Covenant Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted for 1 (Resident #30) of 2 residents reviewed for discharges. Findings included: A facility policy titled, MDS [Minimum Data Set] Completion and Submission Timeframes, revised 07/2017, indicated, Policy Interpretation and Implementation 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' [Centers for Medicare and Medicaid Services] QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare and Medicaid Services - Long term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024,…

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, record review, and facility policy review, the facility failed to ensure reusable resident care equipment was cleaned and disinfected after use and failed to ensure enhanced barrier precautions (EBP) were used for 1 (Resident #64) of 1 resident observed during wound care. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 09/27/2024, specified, Definitions: 'Enhanced barrier precautions' refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi-drug resistant organism] as well as those at increased risk of MDRO acquisition (e.g. [exempli gratia, for example], residents with wounds or indwelling medical devices). The policy revealed the section titled, Policy Explanation and Compliance Guidelines, included, c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that…

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 licensed nurses (LN) administered medications in accordance with professional standards of practice for one of seven sampled residents (Resident 5), when: 1. Resident 5's morning medications were left at the bedside unattended and not administered as prescribed by the physician on 9/16/24. This failure resulted in Resident 5 not receiving the medications as prescribed by the physician, which had the placed Resident 5 at risk for thrombosis (clotting of the blood), embolism (obstruction or blockage in a blood vessel) and had the potential for other facility residents to ingest the medications that were left unattended. 2. One of Two Licensed Nurses failed to lock the medication cart when the cart was out of the nurse ' s sight, according to the facility ' s policy and procedure (P&P). This failure had the potential for staff, visitors, or residents to access medications from the unlocked medication cart. Findings: During a concurrent…

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 one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1's call light was removed from the wall and taken away from her on 2/20/2024. This failure violated Resident 1's right to have her call light accessible and within reach and resulted in Resident 1 to feel isolated and alone and without the ability to call staff for assistance. Findings: During a review of Resident 1 ' s admission Record (AR), dated 3/7/24, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a history of Alzheimer (a brain disease that causes memory loss and other cognitive impairment), Right femur (upper leg bone) fracture (broken bone), Right Artificial Hip Joint (a surgical procedure in which an orthopaedic surgeon removes the diseased parts of the hip joint and replaces them with a new prosthesis), Muscle weakness, and Abnormal gait and mobility (unable to walk in a typical way). During a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions. Findings: During an interview on 9/29/23, at 2:05 p.m., with Resident 1, inside Resident 1's room, Resident 1 stated, On 8/18/23, the Social Services Director (SSD) 1 and Business Manager (BM) came to my room and gave me a copy of the Discharge Notice and they told me that the facility found a Residential Care Facility (RCFE, a homelike environment designed to promote resident independence and self-direction to the greatest extent possible in a residential, non-medical setting.) that is willing to care for me and I will be discharged 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 contain garbage and refuse (nonhazardous solid waste) properly when two out of three dumpsters were found to not have securely closing lids. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness. Findings: During a concurrent observation and interview, on 3/21/23, at 10:51 a.m., with Maintenance Supervisor (MS), in the back parking lot near the dumpsters, three dumpsters were observed with two lids atop of each the dumpsters. Two of the three dumpsters had lids that would not close. Two of the three trashcans were observed to have a gaps in the lids where they should be closed. MS stated, there were gaps between the lids on the two dumpsters observed and that a raccoon could potentially get inside the dumpster because of the gaps. During an interview on 3/22/23, at 9:15 a.m., with Housekeeping Supervisor (HS), HS stated the dumpster should have lids that close and the lids should be closed in the middle without 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 interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for seven of seven sampled residents (Residents 1, 22, 24, 36, 64, 81, and 367) when: 1. Resident 81 was receiving hospice services without a written physician order. 2. Resident 22 , Resident 367 and Resident 64 were receiving hospice services with unsigned hospice agreement. 3. Hospice personnel caring for residents under hospice services were not provided orientation to the facility's policies and procedures. These failures had the potential to place Residents 1, 22, 24, 36, 64, 81, and 367 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: 1. During a concurrent interview and record review, on 3/22/23, at 2:08 p.m., with the Acting Director of Nursing (DON), Resident 81's Physician's Order (PO),…

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 establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when the facility's ATB stewardship and surveillance program was not conducted for January 2023 and February 2023. These failures had the potential to place residents at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use. Findings: During a concurrent interview and record review on 3/27/2023, at 1:32 p.m., with Infection Preventionist (IP) 2, IP 2 stated IP 1 assumed the position two weeks ago. IP 2 stated she is covering for IP 1. IP 2 reviewed the Order Listing Report for the month of January and February 2023. The IP 2 stated, .There are no surveillance line listings for antibiotic use for the month of January and February 2023 . IP…

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 residents were treated with respect and dignity consistent with enhancing each resident's quality of life for three of 10 sampled residents (Residents 1, 366, and 21) when: 1. Resident 1 and Resident 366's fingernails were long with black and brown matter under the fingernails. 2. Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. These failures resulted in the facility not promoting the rights of Resident 1, 366 and 21 to a dignified and respectful existence and had the potential to compromise their health and well-being. Findings: 1. During a concurrent observation and interview on 3/22/23, at 9:00 a.m., with Certified Nurse Assistant (CNA) 8, Resident 1 was sitting in her wheelchair outside her room. CNA 8 stated, Resident 1 was a total care and requires assistance with Activities of Daily Living (ADLs), including during meals. CNA 8 stated, Resident 1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's current status for two of five sampled residents (Resident 75 and 59) when: 1. Resident 75's MDS assessment for hearing, speech and vision was not coded accurately. This failure had the potential for Resident 75 not being provided with the necessary care and services to meet her healthcare needs. 2. Resident 59's smoking status was not coded accurately in the MDS assessment. This failure had the potential for Resident 59's smoking safety and identified care needs to go unmet. Findings: 1. During an observation and interview on [DATE], at 10:41 a.m., with Resident 75, inside Resident 75's room, Resident 75 stated, her prescription eyeglasses was missing since yesterday and staff was not able to find her eyeglasses. Resident 75 stated, she uses her prescription eyeglasses for reading and watching…

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 develop and implement a person-centered baseline care plan within 48 hours of resident admission in the facility for 6 of 12 sampled residents (Residents 60, 80, 81 82, 84, and 107) when: 1. Resident 60 was sent out to general acute care hospital (GACH) on 2/18/23 for a high blood sugar, returned the following day and was sent to the hospital again on 2/23/23 for a swelling and bruising to right elbow as a result of altercation with another resident; care plans were not developed to prevent rehospitalization and keep her safe. This failure had a potential for Resident 60's blood sugar level and right elbow's swelling and bruising to not be monitored. 2. Resident 80 did not have a care plan in place for a critical lab result and received blood transfusion. This failure had a potential for Resident 80 for potential adverse reaction to blood transfusion and laboratory value to not be monitored. 3. Resident 81's care plan for oxygen administration which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for two of four sampled residents (Resident 13 and 84) when: 1. Resident 13's nutrition care plan was not revised with seven days to include significant weight losses on 12/18/22 or 2/1/23. This failure placed Resident 13 at risk for complications due to care needs not being planned by licensed nurses and the interdisciplinary team to determine if interventions needed to be added, changed or completed. 2. Resident 84's care plan was not revised within seven days to reflect the physician's order for diet and oral intake. This failure had the potential for Resident 84's nutritional needs to go unmet. Findings: 1. A review of Resident 13's medical record (MR) was initiated on 3/22/23. Resident 13 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), type 2 diabetes mellitus (a disease when the body's ability to produce…

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 professional standards of practice for seven of 12 sampled residents (Residents' 80, 82, 81, 83, 84, 38 and 107) when: 1. Licensed Nurse failed to follow the facility Change in a Resident's condition or status policy and procedure when Licensed Nurse did not conduct change in resident's condition assessment prior to sending Resident 80 out to general acute care hospital (GACH). This failure had the potential for Resident 80's change of condition to not being addressed by the nursing staff which could lead to delay of treatment and/or services. 2. Resident 81 was administered oxygen without following physician's order. This failure resulted in Resident 81 to receive a high dose of oxygen and had the potential to experience oxygen toxicity (a lung damage that happens from breathing too much supplemental oxygen; it can cause coughing and trouble breathing; in severe cases it can even cause death.) which can lead to difficulty in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care, services and activities of daily living (ADLs -activities related to personal care: bathing, oral care, brushing hair, shaving) for four out of 11 residents (Residents 32, 59, 71 and 91) when the facility did not routinely provide personal hygiene assistance according to the residents needs and preferences. This failure had the potential to result in oral infections, loss of teeth, body odor and skin irritations and infections. Findings: During a resident council meeting (an organized group of people living in a long-term care facility that meets on a regular basis to discuss concerns, develop suggestions on improving services or resolve differences) on 3/22/23, at 11:05 a.m., Residents 32, 29, 72 and 91 stated they were not receiving routine personal hygiene. During a review of Resident 71's admission Record, undated, the admission record indicated, Resident 71 was admitted to the facility on [DATE] with diagnoses which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) were provided to maintain good grooming for two of 10 sampled residents (Resident 1 and Resident 366) when: 1. Resident 1 and Resident 366's fingernails were long with black and brown matter under the fingernails. This failure resulted in Resident 1 and Resident 366's fingernails not being well groomed and the potential for harboring microorganisms (bacteria, virus, or fungus) or infection. 2. Resident 21's lips were dry and crusty and her teeth and tongue were covered with thick yellow and brown substance. This failure resulted in Resident 21's mouth not being clean and the potential for causing oral pain, harboring microorganisms or infection. 3. Facility staff did not provide personal hygiene to ensure Resident 47's fingernails and toenails were short, even, trimmed, and clean at all times, and staff did not trim Resident 47's long facial hair above her upper lip. This failure to provide necessary…

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 residents remained free from accidents and accident hazards as is possible, for one of 12 sampled residents (Resident 47), when: 1. Resident 47 had an unwitnessed fall on 12/9/22, and the facility did not assess Resident 47's risk for falls; did not conduct a change in condition (CIC, a process of evaluation to identify and promptly report and communicate a resident's change of condition to appropriate healthcare personnel), and the interdisciplinary team (IDT, a group of healthcare professionals who work together to assess, develop, implement, and evaluate each resident's treatment plan) did not review or discuss the root cause of Resident 47's fall in order to make recommendations for appropriate resident-centered care plan interventions that could prevent further falls and injuries. This failure resulted in Resident 47 sustaining repeated falls on 2/23/23, 3/19/23, and 3/22/23, Resident 47 experienced pain, bruises and injuries.…

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 the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met for one of four sampled residents (Resident 10) when Resident 10 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) and monitoring for complications on multiple dates. This failure placed Resident 10 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through the blood vessel) access sites. Findings: During a concurrent observation and interview on 3/22/23, at 9:15 a.m., in Resident 10's room, Resident 10 was observed seated up in bed eating and dressed appropriately for the weather. Resident 10 stated she goes to dialysis in Fresno and she gets picked up by a transport company. During a record review of Resident 10's, admission Record, undated, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 212 and Resident 366) were assessed for bed rail risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed) prior to bed rail installation. Facility failed to obtain informed consent (form signed by resident or family explaining the risks of side rail use), physician order with indication for use, and care plan prior to the use of bed rails when Resident 212 and 366 had two raised upper bed rails. This failure had the potential to place Resident 212 and Resident 366 at risk for decreased freedom of movement, entrapment and/or injury. Findings: 1. During a concurrent observation and interview on 3/21/23, at 9:12 a.m., with Resident 212, in Resident 212's room, Resident 212 was laying in bed with two half bed rails raised up. Resident 212 stated she used the bed…

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 Surveyor: King-Rabetsimba, Nic Surveyor: [NAME], [NAME] Based interview and record review the facility failed to periodically and accurately reconcile controlled substances (CS-medication which can be easily abused and under strict government control) when nursing staff did not ensure accurate controlled substance accountability for two of three resident's CS records (Resident 75 and 211). This failure had the potential for Resident 75 and 211 not to be adequately treated for their pain and had a potential for diversion (used illegally) of controlled substance medication. Findings: During a review of Resident 211's Face Sheet (FS- a documented containing resident's personal information), dated 3/23/23, the FS indicated Resident 211 was , admitted [DATE]. The FS indicated, diagnosis Partial traumatic amputation (at least half the diameter of the injured extremity is severed at level between right hip and knee) .Encounter for orthopedic aftercare following surgical amputation. During a review of Resident 211'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 4, 73, 99, 261) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behaviors) medications including quetiapine (antipsychotic medication),olanzapine (antipsychotic medication for bipolar disorder, depression, and schizophrenia) and escitalopram(an antidepressant medication for depression, alcoholism, and schizophrenia) when: 1. Resident 73 was administered olanzapine with no resident specific non-pharmacological interventions were implemented prior to and during use of olanzapine, and no annual gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose of if the dose or medication can be discontinued) was attempted. 2. Resident 99 was administered quetiapine without an appropriate indication and/or clinical justification, no documentation of behaviors to support the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with current accepted professional standards of practice for a facility of 109 when: 1. Medications for Resident 1, 59, 74, 89, 96, 97, 411, 412 did not have patient identifiers. 2. Two tuberculin (used tuberculosis screening) 1 ml (milliliter- unit of measure) vials were found open, partially used and expired, and one Influenza vaccine (a vaccine that protects against the flu) 5 ml vial did not have an open or discard date. These failures had the potential for medication to be given to the incorrect resident which could cause adverse reactions (harmful, unintended result caused by a medication) and for expired tuberculin and influenza vaccine to be given to residents, decreasing the effectiveness of the tuberculin screening and influenza vaccine. Findings: 1. During an observation and concurrent interview on [DATE], at 2:15 p.m , with Licensed Vocational Nurse…

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

Based on observation, interview and record review, the facility failed to ensure the menu was followed when: 1) the Fried [NAME] puree recipe for the lunch meal on 3/23/23 for 17 of 110 residents (Residents 1, 4, 13, 20, 22, 24, 42, 43, 50, 64, 68, 70, 77, 82, 366, 367, 368) was not followed. 2) the Stir Fry Vegetables puree recipe for the lunch meal on 3/23/23 for 17 of 110 residents (Residents 1, 4, 13, 20, 22, 24, 42, 43, 50, 64, 68, 70, 77, 82, 366, 367, 368) was not followed. This failure had the potential to result in not meeting the nutritional needs of the residents and further compromising their medical status. Findings: 1) During a review of the facility document titled, Spring Cycle Menus Week 3 Thursday (menu), dated 3/23/23, the menu indicated for the lunch meal on the puree (blend foods to make it easier to swallow) diet the following: .Szechuan Pork .P .Fried [NAME] .P .Stir Fry Vegetables .P #12 .Parsley Sprig .Flakes .Confetti Coleslaw .P- #12 .Tapioca Pudding .Plain Pudding .Milk .#8=1/2 [cup] (c-unit of measurement) .#12=1/3c .#16=1/4c .P=Pureed . During 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.

Based on observation, interview and record review, the facility failed to ensure professional standards for food safety guidelines were followed when: 1. The ice machine filter screen was on the floor with paper debris, gloves, and dirt; the filter was covered with off-white dirt residue, the ice machine's interior cover had light pink and off-white to light brown color substance in the interior cover; and one rectangular ice machine swithbox was on top of the counter next to a bowl of cut apples and a tray holding special drinking glasses to be used by residents requiring these special devices. 2. Thirty-two (32) cooking and serving utensils were stored inside a rubber lined wooden drawer that was covered with unidentified black spots, food debris, dirt and moist area. Some of the utensils had caked-in substances on its grooves and/or handles. The drawer emitted a rancid ( ) and bad odor. These failures had the potential to result in foodborne illnesses (illness caused by consuming contaminated food) from the growth of microorganisms (a germ that can only be seen through 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.

F813 Based on observation, interview, facility document and policy and procedure review, the facility failed to ensure a policy regarding use and storage of foods brought to residents by family and other visitors was followed to ensure safe and sanitary storage, handling, and consumption. This failure had the potential to limit the resident's rights and enjoyment of food brought in by family or visitors. Findings: On 3/22/23 at 10:34 a.m. an interview was conducted with the Infection Preventionist (IP) 1. When asked how the facility handled food brought to the residents from family or visitors, the IP 1 stated if food was brought to the residents from family or visitors, it must be consumed within two hours, or the food would be discarded. On 3/22/23 at 10:52 a.m. a review of the undated facility document titled, Important Rules Regarding Food and Beverages Not Prepared by Facility Staff, and concurrent interview was conducted with Administrator (ADM). The ADM stated the undated document titled Important Rules Regarding Food and Beverage Not Prepared by the Facility Staff was like 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 interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for four of 12 sampled residents (Residents 107, 108, 211 and 71) when: 1. Resident 107's copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was not signed and readily available as part of Resident 107's current medical records. 2. Resident 108's copy of Consent to Treat, Bed Hold Notification and Influenza-Pneumococcal Immunization Consent or Declination Form were not signed and readily available as part of Resident 108's current medical records. 3. Resident 211's copy of Informed Consent was not signed and readily available as part of Resident 211's current medical records. These failures had the potential risk for Residents' 107, 108 and 211's decisions regarding their healthcare…

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 maintain an effective infection control program when: 1. Two of six sampled residents' (Resident 14 and 81) oxygen concentrator (a device that concentrates the oxygen from the ambient air) were found covered with lint and dust. This failure placed Residents 14 and 81 at an increased risk to develop respiratory and healthcare-associated infections. 2. The Maintenance Supervisor (MS) failed to call pest control on 3/21/23 and 3/22/23 when pest were seen in the facility. This failure potentially placed facility residents at an increased risk for foodborne-related illness. 3. Licensed Vocational Nurse (LVN) 4 failed to properly disinfect resident shared blood pressure cuff (a device used to measure blood pressure) prior to and after resident care. This deficient practice had the potential for the development and the spread of infection to all residents. Findings: 1. During a concurrent observation and interview on 3/22/23, at 9:34 a.m., in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility policy and procedure review, the facility failed to ensure kitchen equipment was maintained in safe operating condition when: 1. The ice machine manufacturer cleaning instructions were not followed, 2. The walk-in refrigerator interior wall was not a cleanable surface, and 3. A food preparation sink was not in proper working order. These failures had the potential to affect the equipment not functioning in the way it was intended which could affect the health status of the residents. 4. One of six sampled residents' (Resident 14) oxygen concentrator was found operating without a filter. This failures placed Residents 14 at an increased risk to develop respiratory and healthcare-associated infections. Findings: 1. On 3/21/23 at 10:08 a.m. an observation of the facility ice machine located in the kitchen and concurrent interview with the Maintenance Supervisor (MS) was conducted. The MS was asked to describe how he cleaned the ice machine. The MS stated he turned 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 interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 75) personal eyeglasses were not inventoried upon admission. This failure resulted in Resident 75's loss of personal eyeglasses. Findings: During an observation and interview on [DATE], at 10:41 a.m., with Resident 75, inside Resident 75's room, Resident was observed sitting on the edge of her bed and watching TV. Resident 75 stated her prescription eyeglasses was missing since yesterday and staff was not able to find her eyeglasses. Resident stated she use her eyeglasses for reading and watching TV. Resident 75 stated, The eyeglasses meant a lot for me. My husband bought it for me before he died. I want it back. During an interview on [DATE], at 10:39 a.m., with Social Services Director (SSD) 2, SSD 2 stated, Resident 75's missing prescription eyeglasses was reported missing on [DATE]. SSD stated, she was aware Resident 75's prescription eyeglasses were last seen on [DATE]. During a concurrent…

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 ongoing activity program to meet the needs, for one of six sampled residents (Resident 89) when Resident 89, who was identified as needing exercise-focused activities due to morbid (severe) obesity (overweight) related to depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and physical sedentary (way of life characterized by too much sitting, lying in bed, and having little or no physical exercise), was not provided with exercise-focused activities as recommended by the Registered Dietitian (RD, a health professional trained in diet and nutrition to help people improve their health and well-being through healthy diet, good eating habits, and exercises for weight control). This failure had the potential to result in Resident 89 to continue to gain more weight that could interfere with breathing, walking, or in performing basic activities of daily living (ADL); and placed Resident 89 at…

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

Based on observation, interview, record review, and manufacturer's guidelines for use, the facility failed to maintain sanitary conditions when preparing and distributing food in accordance with professional standards for food service safety when: 1. A bucket containing sanitizing solution used in the kitchen did not meet manufacturers guidelines and 2. Kitchen staff did not wash hands after touching food and prior to plating food in the tray line. These failures had the potential for food preparation and distribution to not occur under sanitary conditions. Findings: 1. On 1/16/19 at 8:30 AM, during a concurrent observation and interview, the Director of Dining Services (DDS) dipped a test strip into a red bucket which contained a cloudy cleaning solution. The DDS swirled the strip in the solution for approximately three seconds. The strip was pale green at the top and bottom and approximately three inches of beige color. She held the strip against the manufacturer's color scale (determines the amount of cleaning solution in the water; recommendation was for the strip to read…

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 Surveyor: Ovanisyan, Suren Based on interview and record review, the facility failed to develop a comprehensive person centered care plan to establish care needs, interventions and measurable objectives for three of 69 sampled residents (Resident 78 and 302) when: 1. Resident 78 did not have a care plan with measurable goals and interventions for the diagnosis and treatment of pneumonia (lung infection). 2. Resident 302 did not have a care plan with measurable goals and interventions for the diagnosis of Clostridium difficile (C. diff) (infection of the colon-large intestine). 3. Resident 10's care plan for diabetes (abnormal metabolism of carbohydrates resulting in elevated levels of glucose in the blood and urine) was not revised to reflect individualized effective interventions or targeted blood sugar values which frequently ranged between 300 milligrams per deciliter (mg/dL) (a unit of measurement) to 400 mg/dL (normal blood sugar level on an empty stomach range between 70 and 99 mg/dL, normal blood sugar…

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 residents received treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan for two of 69 sampled residents (Resident 10 and Resident 462) when: 1. Resident 10's physician did not provide, and licensed nurses did not clarify, the blood glucose (sugar) parameters for which to notify and alert the physician after elevated blood sugar values continued for three months. 2. Resident 10's care plan for diabetes (abnormal metabolism of carbohydrates resulting in elevated levels of glucose in the blood and urine) was not revised to reflect individualized effective interventions or targeted blood sugar values which frequently ranged between 300 milligrams per deciliter (mg/dL) (a unit of measurement) to 428 (normal blood sugar level on an empty stomach range between 70 and 99 mg/dL, normal blood sugar level two hours after eating is less than 140 mg/dL). 3. Resident 462's dilantin (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 residents were free from unnecessary psychotropic (drugs that affect a person's mental state) drug use when: 1. Psychotropic medications were administered longer than 14 days as a PRN (as needed) designation rather than for a limited time period for one of 69 sampled residents (Resident 29). 2. There was no reduction done as ordered for one of 69 sampled residents (Resident 91) when Resident 91's physician order to reduce the medication Abilify (psychotropic medication) was not followed. These failures had the potential to result in Resident 29 and Resident 91 receipt of medications without the benefit of a physician assessment for the extended need. This failure placed Resident 29 and Resident 91 at potential risk of receiving unnecessary psychotropic medications. Findings: 1. On 1/22/19 at 10:47 a.m., during a concurrent interview and record review, Social Services Director (SSD) 1 reviewed Resident 29's physician orders dated 1/2019, which indicated, . Alprazolam (medication for anxiety) 0.25 milligrams (mg) (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.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional standards when: 1. Expired medications were found in the medication cart, and in the Automated Dispensing Unit (ADU; a drug storage device used to track drug distribution), 2. Medications that were required to be dated when opened were found in the medication cart opened and undated, 3. Resident's medications from home were found opened and unlabeled in the medication cart, and 4. A medication refrigerator temperature log was not completed. This failure resulted in four of 69 sampled residents, Residents 54, 27, 38, and 78, receiving expired and potentially expired medications; one of 69 sampled residents, Resident 19, not receiving medications as ordered, and multiple residents having the potential of receiving medication stored at incorrect temperatures. All of these failures had the potential to cause ineffective medication treatment. Findings: 1. On 1/17/19 at 9:20 AM, during a concurrent…

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 maintain an effective infection control program for four of six sampled residents (Resident 51, Resident 86, Resident 77, and Resident 69) when: 1. Resident 51's nebulizer tubing (drug delivery device used to administer medication in the form of mist inhaled into the lungs through a mouth piece or face mask) was undated. Resident 51's Continuous Positive Airway Pressure (C-pap; forces air into the nasal passages at pressure high enough to overcome obstruction in the airway and stimulate normal breathing) face mask had brownish yellow residue. 2. Resident 86's shared bathroom had an unlabeled urinal; Resident 77 and Resident 69's urinals (portable receptacles used by men for urinating at bedside) were on top of the night stand unlabeled. 3. Medication syringe was found in the medication cart with pink colored liquid residue in the tip. These failures placed Resident 51, Resident 86, Resident 77, and Resident 69 at risk of exposure to healthcare-associated infection. Findings. 1. On 1/16/19 at 9 AM, during 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, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of 69 sampled residents (Resident 41) when Resident 41's gastrostomy tube (g-tube) (a tube inserted through an incision in the abdomen that delivers nutrition directly to the stomach) was visible while Resident 41 was asleep in the facility's hallway. This practice failed to provide Resident 41 with privacy to ensure dignity and respect which resulted in Resident 41's g-tube to be visible to other residents and visitors in the facility and violated Resident 41's right to keep her nutritional status confidential. Findings: Review of Resident 41's clinical record, titled, Face sheet (a document containing resident profile information) indicated Resident 41 was admitted to the facility with diagnoses which included gastrostomy status. On 1/22/19 at 3:06 p.m., during an observation in the facility's hallway, Resident 41 sat in her wheelchair and was asleep. Resident 41's g-tube hung between Resident 41's blouse and pants and was visible to other…

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 provide services which meet professional standards of quality for three of 69 sampled residents (Resident 10, Resident 51 and Resident 36) when: 1. Resident 10's physician did not provide, and licensed nurses did not clarify, the blood glucose (sugar) parameters for which to notify and alert the physician after elevated blood sugar values continued for over 30 days. 2. Licensed nurses did not clarify with Resident 51's physician the flow rate for supplemental oxygen (O2) administration and administered supplemental O2 without a complete physicians order. 3. Resident 36's Midrodine (a medication used to treat low blood pressure) was not administered to Resident 36 on 12/18/18 when Resident 36's blood pressure was 81/48 per physician's order and no blood pressure parameter was in place to determine when to administer the Midodrine medication. For Resident 10 this failure resulted in the administration of medication without parameters which could be harmful without the benefit of adequate monitoring and reporting…

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 report medication irregularities for one of 69 sampled residents (Resident 66) when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's ordered dose of 30 mg. daily. This failure resulted in Resident 66's receipt of a higher dose of medication than the physician ordered daily from 12/9/18 through 1/22/19 which placed the resident at risk of adverse reactions from the higher dosage. Findings: On 1/22/19 at 10:32 a.m., during an interview, Licensed Nurse (LN) 8 stated she administered Duloxetine to Resident 66 from the medication cart bubble pack (a card containing multiple doses of a medication, separated into individual doses). LN 8 stated she did not remember giving Resident 66 half a capsule of the Duloxetine. LN 8 stated if a physician's order did not match the directions on the bubble pack she should clarify with the physician. LN 8 stated the Duloxetine medication order did not match the directions…

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 report medication irregularities for one of 69 sampled residents (Resident 66) when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's order dose of 30 mg. This failure resulted in Resident 66 to receive more than the physican prescribed dose of Duloxetine medication daily from 12/9/18 through 1/22/19 which placed the resident at risk of side effects of a high dose of medication. Findings: On 1/22/19 at 10:32 a.m., during an interview, Licensed Nurse (LN) 8 stated she administered the Duloxetine to Resident 66 from the medication cart bubble pack (a card containing multiple doses of a medication, separated into individual doses). LN 8 stated she did not remember giving Resident 66 half a capsule of the Duloxetine. LN 8 stated if a physician's order did not match the directions on the bubble pack she would clarify with the physician. LN 8 stated the Duloxetine medication order did not match the directions…

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 one of 69 sampled residents (Resident 66) was free from significant medication error when Resident 66 was given a Duloxetine (an antidepressant medication) 40 milligrams (mg- a unit of measurement) from 12/9/18 to 1/22/19 instead of the physician's ordered dose of 30 mg daily. This failure resulted in Resident 66's receipt of a higher dose of medication than the physician ordered daily from 12/9/18 through 1/22/19 which placed the resident at risk of adverse reactions from the higher dosage. Findings: On 1/22/19 at 10:32 a.m., during an interview, Licensed Nurse (LN) 8 stated she administered Duloxetine to Resident 66 from the medication cart bubble pack (a card containing multiple doses of a medication, separated into individual doses). LN 8 stated she did not remember giving Resident 66 half a capsule of the Duloxetine. LN 8 stated if a physician's order did not match the directions on the bubble pack she should clarify with the physician. LN 8 stated the Duloxetine medication order did not match 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.