Sierra Vista

Based on observations, interviews, and record reviews, the facility failed to maintain a sanitary and orderly medication storage room for 45 residents (Residents 1 through 45) when:1. A tub containing various used personal care products-some labeled with resident names and others unlabeled-was stored in a cabinet alongside resident medications.2. A bag of discontinued prescription topical medications awaiting disposal was stored on the bottom shelf of a medication cabinet next to discarded items, disinfectant spray, and trash. This failure had the potential to cause cross-contamination and the transmission of infectious agents for 45 residents who reside in Unit 1 of the facility.Findings: 1. During a medication storage observation and interview on Unit 1 at Nursing Station 1, conducted with a Registered Nurse 1 (RN 1) and the Director of Nursing (DON) on February 25, 2026, from 8:19 AM to 9:23 AM, there were three cabinets in the medication room where medications were stored. In the third cabinet on the third shelf, a tub of personal care products was stored (10 different colognes,…

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 proper maintenance of essential equipment when: 1. The handwashing sink did not consistently maintained water temperatures in accordance with the standard of practice. This failure had the potential for inadequate water temperature which may result in ineffective handwashing putting residents at risk for food borne illness. 2. The Veggie reach-in freezer had ice condensation buildup. This failure had the potential to cause poor quality of food served to a population of 116 out of 116 sample residents who received food from the kitchen. Findings: 1. During a review of FDA (Food and Drug Administration) Food Code 2025, Section 5-202.12., the FDA Food Code indicated, A handwashing sink shall be equipped to provide water at a temperature of at least 85 degrees Fahrenheit ( F - a unit of measurement) through a mixing valve or combination faucet. An inadequate flow or temperature of water may lead to poor handwashing practices by food employees. A mixing valve or combination faucet is needed to provide…

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

Based on observation, interview, and record review, the facility failed to ensure two of two resident's communal shower rooms (blue and green shower rooms) located on unit 1 were maintained in good repair and in a safe and sanitary condition, when the blue and green shower rooms were both observed to have cracked and stained tile surfaces. This failure had the potential to expose all 45 residents on unit 1 who utilize these shared showers to potential harm, contamination and transmission of healthcare-associated infections.Findings:During a concurrent observation and interview on February 25, 2026, at 9:01 AM with Infection Preventionist (IP), in the green and blue shower rooms, it was observed multiple cracked and stained tiles. The IP stated, I see there are multiple cracked and stained tiles within both shower rooms. The IP further stated, shower surfaces should be intact and cleanable to prevent infection control issues.During a concurrent observation and interview on February 25, 2026, at 9:42 AM with Maintenance Supervisor (MS), in the green and blue shower rooms, 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 develop and implement comprehensive care plans (an individualized plan based on assessment that identifies needs, sets goals, and outlines interventions for the medical care of a resident) for two of 35 sampled residents (Resident 14 and 34) when:1. For Resident 14, who had a documented history of falls, the facility did not create a fall risk care plan to address fall risk factors, individualized interventions, and preventive strategies.2. For Resident 34, who was identified as a smoker, the facility did not create a care plan that addressed smoking supervision, safety precautions, and risk mitigation. These failures had the potential to place Residents 14 and 34 at risk for injury, burns, fire hazards, and recurrent falls with injury.Findings: 1. During a review of Resident 14's admission Record (contains medical and demographic information), the admission Record, indicated, Resident 14 was admitted to the facility on [DATE], and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure nursing staff followed physician's orders for one of five sampled residents (Resident 19) investigated for nutrition, when the facility did not have documented weights of Resident 19 in the frequency as ordered by the physician. This failure resulted in Resident 19 not being monitored as ordered by the physician for changes in weight and placed the resident at risk for undetected significant weight loss or gain.Findings: During a review of Resident 19's admission Record (contains medical and demographic information), the admission Record, indicated Resident 19 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a mental disorder characterized by intense paranoia, delusions, and auditory hallucinations), and vitamin D deficiency.During an interview on February 24, 2026, at 8:45 AM, with Resident 19, Resident 19 stated he had lost 60 pounds since he was admitted to the facility.During 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 resident's rights to be free from physical restraint (a manual method, physical or mechanical device or material that restricts the resident's freedom of movement or normal access to his/her body), for one of one resident (Resident 1), were followed when a Certified Nursing Assistant (CNA 1) placed his arm over Resident 1's shoulders, restricting his movement, on June 8, 2025. This failure had the potential for Resident 1to be at risk for physical and psychological harm (the unpleasant emotional or psychological symptoms that individuals experience when they feel overwhelmed, impacting their quality of life). Findings: During a review of Resident 1's admission Record (clinical record with demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [NAME] 3, 2025, with diagnoses which included schizophrenia unspecified (a chronic mental illness characterized by significant disturbances in…

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

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when: 1. A toaster was stored in the dry storage, and it had an accumulation of food residue. 2. On the floor under the industrial mixer, there was black grime, food crumbs, and paint splashes. 3. The shelf under the cook's preparation area that was storing clean pans had crusted food and debris. 4. In the Unit 2 kitchen area where food is served to the residents, the refrigerator door handle had crusted food and smudges. Under the steam table, there was a storage compartment that had black grime and food debris. These failures had the potential to result in accumulating pathogenic microorganisms (germs or infectious agents that can cause disease) and to attract insects or rodents. Findings: 1. During a concurrent observation and interview on December 9, 2024, at 8:10 AM, in the kitchen's dry storage room, an unused toaster with crusted debris and crumbs was observed on a shelf rack. The Dietary Supervisor (DS) stated that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures (P&P) for two of 71 residents (Resident 22 and 85) when: 1. For Resident 22, 11 tablets of Clozapine (medication used to treat severely ill patients with serious mental illness that have difficulty distinguishing what is real and what is not) 50 mg (milligrams- unit of measurement) were found with an expiration date of August 9, 2024 (expired 124 days) and were available for resident use when stored in Unit 2's medication cart (Cart 2). 2. For Resident 85, five tablets of Vitamin B6 (a vitamin used to treat movement disorder) 100 mg were found with an expiration date of December 3, 2024 (expired 8 days) and were available for resident use when stored in Unit 2's medication cart (Cart 1). These failures had the potential for the medications to lose their potency over time, making them less effective and to adversely affect the health and safety 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 ensure secure storage of medications when one of two medication rooms (Unit 2's medication room) and two of three medication carts (Medication Cart 1 and 2 in Unit 2's medication room - carts used by licensed nurses and Psych technicians [PT] to hold medications for all residents) were found unlocked and unattended by a licensed nurse and PT. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 71 residents. Findings: During an observation on December 10, 2024, at 4:40 PM, PT 1 was inside Unit 2's medication room, using medication cart 1 and 2. Psych Tech left the nurses station and went across the hall to a locked closet to assist a resident. PT 1 left Unit 2's medication room, medication cart 1, and medication cart 2 unlocked and unattended. During a concurrent observation and interview on December 10, 2024, at 4:45 PM, with PT 1, PT 1 walked towards the opened Unit 2's medication room door and went inside. When PT 1 was asked…

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

Based on observation, interview, record review, the facility failed to prepare food in a form designed to meet the need of one resident (Resident 28) when Resident 28's lunch on Monday, December 9, 2024, had visible chunks of food. This failure had the potential to result in Resident 28 choking during the meal. Findings: During an observation on December 9, 2024, at 12:24 AM, in Unit 2's dining room, Resident 28's tray consisted of chicken potpie and carrots with notable lumps present. Resident 28's diet ticket stated dysphagia puree. (food texture that is smooth). During an interview on December 10, 2024, at 11:40 AM with the Dietary Supervisor (DS), in the kitchen, the DS stated that Resident 28's diet order is dysphagia puree. The DS further stated the meal should have had a smooth texture with no lumps. During an interview on December 11, 2024, at 8:15 AM with the Registered Dietician, the RD stated that Resident 28's diet order is dysphagia puree and that the order should have been followed. The RD further stated the expectation for a dysphagia puree diet is to have no lumps…

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 equipment in safe operating condition when the refrigerator had corrosion on the walls and expanding foam visible from behind the refrigerator wall. This failure had the potential to result in unsafe temperature control for safety foods and the accumulation of bacterial growth (germs that can cause illness). Findings: During an observation on December 9, 2024, at 8:18 AM, in the kitchen, corrosion on the bottom walls of the walk-in refrigerator was observed. There was a yellow expanding foam visible from behind the posterior refrigerator wall. The Dietary Supervisor (DS) stated the foam was from the previous maintenance repair, and it should not have been visible. The DS further stated there should not be corrosion on the walls. During an interview on December 11, 2024, at 8:15 AM, with the Registered Dietician (RD), the RD stated the fridge should not have had corrosion on the walls and visible expanding foam from repair. During a concurrent interview and record review on December 11, 2024, at 10:20…

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 protect the resident's right to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one resident (Resident 1), when a Certified Nursing Assistant (CNA 1) threw water on Resident 1's face and kicked his right leg. This failure placed Resident 1 at risk for physical and psychological harm. Findings: During a review of Resident 1's admission Record (clinical record with demographic information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia (a mental disorder that affects a person's thoughts, feelings, and behavior). A review of the MDS (Minimum Data Set, and assessment tool), dated November 14, 2024, indicated Resident 1 had cognitive function with a score of 15/15 on the BIMS assessment (Brief Interview for Mental Status) which indicated Resident 1 is likely…

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 three sampled residents (Resident 1) with significant weight loss (10% of his body weigh) was weighed weekly which put Residents 1's nutritional status at risk. This failure resulted in Resident 1's significant weight loss going unmonitored which put this resident at risk for medical complications related to further weight loss. Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which includes: schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), hyperglycemia (high blood sugar), and Crohn's disease (inflammation of the bowels). During a review of Resident 1's Monthly Weights and Vitals Summary Record indicated the following: 1. January 9, 2023, indicated a weight of 168 pounds (unit of measure, lbs.), 2. April 3, 2023, indicated a weight of 166 lbs., 3.…

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 store, prepare, and serve food in accordance with professional standards for food service safety when: 1. Three plastic pitchers and three lids were stored wet. It was placed on a rack where clean and dried cookware and serviceware (containers, bowls, plates, trays, cups, utensils) were stored. 2. An unlabeled large plastic container with red liquid was found inside the fridge. 3. The kitchen floors were observed with build-up of dirt, sticky residue, and crumbs. Behind the stove, the floors had buildup of crumbs and one food thermometer. 4. The metal shelf, above the stove, had grease build-up. 5. There was no thermometer inside the Resident Refrigerator, and the Resident Refrigerator Temperature Log was empty. These failures had the potential to lead to growth of microorganisms (bacteria, virus, fungi) and foodborne illness for 116 highly susceptible residents who receives facility prepared meals. Findings: 1. During the initial kitchen tour, with the Dietary Supervisor (DS), on March 7, 2023, at 8:10 AM,…

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 resident rights were respected for two of five residents (Residents 59 and 18) reviewed for unnecessary medications (any medications which are in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) when: 1. For Resident 18, the informed consent (document signed by resident or representative to give permission for a proposed psychotropic medication [medications that affects brain activities associated with mental processes and behavior] and possible risks and benefits expected) were not obtained for Resident 18's order of Ativan (anti-anxiety medication), Temazepam (hypnotic medication- induce sleep) and Trazodone (anti-depressant medication). 2. For Resident 59, the informed consent was not obtained for Resident 59's order of Invega (anti-psychotic medication).…

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 respect the rights of one resident (Resident 43) reviewed for physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident in the same manner as it was applied by staff) when Resident 43's physician's order for restraint was not discontinued in accordance with the facility's policy. This failure had the potential to result in Resident 43 to be restraint unnecessarily and without a new physician's order. Findings: During an observation on March 7, 2023, at 9:51 AM, Resident 43 was lying in bed, facing right side. Resident 43 refused to be interviewed. During a review of Resident 43's clinical record, the admission Record (contains demographic and medical information) indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (mental disorder in which people interpret reality…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS- a computerized assessment instrument) was completed for one of four residents (Resident 8) reviewed for nutrition after severe weight loss and decline in personal hygiene to reflect current resident's status, care, and services was identified . This failure had the potential to delay identification and implementation of Resident 8's care and support needs, which could result on his care plan not being updated and revised to reflect his current status. Findings: A review of Resident 8's admission Record (a document that contains demographic and clinical data), indicated Resident 8 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (mental illness that can affect your thoughts, mood, and behavior) and hypertension (blood pressure that is higher than normal). During a concurrent interview and record review, on March 10, 2023, at 9:21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services for one of seven residents (Resident 56) reviewed for skin conditions. This failure had the potential to cause inaccuracy in identifying Resident 56's care and support needs. Findings: During a review of Resident 56's admission Record (a document that contains demographic and clinical data), it indicated Resident 56 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a severe long-term mental health condition) and atopic dermatitis (areas of skin to become itchy, dry, cracked, sore and red). A concurrent interview and review of Resident 56's clinical record was conducted with the Minimum Data Set Nurse (MDS Nurse) and the Director of Nursing (DON) on March 10, 2023, at 8:55 AM. The MDS Nurse and the DON reviewed Resident 56's Body Check assessment, conducted…

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 post fall protocol was implemented in accordance with the facility's policy and procedure for one of four residents (Resident 18) reviewed for falls, when Resident 18's care plans (action plan that outline the type of care and treatment a resident need) was not updated, and the Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines working towards a common goal for a resident) did not conduct a review after Resident 18 had a fall. This failure have the potential for Resident 18 to be at risk of further falls which could increase Resident 18's risk of injuries. Findings: During an observation, on March 7, 2023, at 9:23 AM, outside of Resident 18's room, Resident 18 was walking on the hallway, wearing street clothes, talking to a staff. During a review of Resident 18's admission Record (clinical record with demographic information), it indicated, Resident 18 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff followed safe infection control practices when: 1. A Dietary Aide did not perform hand hygiene before serving lunch on March 7, 2023. 2. The Dietary Supervisor (DS) was wearing acrylic nails, longer than the tip of the fingers, while breakfast on March 8, 2023. 3. Resident 23's used towels and linens, with live lice crawling, were not placed in bags. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 116 highly vulnerable residents whose health conditions are already compromised. Findings: 1. During an observation, in Wing 2's dining room, on March 7, 2023, at 12:43 PM, Dietary Aide (DA 1) entered the dining area and applied a pair of gloves. DA 1 did not wash his hands on the sink, which was located at the left side of the steam table (used to keep the food hot). DA 1 proceeded to serve food from the food pans (rectangular pans used for food…

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 an effective pest control program was being implemented when: 1. There was one live cockroach crawling out from the janitor's closet, close to the Wing 1 dining room. 2. There was one live cockroach found in wing 2 Men's shower room. Findings: 1. During an observation, on March 9, 2023, at 2:27 PM, near the Wing 1 dining room, a cockroach came out underneath the Janitor's closet, and crawled towards the Wing 1 dining room. Resident 41 stepped on the roach before it could reach the dining room. During a subsequent observation, on March 9, 2023, at 2:30 PM, Resident 41 stepped on the cockroach twice while he was in line waiting for an activity. During a concurrent observation and interview, with the Activity Director (AD), on March 9, 2023, at 2:33 PM, the AD verified the cockroach was on the floor, near the Wing 1 dining room. 2. During a concurrent observation and interview, with the Pest Control Technician (PCT), March 10, 2023, at 10:45 AM, in the Wing 2 Men's shower room, there was a live cockroach…

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.