Glendora Canyon Transitional Care Unit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility licensed nurses failed to document the intravenous (IV, directly into a vein) antibiotic (a medicine that killed bacteria) medication administrations on the Medication Administrative Record (MAR) for two of two sampled residents (Residents 42 and 48). These deficient practices had the potential to result in lack of communication between staff and delay and interruption of care needed to maintain the residents' highest practicable, physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 42's admission Record (AR), the AR indicated Resident 42 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection [when germs entered the body and caused illness]) and bacteremia (the presence of bacteria in the blood). During a review of Resident 42's History and Physical (H&P) dated 12/25/2025, the H&P indicated Resident 42 could not make decisions. During a review of Resident 42's untitled Care…

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 and follow infection prevention procedures to prevent the transmission of infectious organisms for two of five sampled residents (Residents 33 and 132) by failing to:a. Wear required personal protective equipment (PPE, equipment that protects people from injury or illness ) while providing care to Resident 33 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents who are colonized or infected with an multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing a MDRO, such as, residents with wounds or indwelling medical devices).b. Ensure an EBP signage was posted outside the room of Resident 132 with foley catheter (FC, a common type of indwelling catheter, a soft, plastic or rubber tube that is inserted into the bladder to drain urine). 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.

Based on observation, interview, and record review, the facility failed to ensure the kitchen dry storage area was free of fruit flies on 1/13/2026 and 1/14/2026 for one of one kitchen dry storage area. This deficient practice had the potential to result in pathogen (germ) exposure to residents and placed the residents at risk for developing foodborne illnesses.Findings: During initial observation of the facility kitchen and interview with Dietary Aide 1 (DA1) on 1/13/2026 at 10:49 AM, in the kitchen dry storage area, multiple fruit flies were observed flying around the open banana and white onion storage containers. DA 1 stated it was not acceptable to have fruit flies in the kitchen for infection control. DA 1 stated fruit flies could lay eggs on food. DA 1 stated everyone in the kitchen was responsible for keeping the area clean. During a concurrent observation and interview with the Director of Nutritional Services (DNS) on 1/14/2026 at 11:35 AM, in the kitchen dry storage area, multiple fruit flies were observed flying around the closed banana and white onion storage…

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 its policy and procedure (P&P) on Informed Consent for Physical Restraint, for the use of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of one sampled resident (Resident 76). This failure violated Resident 76's rights and placed Resident 76 at risk for psychological distress from hearing the alarm sound. Findings: During a review of Resident 76's admission Record (AR), the AR indicated Resident 76 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of right arm, dementia (a progressive state of decline in mental abilities) , and history of falling (moving from a higher to a lower level, rapidly and without control). During a review of Resident 76's Order Summary Report (OSR) dated 12/18/2025, the OSR indicated Resident 76 had an order for bed alarm. 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 the Advance Directive (AD, a written instruction, recognized under State law relating to the provision of health care when the individual is incapacitated [lacking the ability to meet essential requirements for physical health, safety, or self-care]) for one of eight sampled residents (Resident 10) was readily accessible in accordance with the facility's Policy and Procedure (P&P) titled Advance Healthcare Directives/POLST. This failure had the potential for facility staff to provide medical treatment and services against Resident 10's will. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), dysphagia (difficulty in swallowing) and encounter for…

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 revise a plan of care for one of one sampled resident (Resident 96), as indicated in the facility's policy Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 96 to not receive appropriate care, treatment and/or services.Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- infection that affects part of the urinary tract), malignant neoplasm (group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body) of the prostate, and acute kidney failure (a sudden decline in kidney function). During a review of Resident 96's untitled Care Plan (CP) initiated on 12/6/2025, the CP indicated Resident 96 required contact isolation precautions related to Extended Spectrum Beta-Lactamase (ESBL- bacteria that is not easily…

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 policies and procedures (P&P) on Smoking were implemented for one of one sampled resident (Resident 95) when Resident 95 did not receive direct supervision and was not offered a smoking apron during smoking break. This failure had the potential to place Resident 95 at risk for burns and accidents during smoking break. Findings: During a review of Resident 95's admission Record (AR), the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses including blindness in both eyes, psychosis (a severe mental condition in which thought, and emotions are affected that contact is lost with reality), schizophrenia (a mental illness that is characterized by disturbances in thought), parkinsonism (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait), and a need for assistance with personal care. During a review of Resident 95'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 provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition/medication directly into the stomach) site as ordered by the physician and as indicated in the plan of care for one of one sampled resident (Resident 10). This failure had the potential for complications related to tube feedings for Resident 10.Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in elevated levels of glucose/sugar in the blood and urine), dysphagia (difficulty in swallowing) and encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support). During a review of Resident 10's History and Physical (H&P) 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 record review, the facility failed to report and a physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) incident to the California Department of Public Health (CDPH, State Agency) for one of three sampled residents (Resident 2) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program.This deficient practice resulted in the delay of notification to the State Agency and had the potential to result in residents residing at the facility to be subjected to further abuse.Cross Reference F600Findings:During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnoses that included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia [a mental illness that is characterized by disturbances in thought] and a mood disorder, such as depression…

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 a safe and comfortable room temperature in 2 of 2 resident shower rooms observed.This deficient practice had the potential to cause discomfort and unsafe conditions for residents who used the shower rooms.During a concurrent observation and interview on 8/26/25 at 11:27 AM, with Certified Nurse Assistant 1 (CNA 1) the thermostat of the third-floor shower room showed 82 F. CNA 1 stated, It is hot and stuffy, not usually like this.During a concurrent observation and interview on 8/26/25 at 11:31 AM with Licensed Vocational Nurse 1 (LVN 1) the thermostat of the second-floor shower room, showed 85 F. LVN 1 stated the room feels hot and stuffy. During an interview on 8/26/25 at 12:40 PM, with Maintenance Supervisor (MS), MS stated, Yes, the AC (air conditioner) has been acting up and it is scheduled to be repaired. MS stated that the temperatures are high in the shower rooms.A review of the facility's policy titled Homelike Environment, revised February 2021, indicated staff are to provide a safe, clean,…

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 implement their policy and procedure (P&P) titled, Change in a Resident's Condition or Status, by failing to ensure:1. Resident 1's responsible party (RP, a person who is responsible for guiding, informing, assisting, and advocating for residents in the healthcare system) was informed when Resident 1's blood sugar level was 480 and Resident 1 had to be given additional dose of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) on 5/17/2025 at 12:23 pm.2. Resident 1's blood sugar level of 480 on 5/17/2025 was documented in Resident 1's medical record.3. An SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form was filled out on 5/17/2025 at 12:23 pm when Resident 1's blood sugar level was 480 and Resident 1 had to be given an additional dose of insulin.These failures resulted in Resident 1's RP not being informed…

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 its policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (ABHR- containing 60%–95% alcohol) and hand washing with soap and water), and Standard Precautions (SP- a set of evidence-based infection control practices designed to prevent the transmission of infectious diseases in healthcare settings), Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves) and Transmission-Based Precautions (TBP- extra measures, used in addition to standard precautions, to prevent the spread of specific infectious agents that can be transmitted through air, contact, or droplets), and recommendations set by the Department of Public Health Medical Doctor…

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 protect the right of one of three sampled residents (Resident 1) to participate in the resident's treatment when the facility failed to give Resident 1's Pramipexole Dihydrochloride (medication used to treat Parkinson's disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) at Resident 1's requested time. This failure had the potential for Resident 1 to experience an increase in tremors (involuntary, rhythmic shaking movements that can affect various parts of the body). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 1/20/2025, with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and need for assistance with personal care. During a review of Resident 1's physician order (PO) dated 1/20/2025, the PO indicated an order for Pramipexole…

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 medications for one of three sampled residents (Resident 2) were kept locked in secure storage when Resident 2's morning medications were observed to be unattended at Resident 2's bedside. This failure had the potential for Resident 2 to not receive Resident 2's scheduled medications and had the potential to cause harm to other residents who could access and swallow the unattended medications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 10/29/2024, with diagnoses including metabolic encephalopathy (brain disease that alters brain function or structure), transient cerebral ischemic attack (a temporary interruption of blood flow to the brain), and dementia (a group of thinking and social symptoms that interferes with daily functioning). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 11/2/2024, the MDS indicated Resident 2 was severely impaired (never/rarely made decisions) in cognitive…

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 call lights were within reach for three of three sampled residents (Residents 14, 211 and 251) as indicated in the facility's Policy and Procedure (P&P) titled Call System, Resident. These deficient practices had the potential for the residents to receive delayed services and placed the residents at risk for falls/accidents. Findings: a. During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) affecting left non-dominant side. During a review of Resident 14's untitled Care Plan dated 12/5/2022, the Care Plan indicated Resident 14 was at risk for fall and/or injuries related to decreased strength and endurance. The Care Plan interventions indicated for nursing staff to ensure the call light was within reach and encourage the 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 implement its Policy and Procedure (P&P) on Advance Directives (AD, a legal document indicating resident preference on end-of-life treatment decisions) for four of four sampled residents (Residents 47, 82, 89 and 92) by failing to: a. Ensure a copy of Resident 47's AD was in the resident's medical record/chart. b. Ensure a copy of Resident 89's Advance Directive Acknowledgement (ADA) Form was in the medical record/chart. c. Complete the ADA Form on admission for Resident 82. d. Ensure a copy of Resident 92's AD was in the medical record/chart. These deficient practices had the potential for the facility staff to provide medical treatment and services against the will of the residents. Findings: a. During a review of Resident 47's admission Records (AR), the AR indicated Resident 47 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cellulitis (a skin infection that causes swelling and redness) 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 provide an effective communication method for two of two non-English speaking sampled residents (Residents 17 and 92). This failure had the potential for Residents 17 and 92 not to receive necessary care and services affecting their quality of life. Findings: a. During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses that included heart failure (a serious condition that occurs when the heart cannot pump enough blood to meet the body's needs) and hypotension (low blood pressure). During a review of Resident 17's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/19/2024, the MDS indicated Resident 17's preferred language was English. The MDS indicated Resident 17 had clear speech, had ability to understand others and had the ability to make self-understood. The MDS indicated Resident 17 required partial/moderate…

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 received treatment and care in accordance with professional standards of practice for two of two sampled residents (Residents 82 and 301) by failing to: a. Implement Resident 82's care plan (CP), when Resident 82's bilateral (both) feet with arterial ulcers (open wounds that form when there was not enough blood flowing to the bilateral extremities) were not offloaded (elevating an extremity to relieve pressure). This failure had the potential to result in worsening or delayed wound healing. b. To provide transportation for one of one sampled resident (Resident 301) to the resident's scheduled physician's appointment. This failure resulted in the delay of Resident 301's diagnostic exam. Findings: a. During a review of Resident 82's admission Record (AR), the AR indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic non-pressure ulcers 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 provide wound care treatments as ordered by the Medical Doctor (MD) for an unstageable pressure ulcer (PU, pressure ulcer [injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time] that was not stageable due to coverage of the wound by slough [white, yellow, tan, gray, or green in color that consist of dead tissue] and or eschar [thick, dry, black or brown scab like covering that forms over the wound]) on the right midback from 10/30/2024 to 11/7/2024 (eight days) for one of two sampled residents (Resident 82). This failure had the potential to result in worsening of Resident 82's right midback unstageable PU. Findings: During a review of Resident 82's admission Record (AR), the AR indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease (PD, brain disorder that causes uncontrollable movements) 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 (P&P) on the use of siderails for two of two sampled residents (Residents 26 and 28) by failing to: a. Ensure Resident 26 had a doctor's order for siderails, siderail use was consented and appropriate alternative interventions were attempted and did not meet the resident's needs before the installation of side rails. b. Ensure Resident 28 was assessed for the use of siderails and appropriate alternative interventions were attempted and did not meet the resident's needs before the installation of side rails. These deficient practices placed Residents 26 and 28 at risk for entrapment and injury from the use of siderails. Findings: a. During a review of Resident 26's admission Record (AR), the AR indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included osteomyelitis (inflammation of bone or bone marrow) of the left ankle 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 interview and record review, the facility failed to implement the facility's Policy and Procedure (P&P) on psychotropic (medications that alter brain function) and antipsychotic (medications that reduce delusions or hallucinations) medication use, for two of five sampled residents (Residents 82 and 96) by failing to: a. Ensure as needed (PRN) psychotropic medication was ordered with a stop date of 14 days when Resident 82 was receiving Lorazepam (medication to treat anxiety) 0.25 milliliters (mL, unit of measurement for volume) every four hours PRN for restlessness and or agitation. b. Ensure Resident 96's target behavior and adverse side effects (unwanted or undesirable effect) was monitored, and the order included a specific indication for the use of Haloperidol (antipsychotic). These deficient practices had the potential to result in the use of unnecessary psychotropic medications, which may result in significant adverse (harmful) consequences to Residents 82 and 96. Findings: a. 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.

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by: a. Placing a staff's personal lunch bag inside the facility's one of one walk-in refrigerator used to store residents' food. b. Failing to ensure one of one dome drying rack was free from rust and dirt. These deficient practices had the potential to result in food-borne illnesses to the residents. Findings: During an observation of the facility's kitchen on 11/5/2024 at 9:16 am, there was a personal lunch bag placed on the shelf of the facility's walk-in refrigerator. The dome drying rack was rusty and had dirt along the metal line. During a concurrent interview, Dietary Aide 3 (DA 3) stated, it was DA 3's lunch box placed inside the walk-in refrigerator. DA 3 stated, DA 3 should not put personal belongings inside the resident's refrigerator. DA 3 stated, putting personal belongings inside the resident's refrigerator could result in cross contamination of residents' food and the residents could get food borne illness. DA 3 stated, the dome drying rack…

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 federally mandated resident assessment tool) was accurately coded for language preference for one of one sampled resident (Resident 17). This failure had the potential risk for Resident 17 not to receive necessary care services. Findings: During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses that included heart failure ( condition when the heart cannot pump enough blood to meet the body's needs) and hypotension (low blood pressure). During a review of Resident 17's quarterly MDS dated [DATE], the MDS indicated Resident 17's preferred language was English. The MDS indicated Resident 17 had clear speech, had ability to understand others and had the ability to make self-understood. The MDS indicated Resident 17 required partial/moderate assistance (helper does less than half the effort) for personal hygiene 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 interview and record review, the facility failed to create a baseline care plan (CP) for one of one sampled resident (Resident 82) upon admission on [DATE]. This failure had the potential for delayed provision of necessary care and services for Resident 82. Findings: During a review of Resident 82's admission Record (AR), the AR indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease (PD, brain disorder that causes uncontrollable movements), deficits in communication, chronic non-pressure ulcers of the right heel, right midfoot, and left foot, and a right hip stage three PU (deep wound that has gone through all layers of the skin exposing subcutaneous fat). During a review of Resident 82's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/23/2024, the MDS indicated Resident 82's cognitive abilities (ability to think, learn, and process information) were severely impaired. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop an individualized/person- centered care plan for one of five sampled residents (Resident 96) who was on Haloperidol (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally) in accordance with the facility's Policy and Procedure (P&P) titled Care Plans, Comprehensive Person - Centered. This deficient practice had the potential for Resident 96 to not receive appropriate treatment and/or services related to the use of Haloperidol. Findings: During a review of Resident 96's admission Record (AR), the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses that included depression (a feeling of severe sadness or hopelessness) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). During a review of Resident 96's Minimum Data Set (MDS - a federally mandated 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 observation, interview, and record review, the facility failed to ensure one of two sampled residents' indwelling catheter (foley catheter, a tube that allows urine to drain from the bladder into a bag) was assessed and monitored for the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria) in the urine in accordance with the facility's Policy and Procedure (P&P) titled Catheter Care, Urinary and the resident's care plan (Resident 44). This deficient practice had the potential for Resident 44 to receive delayed care and treatment to prevent urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system). Findings: During a review of Resident 44's admission Record (AR), the AR indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (abnormal narrowing of the spinal canal) and essential hypertension (elevated blood pressure without a known cause).…

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 its Policy and Procedure (P&P) to post actual nursing hours within two hours of the start of each shift. During a tour of the facility, the posted nursing hours for one of one sampled day (11/7/24) was not updated and did not reflect the current date. This deficient practice had the potential to inaccurately reflect the actual nursing staff providing direct care to the residents. Findings: During an observation and concurrent interview with the Director of Staff Development (DSD) on 11/7/24 at 2:57 p.m., the facility's Daily Nursing Staff Posting for 11/6/24 was posted in the facility's entrance lobby. The DSD stated the daily nursing staff posting (DNSP) should be the DNSP dated 11/7/24. The DNSP posted was for 11/6/24. The DSD stated the posted DNSP was dated 11/6/24 and the DNSP was not posted within two hours of the beginning of the shift on 11/7/24. During an interview with the DSD on 11/7/24 at 3:02 p.m., the DSD stated the DNSP should be updated by the night (11:00 p.m.-7:30 a.m.) shift staff.…

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, for one of three sampled residents (Resident 301) who signed the Resident-Facility Arbitration Agreement (AA, a Binding Arbitration Agreement requires the person who signed it resolve any dispute by binding arbitration, rather than in court) on 10/31/2024, had the capacity to understand and make decisions. This failure had the potential risk to result in Resident 301 to not be able to make an informed decision and/or his rights to be denied. Findings: During a review of the facility's admission Record (AR), the AR indicated Resident 301 was admitted to the facility on [DATE], with diagnoses that included pneumonia (lung infection) and End Stage Renal Disease (ESRD, irreversible kidney failure). During a review of Resident 301's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/29/2024, the MDS indicated Resident 17 had no speech, sometimes understood others, and sometimes made self-understood.…

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 its Policy and Procedures (P&P) titled Isolation - Categories of Transmission - Based Precautions for one of five sampled resident (Resident 89) when Licensed Vocational Nurse 1 (LVN 1) did not wear the required personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection) while administering medication to Resident 89 inside a Contact (precautions used for infections, diseases, or germs that are spread by touching the patient or items in the room) Precaution room. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents in the facility. Findings: During a review of Resident 89's admission Record (AR), the AR indicated the facility initially admitted Resident 89 on 7/8/2024 and readmitted on [DATE] with diagnoses that included essential hypertension (elevated blood pressure without a known cause) and type 2 diabetes…

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 call light device (a means of communication for patients to their care providers that are outside of the patient's room) was functioning for one of one sampled resident (Resident 17). This failure had the potential to result in the delay of the provision of needed care and services to Resident 17. Findings: During a review of Resident 17's admission Record (AR), the AR indicated Resident 17 was readmitted to the facility on [DATE], with diagnoses that included heart failure (the heart cannot pump enough blood to meet the body's needs) and hypotension (low blood pressure). During a review of Resident 17's History and Physical (H&P), dated 3/5/2023, the H&P indicated Resident 17 had the capacity to understand and make decisions. During a review of Resident 17's quarterly MDS dated [DATE], the MDS indicated Resident 17 had clear speech, had ability to understand others and had the ability to make self-understood. The MDS 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 interview and record review, the facility failed to include in its written Policy and Procedure (P&P) titled Abuse Prevention specific information and guideline on how the facility staff would identify, intervene, and manage resident's property including handling of resident's money for one of four sampled residents (Resident 1). This deficiency violated Resident 1's right. Certified Nursing Assistant 1 (CNA 1) and Activity Aide 1 (AA 1) received and encashed multiple personal check from Resident 1. This violation placed Resident 1 at risk for financial abuse (withholding, stealing, or restricting money). Findings: During a review of Resident 1's admission Record (AR), the AR indicated Resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD- lung diseases causing block airflow making it difficult to breathe), chronic pain syndrome (persistent pain lasting weeks to years), and major depressive disorder (mental health…

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 its policy and procedure (P&P) titled, Fingernails/Toenails, Care of, for one of nine sampled residents (Resident 4) and failed to follow Resident 4's untitled care plan by failing to: Ensure assigned Licensed Vocational Nurses (LVNs) notified the Social Services Director (SSD) that Resident 4 needed to be referred and seen by a podiatrist (medical doctor who help with problems that effect the lower legs and feet) for cleaning and trimming of Resident 4's long and overgrown toenails. This failure had the potential to cause injuries and infection to Resident 4. Findings: During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses that included gout (occurs when urate crystals [high levels of uric acid- waste product created when the body breaks down chemicals- in the blood] accumulate in the joints causing inflammation and intense pain), infection 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 provide adequate supervision according to the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, for one of nine sampled residents (Resident 1) by failing to: Ensure Licensed Vocational Nurse (LVN) 1 and LVN 2 obtained an order for a sitter (one-to-one supervision) after Resident 1 sustained a fall (move downward, typically rapidly and freely without control, from a higher to a lower level), was assessed to be confused, and needed a sitter on 8/15/2024. This failure placed Resident 1 at risk for further falls and injuries. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included generalized muscle weakness (weakness of muscles caused by lack of exercise, ageing, injury, or disease), type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), 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 ensure Licensed Vocational Nurse (LVN) 7 reassessed the pain level of one of nine sampled residents (Resident 4) after 30 minutes to one hour of receiving acetaminophen (pain medication used to relieve mild or chronic pain and to reduce fever) for complaint of mild pain on 8/16/2024 at 9:44 am as indicated in the facility's policy and procedure (P&P) titled, Pain- Clinical Protocol. This deficient practice resulted in unrelieved pain for Resident 4 and placed Resident 4 at risk for psychosocial (mental, emotional, social, and spiritual effects) harm. Findings: During a review of Resident 4's admission Record (AR), the AR indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses that included gout (occurs when urate crystals [high levels of uric acid- waste product created when the body breaks down chemicals- in the blood] accumulate in the joints causing inflammation and intense pain), infection of amputation (removal…

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 certified nursing assistants (CNA 1) had an active CNA certification to perform resident care while employed at the facility. This deficient practice had the potential for a knowledge, training, and certification deficit for CNA 1 which could lead to inadequate and unsafe resident care. Findings: During an interview on [DATE] at 3 pm with the Director of Nursing (DON), the DON acknowledged that CNA 1 worked at the facility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] with an expired CNA certificate. During a review of CNA 1's California Department of Public Health Notice of Certification (CDPHNOC), provided by the facility on [DATE], the CDPHNOC indicated CNA 1's certification had an effective date of [DATE] and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify one of two sampled residents (Resident 1) and the resident's responsible party (RP 1) prior to room/bed change in accordance with the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment. This deficient practice had the potential to violate Resident 1 and RP's rights and affect Resident 1's sense of self-worth and well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, the facility initially admitted Resident 1 on 5/30/2023 and readmitted Resident 1 on 10/28/2023, with diagnoses that included difficulty walking, end stage renal disease (ESRD - a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [procedure to remove metabolic waste products or toxic substances from the bloodstream] or a kidney transplant to maintain life). During a review of Resident 1's History and Physical (H&P), 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.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) received care and the necessary services to prevent pressure ulcers (localized damage to the skin usually over a bony prominence) and promote healing by failing to: 1. Ensure licensed nurses set Resident 3's low air loss (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) mattress settings accurately based on comfort or Resident 3's weight. 2. Ensure nursing staff turned and repositioned Resident 3 every two hours as indicated in Resident 3's plan of care. 3. Ensure nursing staff provided timely incontinent care to Resident 3 after a bowel movement. These deficient practices had the potential to lead to further skin breakdown, worsening and/or delayed wound healing for Resident 3. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility initially admitted Resident 3 on 3/8/2018 and readmitted Resident 3 on 2/22/2024, with diagnoses that included multiple sclerosis…

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 treated with dignity and respect for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 not being respected in a manner to maintain dignity. Findings: During a review of the admission Record (AR), the AR indicated Resident 1 was admitted to facility on 10/13/2020 with diagnoses included but not limited to quadriplegia (a form of paralysis that affects all four limbs, plus the torso), gastro esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). During a review of the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool), dated 12/29/2023, the MDS indicated Resident 1 brief interview for mental status (BIMS-standard cognitive assessment scores 00-15) score of 14 indicating cognitive status (ability to understand and process information) was intact. During an interview on 02/09/2024 at 2:34 p.m., with Resident 1, Resident 1 stated, lat week (could not remember date…

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 meals provided to one of four sampled residents (Resident 1) was in accordance with the resident's meal tray ticket (menu based on the resident's diet order, standing orders and food preferences) for one of four sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to not receive adequate nutrition. Findings: During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included osteoarthritis (occurs when flexible tissue at the ends of bones wears down), stage 3 pressure ulcer of sacral (skin injury that occurs near the lower back and spine) region, and quadriplegia (complete paralysis of both the arms and legs). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/10/23, indicated Resident 1 was understood by others and had the ability to understand…

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 needed care and services in accordance with the physician's order and facility's policy and procedure for three of three sampled residents (Residents 35, Resident 305 and Resident 60) by failing to; a. Provide nectar thickened liquid in accordance to the physician's order for Residents 35 and 305. b. Provide Resident 60 an arm sling (device to support an injured upper arm, forearm, and wrist) for the left shoulder as ordered by the physician. Findings: a. During a review of Resident 35's admission Record, the admission record indicated the facility readmitted the resident on 9/7/23, with diagnoses that included dysarthria following cerebral infarction (slurred speech after a stroke) and dysphagia following cerebral infarction (difficulty swallowing after a stroke.) During a review of Resident 35's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/11/2023, the MDS indicated Resident 35 had severe…

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 During an observation, interview, and record review the facility failed to ensure food delivered to the residents were within recommended temperature range as indicated in the facility's policy for Meal Service for three of seven sampled residents who attended the resident council meeting (Residents 44, 59 and 66). This deficient practice had the potential to affect the resident's appetite to eat. Findings: During a review of Resident 44's admission Record, the admission record indicated the facility admitted the resident on 8/4/2018, with diagnoses that included heart failure (the heart muscle does not pump enough blood) and Chronic Obstructive Pulmonary Disease (COPD - type of obstructive lung disease characterized by long-term poor airflow). During a review of Resident 44's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 9/18/2023, the MDS indicated the resident had no cognitive (ability to understand) impairment. During a review of Resident 59's admission Record, the admission…

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 it's Policy and Procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure: a. Stored food items were dated when it was first opened, in one of two kitchen freezers. b. One box of potatoes was not placed directly on the floor in one of one dry storage area. c. One of one facility staff (Housekeeping 1 [HKP 1]) performed hand hygiene before entering the kitchen and not place personal item on top of the food preparation area. These deficient practices had the potential for residents to be at risk for food borne illnesses (infections caused by ingesting contaminated food or beverages) Findings: a. During an initial tour of the kitchen on 10/24/2023 at 9:26 AM, together with the facility's Director of Nutrition Services (DNS), one of two freezers had an unsealed bag of vegetable patty, beef patty, frozen waffles and mixed vegetables without a label or date when it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide safe and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for four of five sampled residents ( Residents 23, 38, 77 and 155), by failing to: a. Ensure Resident 155's peripheral IV site (a site where a thin, flexible tube was inserted through the skin into a small vein in the periphery such as the hand, elbow, or foot) was labeled to indicate the date of insertion. b. Ensure Resident 38's unused and unlabeled nasal cannula with nasal prongs did not touch the back of the resident's wheelchair. c. Ensure Resident 23's unused breathing treatment tubing was not hanging inside the trash bin. d. Ensure Resident 77's nasal cannula tubing was labeled with date. These deficient practices placed the residents at risk for infection. Findings: a. 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 observation, interview, and record review, the facility failed to ensure the resident's suprapubic catheter (a hollow, flexible tube that is used to drain urine from the bladder through a cut in the abdomen) was secured and the nephrostomy (a tube that drains urine from the kidney through an opening in the skin on the back) tube bag was covered with a privacy bag for one of six sampled residents. This deficient practice resulted in the violation of Resident 1's privacy and had the potential to affect Resident 1's self-esteem, self-worth, and psychosocial well-being. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included hydronephrosis (a swelling of one or both kidneys) and urinary tract infection (an infection in any part of the urinary system). During a review of Resident 1's Care Plan (CP) titled Resident has Suprapubic Catheter, revised 4/17/2023, the CP…

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 reasonable accommodation of needs for one of one sampled resident (Resident 38) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Answering the Cal Light and resident's Care Plan titled Risk for Falls and/or Injuries. This deficient practice had the potential for Resident 38 not to receive or received delayed care to meet the necessary services that could result in falls and accidents. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 1/14/2023 with diagnoses that included parkinsonism (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) and left hand contracture (a permanent tightening of the muscles, tendons, skin, and tissues that causes the joints to shorten and become very stiff and painful). During a review of Resident 38'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 for two of four sampled residents (Residents 69 and 65), the facility failed to: a. Provide information on advance care planning (a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) to Resident 69. b. Ensure Resident 65's AD (AD, a written instruction, such as a living will or durable power of attorney for health care relating to the provision of health care when the individual is incapacitated) was in Resident 65's medical record. These deficient practices had the potential to result in failure to provide treatment and services in accordance with the resident's will. Findings: a. During a review of the facility's admission Record, the admission record indicated Resident 69 was readmitted to the facility on [DATE], with diagnoses including hypertension (increased blood pressure) and paraplegia…

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 staff failed to notify the attending physician of a change of condition for one of one sampled resident (Resident 104). This deficient practice resulted in Resident 104 not getting the treatment and services needed in a timely manner. Findings: During a review of Resident 104's admission Record, the admission record indicated the facility admitted the resident on 10/3/2023 with diagnoses that included acute respiratory failure with hypoxia (when the body does not have enough oxygen) and pleural effusion (fluid buildup in the space between the lungs and chest cavity.) During a review of Resident 104's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 10/8/2023, the MDS indicated the resident had severe cognitive (ability to understand) impairment. The MDS indicated Resident 104 required supervision with eating with partial moderate assistance (helper does less than half the effort) and was totally dependent with toileting, shower/bathing. During a review of Resident 104's Daily Skilled Medicare Charting…

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 one sampled resident (Resident 102)'s Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 9/2/2023 accurately assessed to reflect the resident's discharge destination. Resident 102, who was discharged home, was coded in the MDS assessment as discharged to a general acute care hospital. This deficient practice resulted to inaccurate reporting to the Centers for Medicare & Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Resident 102 not to receive interventions to address specific care concerns. Findings: During a review of Resident 102's Physician's Order (PO), dated 9/2/2023, the PO indicated a physician's order to discharge Resident 102 to home. During a review of Resident 102's MDS dated [DATE], the MDS indicated Resident 102 was discharge to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 19) wore hearing aid (device used to increase the volume of a sound) as ordered by the physician. This deficient practice had the potential to result in Resident 19's decline or loss of the ability to communicate with others. Findings: During a review of Resident 19's admission Record (AR), the AR indicated Resident 19 was admitted to the facility on [DATE], with diagnoses that included anxiety (fear of the unknown) and glaucoma (a group of eye conditions that can cause blindness). During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/1/2023, the MDS indicated Resident 19 used hearing aids for hearing. During a review of Resident 19's Care Plan (CP) titled Hearing Impairment, revised 9/19/2023, the CP indicated Resident 19 wore hearing aids and the goal was for Resident 19 to understand others when communicating. 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 chair alarm was connected to the chair pad and the chair alarm was turned on in accordance to the physician's order, for one of five sampled residents (Resident 19). This deficient practice had the potential for accidents for Resident 19. Findings: During a review of Resident 19 admission Record indicated the facility readmitted the resident on 1/13/2022, with diagnoses that included hypertensive heart disease with heart failure (occurs when the heart muscle does not pump bloods as well as it should,) atherosclerotic heart disease (hardening of the arteries that carry blood to the heart muscle.) During a review of Resident 19's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 9/1/2023, indicated the resident had severe cognitive impairment, the resident usually understands verbal content and usually able to express ideas and wants. The MDS indicated the resident required supervision with eating, and required extensive assistance (resident involved in activity, staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental, or extra, oxygen) in accordance with accepted standards of clinical practice and with the facility's Policy and Procedure on Oxygen Administration, for two of five sampled residents (Resident 13 and 23). These deficient practices placed Residents 13 and 23 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious complications. Findings: a. During a review of Resident 13's admission Record, the admission record indicated the facility admitted Resident 13 on 1/5/2021 with diagnoses that included Corona Virus 19 [COVID-19, a respiratory illness that can spread from person to person], heart failure (heart disease that affects the pumping action of the heart muscle), anemia (lack of red blood cells to carry adequate oxygen to the body's tissues) and Alzheimer's disease (irreversible, progressive brain disorder 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 safe administering a medication, Mesalamine (a drug that treats symptoms of ulcerative colitis [an inflammatory bowel disease]) Delayed Release (DR, a drug which should not be crushed, that do not immediately release the active ingredients into the body) by crushing the medication, for one of four sampled residents (Resident 307). This deficient practice had the potential to result in the drug being released too early, destroyed by stomach acid, or irritating the stomach lining, and causing harm to the resident. Findings: During a review of the facility's admission Record, the admission record indicated Resident 307 was readmitted to the facility on [DATE], with diagnoses including ulcerative colitis and hypertension (increased blood pressure). During a review of Resident 307's Minimum Data Set (MDS, a resident assessment and care screening tool) dated 9/1/2023, the MDS indicated Resident 307 had clear speech, usually understood…

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's Licensed Vocational Nurse 1 (LVN1) failed to hold Metoprolol (medication to lower blood pressure [BP]) on 10/12/2023, based on parameters and in accordance with the physician's order for one of one sampled resident (Resident 104). This deficient practice had the potential to lower further Resident 104's blood pressure and had the potential to lead to complications. Findings: During a review of Resident 104's admission Record, the admission record indicated the facility admitted the resident on 10/3/2023 with diagnoses that included acute respiratory failure with hypoxia (when the body does not have enough oxygen) and pleural effusion (fluid buildup in the space between the lungs and chest cavity.) During a review of Resident 104's Minimum Data Set (MDS- a standardized assessment and care planning tool) dated 10/8/2023, the MDS indicated the resident had severe cognitive (ability to understand) impairment. The MDS indicated Resident 104 required supervision with eating with partial moderate assistance (helper does less than half…

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 opened bottle of Firvanq (Vancomycin Hydrochloride - antibiotic used to treat bacterial infections) 50 milligrams per milliliter (mg/ml, a unit of measurement) 150 ml solution was labeled with the date opened as indicated in the facility policy on Medications Requiring Notation of Date Opened, for one of one medication refrigerator inspected. This deficient practice had the potential to result in the loss of efficacy and unsafe storage of the medications. Findings: During a review of Resident 61's admission Record, the admission record indicated the facility admitted Resident 61 on [DATE] with diagnoses that included sepsis (severe infection), and enterocolitis (inflammation that occurs throughout the intestines) due to Clostridium difficile (C. difficile - bacteria that causes diarrhea and more serious intestinal conditions). During a review of Resident 61's History and Physical (H&P), dated [DATE], the H&P indicated 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 observation, interview and record review, the facility failed to ensure meal was provided according to resident's meal ticket (a slip of paper on the meal tray with detailed food information) for one of six sampled residents (Resident 14). This deficient practice had the potential to affect the resident's dietary intake which may cause inadequate nutrition for Resident 14. Findings: During a review of the facility's admission Record, the admission record indicated Resident 14 was admitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) and type 2 diabetes mellitus (elevated blood sugar level). During a review of Resident 14's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 9/2/2023, the MDS indicated Resident 14 had clear speech, had the ability to understood others and made self-understood. The MDS indicated Resident 14 was totally dependent (full staff performance) with…

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 designate a member of the facility's Interdisciplinary Team (IDT- a group of health care professionals who work together toward the goals of their patients) who was responsible for working with Hospice (a program designed to provide comfort care and emotional support to the terminally ill) representatives to coordinate care to the resident for one of one sampled resident (Resident 77). This deficient practice had the potential to affect Resident 77's quality of life during Hospice Care. Findings: During a review of the facility's admission Record, the admission record indicated Resident 77 was readmitted to the facility on [DATE], with diagnoses including chronic obstructive pyelonephritis (continuing bacterial infection of the kidney that occurs almost exclusively in patients with major anatomic abnormalities), and encounter for palliative care (specialized medical care for people living with a serious illness). During a review of Resident 77's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow standard infection control practices during a Coronavirus (COVID 19, a mild to severe respiratory illness that spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in accordance with the Department of Public Health's (DPH) guidelines and the facility's policy and procedures (P&P) by failing to: 1. Ensure Resident 1 who was exposed to Resident 2 with confirmed positive for COVID 19 wore facemask during group activities . 2. Ensure Housekeeping 1 (HKP 1) kept and monitored the log for cleaning and disinfecting of high touch areas (surfaces that are frequently touched) in the facility's red zone (an area dedicated for residents who are Corona Virus 19 positive). 3. Ensure Social Services Assistant wore an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne…

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 Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) was involved in developing a discharge plan that reflected the resident's discharge needs, goals, and treatment preferences) as indicated on the facility's policy and procedure, titled Discharge Summary and Plan, for one of one sampled residents (Resident 5). This failure had the potential to result in incomplete or ineffective discharge planning and could have led to lack of necessary care for Resident 5 after discharge. Findings: A review of Resident 5's admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission Record indicated Resident 5's diagnoses included history of falling, hemiplegia (paralysis of the left side of the body and hemiparesis weakness on one side of the body) following a cerebral infarction (disrupted blood flow to the brain due…

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) received antibiotics (medicine to treat infection) for completion of the treatment that was started at the General Acute Care Hospital 1 (GACH 1). Resident 1 was not administered Piperacillin/Tazobactam (Zosyn, a combination of two antibiotic medication for the treatment of bacterial infection) from 7/22/2023 to 7/27/2023. This deficient practice resulted in the interruption for the completion of the antibiotic treatment for Resident 1 and had the potential risk to worsen Resident 1's bacterial infection. Findings: During a review of Resident 1's GACH 1 medical records, the medical records indicated Resident 1 was admitted at GACH 1 from 7/17/2023 to 7/22/2023 due to acute respiratory failure with hypoxia (not enough oxygen in the blood due to a failure in oxygen exchange in the lungs), pneumonia (lung inflammation), and urinary tract infection (UTI, infection in the urinary system). Resident 1's GACH…

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, facility failed to ensure a base line plan of care was developed and implemented for one of four sampled residents (Resident 1). There was no base line care plan that was developed to address and manage Resident 1's diabetes mellitus (high levels of sugar in the blood). This deficient practice resulted for Resident 1 to not receive management for diabetes while at the facility which had the potential to result to the development of complications related to diabetes. Findings: During a review of Resident 1's medical records from General Acute Care Hospital 1(GACH 1), the medical records indicated Resident 1 was admitted at GACH 1 from 7/17/2023 to 7/22/2023 due to acute respiratory failure with hypoxia (not enough oxygen in the blood due to a failure in oxygen exchange in the lungs), pneumonia (infection of the lungs), diabetes mellitus without complications, and urinary tract infection (UTI, infection in the urinary system). The GACH 1 record indicated Resident 1 received…

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