Johnson Memorial Hospital & Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure all 9 licensed nurses (registered nurse (RN)-A, RN-C, RN-D, RN-G, RN-I, licensed nurse (LPN)-A, LPN-B, LPN-C, and LPN-D) and all 5 agency licensed nurses (RN-E, RN-J, RN-K, LPN-E, and LPN-F) who administer or had the potential to administer insulin were appropriately trained and deemed competent to facility policy and manufacturer's instructions for insulin administration. This had the potential to affect all residents who recieved insulin. Findings include: Review of the [DATE], report to the facility identified R106 was scheduled to receive 36 units of Basaglar (a long-acting insulin). The staff nurse attempted to document R106's insulin administration on the medical record and realized R106 had actually received 36 units of Fiasp (a short acting insulin), instead. The staff nurse reported the incident to R106's primary provider and was directed to monitor R106 blood sugars. R106's face sheet identified R106 was admitted [DATE]…

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 document review, the facility failed to implement 1 of 1 facility assessment and ensure the identified number of staff deemed required to provide care and services to residents had been scheduled and maintained on the weekends. Findings include: Review of the 8/8/24, Facility Assessment identified resources needed to provide care and competent support to the residents residing in the facility daily included staffing plan of: 1. Days-weekdays registered nurse (RN) 24 hours, licensed practical nurse/trained medication aide (LPN/TMA) 24-hour, nursing assistant (NA) 45-54 hours, director of nursing/assistant director of nursing (DON/ADON) 16 hours. 2. Days-weekends RN 12 hours, LPN/TMA 12 hours, NA 54 hours 3. Evenings -weekday RN 0 hours, LPN/TMA 16 hours, NA 37-42 hours 4. Evenings-weekend RN 0 hours, LPN/TMA 16 hours, NA 54 hours 5. Nights-weekdays RN 12 hours, LPN/TMA 0 hours, NA 24 hours 6. Nights- weekends RN 12 hours, LPN/TMA 0 hours, NA 32 hours Review of the 6 sampled weekend dates identified on: 1) 7/6/24 day shift RN-12 hours, LPN/TMA 12 hours, NA 44…

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 document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 4) 2024 (July 1 - September 30) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D identified excessively low weekend staffing had triggered. Review of the schedules and staff timecards identified on 7/6/24 registered nurse (RN)-E a contracted nurse had worked a 12-hour shift. RN-E had not clocked in on the facilities system to track hours worked for the PBJ report. On 8/17/24 RN-F, a hospital nurse who worked at the care facility in an on-call basis, had worked an 8-hour shift. Interview on 2/20/25 at 10:05 a.m., with director of nursing (DON) identified that staff punch in with a code, she was not sure how the on-call hospital staff punched in though. She thought the hospital staff punched in the same way they always do 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 document review, the facility failed to ensure appropriate oversight by the infection preventionist (IP) and follow up when multiple departments heads consistently failed to report required surveillance data used in tracking employee illness for 33 of 60 (unidentified in the tracking) facility staff and note return to work dates for 3 months reviewed (November 2024 through January 2025). This had the potential to affect all 55 residents at the facility. Findings include: Review of the November 2024, December 2024, and January 2025, staff surveillance identified: 1) November 2024: 8 staff called in sick. 2 with cold symptoms, 2 with nausea, 1 with fever, 1 with a rash, and 1 with a headache. 2 of the 8 staff that called in sick lacked a return to work date. 2) December 2024: 18 staff called in sick. 4 with diarrhea, 7 with cold symptoms, 1 with vomiting, 1 with nausea, 2 with abdominal pain, and 3 with other. 12 of 18 staff who called in sick lacked a return to work date. 3) January 2024: 28 staff called in sick. 4 with diarrhea, 11 with cold symptoms, 5 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to follow manufacturer's instructions and label insulin pens with an open and discard date for 6 of 6 residents (R7, R23, R28, R29, R51, and R106) sampled insulin pens. Findings include: Observation on [DATE] at 11:37 a.m., with registered nurse (RN)-G, on Prairie Lane hall, reviewed R23's insulin order on Point Click Care (PCC) an online electronic medical record identified R23 was to receive 5 units of Lantus (a long-acting) insulin that was to be given daily at 11:00 a.m. RN-G removed the insulin pen from R23's medication cupboard and read the label. RN-G had sanitized her hands, applied gloves, and administered the insulin. RN-G documented on R23's medication chart in PCC. The label on the insulin pen had an open date of [DATE]. There was no discard date labeled on the insulin pen. Observation on [DATE] at 11:41 a.m., with RN-G, on Prairie Lane Hall, reviewed R29's blood sugar reading from her portable glucometer phone and confirmed…

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 1 of 14 residents (R47) care plan was revised to identify that she had an actual elopement event. Findings include: Review of the report to the State Agency (SA) identified on 5/27/24 at 11:10 a.m., R47 was observed by another resident exiting the building without staff knowledge. Once notified, facility staff acted and found R47 approximately 10 feet from the door. R47 had been wearing a WanderGuard bracelet however, staff identified the door did not engage the lock and the alarm did not sound per normal when a resident wore a WanderGuard. R47's 11/22/24, annual Minimum Data Set (MDS) assessment identified her cognition was severely impaired. R47 had diagnoses of Alzheimer's dementia, delirium, and disorientation. R47 was noted to be independent with transfers and required extensive assistance with dressing and hygiene. R47 wore a wander/elopement alarm. R47's care plan identified she was at risk for elopement and had a history of attempts to leave the facility unattended and had impaired safety awareness. R47 wore…

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 The facility failed to administer insulin according to physician orders and manufacturers instruction for 1 of 1 (R106) resident who was administered the wrong insulin. Findings include: Review of report to the State Agency on [DATE] at 9:00 p.m., identified R106 was scheduled to receive 36 units of Basaglar (a long-acting insulin). The staff nurse attempted to document R106's insulin administration on the medical record and identified they made an error and R106 had received 36 units of Fiasp (a short acting insulin) instead. The staff nurse reported the incident to R106's primary provider and was directed to monitor R106 blood sugars. R106 face sheet identified they were admitted [DATE] with a diagnoses of Alzheimer's, dementia with psychotic disturbance, depression and diabetes. R106's, February Medication Administration Record identified R106 was to receive 36 units of glargine twice a day for diabetes and Fiasp sliding scale insulin, give 70-199= 0 units, 200-999= 2 units, give subcutaneously (the fat layer…

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 document review the facility failed to comprehensively assess and identify target behaviors or symptoms and non-pharmacological interventions for scheduled antidepressant and antipsychotic medication to ensure efficacy of the medication for 1 of 5 residents (R32) reviewed for unnecessary medication usage. Findings include: R32's 2/20/25, diagnosis list included generalized anxiety disorder, insomnia, major depressive disorder single episode, and unspecified psychosis not due to a substance or known physiological condition. R32's 1/8/25, quarterly Minimum Data Set (MDS) assessment identified R32's cognition was intact with no behaviors identified. R32 was independent with transfers and eating, R32 required assistance with some personnel cares. R32 had frequent pain that he rated a 3 on scale of 1-10. R32 took a daily antipsychotic, antidepressant, antianxiety, diuretic, hypoglycemic, and opioid. R32's 7/16/24, significant change MDS identified R32 felt down, depressed, or helpless more than half of the days, had trouble falling asleep or staying asleep more…

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 document review, the facility failed to notify the county (designated state mental health authority (SMHA)) when 1 of 1 resident (R2) had new on-set of mental illness since admission. R2's 2/22/24, annual Minimum Data Set (MDS) assessment identified R2 had diagnosis of delusional disorders, paranoid schizophrenia, obsessive-compulsive disorder, depression, and anxiety. R2's 8/16/10, pre-admission screen (PAS) identified R2 did not have a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM), current edition. R2's undated, current diagnosis list identified R2 received a new diagnosis of schizophrenia on 10/15/15, obsessive-compulsive disorder on 10/15/15, and a new delusional disorder on 2/29/24. R2's medical record lacked any indication that the county (SMHA) had been notified since the new-onset of R2's mental illnesses. Interview on 4/9/24 at 9:48 a.m., with the social service designee identified he reviews the PAS upon admission but there is no process in place to ensure he is notified if a resident receives…

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 document review the facility failed to revise the care plan for 1 of 1 resident (R20) with peripheral edema and diagnosis of cardiomyopathy (disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). Findings include: R20 was admitted [DATE], with diagnoses of diabetes, implantable cardiac defibrillator, and hypertensive heart disease (disease cause by high blood pressure affecting the heart). R20's 3/29/24 psychosocial note identified she had attended her care conference and nursing had discussed her leg edema with suggestions for management. R20 voiced agreement to try some interventions. R20's 3/21/24 dietary progress note identified her weight had increased 11.2% in the past 30 days. It was noted that some of the increased weight could be related to fluid retention, but it was suspected she was non compliant with her diet restrictions and her feet and ankles were edematous. R20's 3/12/24, nurse practioner (NP) identified…

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.