmonary Disease), anemia, and and atrial fibrillation. A Quarterly MDS (Minimum Data Set) Assessment, dated 5/29/24 indicated Resident 16 was cognitively intact. The Resident required limited assistance with bed mobility, transfers, and toileting. The MDS indicated Resident 16 was not taking an antiplatelet and had not been on oxygen. Current physician orders included, but were not limited to, aspirin (an antiplatelet medication) 81 MG (milligrams) 1 tablet 2 times per week, dated 7/24/24. The MAR (medication administration record) for August 2024 included 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 a comprehensive person-centered care plan for each resident for 6 of 6 residents reviewed for unnecessary medications. Residents on antipyschotic, antidepressant, antianxiety, and diuretic medications and a resident on oxygen did not have care plans developed. (Resident 15, Resident 16, Resident 7, Resident 25, Resident 6, Resident 28) Findings include: 1. During an interview on 8/27/24 at 4:05 P.M., the Administrator indicated Resident 15 had a history of substance abuse and that was how he ended up in his condition. On 8/28/24 at 1:40 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, depression, chronic pain syndrome, and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/25/24, indicated Resident 15 was cognitively intact, totally dependent on 2 staff to assist him for bed mobility, transfers, toileting, and was taking opiod and antipyschotic medication. Current Physician's 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.

Based on observation, interview, and record review, the facility failed to ensure a resident received necessary respiratory care and services in accordance with professional standards of practice. The facility failed to have an order for oxygen use, follow physician oxygenation orders, date oxygen tubing, and clean the oxygen filters for 4 of 5 residents reviewed for respiratory care. (Resident 5, Resident 23, Resident 14, Resident 6) Finding includes: 1. During an interview and observation on 8/26/24 at 1:47 P.M., Resident 6's oxygen tank was observed with debris on it and the filter was caked with dust. At that time, Resident 6 was in bed and indicated she only used the oxygen at night and the filter had not been cleaned by the facility. During an observation on 8/29/24 at 10:38 A.M., the same was observed. On 8/28/24 at 11:10 A.M., Resident 6's clinical record was reviewed. Current diagnoses included, but were not limited to, asthma and diabetes mellitus. The most recent Quarterly and State Optional MDS (Minimum Data Set) Assessment, dated 8/9/24 indicated Resident 6 had moderate…

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 all physician's orders were obtained from the pharmacy for 1 of 6 residents reviewed for medication administration and 3 of 5 residents reviewed for respiratory care. The facility lacked August 2024 physician orders for insulin and oxygen. (Resident 14, Resident 5, Resident 23, Resident 2) Findings include: 1. On 8/28/24 at 1:03 P.M., Resident 2's clinical records were reviewed. Diagnosis, included, but were not limited to unspecified intracranial injury and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/28/24 indicated Resident 2 had a severe cognitive impairment. Resident 2 lacked a current physician order for Tresiba Flextouch 100 u/ml (units/milliliter) 6 u subcu (subcutaneous) once a day. At that time, RN (Registered Nurse) 5 indicated Resident 2 was on insulin daily. On 8/28/24 at 11:30 A.M., the DON (Director of Nursing) provided a copy of the August Blood sugar log which indicated Resident 2 received Tresiba 6 units subcu at bedtime from 8/1/24 through…

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 safe and secure storage of medications for 2 of 2 medication carts observed and 1 of 2 medication storage rooms observed. Medications with no open date were observed in the medication carts, and refrigerator temperature logs were not filled out completely in the medication room. (Back Hall Medication Cart, Back Hall Medication Storage Room, Front Hall Medication Cart) Findings include: On 8/26/24 at 1:15 P.M., the following medications were observed during review of the Back Hall Medication Cart with RN 5: Resident 11 Albuterol Sulfate inhaler-no open date Resident 7 Breyna 160-4.5 mcg (microgram) inhaler-no open date Resident 20 Neo/Poly/HC (Neomycin-Polymyxin-Hydrocortisone) otic drops-started on 8/16/24, ended on 8/22/24, still in the drawer Resident 10 ferrous sulfate pill in medication cup with no identification Resident 28 Trelegy Ellipta with an open date of 5/21/24 Resident 28 allergy relief nasal spray-no open date Resident 28 a second Trelegy Ellipta with a tag to discard after 6 weeks-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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchens observed. Staff did not wear hairnets that covered all their hair, appropriate footwear was not worn, food was not labeled, the dishwasher was not monitored daily for safe sanitation, staff did not wash hands for appropriate length of time, and scoops were left in containers. (Kitchen) Findings include: 1. On 8/26/24 at 1:00 P.M., the following was observed during a tour of the kitchen: Kitchen on main floor: No soap in the dispenser at the hand washing sink. The Dietary Manager did not have a hairnet on and was wearing Crocs (shoes with holes on the top). When she put a hairnet on, it did not cover the hair at the nape of her neck. Kitchen Staff 1's hairnet covered the crown of her head only, leaving hair out at her temples and nape of the neck. Freezer/refrigerator #8: Opened frozen pancakes, no label Opened frozen waffles, had 6/24 handwritten on them Opened frozen Hashbrowns, no date A brown liquid 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, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Gloves were not changed between dirty and clean tasks, hands were not sanitized between changing gloves, a resident was not completely cleaned, and staff did not offer a resident the opportunity to wash hands after toileting for 4 of 5 resident observations of incontinence care. Staff did not cover clean clothing when transporting clean clothes to residents, and carried clean clothes against their uniform top when carrying for 2 of 2 observations of linen handling. Residents were not placed on Enhanced Barrier Precautions (EBP) when indicated for 6 of 6 residents with wounds, 2 of 2 residents with urinary catheters, and 1 of 1 residents with a stoma. (Resident 28, Resident 3, Resident 23, Resident 21, Resident 16, Resident 15, Resident 11, Resident 2, Resident 184, Resident 4) Findings include: 1. On 8/30/24 at 12:34 P.M., the Director of Nursing (DON) indicated 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 ensure a safe, sanitary, and homelike environment for 1 of 1 resident communal restrooms and 3 of 3 shower rooms observed. A three-quarter inch gap was observed on 1 of 2 doors to the courtyard. A random couch was observed to have fabric peeled off of it in 1 of 2 common areas. A brown substance was observed around the bottom of toilets, doors had chips, toilet paper holders were rusted, gnats were on the floor, tile was missing in the shower, spiderwebs were on the ceiling, and grout was soiled. (Front Hall Shower Room, Middle Hall Shower Room, Back Hall Shower Room, Communal Restroom) Findings include: 1. During an observation on 8/28/24 at 10:37 A.M., the communal restroom for residents on the front hall was observed with a brown substance around the bottom of the toilet, the toilet paper holder was rusted, and the door to the restroom had chips on the bottom of it. On 8/30/24 at 11:19 A.M., the same was observed. 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 and interview, the facility failed to ensure an effective pest control program to keep the facility free of pests and rodents. (Downstairs Dry Storage Room) Finding includes: On 8/26/24 at 1:20 P.M., a sticky pad for catching insects and rodents was observed full of insects and a dead mouse in a trap was attached to it downstairs in the dry storage room behind the staff refrigerator. On 8/29/24 at 11:04 A.M., the same was observed. Also, a live mouse was stuck to the sticky pad, and flying insects, some dead and 2 flying, were observed in the other refrigerator in the dry storage room downstairs. The refrigerator door was not closed all the way and had 1 closed gallon jug of coleslaw dressing in it. On 8/28/24 at 11:05 A.M., the contract for pest control company was reviewed and indicated they were to come to the facility monthly (except January when they were to come twice a month) to monitor for spiders, mice, and german cockroaches specifically. At that time, the Administrator indicated they have had issues in the past with mice but have had no recent trouble…

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 determine that self-administration of medications was clinically appropriate for 1 of 2 residents reviewed with medication in their room. A resident had an Albuterol inhaler in her room without an order to keep at the bedside or a self-administer assessment. (Resident 5) Finding includes: On 8/29/24 at 11:40 A.M., an Albuterol inhaler (used for asthma to assist in opening airways) was observed lying on a table next to the recliner in Resident 5's room. At that time, RN 5 indicated the inhaler could be kept at the bedside. On 8/29/24 at 9:08 A.M., Resident 5's clinical records were reviewed. Diagnosis included, but were not limited to chronic obstructive pulmonary disease (COPD), and asthma. The most current Annual MDS (Minimum Data Set) assessment, dated 7/4/24, indicated Resident 5 was cognitively intact. Physician orders included, but were not limited to the following: Albuterol Aerosol HFA (hydrofluoralkane) inhaler, inhale 2 puffs every 4 hours as needed for SOB (shortness of breath)/Asthma, ordered…

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 that the comprehensive care plan was reviewed and revised for 3 of 12 residents reviewed for care plans. A care plan was not revised to include bed rails as a fall intervention, and care plans were not revised after medications were discontinued. (Resident 2, Resident 16, Resident 15) Findings include: 1. On 8/26/24 at 2:10 P.M., Resident 2 was observed lying in bed with his eyes open, a 1/2 bed rail was up in the middle of the mattress, call light was lying on the bed and one side of the bed was against the wall. On 8/28/24 at 1:03 P.M., Resident 2's clinical record was reviewed. Diagnosis included, but were not limited to, unspecified intracranial injury, anxiety, depression, obsessive-compulsive behavior, and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/28/24, indicated a severe cognitive impairment, required extensive assistance of two for bed mobility, transfers, and toilet use and limited assistance of one for eating. Current physician orders included,…

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

Based on observation, interview, and record review, the facility failed to ensure effective services were provided to prevent the development of a facility-acquired stage three pressure injury and multiple stage two pressure injuries for Resident 28, who was admitted to the facility without pressure injuries, and were identified by the facility upon admission to be at risk to develop pressure injuries. (Resident 28) Findings included: On 8/28/24 at 9:35 A.M., Resident 28 indicated that his buttocks was hurting, and had been for 2 or 3 weeks. He indicated he had told staff about it. On 8/30/24 at 10:43 A.M., Resident 28's clinical record was reviewed. Diagnosis included, but were not limited to, cerebral infarction (damage to the brain from lack of blood flow due to a blood clot), anemia, and heart failure. The most recent admission MDS (Minimum Data Set) Assessment, dated 7/1/24, indicated a moderate cognitive impairment. Resident 28 was dependent or required extensive assistance with bed, transfer, and toileting mobility. Resident had an indwelling urinary catheter and was always…

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 receives adequate supervision and assistive devices to prevent accidents for 2 random observations of residents having vapes (electronic cigarette) in their possession. (Resident 15, Resident 24) Findings include: 1. During a random observation on 8/29/24 at 10:17 A.M., 2 vapes (electronic cigarettes) were laying on Resident 15's bedside table while he was laying in his bed. At that time QMA (Qualified Medication Aide) 3 went into his room and back out leaving the vapes in the same place. Then the Dietary Manager brought ice water into the room and did not ask about the vapes. QMA 3 went back into the room and back out without asking the resident to return the vapes to the staff. On 8/28/24 at 1:40 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, depression, chronic pain syndrome, and anxiety. Resident 15 was admitted on [DATE] and was [AGE] years old. The most recent…

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 clinical record documentation was complete and accurate for 1 of 2 residents reviewed for hospitalizations and 1 of 1 residents reviewed for general skin conditions. (Resident 15, Resident 23) Findings include: 1. On 8/28/24 at 1:40 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, depression, chronic pain syndrome, epilepsy, and anxiety. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/25/24, indicated Resident 15 was cognitively intact, totally dependent on 2 staff to assist him for bed mobility, transfers, and toileting. Non dated neuro (neurological) checks were found in the resident's clinical record and indicated he was sent out to the hospital. During an interview on 8/27/24 at 4:05 P.M., the Administrator indicated Resident 15 has a history of substance abuse and that was how he ended up in his condition. She was not sure what the exact date was or why it wasn't indicated on the neurocheck form, but they were ordered because of 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 develop, implement, and maintain an effective training program for all new and existing staff based on the needs of the resident population in the facility for 2 of 3 residents reviewed for accidents and 1 of 1 residents reviewed for having a diagnosis of PTSD (Post Traumatic Stress Disorder). (Resident 15, Resident 24) Findings include: 1. During an interview on 8/27/24 at 4:05 P.M., the Administrator indicated Resident 15 had a history of substance abuse. On 8/28/24 at 1:40 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, depression, chronic pain syndrome, and anxiety. Resident 15 was admitted on [DATE] and was [AGE] years old. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/25/24, indicated Resident 15 was cognitively intact, totally dependent on 2 staff to assist him for bed mobility, transfers, and toileting. Current Physician's Orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient behavioral health care for 1 of 1 residents reviewed for elopement. A resident with documented behaviors was not provided additional monitoring or services during a behavioral episode that resulted in the resident eloping from the facility, unwitnessed. (Resident B) Finding includes: During a review of facility reported incidents on 3/21/24 at 10:45 A.M., an incident dated 2/25/24 at 8:20 P.M., included that Resident B was requesting nursing staff to buy him cigarettes throughout the day. Resident B was upset and demanded to go to the gas station across the street for cigarettes. While staff was down the hall, Resident B went outside into the courtyard and exited the courtyard gate. During record review on 3/21/24 at 12:00 P.M., Resident B's diagnoses included, but were not limited to undifferentiated schizophrenia, acquired absence of right leg below knee, partial traumatic amputation of left midfoot and nicotine…

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 that complete and accurate records were maintained for 2 of 4 resident records reviewed. A resident's record contained no documentation of an elopement occurrence, nor were the behaviors that reportedly led up to the incident or any monitoring following the elopement documented. A resident's wound treatment orders were not updated in the resident's record and wound treatment documentation was not completed accordingly. (Resident B, Resident C) Findings include: 1. During a review of facility reported incidents on 3/21/24 at 10:45 A.M., an incident dated 2/25/24 at 8:20 P.M., included that Resident B was requesting nursing staff to buy him cigarettes throughout the day. Resident B was upset and demanded to go to the gas station across the street for cigarettes. While staff was down the hall, Resident B went outside into the courtyard and exited the courtyard gate During record review on 3/21/24 at 12:00 P.M., Resident B's diagnoses included, but were not limited to undifferentiated schizophrenia, acquired absence of…

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

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 2 resident rooms observed for water temperatures and 2 of 2 shared resident shower rooms observed for water temperatures. Resident rooms and restrooms were not cleaned and/or needed repairs for 3 of 6 rooms observed and 1 of 2 shared shower rooms observed. Residents indicated their shared bathrooms are not cleaned daily, flooring was damaged around a commode and plumbing was leaking onto the bathroom floor, a wall cover was loose and exposing a hole used for plumbing, commodes appeared to be unclean, a soap dispenser was dripping soap onto a towel placed on the floor, and a shared shower room had broken tiles, a towel left on the floor, and a wall behind the commode had not been cleaned. (Resident B, Resident C, Resident D, Resident G, Resident F, Resident H, Resident J, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] B, room [ROOM…

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 accurate Minimum Data Set (MDS) Assessment was completed for 3 of 5 residents reviewed for unnecessary medications and 3 of 7 reviewed during initial record review and 1 of 3 observed during care. Two residents had medications that were not signed off in the MAR (Medication Administration Record) as given for 7 days in the MDS. The MDS for four residents indicated they had a medication being given when one was not ordered. One resident was independent with transfers when the MDS indicated he needed extensive assistance of 2 staff for transfers. (Residents 4, 9, 13, 17, 29, 30, 35, and 39) Findings include: 1. On 9/20/23 at 10:58 A.M., Resident 4's clinical records were reviewed. Diagnoses included, but were not limited to, hypertension, arthritis, right below the knee amputation, and behavioral dementia. He was admitted on [DATE]. The most recent Annual MDS Assessment, dated 7/16/23, indicated Resident 4 had severe cognitive…

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 that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their rooms. The facility failed to obtain a Physician's Order to self administer medications. (Resident 18) Findings include: During an observation on 9/18/23 at 11:04 A.M., Resident 18 was observed lying in bed. A medication cup was on her bedside table and had an orange liquid in it. Resident 18 also had 2 nasal spray bottles and a dry mouth bottle on the bedside table. At that time QMA (Qualified Medication Aide) 14 indicated Resident 18 did not have a self administration order and she should have stayed at the bedside while Resident 18 took the liquid protein in the medication cup. During an interview on 9/18/23 at 11:16 A.M., Resident 18 indicated staff always left the medications in her room. During an observation on 9/20/23 at 11:43 A.M., Resident 18 had the following on her bedside table: antifungal powder, chloraseptic spray, two…

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 received necessary respiratory care and services in accordance with professional standards of practice. The facility failed to obtain a Physician's Order for oxygenation. (Resident 18) Findings include: During an observation on 9/18/23 at 11:13 A.M., Resident 18 was observed lying in bed. Resident 18 had oxygen on at 3.5 LPM (liters per minute) via nasal cannula. During an observation on 9/20/23 at 11:43 A.M., Resident 18 had oxygen on at 3.5 LPM via nasal cannula. During an observation on 9/21/23 at 9:22 A.M., Resident 18 had oxygen on at 3.5 LPM via nasal cannula. On 9/20/23 at 8:43 A.M., Resident 18's clinical record was reviewed. Diagnoses included, but were not limited to, asthma and COPD (chronic obstructive pulmonary disease). The most recent admission MDS (minimum data set) Assessment, dated 6/14/23, indicated Resident 18 had moderate cognitive impairment. The MDS indicated Resident 18 was on oxygen while a resident. Resident 18's current orders lacked an order for oxygen. Care plans…

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

Based on observation, 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 139) Finding includes: On 9/20/23 at 11:50 A.M., RN (Registered Nurse) 10 was observed administering insulin to Resident 139. RN 10 took Resident 139's blood sugar reading and it was 345. RN 10 wiped the tip of the Lispro Kwikpen with an alcohol swab, applied the needle, and dialed the Kwikpen to 10 units without priming the pen. RN 10 put on gloves and administered the insulin into Resident 139's abdomen. On 9/22/23 at 10:06 A.M., Resident 139's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 9/10/23, indicated Resident 139 was severely cognitively impaired and was an extensive assist of 2 staff for bed mobility, transfer, and toileting. Current Physician's Orders included, but 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 infection control practices were followed for 3 of 3 residents during observation of perineal care. Gloves were not changed between dirty and clean tasks during peri care, staff failed to wash hands or sanitize between dirty and clean tasks. (Resident 4, Resident 17, Resident 35) Findings include: 1. During an observation on 9/21/23 at 9:14 A.M., CNA (Certified Nursing Aide) 25 and CNA 28 provided incontinence care for Resident 35. CNA 24 and CNA 28 donned gloves and then picked up the resident's fall mat and moved it against the wall, removed the blankets, and removed the resident's dirty brief. CNA 28 used two wipes on Resident 35's bottom and removed her gloves. After she donned new gloves, CNA 28 removed the soiled brief from under the resident and placed it in the trashcan. At that time, CNA 28 placed a clean brief under Resident 35 with her dirty gloves. Resident 35 was placed on her back and CNA 28 used a wipe to clean the front of the resident before she changed gloves. CNA 28 failed to remove…

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.