Highland Square Nursing And Rehabilitation

Based on observation, interview with staff and review of the facility policy, the facility failed to implement the smoking policy to maintain a safe and clean environment free from discarded cigarette butts at the facility's side entrance door and the resident smoking area. This had the potential to affect all the residents in the facility. The facility census was 58. Findings included: Observation of the resident smoking area on 07/23/24 at 4:10 P.M. with the administrator revealed several cigarette butts (over 30) all over in the mulch. The cigarette butts were also observed on the facility window ledge. The administrator stated staff go out with the residents. She verified there were cigarette butts in the mulch. Observation of the side guest entrance of the facility on 07/24/24 at 11:35 A.M. revealed several cigarette butts (over 50) all over in the mulch and bushes. An interview at this time with the Administrator verified there were cigarette butts in the mulch. She stated she would have them cleaned up. Review of the undated facility policy titled, Smoking Policy 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a palliative care consult was arranged for Resident #24 to address the resident's chronic pain. This affected one resident (#24) of three residents reviewed for pain management. The facility census was 58. Findings included: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including osteoarthritis left knee, spinal stenosis, radiculopathy, pain in the left knee, benign prostatic hyperplasia, hypertension, chronic pain, alcohol abuse, anxiety disorder, and depression. Review of a progress notes dated 05/02/24 at 3:46 P.M. revealed the nurse spoke to the resident regarding his chronic pain. Resident #24 stated he had tried everything for pain and nothing seemed to be working. Resident #24 was informed that palliative care was an option to which he responded he would like to try it. A request was sent to the nurse practitioner. Review of the physician's order dated 05/04/24 revealed 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 record review and interviews, the facility failed to ensure pain medications were available and administered as ordered by the physician. This affected one (Resident #5) of three residents reviewed for pain management. The facility census was 57. Findings include: Review of the medical record for Resident #5 revealed an admission date of 01/29/24 with diagnoses including chronic pain. Review of the physician's orders for Resident #5 revealed she had an order dated 01/29/24 for Methadone HCl 80 milligrams (mg) two times a day for pain. Review of the care plan dated 01/30/24 for Resident #5 revealed she was on pain medication related to having pain. Interventions included to take Methadone HCl 80 mg two times a day for pain. Review of the Medication Administration Record (MAR) for May 2024 and June 2024 revealed Resident #5 did not receive her Methadone HCl 80 mg on 05/18/24, 06/01/24, 06/09/24, 06/20/24 and 06/21/24 in the morning and on 06/09/24 and 06/20/24 at night. Review of the nursing progress notes for Resident #5 revealed on 05/18/24 at 8:10 A.M. her Methadone was…

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, medical record review, policy review and interview, the facility failed to provide a phone in a private area where calls could be made without being overheard. This affected 47 residents (Residents #25, #11, #23, #40, #49, #45, #69, #53, #8, #3, #72, #52, #47, #2, #44, #63, #54, #57, #22, #55, #58, #19, #28, #33, #6, #66, #64, #27, #48, #31, #26, #32, #51, #16, #30, #35, #56, #69, #36, #61, #15, #29, #24, #14, #7, #62 and #10) who resided on the second and third floor units. The census was 74. Findings include: Review of the medical record for Resident #33 revealed an admission date of 03/10/23 with diagnoses of diabetes, symbolic dysfunction, bipolar disorder, atrial flutter, psychoactive substance abuse, anxiety disorder and dementia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #33 was severely cognitively impaired and independent with walking. Resident #33 resided on the third-floor unit. Review of the general progress note dated 12/28/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, Self-Reported Incident (SRI) review, employee warning notice review, policy review and interview, the facility failed to ensure Resident #38 was free from staff-to-resident abuse. This affected one (Resident #38) of three residents reviewed for abuse. The census was 74. Findings include: Review of the medical record for Resident #38 revealed an admission date of 10/23/23 with diagnoses of injury in motor vehicle accident, opioid abuse with opioid-induced psychotic disorder, anxiety disorder, behavior insomnia of childhood sleep onset. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #38 was cognitively intact. Review of the behavior care plan updated 02/20/24 revealed Resident #38 had a behavior problem related to being very manipulative, would twist what people said to him and would state things that been proven not factual. Interventions included caregivers to provided opportunity for positive interaction/attention, approach/speak in 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, medical record review, policy review and interview, the facility failed to provide care and services to ensure the safety of Resident #33 who had a diagnosis of dementia. This affected one (Resident #33) of three residents reviewed for dementia. The census was 74. Findings include: Review of the medical record for Resident #33 revealed an admission date of 03/10/23 with diagnoses of diabetes, symbolic dysfunction, bipolar disorder, atrial flutter, psychoactive substance abuse, anxiety disorder and dementia. Resident #33 resided on the third-floor unit and the only emergency contact was her brother-in-law/significant other. Review of the weight note dated 11/08/23 revealed Resident #33 ate well but went on leave of absences (LOAs) where she did not get fed. Review of the general progress note dated 11/09/23 timed 5:17 P.M. revealed family was at the facility to take Resident #33 on LOA. Family member was instructed that resident did not feel well and should not go out of the facility. 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 record review and interview, the facility failed to ensure all residents and their guardians were provided the opportunity to choose a physician prior to their attending physician leaving the facility. This affected two residents (#8 and #24) of 14 residents reviewed for choice of physician. The facility census was 72. Findings include: 1. Review of the medical record for Resident #8 revealed an admission date of 8/05/22. Diagnoses included dementia with behavioral disturbance, adult failure to thrive, and cocaine dependence. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Further review of Resident #8's medical record revealed the resident had a legal guardian. Resident #8's physician's last day at the facility was 01/20/24. There was no documentation that the guardian was notified the attending physician was leaving or was given the opportunity to choose a new physician. Interview on 02/14/24 at 2:41 P.M. with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident and staff interview, the facility failed to ensure a resident was afforded the right manage their financial affairs as requested. This affected one resident (Resident #29) of two residents reviewed for finances. The facility census was 72. Findings Include: Review of the medical record for Resident #29 revealed an admission date of 8/18/23. Diagnoses included osteoarthritis of the left knee, alcohol abuse, anxiety, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] under section C revealed Resident #29 had a brief interview for mental status score of 15 indicating no cognitive impairment. Review of the face sheet for Resident #29 was his own responsible party and managed his own medical and financial affairs. Review of the Social Security Administration form (SSA)787 dated 09/26/23, revealed the resident was not able to handle his own benefits due to cognitive impairment from alcohol abuse, and the ability to make sound financial decisions.…

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, record review, and facility Self-Reported Incident (SRI) review, the facility failed to ensure all allegations of sexual abuse and potential neglect were reported to the proper officials. This affected two residents (Resident #37 and #71) of three residents reviewed for abuse, neglect, exploitation, or mistreatment. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 10/23/23. Diagnoses included left leg fractures and nasal bone fracture following a motor vehicle accident, opioid abuse, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Interviews 02/13/24 at 9:54 A.M. and 4:21 P.M. with Resident #37 revealed on the night of his admission, Licensed Practical Nurse (LPN) #366 performed oral sex on him and then three nights later she entered his room and asked if he wanted to have sexual intercourse with her. Resident #37 stated they had sexual intercourse and later on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility Self-Reported Incident (SRI) Review, the facility failed to thoroughly investigate an allegation of staff to resident sexual abuse towards Resident #37. This affected one resident (#37) of three residents reviewed for abuse, neglect, exploitation, or mistreatment. Findings include: Review of the medical record for Resident #37 revealed an admission date of 10/23/23. Diagnoses included left leg fractures and nasal bone fracture following a motor vehicle accident, opioid abuse, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Further review of Resident #37's record revealed no documented concerns related to reported allegations of sexual interactions or abuse with facility staff. Interviews 02/13/24 at 9:54 A.M. and 4:21 P.M. with Resident #37 revealed on the night of his admission, Licensed Practical Nurse (LPN) #366 performed oral sex on him and then three nights later she entered his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure staff provided care and services that met professional standards. This affected one resident (#37) of three residents reviewed for abuse, neglect, exploitation, and mistreatment. Findings include: Review of the medical record for Resident #37 revealed an admission date of 10/23/23. Diagnoses included left leg fractures and nasal bone fracture following a motor vehicle accident, opioid abuse, and depression. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Further review of Resident #37's record revealed no documented concerns related to reported allegations of sexual interactions or abuse with facility staff. Interviews 02/13/24 at 9:54 A.M. and 4:21 P.M. with Resident #37 revealed on the night of his admission, Licensed Practical Nurse (LPN) #366 performed oral sex on him and then three nights later she entered his room and asked if he wanted to have sexual intercourse with her.…

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 record review, review of the facility Self-Reported Incident (SRI), review of the facility investigation, and interview the facility failed to ensure Resident #70's medical record was accurate and completed to reflect incidents. This affected one resident (#70) of three residents reviewed for medical record accuracy. The facility census was 65. Findings include: Review of the medical record for Resident #70 revealed an admission date of 12/28/23 with diagnoses including aphasia following cerebral infarction, unspecified sequelae of other cerebrovascular disease, unspecified dementia, severe with agitation, transient ischemic attack, and cerebral infarction. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had severe impaired cognition as his Brief Interview for Mental Status (BIMS) score was a seven (out of 15). The assessment revealed Resident #70 did not show any behavior of wandering. Resident #70 required set-up or clean-up assistance with activities…

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 staff interview, the facility failed to ensure residents rooms and restrooms were maintained in a clean, comfortable, and homelike environment. This affected one resident (#39) of three residents reviewed for homelike environment. The facility census was 65. Findings include: Observation of Resident #39's room and bathroom and interview with Maintenance Director #371 and Interim Administrator at approximately 10:47 A.M. on 01/16/ 24 confirmed the exposed baseboard by Resident #39's head of the bed and nightstand was peeling and falling off the wall, the shower in the resident's bathroom had black discoloration and buildup along the shower floor as well as the shower tiles along the wall, the toilet had a black ring on the inside of the toilet where the water sits, the ceiling plaster was cracked and peeling away from the ceiling and the wallpaper to the left of the toilet next to the shower was peeling off the wall. Interview with Housekeeping Manager #333 on 01/16/24 4:30 P.M. stated that Resident #39's shower should have been cleaned and that she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, review of facility policy, and interview, the facility failed to implement physician orders, care-planned interventions and professional standards of practice to promote healing of a Stage 3 pressure ulcer to Resident #52's heel. This affected one (Resident #52) of three residents reviewed for pressure ulcers. The census was 74. Finding include: Review of the medical record for Resident #52 revealed an admission date of 03/15/23 with diagnoses of morbid obesity, reduced mobility, weakness, encephalopathy, conversion disorder with seizures or convulsions and pressure ulcer of the left heel. Review of the skin integrity care plan updated 08/28/23 revealed Resident #52 was at risk for the potential/actual impairment to skin integrity related to diagnoses of cellulitis of left lower extremity, muscle weakness, lymphedema, hypertension, heart failure, and spinal stenosis with an intervention to encourage to float heels as tolerated. Review of the Wound Weekly Observation…

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 FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of facility self-reported incident (SRI), facility investigation, facility policy review, and interview, the facility failed to ensure a resident was free from misappropriation of medications. This affected one resident (#74) of three residents reviewed for misappropriation. Findings include: Review of the medical record for Resident #74 revealed an admission date of 08/29/23. Diagnoses included unilateral primary osteoarthritis of the right knee, low back pain, chronic obstructive pulmonary disease, and type two diabetes mellitus. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was cognitively intact. The resident required limited assistance from one staff member for bed mobility, transfers, dressing and required extensive assistance of one staff member for toileting. Review of Resident #74's physician…

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 record review and interview, the facility failed to safeguard Resident #69's personal funds to ensure funds were only dispersed for Resident #69. This finding affected one (Resident #69) of three residents reviewed for personal funds. Findings include: Review of Resident #69's medical record revealed the resident was initially admitted on [DATE] and was discharged to the hospital on [DATE]. Facility stopped billing the resident on 02/28/23. Review of Resident #69's Resident Fund Management Service Statement with an ending balance date of 12/14/22 revealed the resident's balance in his personal fund account was 11,683.15 dollars ($). Review of Resident #69's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #69's Resident Fund Management Service Statement revealed on 01/03/23 the resident received a credit for $756.50 and interest of $53.16 for a starting balance of $12,492.81. Review of Resident #69's Resident Fund…

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 record review and interview, the facility failed to ensure only non-covered items and services from Resident #69 were paid from the resident's personal funds account. This finding affected one (Resident #69) of three residents reviewed for personal funds accounts. Findings include: Review of Resident #69's medical record revealed the resident was initially admitted on [DATE] and was discharged to the hospital on [DATE]. Facility stopped billing the resident on 02/28/23. Review of Resident #69's Resident Fund Management Service Statement with an ending balance date of 12/14/22 revealed the resident's balance in his personal fund account was 11,683.15 dollars ($). Review of Resident #69's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #69's Resident Fund Management Service Statement revealed on 01/03/23 the resident received a credit for $756.50 and interest of $53.16 for a starting balance of $12,492.81. Review 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 record review and interview, the facility failed to ensure Residents #27 and Resident #70 were free from sexual abuse. This finding affected two (Residents #27 and #70) of three residents investigated for abuse. Findings include: 1. Review of Resident #27's medical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including early onset Alzheimer's disease, paranoid schizophrenia and muscle weakness. Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's medical record revealed an admission date of 12/08/20 with diagnoses including hyperlipidemia, schizoaffective disorder and unspecified dementia with mood disorder. Review of Resident #53's MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #27's and #53's medical record revealed no evidence an incident of sexual abuse…

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 record review and interview, the facility failed to ensure all staff reported an allegation of sexual abuse immediately and then reported the allegation to the State agency timely. This finding affected one (Resident #27) of three residents investigated for abuse. Findings include: Review of Resident #27's medical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including early onset Alzheimer's disease, paranoid schizophrenia and muscle weakness. Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's medical record revealed an admission date of 12/08/20 with diagnoses including hyperlipidemia, schizoaffective disorder and unspecified dementia with mood disorder. Review of Resident #53's MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #53's Every 30-Minute Check form…

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 facility policy review the facility failed to ensure kitchen staff wore hair restraints, food items were properly stored and labeled, refrigerator temperatures were monitored, the kitchen was maintained in a clean and sanitary manner to prevent contamination and/or food borne illness. This had the potential to affect 66 of 66 residents who received meals from the kitchen. The facility identified two residents (#5 and #54) who received nothing by mouth. The facility census was 68. Findings include: Initial tour of the kitchen on 05/16/22 at 9:00 A.M. revealed [NAME] #463 was not wearing a hair restraint properly with hair exposed around the face and hanging to the shoulders while slicing ham. Dietary Aide (DA) #497 was not wearing any hair restraint with long hair exposed. In addition, the following was observed: 1. A large bin of onions was uncovered and stored on the bottom shelf under the food preparation table. 2. A box of frozen green vegetables was on a shelf next to frozen meat in the walk-in freezer. 3. A bag of pepperoni dated 03/18/22 in…

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, record review, facility policy review, review of guidelines from the Centers for Disease Control and Prevention the facility failed to maintain clean fans in the clean linen areas of the laundry rooms, failed to ensure proper use of Personal Protective Equipment (PPE) by staff in a transmission based precaution room for Resident #23 and throughout the facility and failed to ensure staff practiced proper hand hygiene during medication administration and food service for Residents #7, #29, #46, #50 and #220. This affected six residents (#7, #23, #29, #46, #50 and #220) and had the potential to affect all 68 residents residing currently residing in the facility. Findings include: 1. Observation on 05/17/22 at 10:07 A.M. of the clean laundry folding area revealed a box fan sitting on the countertop with heavily soiled fan blades and debris attached to the front of the fan which was pointed toward shelves holding clean laundry items. Interview at the time of the observation 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 medical record review, interview, and review of facility policy, the facility failed to notify the State Long Term Care Ombudsman of the transfer and discharge for Resident #68 and failed to provide written notification of transfer and discharge and bed-hold policy to Resident #68's representative. This affected one of one residents reviewed for hospitalization. The facility census was 68. Findings include: Review of the medical record for Resident #68 revealed an admission date of 11/10/21 and a discharge date of 03/11/22. Diagnoses included acute respiratory failure with hypoxia, acute kidney failure, urinary tract infection, COVID-19, type 2 diabetes, atrial fibrillation, heart failure, and senile degeneration of the brain. Review of the discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. She required extensive assistance of two staff members for bed mobility, toilet use, dressing,…

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, interview and facility policy review the facility failed to submit Minimum Data Set 3.0 assessments timely. This affected two residents (Resident #1 and #2) of three reviewed (Resident #1, #2, and #3). The facility census was 68. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 07/26/21 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting non-dominant left side, essential primary hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 12/31/21 revealed it was completed on 01/13/22. A modification of the quarterly MDS with an ARD date of 12/31/21 revealed it was was completed on 01/14/22. The assessment not submitted as required until 05/18/22. Interview on 05/19/22 at 12:46 P.M. with MDS Registered Nurse (RN) #413 confirmed Resident #1's MDS modification was completed on 01/14/22 but was not encoded and transmitted until 05/18/22 and was late. 2. Review of medical record for Resident #2…

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 medical record review, interview and review of facility policy the facility failed to develop a comprehensive person-centered care plan timely after admission. This affected one resident (Resident #316) of seven residents (Residents #1, #18, #26, #49, #51, #67 and #316) reviewed. The facility census was 68. Findings include: Review of the medical record for Resident #316 revealed and admission date of 04/15/22 and diagnoses including type II diabetes mellitus without complications, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, adult failure to thrive and epilepsy. Review of the minimum data set (MDS) 3.0 assessment dated [DATE], revealed Resident #316 was alert and oriented, had adequate hearing, usually understands others, had unclear speech, and was sometimes understood. Functionally, Resident #316 required one-person extensive assist for bed mobility, transfers, dressing, toileting and bathing, and locomotion on and off the unit. Review 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 record review and staff interview the facility failed to timely revise care plans following a change in resident status and failed to provide care conferences as required. This affected three (Residents #24, Resident #26 and #49) of eight residents (Residents #1, #18, #24, #26, #49, #51, #67, and #316) reviewed for care plans. The facility census was 68. Findings include: 1. Resident #49 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right non-dominant side, dysphagia following unspecified cerebrovascular disease, irritable bowel syndrome and gastro-esophageal reflux disease. Review of the modified quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 was rarely/never understood and required two staff assistance for activities of daily living (ADLs). Review of a progress note dated 12/12/21 revealed the resident had one or more falls in the last 2- 6 months. Resident #49 had a fall…

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, interview the facility failed to ensure Resident #59 kept all smoking materials at the nurses' station as assessed and care planned. This affected one (Resident #59) of four residents (Resident #39, Resident #44, Resident #55 and Resident #59) reviewed for smoking. Findings include: Review of the medical record for Resident #59 revealed an admission date of 06/01/21. Diagnoses included type two diabetes mellitus, schizophrenia and anxiety disorder. Review of the care plan dated 07/08/21 revealed Resident #59 was to maintain a safe environment while smoking. Interventions included for him to keep smoking materials at the nurses' station. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #59 was cognitively intact. He required supervision for his activities of daily living. Review of the smoking assessment dated [DATE] revealed Resident #59 was able to smoke with supervision and needed assistance with lighting cigarettes. Materials were to be kept 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 record review, interview, and policy review the facility failed to ensure residents' monthly weights were consistently obtained for adequate monitoring of resident nutritional status. This affected three (Residents #26, #49 and #51) of seven residents (Resident #1, #18, #26, #49, #51, #67, and #316) reviewed for nutrition. 1. Resident #26's medical record revealed an admission date of 04/06/20 and diagnoses of chronic obstructive pulmonary disease, vascular dementia with behavioral disturbance, epilepsy, and stage III kidney disease. Review of Resident #26's physician orders dated 04/20/22 revealed to obtain weights monthly. Review of Resident #26's weights revealed a weight of 202.5 pounds (#) on 11/05/21, 204# on 12/27/21, 204.4# on 01/03/22, 197.6# on 02/02/22, and 188.5# on 04/12/22. There was no weight recorded for March or May of 2022. There was a weight loss over three months from 01/10/22 to 04/12/22 of 14.9# which was 7.8 percent (%). Interview on 05/17/22 at 1:54 P.M. with Registered Dietitian…

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 and interview, the facility failed to ensure the dietary department had adequate staffing to carry out dietary services. This had the potential to affect all 91 residents residing in the facility. Findings include: Tour of the facility with the Housekeeping/Laundry Supervisor on 06/03/19 at 9:07 A.M. and Culinary Supervisor #103 on 06/03/19 at 9:15 A.M., 06/03/19 at 11:15 A.M., and 06/05/19 at 9:50 A.M. revealed the following: a. Free standing water and black debris was observed in a tan trash can, which also did not have a liner. b. The handwashing sink was stained, soiled, and had a buildup of loose debris. c. The ice machine vent was covered with dust and debris. The floor around the ice machine had loose paper, loose debris, and dust. d. The walk-in refrigerator had a spilled red substance. e. The metal storage carts had dishes and pans placed in free standing water near the large exhaust fan. f. The large exhaust fan screen was covered with dust and debris. g. Five long large metal pans…

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 food was stored and prepared under sanitary conditions. This had the potential to affect all 91 residents who were served meals prepared in the facility kitchen. Findings include: Tour of the facility with the Housekeeping /Laundry Supervisor on 06/03/19 at 9:07 A.M. and Culinary Supervisor #103 on 06/03/19 at 9:15 A.M., 06/03/19 at 11:15 A.M., and 06/05/19 at 9:50 A.M. revealed the following: a. Free standing water and black debris was observed in a tan trash can, which also did not have a liner. b. The handwashing sink was stained, soiled, and had a buildup of loose debris. c. The ice machine vent was covered with dust and debris. The floor around the ice machine had loose paper, loose debris, and dust. d. The walk-in refrigerator had a spilled red substance. e. The metal storage carts had dishes and pans placed in free standing water near the large exhaust fan. f. The large exhaust fan screen was covered with dust and debris. g. Five long large metal pans were stored with a greasy substance on the outside, which…

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 the food delivery system was working properly in order to assure hot food temperatures were maintained during meal service. This had the potential to affect all 91 residents receiving meals served from the facility kitchen. Findings include: Interview with the resident group on 06/06/19 at 1:30 P.M. revealed Residents #37, #56, #72, #95 complained of meals which were cold or lukewarm when served to them. On 06/03/19 from 11:38 A.M. to 12:30 P.M., observation of the plate warmer used during meal service in the kitchen revealed the warmer was flashing an error message and not beeping when the plate had been warmed. Interview with Culinary Supervisor #103 at the time of the observation revealed the plate warmer was not working properly.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement care plans for Resident #63 for a palm enabler, Resident #53 for anticoagulant use, and for Resident #57 for sleep apnea. This affected three of 19 residents reviewed for the development and implementation of care plans. The facility census was 91. Findings include: 1. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of atrial flutter, chronic obstructive pulmonary disease, heart failure, alcohol dependence with withdrawal. type II diabetes, opioid abuse, obstructive sleep apnea, and depressive disorders. Review of Resident #57's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident as independent with set up only to minimal assist for activities of daily. Resident #57's medical record revealed no plan of care that addressed the resident's diagnosis of sleep apnea or for the use of oxygen. Interview with Registered Nurse…

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 record review and interview the facility failed to revise the plan of care for Resident #8 for activities of daily living (ADL) and for Resident #38 for dialysis and nutritional needs, and failed to include Resident #79's son during the plan of care meetings. This affected two (Residents #8 and #38) of 29 resident (#5, #7, #8, #22, #28, #29, #30, #34, #38, #47, #49, #51, #52, #53, #54, #57, #59, #62, #63, #67, #69, #71, #75, #79, #87, #88, #89, #91, and #290 ) were reviewed for care plans, and one (Resident #79) of three residents (#18, #71, #79) reviewed for participation in care plan meetings. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses of acute pulmonary edema, altered mental status, reduced mobility, cerebral infarction, hypertension, chronic respiratory failure, rheumatic mitral stenosis, diabetes, polyneuropathy, atrial fibrillation, depression, pain, hemiplegia affecting the left side, acquired deformity of the head, and muscle weakness. Review 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.

Based on observation and interview, the facility failed to ensure there was adequate staffing to provide for the direct care needs of the residents. This affected 26 (Residents #4, #5, #12, #18, #22, #28, #30, #31, #34, #37, #38, #47, #49, #53, #54, #56, #57, #63, #69, #71, #72, #73, #75, #83, #95, and #29) residents, and had the potential to affect the remaining 65 residents. The facility census was 91 residents. Findings include: During individual resident interviews on 06/03/19 and 06/04/19 with Residents #4, #5, #12, #22, #28, #30, #31, #34, #38, #47, #49, #53, #54, #57, #63, #69, #73, #75, #83, and #29, as well as during the group interview on 06/06/19 at 2:10 P.M. which included Residents #37, #56, #72, and #95), it was revealed that there were not enough staff to meet their needs citing lack of showers, call light response time, and having beds made. Family members of residents #18 and #71 also complained of insufficient staff to meet resident care needs. Confidential interview across all shifts on all days of the survey with seven staff revealed there were not enough…

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 and interview, the facility failed to ensure medications stored in the medication room and the first floor medication cart were not expired. This affected three (Residents #37, #43, and #72), and had the potential to affect all 91 facility residents. Findings include: 1. On [DATE] at 8:15 A.M. during the medication administration task one plastic bottle of aspirin 81 milligrams (mg) was observed with an expiration date of 04/2019. Registered Nurse (RN) #3 administered oral medications to Resident #37 including one 81 mg aspirin tablet. RN #3 dispensed the aspirin in the medication cup and proceeded to enter Resident #37's room to administer the medication. The surveyor stopped RN #3 and verified the plastic bottle of aspirin 81 mg used to dispense Resident #37's 81 mg aspirin tablet had expired on 04/2019. RN #3 verified there were 118 aspirin tablets left in the plastic bottle containing a total of 300 aspirin tablets when opened. A review of Resident #43's, Resident #37's and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure privacy during incontinence care for Resident #59. This affected one resident of 19 sampled residents. The facility census was 91. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, full bowel incontinence, spinal stenosis, dementia without behavioral disturbance, diverticulosis of large intestine, cachexia, and muscle wasting and atrophy. Review of Resident #59's quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident required and extensive assist of two persons for bed mobility. Resident #59 required total dependence of two persons for transfers and total dependence of one person for toilet use and personal hygiene. Review of Resident #59's plan of care dated 08/27/18 revealed the resident had bowel incontinence related to functional incontinence. Resident #59's goal indicated the resident will be maintained in…

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 maintain resident rooms in good repair for Residents #28, #38, and #75. This affected three of 19 sampled residents whose rooms were observed. The facility census was 91. Findings include: Tour of the facility with the Maintenance Director on 06/06/19 at 1:30 p.m. revealed the following: 1. In Resident #38's room, on the wall behind the head of the bed, about a foot from the floor, the wall paper and the drywall were gouged. 2. In Resident #28's room, there was wall paper coming off the wall to the right side of his bed. 3. In Resident #75's room, there was wall paper coming off the wall and the wall had gouges in it. Interview with the Maintenance Director on 06/06/19 at 1:30 P.M. verified the disrepair of the walls in the rooms including gouges and wall paper coming off the walls. This deficiency is a recite to the complaint survey completed on 05/01/19.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure an accurate comprehensive was completed for Resident #7. This affected one of 29 (#5, #7, #8, #22, #28, #29, #30, #34, #38, #47, #49, #51, #52, #53, #54, #57, #59, #62, #63, #67, #69, #71, #75, #79, #87, #88, #89, #91, #290 ) residents who were reviewed for comprehensive assessments. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, dementia, chronic pain syndrome, metabolic encephalopathy, trigeminal neuralgia, major depressive disorder, and anxiety. Review of the quarterly comprehensive assessment dated [DATE] and 05/05/19 documented the resident as not receiving Hospice and End of Life care. Review of the physicians orders revealed the resident was admitted to hospice care on 09/27/17 with the admitting diagnosis of multiple sclerosis, dementia and chronic pain. On 06/05/19 at 10:32 A.M. Registered Nurse (RN) #3 verified Resident #7 continued with hospice services…

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 record review and interview the facility failed to provide interventions for decline in eating ability for Resident #8. This affected one (Resident #8) of five residents reviewed for activities of daily living. The facility census was 91. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses of acute pulmonary edema, altered mental status, reduced mobility, cerebral infarction, hypertension, chronic respiratory failure, rheumatic mitral stenosis, anemia, diabetes, polyneuropathy, atrial fibrillation, depression, pain, hemiplegia affecting the left side, dysphagia, acquired deformity of the head, and muscle weakness. Review of the Comprehensive assessments dated 04/12/18 and 09/21/18 revealed the resident had a decline in eating ability from set-up assistance to extensive assistance of one staff. Review of physician orders dated 08/09/18 revealed the resident was to receive a regular textured carb controlled diet, and the last speech therapy order for evaluation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate supervision for Resident #59 to prevent falls. This affected one of two residents reviewed for accidents. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, full incontinence of the bowel, spinal stenosis, dementia without behavioral disturbance, diverticulosis of large intestine, cachexia, and muscle wasting and atrophy. Review of Resident #59's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assist of two persons for bed mobility. Resident #59 required total dependence of two persons for transfers and total dependence of one person for toilet use and personal hygiene. Review of Resident #59's plan of care dated 03/16/19 revealed the resident was at risk for falls due to decreased mobility with a goal to minimize risk for falls. Interventions included to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility policy and procedure, the facility failed to ensure infection control standards were followed during incontinence care and wound care. This affected one (Residents #22) of two residents reviewed for wound care and one (Resident #59) resident observed for incontinence care. The facility census was 91 residents. Findings include: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses including a bacterial infection, pulmonary disease, severe protein-calorie malnutrition, osteoarthritis, muscle weakness, peripheral vascular disease, and fibromyalgia. A review of Resident #22's clinical record indicated a pressure ulcer was present upon admission on the left outer ankle. On 05/25/19 the skin assessment indicated venous stasis ulcers were present on both lower extremities on the inner calf area. Wound treatments were provided daily. Resident #22's physician order dated 04/16/19 indicated to clean the venous stasis ulcer wounds and left lateral…

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.