St John Kronstadt Convalescent Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that Resident 1's alleged abuse incident was reported within the prescribed timeframes. This failure placed the Resident 1 at risk for further possible abuse incidents, mental anguish or emotional distress. This failure also resulted in the delay in the abuse investigation. Findings: During a review of Resident 1's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity) and major depressive disorder (a mental disorder characterized by persistently depressed mood and loss of pleasure and interest in life). During an interview on 4/16/25 at 12:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/14/25 at approximately 7:30 a.m., Resident 1 was complaining of left arm pain and stated that the night shift Certified Nursing Assistant (CNA) 1 was mean 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 provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide gender specific bathrooms to five of five sampled residents (Residents 1, 30, 32, 33 and 41). A female resident (Resident 32) shared a [NAME] and [NAME] bathroom (a bathroom that has two doors and is accessible from two bedrooms) with two male residents (Resident 30 and Resident 33) in the adjacent room. A female resident (Resident 1) shared [NAME] and [NAME] bathroom set up with a male resident (Resident 41). This failure placed Residents 1, 30, 32, 33 and 41 at risk for humiliation and discomfort. Findings: 1. During a concurrent observation and interview on 6/3/24 at 11:00 a.m., in Resident 41's room, Resident 41 was sitting in wheelchair. Resident 41 stated he shared the bathroom with a female resident (Resident 1) residing in the adjacent room. Resident 41 stated sharing the bathroom with a female resident was unacceptable. Resident 41 stated it was concerning for him as he would look bad if he happened to enter the bathroom…

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

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 16, Resident 23, and Resident 11) received proper grooming including nailcare when: 1) Resident 16 had long sharp fingernails. 2) Resident 23 had long sharp fingernails. 3) Resident 16 had long, thick fingernails. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromise physical and psychosocial wellbeing. Findings: 1. During a review of Resident 16's Resident Face Sheet, printed on 6/5/24, the Face Sheet showed Resident 16 was admitted to the facility in November 2023 and had multiple medical diagnoses including glaucoma (a group of eye diseases that damage the optic nerve and can cause blindness) and Parkinson's disease (a progressive disease of the nervous system that affects movement). During a record review of Resident 16's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan),…

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 store and label mediations in accordance with manufacturer specifications and currently accepted professional principles when: 1. The medication refrigerator temperature was below recommended temperature range for storage of refrigerated medications. 2. The medication refrigerator temperature was not consistently monitored and recorded twice daily for seven out of seven months, from [DATE] to [DATE]. 3. The temperature log had an incorrect temperature range for monitoring. 4. Nursing staff failed to notify the Maintenance Supervisor (MS) when the medication refrigerator temperature was out of range. 5. Six (6) bottles of eyedrops and one (1) insulin pen were not correctly labeled. These failures had the potential to result in 44 residents receiving medications or vaccines of unknown effectiveness and seven (7) residents potentially receiving an incorrect or expired medication. Findings: 1. During a concurrent observation and interview on…

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

Based on observation, interview, and record review the facility failed to ensure effective medication administration and accurate accountability of a controlled substance (medications that can be easily abused and are under strict government control) when: 1. Nursing staff did not correctly prime the pen needle during the administration of insulin (medication to lower blood sugar) for one of two sampled residents (Resident 27) receiving an insulin injection. This had the potential to result in Resident 27 to not receive a full dose of insulin. 2. One of 31 sampled residents (Resident 19) received calcium and iron at the same time. This had the potential for an interaction leading to the decreased absorption of iron, and the resident not receiving the full therapeutic effect of the medication. 3. During a random controlled medication use audit, one of two randomly sampled residents (Resident 7) did not have all administered medications correctly documented on the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medication) and on the…

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

Based on observation, interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Cake was not served to 10 of 10 Controlled Carbohydrate diets (CCHO; a diet to control the amount of carbohydrate or sugar a person receives at each meal); 2. A smaller portion of vegetables and potatoes than what was indicated on the menu were served to 9 of 9 residents on regular portion/regular textured diets; 3. A smaller portion of meat, a larger portion of vegetable, and a larger portion of cake than what was indicated on the menu were served to 7 of 7 residents on regular pureed diets; 4. A larger portion of meat and a larger portion of potatoes than what was indicated on the menu and traycard was served to Random Resident 1 (RR1) 5. A smaller portion of meat than what was indicated on the menu and traycard was served to Resident 6. This failure had the potential for residents to not receive the nutrients intended by the physician's order and the planned menu for 29 residents out of a facility census of 35. Findings: Review of the 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.

Based on observation, interview, and facility document review, the facility failed to serve food that was palatable when the food was bland (lacking flavor) and the food was not maintained at a warm temperature. This failure had the potential for 34 residents to consume less food resulting in the consumption of fewer calories and nutrients provided by the planned menu, out of a facility census of 34. Findings: Review of the policy and procedure titled Meal Service Subject: Cultural Dining dated 2023, showed a possible problem during food service is maintaining food temperatures at the dining table. The procedures showed a solution for this problem is food should be 120 degrees or above upon arrival to the dining room. Review of the Daily Spreadsheet dated Tuesday - Day 3 and used for lunch on 2/14/23, showed the regular consistency food included Braised Pork Shoulder, Sauteed Broccoli Florets, and Hawaiian Rice. The pureed food included Braised Pork Shoulder Puree, Pureed Sauteed Broccoli Florets, and Seasoned [NAME] Puree. Review of the undated recipe titled Braised Pork Shoulder…

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 document review, the facility failed to store, prepare, and distribute in a safe and sanitary manner when: 1. Perishable and time/temperature control for safety (TCS) food (Time/Temperature for safety food means a food that requires time/temperature control for safety to limit pathogenic microorganism [an organism which can cause disease] growth or toxin [a naturally occurring organic poison] was not stored at a safe temperature (Cross-reference F801); 2. Sanitizer strength for a low temperature dish machine was not monitored and the dish machine water temperature was below the recommended temperature (Cross-reference F801); 3. Surface sanitizer was not used on appropriately for kitchen and equipment surfaces, such as countertops and food processors, to ensure surfaces sanitized (Cross-reference F801); 4. The ice machine was not clean; 5. The juice machine was not clean; 6. A reach-in food refrigerator was not clean; 7. A wall in a food preparation area was not clean and the area above the stove was not clean; 8. A fresh air intake vent in a dry…

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 implement infection control practices, when following was noted: 1. Oxygen (O2) tubing for Resident 20 was unlabeled/ undated and was touching the floor. 2. Resident 24's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask and tubing was left uncovered on the nightstand. The tubing was not labeled and or dated with yellowish tinged discoloration. 3. Facility did not create and maintain an active water management plan. The above failures placed Residents 20 and 24 at risk for respiratory and skin infections, not having a water management plan placed all 34 residents at risk for gastrointestinal infection (gut inflammation caused by consuming contaminated water or food, characterized with stomach pain, nausea, vomiting, diarrhea, fever etc.) Findings. 1. During a review of Resident 20's Resident Face Sheet printed on 02/13/23, the record indicated Resident 20 was admitted to the…

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

Based on interview and record review, the facility failed to have a qualified and certified Infection Preventionist (IP) (a professionally trained individual responsible for facility's Infection Prevention and Control Program) staff for over two years. This failure resulted in facility not having a qualified staff responsible for assessing, developing, implementing, monitoring, and managing facility's Infection Prevention and Control Program and placed 34 residents at risk for infections. Findings A review of the Resident Census dated February 13, 2023, showed the facility had a total number of 34 residents in the facility. During an interview and record review on 02/14/23, at 10:43 a.m., DON's training certificate titled Module 1- Infection Prevention and Control Program dated 5/8/20 was reviewed. The DON stated, she had completed only Module 1 out of a total 24 required Modules for the completion of IP course. The DON stated, she had been performing IP duties since 2021 without a certification. The DON stated, she did not complete the IP certification course since 2020, as she 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.

Based on observation, interview, and facility document review, the facility failed to maintain the 2-compartment sink for manual warewashing when there were no stoppers available to allow the sinks to be filled. This failure did not allow the kitchen staff to follow the appropriate procedures for cleaning equipment and utensils used for food preparation when the dish machine was not working which led to the potential for food borne illness for 34 residents who received food from the kitchen out of a facility census of 34. Findings: Review of the policy and procedure titled Sanitation and Infection Control Subject: Warewashing (Hand Washing Method) dated 2023, showed when a two-compartment sink is used, compartment one is for washing and compartment 2 is for rinsing and sanitizing. For sanitizing, items are to be: immersed or at least 30 seconds if hot water of 171 degrees F or more is used, immersed for at least 30 seconds in a chlorine solution of 100 parts per million (ppm), immersed for at least 1 minute in an iodine solution of 25 ppm, or immersed for at least 1 minute 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.

Based on observation, and interview the facility failed to maintain working clocks for 10 of 10 sampled residents (Resident 1, 2, 7, 8B, 12, 16, 22, 23, 26 and 36) in their rooms. This failure placed Resident 1, 2, 7, 8B, 12, 16, 22, 23, 26 and 36 at risk for confusion and disorientation. Findings. During an observation and interview on 02/14/23, at 10:24 a.m., with Licensed Vocational Nurse (LVN 3), the wall clock in shared room for Resident 23 and Resident 26, indicated the time was 6:20. During an observation and interview on 2/14/23, at 10:29 a.m., in Resident 12 and 22's shared room, LVN 3 stated, the wall clock indicated time was 2:48. During an observation and interview on 2/14/23, at 10:31 a.m., with LVN 3, wall clock in Resident 36's room showed time was 11:45; and the wall clock in Resident 2 and 16's room indicated time was 11:30. During another observation and interview on 2/14/23, at 10:32 a.m., in shared room for Resident 1,7 and 8B, LVN 3 stated, wall clock indicated time was 5:15. During an interview on 2/14/23, at 10:33 a.m., LVN 3 stated, Resident 23, 26, 12, 22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide an easily accessible bathroom to three of three sampled residents (Resident 5, 32 and 29). Resident 5 and 32 shared a bathroom with two female residents, that they could not use. Resident 29 did not have a bathroom in the room. This failure resulted in Resident 5, Resident 32 and Resident 29 to not have a homelike environment, having to wait for extended periods of time to use the bathroom, and an increased number of incontinent (unable to voluntarily control their bladder and/or bowels) episodes. Findings: 1. During an observation on 2/14/23, at 8:08 a.m., in Resident 32 and 5's shared room, a sign was posted on the bathroom door indicating, BATHROOM CLOSED USE HALLWAY BATHROOM. During an interview with Resdent 32 on 2/14/23 at 8:08 a.m., Resident 32 stated, Resident 5 and himself shared the bathroom with two female residents (Resident 19 and 33) residing in the adjacent room. Resident 32 stated, he used the hallway bathroom and it…

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 complete a performance review for four of five CNA's (Certified Nurse Assistant) at least once every 12 months. This failure had the potential to result in inadequate care and services provided to residents. Findings: During a concurrent interview and record review, on 2/15/23, at 1:00 p.m., with the Director Of Nursing (DON), a review of the following CNA record indicated: a. CNA 4 was hired on 4/15/85, no performance review on file for 2022. b. CNA 5 was hired on 6/16/09, no performance review on file for2022. c. CNA 3 was hired on 4/15/10, last performance review on file was 12/20/21. d. CNA 6 was hired on 7/29/17, last performance review on file was 11/2019. The Director of nursing (DON) stated, she was the previous Director of Staff Development (DSD) until January 2023. DON stated, she did not perform performance review for the unlicensed nurses in 2022 because she did not have time to do it. DON further added, resident safety is at risk when performance review of direct care staff was not done. During a review of the…

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

Based on observation, interview and record review, the facility failed to administer medications below five percent (5%) error rate when: 1. Licensed Vocational Nurse (LVN 2) did not administer Loratadine( drug used for relief of nasal and non-nasal symptoms of seasonal allergies) 10 mg medication to Resident 29. 2. LVN 2 crushed Metoprolol (a medication used to lower the blood pressure) Extended Release (a medication released slowly in the bloodstream) 25 milligrams (mg) tablet without a physician's order. LVN 2 did not administer two eye drops, Alphagan 0.1% and Dorzolamide-timolol 2-0.5%, to Resident 34. 3. LVN 3 documented she gave Metformin (a medication used for diabetes) 500 mg to Resident 8B, but did not give the medication as prescribed. These significant medication errors resulted in Residents 29, 34 and 8B receiving medications that were not prescribed by their physicians. Findings: 1. During a medication administration observation on 2/14/23, at 8:44 a.m., Licensed Vocational Nurse 2 (LVN 2) prepared the following seven medications for Resident 29: Loratadine was not…

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 administer medications per physician order or manufacturer's specifications to three of seven sampled residents when the following was noted: 1. Licensed Vocational Nurse (LVN 2) did not administer Loratadine (drug used for relief of nasal and non-nasal symptoms of seasonal allergies. ) 10 mg medication to Resident 29. 2. LVN 2 crushed Metoprolol (a medication used to lower the blood pressure) Extended Release (a medication released slowly in the bloodstream) 25 milligrams (mg) tablet without a physician's order. LVN 2 did not administer two eye drops, Alphagan (eye drops for glaucoma) 0.1% and Dorzolamide-timolol(eye drops for glaucoma and intraocular/eye pressure) 2-0.5%, to Resident 34. 3. LVN 3 documented Metformin (a medication used for diabetes) 500 mg as given to Resident 8B, but did not give at the documented time. These significant medication errors resulted in Residents 29, 34 and 8B not receiving medications as ordered by 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.

Based on observation, interview, and facility document review, the facility failed to ensure a cook was competent in the task of following a recipe to puree food. The failure had the potential to affect the nutrient content and or palatability of the food and result in decreased nutrient intake by nine residents on a physician prescribed pureed diet out of a facility census of 35. Findings: Review of the policy and procedure titled Food Preparation Subject: Portion Control dated 2023, showed portion control assures correct quantities are served to residents to meet the nutritional specifications as determined by the menu. Standard portions are necessary to control quality, attractiveness and appeal of food. Standard tools are utilized to assure portion control including recipes. Review of the Job Description titled Cook and signed by [NAME] 1 on 8/13/2017, showed duties and responsibilities included preparing food in accordance with standardized recipes. Review of the undated recipe tiled Pot Roast - 3 oz [ounce], showed directions on how to prepare the pot roast. Under the sections…

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 document review, the facility failed to ensure pureed food was prepared in a consistency to meet resident needs. This failure placed eight (8) residents who received a pureed diet at risk for choking and/or aspirating (inhaling food into the lungs) out of a facility census of 34. Findings: Review of the Diet Manual Rehabilitation, Residential, and Long-Term Care Facilities dated 2018, foods for the pureed diet should be smooth and pureed to the consistency of pudding and holds its shape on a plate. Blendarized foods that are liquid may need to be thickened. Review of the Daily Spreadsheet dated Tuesday - Day 3 and used for lunch on 2/14/23, showed the Pureed food included Braised Pork Shoulder Puree, Pureed Sauteed Broccoli Florets, and Seasoned [NAME] Puree. Review of the undated recipe titled Braised Pork Shoulder showed for the pureed diet, to refer to the Pureed Meat recipe. Review of the undated recipe titled Sauteed Broccoli Florets (Fresh), for the puree diet, to refer to the Pureed Vegetables Recipe. On 2/14/23 at 11:34 a.m.,…

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 meet the required room size of at least 80 square feet per resident for one of 23 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents. Findings: During an interview on 2/13/23, at 8:20 a.m., with the Administrator (ADM), ADM stated, room [ROOM NUMBER] had less than 80 sq ft per resident and had four resident beds. ADM also stated, there was no room waiver for room [ROOM NUMBER]. During a concurrent observation and interview on 2/14/23, at 12:35 p.m., room [ROOM NUMBER] had four resident beds. The privacy of residents in room [ROOM NUMBER] were not impacted by shortage of space. Storage spaces were sufficient to accommodate the needs of residents. Resident 7 was sitting up in her wheelchair watching television. Resident 7 stated, she had no issues with maneuvering her wheelchair inside room [ROOM NUMBER]. Resident 8B…

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.