Springdale Village Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, facility policy review, State Agency complaint tracking system, the facility failed to ensure medical records were complete and readily accessible for one resident (#110). The deficient practice could result pertinent medical information being missed by staff members which could be harmful. Findings include: Resident #110 was admitted to the facility on [DATE]. 2023 with a diagnosis of anemia in chronic kidney disease, chronic obstructive pulmonary and type 2 diabetes. Review of the MDS (Minimum Data Set) assessment dated [DATE]. 2023 reveals a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. The complaint filed at the State Agency on March 9, 2023, revealed that while the resident was admitted to the facility she did not receive the insurance authorized time for therapy. Review of the facility documentation revealed the facility ownership had changed on March 1, 2025. The clinical record revealed no documentation of any…

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, clinical record review, interviews with residents and staff, and review of facility policy, the facility failed to ensure appropriate infection control guidelines were implemented and followed for one resident (#1). The deficient practice could result in the spread of infectious disease. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, allergic rhinitis, and type 2 diabetes mellitus with diabetic polyneuropathy. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognition was intact. Review of the Certified Nursing Assistant (CNA) task log for bowel movements revealed an entry on January 1, 2025 at 9:39PM, which indicated Resident #1 had experienced three episodes of loose/ diarrhea stools. It was also revealed that the bowel movements charted on January 1, 2025 at both 4:23PM and 9:39PM were incontinent bowel…

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 clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#1) to be free from abuse by staff. The deficient practice could result in appropriate action not taken and further abuse of residents. Findings include: Resident #1 was readmitted on [DATE] with diagnoses of cerebrovascular disease (CVA), dementia and major depressive disorder. The care plan dated August 22, 2024 revealed that the resident was at risk for skin breakdown related to a decline in mobility/transfers/repositioning. Interventions included to administer ointments or medications as ordered as preventative measure and to assist resident to reposition while in bed or wheelchair as needed. The care plan on ADLs (activities of daily living) dated August 22, 2024 revealed that the resident was at risk for ADL self-care performance deficit related to weakness/debility. Interventions included staff participation was required with bathing, turning and repositioning,…

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 clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) 3.0 User's manual, the facility failed to ensure the completion of comprehensive Minimum Data Set (MDS) assessments for three residents (#8, #10, #12) within the regulatory time frames. The deficient practice could result in inadequate assessment of resident needs. Findings include: Regarding Resident #8 Resident #8 was admitted to the facility on [DATE]. Review of the MDS revealed both an annual assessment dated [DATE] and a quarterly assessment dated [DATE] were still In Progress. The annual and quarterly assessments were not completed in the required timeframe for resident #8. Regarding Resident #10 Resident #10 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Review of the MDS revealed a quarterly assessment dated [DATE] was In Progress. The MDS assessment for resident #10 was not completed in the required timeframe. Regarding Resident #12 -Resident #12 was admitted to the facility 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 observations, interviews, review of records, documents and policy, the facility failed to develop and implement a care plan for one resident (#4). The deficient practice could result in the resident's care needs not being met. Findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, atrial fibrillation, depression, anxiety disorder, and seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact; and, resident received antipsychotic and antidepressant medications. Review of the physician orders revealed the following orders: abilify oral tablet 10 milligrams (mg) one tablet by mouth one time a day for bipolar disorder dated November 27, 2023 and end date on November 30, 2023; abilify 10 mg one tablet by mouth at bedtime for bipolar disorder frequent mood changes dated December 29, 2023; anti-psychotic medication use: observe…

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 interviews, record review, facility document review, and facility policy review, the facility failed to ensure that three staff members (#35, staff #15, and staff #17) had current cardiopulmonary resuscitation (CPR) certification training on file. The deficient practice could put the resident's safety at risk and could result in needs not being met. Findings included: On [DATE] at 11:14 AM, a review of employees' files was conducted along with the Human Resources (HR) Director and Business Office Director (staff #52). During the employees' files review the following were identified: - License Practical Nurse (LPN/staff #35) CPR certification expiration date [DATE]. - Certified Nursing Assistant (CNA/staff #15) CPR certification expiration date [DATE]. - Certified Nursing Assistant (CNA)/staff #17) CPR certification expiration date [DATE]. On [DATE] at 12:35 PM, an interview was conducted with Staff #52 and he stated that he oversaw the operation for the HR and business office, performed and provided…

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 clinical record review, interviews, and review of facility policy and procedure, the facility failed to ensure a discharge summary was completed for a resident (#14) discharge. The deficient practice could result in an unsafe discharge for residents. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses of dementia, kidney disease, and type 2 diabetes. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of a progress note indicated resident #14 received a notice of discharge on [DATE] and transferred to a sister facility on January 2, 2024. The progress note did not indicate a full discharge summary was provided to the resident or the resident's representative at the time of discharge. An interview was conducted with the Director of Social Services (staff #72) on April 3, 2024 at 8:53 AM. Staff #72 indicated they were not sure what 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 interviews, facility documents and employee record review, the facility failed to ensure that the activities program was directed by a qualified professional. The deficient practice could result in the activities program not being directed by a qualified professional Findings included: On [DATE] at 11:14 AM, a review of staff #21's file was conducted with the Human Resources (HR) Director and Business Office Director (staff #52). On [DATE] at 12:35 PM, an interview was conducted with Staff #52 and he stated that he oversaw the operation for the HR and business office, performed and provided standard operating procedure for HR which included full screening and scheduling interview, conducted onboarding, ensuring paper work and packets were up to date, and verified licenses, fingerprint cards, and references. He said he also updated employee files. Staff #52 stated that he did not know the policy on licenses and certifications. He added that staff would be removed from the schedule immediately if their…

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 interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one resident (#4) was administered pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines. Findings included: Resident #4 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, atrial fibrillation, asthma, chronic obstructive pulmonary disease, and seizures. The admission Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of a document titled, Consent/Pneumonia Vaccine revealed a signed consent to receive the pneumonia vaccine on her initial admission date in August 23, 2023 and on November 26, 2023 readmission date. Her record revealed that an immunization of Pneumococcal PCV13 vaccine was required and there was no evidence that the resident received the vaccine. An interview was conducted on April 4, 2024 at 8:56 AM with the Infection Preventionist…

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 clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the comprehensive care plan was updated to reflect the changing needs of 1 out of 2 sampled residents (#3). The deficient practice could increase the risk for further falls and injuries. Findings include: Resident #3 admitted on [DATE] with diagnoses of a displaced intertrochanteric fracture of the right hip, primary hypertension and cognitive communication deficit. The admission clinical evaluation with Braden Scale note dated August 11, 2022 revealed the resident had an admitting diagnosis of fracture of the right hip and had a history of falls. The admission Minimum Data Set assessment dated [DATE] revealed the resident required extensive assistance for most activities of daily living (ADLs) and a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. A care plan dated August 17, 2022 revealed resident was at risk for falls related to unsteady gait and/or balance 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 clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure necessary care and services related to pressure ulcer was provided for one resident (#3). The sample size was 18. The deficient practice may result in development of pressure ulcer. Findings include: Resident #3 admitted on [DATE] with diagnoses of a displaced intertrochanteric fracture of the right hip, type 2 diabetes mellitus and cognitive communication deficit. The admission clinical evaluation with Braden Scale dated August 11, 2022 included that the resident had admitted with a surgical incision to her right trochanter (hip). She required extensive 2-person assistance with bed mobility and was incontinent of both bowel and bladder. According to the Braden Scale, the resident was at moderate risk for skin breakdown. A physician order dated August 11, 2022 included skin prep to bilateral heels every shift for prophylaxis. A care plan dated August 12, 2022 revealed the resident had skin…

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 clinical record review, staff interviews, and review of policy, the facility failed to ensure catheter care was provided according to physician orders for two residents (#42 and #222); and, failed to provide incontinence care to one resident (#274). The deficient practice could result in increased risk for complication such as infection, pain, and rehospitalization. Findings include: -Resident #42 admitted on [DATE] with diagnoses of carpal tunnel syndrome, multiple sclerosis, type 2 diabetes mellitus, hypertension, edema, and major depressive disorder, A physicians order dated November 21, 2022 included an order for a foley catheter, and catheter care every shift. The care plan initiated on November 21, 2022 revealed resident had foley catheter related to urinary retention as evidenced by neurogenic bladder. The goal was to minimize the risk and being free from urinary tract infections (UTI). Interventions included emptying drainage bag each shift and as needed; monitor amount and any changes 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, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure the medication error rate was less than 5% by failing to ensure two out of three residents reviewed (#20 and #62 ) received medications according to the physician orders. The medication error rate was 6.67%. The deficient practice could result in further medication errors. Findings include: -Resident #20 was admitted on [DATE] with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal, type 2 diabetes mellitus and primary hypertension. A physician order dated November 10, 2022 included for bumetanide (diuretic) 1 mg (milligram) give one time a day for edema for 10 days and, to hold if SBP (systolic blood pressure) is less than 100. During the medication pass observation conducted with a licensed pratical nurse (LPN/staff #76) on December 13, 2022 at 7:37 a.m., staff #76 pulled all the resident's medications from the medication cart and reviewed the resident's…

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

Based on observation, staff interviews, and review of policy and procedure, the facility failed to ensure that expired supplies and medication with missing and/or damaged labels were not available for resident use; and failed to ensure that a resident's home medications were not left unsecured on a counter in the medication room. The deficient practice could result in ineffective treatments/procedures, and/or in residents receiving expired medications, and/or schedule II - V controlled medications being unsecured. Findings include: An observation of the medication room was conducted with a licensed practical nurse (LPN/staff #76) on December 15, 2022 at 2:49 p.m. During the observation, the following expired biological/drugs were found mixed with unexpired items on the shelves in the medication room: -A tray of 29 red-topped blood collection tubes with an expiration date of October 31, 2022; -A box containing approximately 23 BD Safety LOK vacutainer blood collection sets with an expiration date of October 31, 2022; -A box of approximately 30 Regulator IV (intravenous) sets with 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, staff interviews and review of policy and procedures, the facility failed to ensure that biohazardous material/sharps were disposed of properly. The deficient practice may increase the risk for needle sticks and/or the spread of bloodborne pathogens. Findings include: On December 15, 2022 at 2:49 p.m., an observation of a medication room was conducted with a Licensed Practical Nurse (LPN/staff #76). On the counter above the medication refrigerator was an IV (intravenous) start kit that contained sterile IV supplies and a red container with a clear lid. There was also a saline flush connected to an IV start line lying across the top of the sterile supplies in the kit. On the end of the start line was a catheter which appeared to be soiled with a reddish substance. An interview with staff #76 was conducted on December 15, 2022 at 3:13 p.m. Staff #76 stated that the item laying on top of the IV start kit was an IV start line; and, there was a saline flush attached to the line on one end and a catheter attached to the other end. Staff #76 said that the catheter…

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 observations, clinical record review, resident and staff interviews, and review of facility policy/procedure, the facility failed to ensure housekeeping services necessary to maintain a safe and clean environment were provided for one resident (#58). The sample size was 18. The deficient practice could result in residents not having a safe and clean environment. Findings include: Resident #58 was admitted on [DATE] with diagnoses of urine retention, dysphagia, metabolic encephalopathy, chronic kidney disease, pneumonia, and dependence on oxygen. A care plan dated November 29, 2022 revealed resident was functioning at a reasonably dependent level concerning leisure pursuits. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which resident had intact cognition. An interview was conducted on December 12, 2022 at 12:16 p.m. with the resident's family who stated she visits resident #58 every day and stays until the evening.…

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 closed record review, staff interviews and facility policy and procedures, the facility failed to ensure medications were administered as ordered by the physician for one resident (#123). The deficient practice could result in resident not provided with medication needed. Findings include: Resident #123 was admitted on [DATE] with diagnoses of orthopedic aftercare, cervicalgia, spondylosis with myelopathy and spinal stenosis. The admission note dated November 26, 2021 included the resident had a surgical wound and had an admitting diagnosis of C5 cervical fusion. The health status note dated November 26, 2021 revealed the resident was alert and oriented x4 and was aware of orders for oxycodone (opioid) but would like to try Flexeril (muscle relaxant) first before taking oxycodone. Per the note, the resident did not like the feeling he gets when he takes oxycodone. A physician order dated November 26, 2021 revealed the following orders: -Acetaminophen (analgesic) 325 mg (milligrams) give 2 tablets by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, staff interviews, and review of policy, the facility failed to ensure one resident (#8) was provided showers. The deficient practice could result in grooming and hygiene needs not being met. Findings include: Resident #8 was admitted on [DATE] with diagnoses that included strain of muscle, fascia, and tendon at wrist and hand level, muscle weakness, spinal stenosis, and cerebral infarction. A physician order dated October 25, 2022 revealed an order for occupational therapy (OT) evaluation and treatment for ADL (activities of daily living) retraining. Review of admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 which indicated the resident had intact cognition. The assessment also revealed the resident required extensive assistance with all ADLs and total dependence on staff for bathing. Review of the care plan initiated on November 7, 2022 revealed resident needed assistance with self-care and 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 clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#223) received treatment and care in accordance with professional standards of practice. The sample size was one. The deficient practice could rsult in resident not receiving the treatment based on their assessed need. Findings include: Resident #223 admitted on [DATE] with diagnoses of pneumonia, acute systolic (congestive) heart failure, and lymphedema. A care plan dated December 2, 2022 revealed resident had a skin breakdown related to lower extremity cellulitis and lymphedema. The goal was to minimize the risk of infection. Interventions included provision of treatments as ordered. The active orders for December 2022 revealed the following treatment: -Apply size F tubigrip (compression garment) to left and right lower extremity one time a day for alteration/edema management; -Cleanse left lateral and posterior lower leg with normal saline, pat dry, apply calcium alginate (absorbent),…

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, staff interviews, and policy review, the facility failed to ensure the Daily Staff Postings for nursing staff was accurate for actual hours worked by licensed and unlicensed direct care nursing staff. The facility census was 74 residents and the sample was 18. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include: Review of the following four randomly chosen days of staff postings compared with the actual hours worked by staff on those days revealed that none of the staff postings matched the actual hours worked by staff: -December 1, 2022 staff posting indicated 80 Licensed Practical Nurse (LPN) hours worked, and 136 Certified Nursing Assistant (CNA) hours worked. However, the total hours worked revealed 87 LPN hours worked and 122.75 CNA hours worked; -December 2, 2022 staff posting indicated 96 LPN hours worked, and 136 CNA hours worked. However, the total hours worked revealed 90 LPN hours worked, and 142.95 CNA hours worked; -December 3, 2022 staff posting indicated…

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