The Dorothy & Joseph Goldberg Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure its pharmacist consultant (PC) identified medication irregularities during the monthly medication regimen review (MRR) for two sampled residents (Resident 33 and 39).As a result, there was the potential for residents to receive medications with inappropriate duration and in excessive dosages. Cross reference F757. 1.A review of Resident 39's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include urinary tract infection (UTI). A review of Resident 39's History and Physical dated 6/6/25, indicated the resident was in the hospital from [DATE] through 6/3/25, and .For presumed urinary tract infection, the patient was treated with Rocephin [antibiotic].The patient's Rocephin was completed after a 5-day course on 6/1/25 and the patient was restarted on penicillin [antibiotic]. It was suspected that the patient had osteomyelitis [bone infection] of the left second toe. The patient's urine culture 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 and record review, the facility failed to ensure two of 15 sampled residents (Resident 33 and 39) were free from unnecessary medications when both residents were given antibiotics without verification of a stop date. As a result, there was the potential for Resident 33 and 39 to experience antibiotic resistance (when bacteria or other microorganisms evolve to become resistant to the drugs designed to kill them). Findings: 1.A review of Resident 33's Resident Face Sheet indicated the resident was re-admitted to the facility on [DATE] with a diagnosis of Unspecified dementia (a disease affecting cognition and memory), severe, with agitation. A review of Resident 33's physician orders, dated 6/13/25, indicated an order for nitrofurantoin macrocrystal (antibiotic) 100 milligrams (mg) one capsule once a day for UTI (Urinary Tract Infection) Prophylaxis with no stop date. A review of Resident 33's medication administration record (MAR) from 6/14/25 through 7/23/25, indicated the resident received…

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 food and nutrition services staff was able to safely and effectively carry out the functions of the department, when one Dietary Aide (DA 22) incorrectly demonstrated how to calibrate a food thermometer. This failure in staff competence could led to incorrect food temperature, which could increase the risk of foodborne illness in the resident population of 47. Findings: On 7/23/25 at 11:22 A.M., an observation of DA 22 calibrating the food thermometer, with the presence of the Registered Dietitian (RD) and an interview was conducted with DA 22. DA 22 put some ice into a glass then put some water into it. DA 22 immersed the food thermometer into the glass with the probe touching the bottom and side of the glass. DA 22 stated he was unable to get the right temperature to calibrate the food thermometer. DA 22 asked Do I have to put more ice in it? On 7/24/25, a review of DA 22's culinary competency assessment tool was conducted. The assessment tool indicated DA 22 was signed off as competent 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 safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1.Food item had brown spots and was not able to be served to the residents. 2. Cool down process (hot food must be cooled within 2 hours to 70 degree Fahrenheit, additional 4 hours to less than 41 degree Fahrenheit, total of 6 hours to cool down hot foods) was not properly followed per the facility's policy on handling potentially hazardous food (PHF, means any food which consists in whole or in part of milk or milk products, eggs, meat, poultry, rice ,fish, shellfish, edible crustacean, raw-seed sprouts, heat-treated vegetables and vegetable products and other ingredients in a form capable of supporting rapid and progressive growth of microorganism) item. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.Findings: 1. On 7/21/25 at 8:07 A.M., an observation of the produce walk-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 interview, observation, and record review, the facility failed to implement their infection control policies and procedures when:1. Hand hygiene (washing hands or using hand sanitizer) was not offered to residents prior to eating in the dining room.2. Hand hygiene was not consistently performed during wound treatment. As a result there was a potential for cross contamination and transmission of infections to residents, staff, and visitors. 1a. On 7/21/25 at 11:20 A.M., an observation was conducted in the dining room. Two female residents in wheel chairs were being assisted by staff to table 10. Staff did not offer hand wipes or sanitizer to both residents. On 7/21/25 at 11:40 A.M., an observation of the female residents at table 10 was conducted. One of the two female residents was wheeled out of the dining room; Resident 42 remained seated and ate her lunch. Resident 42 held the bread roll with bare hands. On 7/21/25 at 12:40 P.M., an interview was conducted with Resident 42 from table 10. Resident 42…

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 implement its antibiotic stewardship program when two sampled residents' (Resident 33 and 39) infections and antibiotic use was not monitored and reviewed June and July 2025.As a result, Resident 33 and 39 were both on antibiotics without verification of a stop date. This potentially excessive use of antibiotics had the potential to contribute to antibiotic resistance (when bacteria or other microorganisms evolve to become resistant to the drugs designed to kill them) in the facility. Findings: 1.A review of Resident 33's Resident Face Sheet indicated the resident was re-admitted to the facility on [DATE] with a diagnosis of Unspecified dementia (a disease affecting cognition and memory), severe, with agitation. A review of Resident 33's physician orders, dated 6/13/25, indicated an order for nitrofurantoin macrocrystal (antibiotic) 100 milligrams (mg) one capsule once a day for UTI (Urinary Tract Infection) Prophylaxis with no stop date. 2. A review…

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 one of 13 residents (Resident 151) had a physician ordered medication available to be administered. As a result, Resident 151 was not administered one of his medications for six days. Findings: A review of Resident 151's admission Record indicated the resident was admitted to the facility on [DATE]. On 7/11/24 at 8:20 A.M., a medication administration observation was conducted with licensed nurse (LN) 3. LN 3 was observed preparing medications for Resident 151. LN 3 stated Resident 151's calcium carbonate with vitamin D 1250 milligrams-5 micrograms was not available for her to administer to the resident. A review of Resident 151's physician orders dated 7/5/24, indicated the resident was to receive calcium carbonated-vitamin D 500 mg tablet; 1250 milligram-5 micrograms once a day at 8 A.M. for the diagnosis of vitamin D deficiency. A review of Resident 151's medication administration record (MAR) indicated the resident's calcium…

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 follow the prn (as needed) guidelines for psychotropic medications (medications which alters the mind) for one of five residents (Resident 33) selected for Medication Review, when: 1. A specific behavior was not documented, indicating the necessity of a prn psychotropic medication; and 2. The physician did not document a rationale for the continued use of a prn psychotropic medication beyond the 14-day limit. This failure had the potential for Resident 33 to have increased risk of side effects and a prolonged duration of use. Findings: 1 Resident 33 was admitted to the facility on [DATE], with diagnoses which included non-traumatic intracerebral hemorrhage (bleeding in the brain), per the facility's Resident Face Sheet. On 7/10/24 Resident 33's clinical record was viewed: According to the physician's order, dated 3/17/24, Lorazepam (a drug used to treat anxiety, which act on the brain and nerves), 0.5 milligrams (mg) give twice a day, by mouth, under…

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 information in one of 13 resident's (Resident 3) medical/clinical record was readily accessible. As a result, it could not be determined if Resident 3 had been administered a controlled medication (medication with high potential for abuse). Findings: A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE]. On 7/11/24 at 4 P.M., copies of Resident 3's physician's orders, medication administration record (MAR), and controlled drug record (CDR, a written record that tracked when a controlled medication was removed from supply) for the resident's lorazepam (a controlled medication) 0.5 milligram tablets was requested from the medical records director (MRD). The MRD confirmed the requested documents would be available by 8 A.M. the following day. On 7/12/24, Resident 3's lorazepam 0.5 mg order, MAR, and CDR were reviewed. Resident 3's CDR indicated the resident's lorazepam had been removed from supply…

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 meal assistance provided to one sampled resident (Resident 3) was conducted in a sanitary manner when certified nursing assistant (CNA) 1 did not perform hand hygiene (washing hands or using an alcohol-based hand rub) after assisting another resident and did not wear gloves while feeding Resident 3 a sandwich using her bare hands. This deficient practice had the potential to spread microorganisms and to cause foodborne illness among residents. Findings: A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses to include right sided weakness and paralysis following a stroke, difficulty swallowing, and was receiving palliative care (end of life). On 7/9/24 at 12:35 P.M., a lunchtime observation was conducted in the dining room designated for residents that required staff assistance to eat. CNA 1 was observed feeding Resident A, touching the resident's wheelchair, 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 observations, staff interviews, and record reviews, the facility failed to ensure overall operational systems were established for oversight of the Food and Nutrition Services department. This failure to ensure an effective system for day-to-day dietary operations oversight may have placed 49 residents at risk for foodborne illness or further compromised their nutrition and health status due to unsafe, unsanitary, and improper dietetic service practices. Cross reference F802, F804, and F812 Findings: During the facility's recertification survey from 1/24/23-1/27/23, multiple deficient practices were identified in the Food and Nutrition Services Department's main and satellite kitchens, which included storage of expired, unlabeled, or undated foods; unsanitary kitchen food storage equipment; untrained staff in therapeutic diet food preparation; sanitary equipment cleaning; and no hairnet use with staff entry into the satellite kitchen. Findings: Storage of Expired, Unlabeled, and Undated Foods During the initial tour of the main kitchen on 1/24/2023 at 8:36 A.M. with 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 observations, interviews, and record review, the facility failed to ensure the kitchen staff obtained sufficient training to perform and competently when: 1. A Dishwasher (DSW) did not follow the proper procedure to clean dishes in the dish machine and was unable to demonstrate the correct process to test the dish machine sanitizer solution. 2. A DSW did not follow the manufacturer's guidelines for cleaning the Ice Machine. 3. Kitchen staff and non-kitchen staff did not follow food safety and sanitation practices by not wearing hair nets or performing hand hygiene when entering the satellite kitchen. 4. A DSW did not follow did not perform proper hand hygiene or change gloves after disposing the kitchen garbage and re-entering the kitchen. 5. Two Cooks and a Diet Aide were not trained on pureed diet preparation. These failures placed all residents at risk for developing a food-borne illness, and the potential for a choking hazard or altered nutrient intake for nine residents on pureed diets. Cross reference F800, F804, F812 Findings: 1. During a kitchen observation 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 record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. Expired ground meat was in the main kitchen PARVE (Jewish term that refers to neutral foods that may be eaten with milk and dairy or meats) walk-in refrigerator. 2. A dirty filter with gray lint, dust and black scum was inside the PARVE walk-in refrigerator's that contained uncovered pans of vegetables and meat. 3. The dish machine sanitizer solution was outside of the correct chemical range and tested at 200 ppm (parts per million); and the Dishwasher (DSW) could not correctly test the sanitizer. 4. The Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 5. [NAME] and flour were in large bulk unlabeled and dated in plastic bin containers. 6. A large plastic bin with 24 mighty shakes were found without the correct label and date in the satellite kitchen's reach-in refrigerator. 7. A case of vegetable egg rolls and case of rainbow sherbet ice…

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 consistently document a POLST (Physician Orders for Life-Sustaining Treatment) form signed by the family, physician's order, and the computer indicator for code status (Full resuscitation vs Do Not Resuscitate-DNR), for one of three residents (Resident 33), reviewed for Advanced Directives. As a result, there was the potential for Resident 33's wishes to not be honored based on staff confusion of what the resident's wishes were. Findings: Resident 33 was re-admitted to the facility on [DATE], with diagnoses which included pneumonitis (inflammation of the lungs), due to inhalation of food, per the facility's Resident Face Sheet. On 1/24/23, Resident 33's clinical record was reviewed: According to the POLST form, signed by Resident 33's Responsible Party (RP-a person assigned by the resident to make medical and financial decisions on the resident's behalf), dated 12/1/22. The POLST, section A was checked for .Attempt Resuscitation/CPR. Section A requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a physician's order for a pain medication was followed for 1 of 13 sampled residents (247) when the order for tramadol PRN at bedtime for pain was given at random times. The facility also failed to ensure pain medications ware ordered for all levels of pain for 1 of 13 sampled residents (247). As a result, there was the potential to not properly medicate the residents for pain Findings: Resident #247 was admitted to the facility on [DATE], with diagnosis that included a fractured right hip and surgical repair per the Record of Admission. A care plan for pain was developed on 1/13/23, That included three ordered pain medications: Tramadol, Percocet, and Tylenol. The first approach listed on Resident 247's care plan was to re-administer medications as ordered and evaluate slash record slash report effectiveness and any adverse side effects. An additional approach was to assess past effectiveness and ineffective pain relief measures. There was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed according to facility policy for two of two sampled Residents (2, 29) reviewed for oxygen use. In addition, an oxygen humidifier was not changed and replaced for Resident 29. These failures had the potential for residents to be exposed for infection and not receive adequate oxygen humidification. Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included atelectasis (collapsed lung) and respiratory failure with hypoxia (not enough oxygen) per the facility's Face Sheet. 2. Resident 29 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia per the facility's Face Sheet. On 1/24/23 at 8:57 A.M., Resident 29 was observed laying on her bed wearing an oxygen cannula (tube) connected to an oxygen concentrator. Resident 2 stated, My nose felt a little dry. The oxygen concentrator was set to three liters and connected to 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 interview and record review the facility failed to ensure nurses' clinical skills and competencies were maintained on an annual basis. This failure had the potential to affect Resident's quality of care and treatment. Findings: On 1/26/23 a joint interview and record review of nurses' competencies was reviewed with the DSD. The DSD stated when a new Licensed Nurse (LN) was hired, the LN attended an orientation in class and on the nursing unit. The DSD stated LNs went through an annual competency skill and used the form titled, Annual Competency Nurses. The DSD stated that the facility has not been doing the annual competency for about a year. On 1/27/23 at 7:15 A.M., an interview was conducted with LN 23. LN 23 stated she had been working in the facility for a year and was not sure if the facility had been doing an annual competency check. LN 23 stated it was important for the nurses to have an annual competency because it was a good reminder to refresh their skills and to make sure they were doing clinical procedures correct. In addition, LN 23 stated she did not have 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, interview, and record review, the facility failed to secure (lock) one of three treatment carts (South unit cart), reviewed for medication storage. Findings: On 1/25/23 at 10:33 A.M., an observation was conducted in the South unit. The treatment cart was unlocked, and no staff were nearby. The top two drawers contained multiple prescriptions of residents' creams and ointments. On 1/25/23 10:35 A.M. a observation and interview was conducted with LN 16. LN 16 was observed going to the medication cart, which was next to the treatment cart. LN 16 locked the treatment cart when she observed it was unlocked. LN 16 stated she locked the cart because, Someone could get into the cart, that should not be allowed to. On 1/25/23 at 10:45 A.M., an interview was conducted with the DSD. The DSD stated the treatment cart should be locked, whenever it was not in use. The DSD stated if the treatment cart was left unlocked, anyone could have access to prescription medications. On 1/26/23 at 11:12 A.M., an observation was conducted in the South unit. The treatment cart was left…

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 the pureed diet was prepared and served in a manner that conserved nutritive value, flavor, and appearance. This deficient practice affected the nutrient content and increased the risk of choking for eight residents on a pureed diet, and one sampled resident (R2) on a liquefied (drinkable) pureed diet. Cross reference F800, F802 Findings: During a kitchen observation and interview on 1/24/23 at 9:21 AM, [NAME] (CK) 2 had already prepared the pureed diet meals, prior to surveyor observation. The pureed diet lunch meal items including pureed vegetables, pureed hummus, pureed sausage, pureed pear, and pureed coleslaw were in individual 1x6-inch metal hotel shot pans inside the steamer warming. CK 2 stated there were eight residents on pureed diets and the lunch tray line service would start at 11:30 A.M. According to the facility's therapeutic menu spreadsheet on Monday, 1/24/23 for lunch, the pureed diets were to receive: 4 oz. pureed vegetables and 4 oz. of pureed hummus HOT, 4 oz. pureed sausage, 4 oz.…

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 safe infection control practices were followed when: 1. A kitchen aide did not disinfect hands between delivery of meals to residents in one of two resident dining rooms (main dining room), reviewed for dining observation task; and 2. A urinary catheter drainage bag was in contact with the floor for one of three residents (Resident 33), reviewed for urinary catheter care. As a result, there was the potential for cross contamination of microorganisms (bacteria, virus, fungus). Findings: 1. On 1/24/23 at 12:03 P.M., an observation was conducted in the main dining room during the first dining observation. Food server 16 (FS 16) was passing out coffee to residents sitting at a table. FS 16 was observed putting his gloved right hand on a resident's wheelchair handle as he leaned into the resident and asked her if wanted a bowl of soup. FS 16 returned to the coffee/soup area without changing his gloves or washing his hands 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.