Broadway Manor Care Center

Based on observation, interview, and record review, the facility failed to ensure that one of three sample residents (Resident 2, a resident who had kidney failure (failure of the kidney to filter toxins and remove extra fluid in the body) and receives hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) fluid intake restriction was monitored properly and followed the Registered Dietitian's (RD) fluid restriction recommendation of 750 to 1500 milliliters (mL, unit of measure) as indicated in the Nutritional Assessment on 1/26/2026. These failures had the potential to place Resident 2 at risk for altered hydration status which may lead to severe dehydration or fluid overload which may result in a hypotensive (low blood pressure) or hypertensive (high blood pressure) blood pressure emergency, edema (swelling), shortness of breath, heart failure (heart cannot effectively pump blood to the rest of the body) and may ultimately lead to hospitalization. Findings: During a review of Resident 2's…

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

Based on observation, interview, and record review, the facility failed to ensure that Certified Nurse Assistant (CNA) 6 had the competency skill to accurately monitor and document one of one sampled residents (Resident 2) food intake who was receiving a renal diet (a specialized diet prescribed by the physicians for residents with kidney disorder) as indicated in the facility's policy and procedures. This failure had the potential to place Resident 2 at risk for unintended weight loss and fluid deficit or excess that could further decline in her nutritional management. Findings: During a review of Resident 2's admission Record (AR), the facility admitted Resident 2 on 12/27/2023 and readmitted Resident 2 on 1/16/2026 with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD, irreversible kidney failure), and hypothyroidism (thyroid does not make enough thyroid hormone to meet the body's needs). During a review of Resident 2's History and Physical (HP), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, the facility failed to provide care and services to one of one sampled resident (Resident 8) with loss of dentures in accordance with facility policy and procedure titled Dental Services. This deficient practice had resulted in the Resident 8's ability to chew his food that could lead to choking or pain with chewing potentially leading to weight loss. Findings: During a review of Resident 8' face sheet, the face sheet indicated Resident 8 had an initial admission on [DATE] with the diagnoses but not limited to; major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , chronic ataxia (neurological sign characterized by impaired muscle coordination that leads to unsteady movements) and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/11/2025, MDS…

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 complete and accurate medical records were complete and accurate for 2 of 8 sampled residents (Resident 64 and 42) by failure to ensure: Advance Directive (document used to verify and record that the resident or legal representative was informed of their rights to accept or refuse treatment) for Resident 64 was dated. Physician Orders for Life -Sustaining Treatment form (POLST- a physician's order that includes level of medical intervention) for Resident 42 contained required signature. This failure had the potential to result in confusion regarding the validity of resident's treatment preferences and delay or delivery of care that may not have been consistent with the residents wishes. Findings: During a review of Resident 64's admission Record indicated the facility admitted the resident originally on 09/07/2022, with a diagnosis of acute respiratory failure( lungs cannot get enough oxygen into the blood), kidney failure( kidneys cannot properly filter waste and excess fluid from the blood) and atrial…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's infection control program for one of eight sample residents (Resident 62) by failing to assess and document signs and symptoms of respiratory infection as indicated in the facility's policy and procedure titled Infection Control. This deficient practice placed other residents at risk of repiratory infection. Findings: During a record review of Resident 62's admission Record (AR) the AR indicated Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), encephalopathy (malfunction of the brain that alters its structure or function), respiratory syncytial virus (RSV - a common, contagious virus causing mild, cold-like symptoms in most people but it can lead to severe lung infections like bronchiolitis or pneumonia in older adults). During a record review of Resident 62's Minimum Data Set (MDS - a resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67). This deficient practice had the potential to result in confusion regarding the care and services provided to the residents, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: 1.During a review of Resident 2's admission Record indicated the facility admitted Resident 2 on 4/30/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hyperlipidemia (a condition where there are high levels of fat in the blood). During a review of Resident 2's MDS summary 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.

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices in accordance with the facility ' s policy and procedure by failing to ensure the scoop was not left inside the thickener (products used to modify the consistency of drinks, helping people with dysphagia [difficulty swallowing to control the way they swallow]) container/bin after each use. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated (transfer of disease-causing organism the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) food. Findings: During a kitchen observation on 12/17/24 12:30 PM, in the presence of the Dietary Supervisor (DS), a scoop was found inside the thickener container with its handle touching the contents. DS stated that the scoop should not have been left inside the container because the handle could introduce bacteria or other contaminants, leading to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility's Quality Assurance Performance Improvement (QAPI-a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) committee failed to develop and evaluate a QAPI plan to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) were transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67) which was an identified care area concern from the last annual recertification survey conducted from 12/18/2023 to 12/21/2023. These deficient practices had resulted in the late MDS transmission to the CMS data system that affects the care planning, quality of care and quality of life of the residents. Findings: 1. During a review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 4/30/2024 with diagnoses that included dementia (a general term for the impaired…

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 accommodate the needs of one of two sampled residents (Resident 14) in accordance with the facility's policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 14 not able to call the facility staff to ask for help or assistance especially during emergency. Findings: During a review of Resident 14's admission Record, indicated the facility originally admitted Resident 14 on 7/31/2024 and readmitted on [DATE] with diagnoses that included generalized anxiety disorder (worry that are difficult to control and interfere with day-to-day activities), difficulty walking, and generalized muscle weakness. During a review of Resident 14's, Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 11/7/2024, indicated Resident 14 required supervision or touching assistance (helper provides…

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 provide a safe and homelike environment for one of two sampled residents (Resident 50) with five plastic bags tied together and used as an extension to pull as a string to turn on and turn off the overhead light above the bed. This deficient practice had the potential to cause accident and created a non homelike environment and frustration to Resident 50 when pulling the string. Findings: During a review of Resident 50's admission Record, indicated the facility originally admitted Resident 50 on 10/27/2023 and readmitted on [DATE] with diagnoses that included Dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness), depression (a constant feeling of sadness and loss of interest), and psychosis (loss of contact with reality). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated…

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 closed record review, the facility failed to ensure that one of three sampled residents (Resident 58), indicated the reason of discharge or transfer in the Notice of Proposed Transfer/Discharge form (a written notification to the resident or responsible party that included the reason for the transfer or discharge, where the resident will be transferred or discharged to, how to contact the State Long Term Care Ombudsman, and how to appeal the transfer or discharge if necessary) was not completed in accordance with the facility's policy and procedure. This deficient practice violated the residents right and the facility's policy procudere that had the potential for Resident 38 not to be informed about the reasons of his transfer/discharge. Findings: During a review of Resident 58 ' s admission Record (Face Sheet), indicated the facility admitted Resident 58 on 3/20/2023, and readmitted on [DATE] with diagnoses including Alzheimer's disease (progressive brain disorder that affects the person…

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 complete the Notification of bed-hold and Return form (a form that indicates the resident's rights to return to the facility after hospitalization) in accordance with the facility's policy and procedures, for two of three sampled residents (Resident 38 and 58) who were transferred to the General Acute Care Hospital (GACH) as ordered by the physician. This deficient practice resulted in the violation of the resident's rights to be informed about the Notification of bed-hold and Return policy and to be aware that he/she can return to the facility after hospitalization as ordered by the physician. Findings: 1. During a review of Resident 38's admission Record (Face Sheet), the facility admitted Resident 38 on 1/14/2023, and readmitted on [DATE] with diagnoses including Alzheimer's disease (end stage renal disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis), heart failure (a condition in which the heart…

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 follow up a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) evaluation for two of two sampled residents (Residents 49 and 69): 1. For Resident 49 who assessed as having positive level 1 screening on 4/29/2022, indicated required a level II mental health screening. 2) for Resident 69 who assessed as having negative level 1 screening on 6/3/2024, indicated to resubmit a PASRR level 1 screening if the resident remained at the facility longer than 30 days. (Resident 69 remained in the facility for more than six months and still in the facility. This failure had the potential to result in Resident 49 and Resident 69 not to receive care and services in the most integrated setting…

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 one sampled resident (Resident 20) who had a right heel blood filled blister, had an air loss mattress ( LAL- mattress designed to prevent and treat pressure sore [a skin breakdown due to unrelieved pressure and friction to the skin]) setting was not set according to residents weight, the manufacturer's guidelines was set based on the resident's weight to prevent and/or minimize skin pressure on the bony prominences of the body. This deficient practice had the potential to delay healing, worsened pressure sore and that negatively affect Resident 20's quality of life. Findings: A review of Residents 20's admission Record indicated the resident was admitted , on 11/6/2024 with diagnoses that included atherosclerosis on native arteries of extremities, bilateral legs (cause long-term poor blood flow in your legs), peripheral vascular disease (PVD-a condition where blood vessels in your arms or legs become narrowed, preventing enough blood from reaching those areas), diabetes mellitus (lifelong…

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 three sample residents (Resident 70) who was incontinent (no control) of bladder receives appropriate treatment and services for the urinary indwelling catheter (or Foley Catheter is a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) by failing to: 1. Assess and document presence of sediments (visible solid particles in the urine containing blood, crystals and bacteria, including sloughing of tissue (debris), or cells) in the urine which commonly due to urinary tract infection (UTI). 2. Notify the physician presence of sediments in Resident 70's urine. 3. Securely anchor Resident 70's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent from pulling tractions and dislodgement of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a supply of Norco (a medication used to treat pain) was available pursuant to an active physician order for one of five residents (Resident 44) observed for medication administration. The deficient practice of failing to maintain an adequate supply of Resident 44 ' s pain medication increased the risk for the resident to experience pain at a higher level for longer than necessary due to the unavailability of his medication that could lead to a decline in his quality of life. Findings: A review of Resident 44 ' s admission Record (a document containing a resident ' s demographic and diagnostic information), dated 12/18/24, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including osteoarthritis of the knee (a medical condition caused by a gradual wearing down of protective cartilage between the bones in the knee joints causing stiffness, swelling, and pain.) 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 observation, interview, and record review the facility failed to ensure the entire dose of warfarin (a blood-thinning medication used to prevent life-threatening blood clots from forming) 2.5 milligrams (mg - a unit of measure for mass) was administered via gastrostomy tube (g-tube - a tube surgically implanted in the stomach for feeding and medication administration) in accordance with the physician ' s order on 12/17/24 for one of five residents (Resident 279) who observed during medication administration. The deficient practice of failing to administer Resident 279's entire dose of warfarin 2.5 mg could increase the risk of the resident to develop blood clot and result in a stroke (interruption of blood flow to the brain) or heart attack (lack of or interruption of blood flow to the heart) due to blood clot and/ or other complications resulting from blood clots that could lead to hospitalization or death. Findings: A review of Resident 279 ' s admission Record (a document containing a resident ' s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prepare and served food and menus that meet resident choices including their nutritional needs by failing to: 1. Ensure [NAME] 1 and [NAME] Assistant uses and have access to preparation guides and recipes during food preparation or puree diet (blended until they reach a smooth consistency) and thickened liquids for 18 of 18 residents receiving puree diet. 2. Ensure one of three sampled residents ( Resident 17) received double portion of meat as specified in the physician's order. This had the potential for residents to not receive the nutrition they need that could lead to food dissatisfaction and weight loss. Findings: 1.During a tray line observation on 12/17/2024 at 11:45 AM, [NAME] 1 was observed preparing a puree diet by scooping a powder of thickener (products used to modify the consistency of drinks, helping people with dysphagia (difficulty swallowing to control the way they swallow ) directly from the jar and adding it to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure to administer the morning medications as ordered by the physician for one of three sampled residents (Resident 1), who receives dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) treatments three times a week outside the facility, at 7:45 AM as ordered by the physician. This deficient practice had the potential for worsening Resident 1 ' s medical condition such as fluid overload, high blood pressure, and heart complications. Findings: During a review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis, hyperglycemia (high blood sugar), hypertension (high blood pressure). During a review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a resident was free from significant medication error by failing to administer insulin as ordered by the physician for one of three sampled residents (Resident 1), who receives dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) treatments three times a week outside the facility. This deficient practice had the potential for Resident 1 to have high blood sugar and complication such as Diabetic ketoacidosis (condition develops when body does not have enough insulin and glucose can't enter cells for energy, blood sugar level rises, and body begins to break down fat for energy which produces toxic acids called ketones. Ketones accumulate in the blood and eventually spill into the urine. Diabetic ketoacidosis can lead to a diabetic coma that can be life-threatening. Findings: During a review of Resident 1's Face Sheet…

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 treat one of four sampled residents (Resident 4) with respect and dignity by failing to ensure to maintain Resident 4 ' s bodily privacy during an inspection of her G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach) by LVN 1, which resulted in the resident's gastrointestinal tube being exposed in the resident ' s common Dining Area. This deficient practice had the potential to negatively impact residents leading to shame, depression, and embarrassment, diminishing the importance of emotional and psychological health. Findings: 1. A review of Resident 4 ' s admission Record indicated the resident was admitted on [DATE], with diagnoses that included dysphagia (difficulty swallowing or not able to swallow) and gastro-esophageal reflux (a condition which the stomach contents move up into the throat) disease. A review of Resident ' 4 History and Physical dated 5/21/24, indicated the resident dis not have the capacity to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a standardized assessment and screening tool) were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) data base within the required time frame for 5 of 14 sampled residents (Residents 26, 65, 58, 28, 40). This deficient practice had the potential to negatively affect the provision of necessary care and services and care planning to ensure they meet their highest potentials for Residents 26, 65, 58, 28, 40). Findings: 1. A review of Resident 26's admission Record, dated 12/20/23 indicated, Resident 26's was admitted on [DATE], with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities]. A review of Resident 26's quarterly MDS, dated [DATE], as the assessment reference date (ARD- last day of the observation period that the assessment covers for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to failure of the licensed staffs to follow the facility's policy and procedure on medication administration for three of four selected residents (Residents 26, 13 and 28) during medication administration observation. These deficient practices resulted in four (4) medication errors out of twenty-seven opportunities (medications observed administered or attempted to administer) which resulted in a medication administration error rate of fifteen percent (15%), that exceeded the five (5) percent threshold. Cross reference to F760 Findings: During an observation of the medication pass, on 12/20/23, there were three medication errors, which included: 1. A review of Resident 26's admission Record, dated 12/19/23, the record indicated, Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (the loss of cognitive functioning…

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 its residents were free from significant medication error as indicated in the facility's policy and procedure related to medication administration by failing to: 1. For Resident 26, the licensed nurse attempted to administer Morphine Sulfate (MS-a medication used to relieve sever pain) solution via mouth instead of via the gastrostomy tube (G-tube, a tube that is surgically inserted into the resident's stomach to allow access for food fluids and medications) as ordered by the physician. 2. For Resident 13, the licensed nurse failed to check the resident's apical pulse (a pulse site on the left side of the chest over the pointed end of the heart) before administering Digoxin (a heart medication) as ordered by the physician. 3. For Resident 28, the licensed nurse did not verify the physician's orders for Vitamin C tablet (vitamin supplement) and Zinc Sulfate (mineral supplement used for wound healing) capsule by mouth to Resident 28,…

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 follow professional standards for food service safety, in accordance with the facility's policy and procedure on Refrigerator / Freezer Storage, by failing to: 1. Label and date 31 covered glasses of milk in the refrigerator. 2. Label and date an open bag of hashbrown in the freezer. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food. Findings: During an initial kitchen observation conducted with the Dietary Service Supervisor (DSS) on 12/18/2023 at 8:30 AM, the facility's refrigerator had 31 covered glasses of milk without a label or date. In a concurrent interview, the DSS stated, the glasses of milk should be dated to ensure it is used first and the milk is still fresh, not spoiled for the residents to consume. The DSS stated, spoiled milk…

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 did not dispose garbage and refuse properly by not covering two of two metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing garbage bags, leaving 10 trash bags on the ground next to the dumpster, while waiting for trash to be picked up by the garbage truck. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 70 of 70 facility residents and affect including staff and visitors. Findings: During an observation of the dumpster area outside of the facility side entrance on 12/18/2023 at 8 AM, two out of two metal dumpsters were not covered due to overflowing trash bags leaving 10 trash bags on the ground next to the dumpster. During a concurrent observation of the dumpster area outside the facility side entrance and interview with Dietary Service Supervisor (DSS) dated 12/18/2023 at 8:40 AM, the DSS stated that the two-metal dumpsters were overflowing with trash bags and 10 trash bags were found on the ground. The DSS…

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 implement the facility's policy and procedure on infection control to prevent spread of infection by failing to 1. ensure the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was changed weekly for Resident 60 and Resident 61. 2. ensure to date the gastrostomy (a creation of an artificial external opening into the stomach for nutritional support) feeding tubing for Resident 28 and Resident 37. 3. ensure the facility staff to perform hand hygiene and wear proper personal protective equipment before providing care to Resident 26. 4. ensure the facility to conduct water testing for legionella (bacteria most found in water, including groundwater, fresh and marine surface waters that causes severe pneumonia [severe infection in the lungs]) These deficient practices had the potential to result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes…

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 treat one of one resident (Resident 2) with respect and dignity by ensuring the facility staff who assisted Resident 2 to eat was not standing next to the resident who was sitting, did not take the spoon from the resident without permission and, the staff had an eye contact with Resident 2 while assisting the resident to eat. These deficient practices had the potential for Resident 2 to have decreased feeling of self-worth, lower self-esteem and a decline in psychosocial (social and emotional being) wellbeing. Findings: During a review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 6/11/21 and readmitted her on 12/20/21 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/6/23, indicated Resident 2 had…

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 did not implement its policy and procedures titled, Theft and Loss Policy and Procedures and Abuse Prevention and Prohibition Program by not thoroughly investigating an alleged misappropriation of property (he deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 45). Resident 45 reported missing $1500 on 12/11/23 to the Administrator (the Abuse Coordinator) and the ADM Designee (ADMD) that was not thoroughly investigated by the facility. This deficient practice had resulted in Resident 45's verbalization of feeling sadness for not being able to share money to his family, and a potential to negatively affect Resident 45s quality of life, such as sadness and mistrust to facility staff. Findings: A review of Resident 45s admission record indicated the resident was originally admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure titled Theft and Loss Policy and Procedures by not reporting to the California Department of Public Health, Ombudsman (state agency that advocates for the residents and the Police Department) within 24 hours, the allegation of misappropriation of property (he deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 45) who reported missing $1500.00 to the Administrator (ADM) and Administrator Designee (ADMD) on 12/11/23. As a result of this deficient practice Resident 45 felt sad that he could not give money to his family during the Christmas time. This deficiency could also result in other potential residents to be a subject for theft or loss that could lead to a psychosocial decline and mistrust with the facility staffs. Findings: A review of Resident 45s…

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 the comprehensive Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long-Term Care) data base within the required time frame for two of 14 selected residents (Resident 42 and Resident 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 42 and Resident 62. Findings: 1.A review of Resident 42's admission Record dated 12/20/23 indicated, Resident 42's most recent admission date to the facility was 8/23/19, with diagnosis that included dementia [the loss of cognitive functioning (thinking, remembering, and reasoning) to such an extent that it interferes with a person's daily life and activities], hypertension (high blood pressure), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear) A review of Resident 42's annual comprehensive MDS indicated October 19, 2023, as the assessment…

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 the Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one of 14 sampled residents (Resident 68). This deficient practice had the potential to result in confusion regarding the care and services provided to Resident 41, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: During a review of Resident 68's admission Record indicated the facility admitted Resident 68 on 4/15/23 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and end stage renal disease [a condition in which the kidneys (human organ) lose the ability to remove waste and balance fluids. During a review of Resident 68's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated…

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 obtain a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of three sampled residents (Residents 9 and 66). This failure had the potential to result in Resident 9 and Resident 66 not to receive the necessary mental health services which can negatively affect their quality of life. Findings: 1. A review of Resident 9's face sheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of dementia (a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities), anxiety disorder (a feeling of unease, such as worry or fear, that can be mild or severe) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary care and services to one of one sampled resident (Resident 27) by ensuring the resident was assisted immediately when calling for help to change a soaking wet brief from urine incontinence (no control) and to ensure the call light was within reach to be used by the resident who needed assistance with ADL (Activities of Daily Living) as indicated in the residents plan of care and facility's policy and procedures. This failure resulted in Resident 27's developing skin damaged from prolonged sitting on a wet incontinent brief and a high risk for resident to fall and sustain injuries when unable to use a call light for assistance. Findings: A review of Resident 27's admission Record, dated 12/19/23, the record indicated, Resident 27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized weakness, gastrostomy (a surgical procedure in which a tube is inserted in the stomach…

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 with limited range of motion (limited ROM-joint that has a reduction in its ability to move) to receive Restorative Nursing Assistant (RNA) assisted active range of motion (AAROM) exercises followed by application and removal of left elbow splint (a plastic device used to immobilize elbow to support healing and to prevent further damage) to increase, prevent, or maintain the ROM mobility as ordered by the physician's for one of two residents (Resident 15). Residents 15 did not receive RNA assisted exercises on 12/18/23, left elbow splint application and removal with wear time of at least four hours a day on 12/12/23, 12/13/23, 12/15/23, 12/19/23 was not placed. As a result of these deficient practices Resident 15 verbalized being upset and angry and concerned of further risk for increasing left arm contractures (a condition that results in muscles, tendons, joints, or other tissues to tighten or shorten causing 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 provide a hazard free environment by ensuring one of one sampled resident (Resident 47) who smokes did not possess a pack of cigarettes and a lighter in his pocket while in the facility as indicated in the resident's plan of care. This deficient practice had the potential to result in an accidental fire in the facility and can lead to injury to the residents. Findings: During a review of Resident 47's admission Record indicated the facility initially admitted Resident 47 on 9/7/22 and readmitted him on 10/4/22 with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and suicidal ideations (thinking or planning to kill or hurt himself) During a review of Resident 47's Interdisciplinary Team (IDT- a team of staffs from different disciplines that develops the plan of care for the residents) Education Regarding Smoking Policy and Need for Supervision, dated 4/25/23, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 55), received the Jevity 1.5 (feeding formula) as ordered by the physician, and was not administered Glucerna 1.5 (a feeding formula). This failure had a potential to result in Resident 55's unplanned weight loss/weight gain and/or an allergic reaction to the formula. Findings: A review of Resident 55's admission Record, dated 12/19/23, the record indicated, Resident 55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach), cerebral infarction (or a stroke, occurs as a result of disrupted blood flow to the brain due to narrowing of the blood vessels, blood clot and bleeding), hypertension (high blood pressure), hyperlipidemia (an abnormally high concentration of fat particles in the blood), adult failure to thrive (syndrome of…

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

Based on interview and record review, the facility failed to ensure the Minimal Date Set (MDS- a comprehensive standardized assessment and screening tool) (MDS) Coordinator had necessary skill sets and competency to complete and transmit to CMS (Centers for Medicare and Medical Services) data base the MDS assessments for all the facility residents in accordance with the facility's policy and procedure. This failure had a potential to result in inaccurate MDS assessment, documentation, late or missed completion and submission of MDS assessment to the CMS data base, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: During an interview on 12/19/23 at 3:18 PM with the MDS Coordinator, MDS coordinator stated, he did not have certification for MDS and admitted he did not have any proof that he attended the MDS trainings for completion and transmission of the MDS assessments. During an interview on 12/20/23 at 10:32 AM, with the Administrator (ADM), the ADM…

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 five sampled residents (Resident 54) who was assessed by the facility as allergic to fish, was not served fish with the meal as indicated in Resident 54's plan of care and the facility's policy and procedure. This deficient practice had the potential to result in Resident 54 to experience an allergic reaction and anaphylactic shock (a severe, potentially life-threatening allergic reaction that can develop rapidly) which could lead to death. Findings: During a review of Resident 54's admission Record indicated the facility initially admitted Resident 54 on 1/19/23 and readmitted him on 11/10/23 with diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 54's Minimum Data Set (MDS, a standardized…

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's Quality Assurance Performance Improvement ([QAPI] performed a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) committee failed to identify facility and resident care issues, develop, and implement appropriate plans of action, in accordance with the facility's policy and procedures on Continuous Quality Improvement Program (QAPI), by failing to: 1a. Ensure the QAPI committee identified and developed measures to ensure the Minimum Data Set-a resident assessment and care planning tool (MDS) were completed and transmitted timely to the CMS data System timely by the MDS Coordinator after reviewed by the DON for eight of eight residents (Residents 42, 62, 26, 65, 58, 28, 40 and 41). 1b. Ensure the QAPI committee evaluated that competency of the MDS coordinator to ensure timely completion and submission of the MDS assessments to the Center for Medicaid and Medicare System (CMS). These deficient…

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 five sampled residents (Resident 62), was informed of the benefits and potential side effects (undesired effect) of Influenza (Flu- a type of respiratory infection due to virus) vaccine (a substance injected into the muscle with the use of a needle to stimulate immunity [defense against fight infection] to a particular infectious disease) prior to administration. As a result of this failure Resident 62 was not able to exercise his right to have informed consent prior to accepting to receive or not receive the annual influenza vaccine. Findings: A review of Resident 62's admission Record, dated 12/19/23, the record indicated, Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (or a stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Type 2 diabetes (disease that occurs when blood sugar is too high),…

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.