Overland Terrace Healthcare & Wellness Centre, LP

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain proper weight settings for the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) for three of five sampled residents (Resident 3, Resident 19 and Resident 57).This deficient practice had the potential for Resident 3, Resident 19 and Resident 57's pressure injuries to worsen or to develop new pressure injuries.Findings: 1. A review of Resident 3's admission record indicated the facility originally admitted the resident on 9/20/2024 and readmitted the resident on 5/8/2026 with diagnosis that included unstageable pressure ulcer of sacral region (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), type 2 diabetes mellitus (high blood sugar) with foot ulcer, and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). A review of Resident 3's potential…

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 that enteral feed tubing (a flexible tube for delivering nutrient-rich liquid formula directly into the stomach or small intestine) was labeled with the date and time when hung up for one of one sampled resident (Resident 43). This deficient practice had potential for Resident 43 to suffer abdominal discomfort and infection.Findings: During a review of Resident 43's admission Record, the admission record indicated the facility admitted the resident on 4/6/2026 with diagnoses that included but not limited to Dysphagia (inability to swallow) and unspecified Protein-Calorie malnutrition (potentially life-threatening condition due to inadequate intake of protein, calories or both). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 43 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 43 was dependent on staff and required maximum staff assist for activities of daily living (ADL-…

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 one of one sampled residents (Resident 77) who received dialysis (process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, by failing to:1. Complete Post Dialysis Assessment following Resident 77 returning from dialysis treatment.2. Implement the physician's order for fluid restriction of 1200 cubic centimeters (cc-unit of measurement) a day. These deficient practices had the potential to result in harm to the resident which could include edema or unchecked bleeding. Findings: A review of Resident 77's admission record indicated the facility originally admitted the resident on 1/2/20213 and readmitted the resident on 8/1/2025 with diagnoses that included end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs) and dependence on renal dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) and heart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to observe infection control measures for three of four sampled residents (Resident 3, Resident 12, and Resident 79) by failing to ensure: 1. Resident 3's urinals (a container used to collect urine closed parentheses were labeled with the residents names and room numbers. 2. Ensure staff did not pick up a meal ticket off the floor then placed the contaminated (something has been made impure, unclean, or dangerous by contact with or the addition of a harmful, foreign, or undesirable substance) meal ticket on one of six residents' (Resident 12) food trays then walked towards the dining room to serve the food tray to Resident 12 with the contaminated meal ticket still on the food tray. 3. Ensure the toilet bowl in one of one resident (Resident 79) was clean and sanitary (clean and free from germs). These deficient practices had the potential for the residents to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and…

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

Based on observation, interview, and record review, the facility failed to ensure one of one staff (Licensed Vocational Nurse (LVN) 7) completed Elder Abuse Mandated Reporter training according to the facility's policy and procedures (P&P) titled, Training Requirements dated reviewed, January 2026. had proof in the personnel file of the necessary training to care for residents in a safe and secure manner. This deficient practice had the potential for LVN 7 not to be able to identify and report suspected/allegation of abuse and placed the residents in the facility at increased risk for abuse. Findings: During a concurrent interview and record review on 6/5/26 at 12:04 PM of LVN 7's personnel file. The personnel file indicated LVN 7 did not have Elder Abuse Mandated Reporter training upon hire. The Director of Staff Development (DSD)/LVN 2, stated, there is no Elder Abuse Mandated Reporter training in this staff members' file. DSD/LVN 2 checked and reviewed the facility electronic system but was not able to provide any additional information regarding abuse training for LVN 7. DSD/LVN…

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 their policy regarding reporting resident to resident's allegation of physical abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of six sampled residents (Resident 1 and Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further physical abuse for Resident 1.Findings: A. During a review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side, dysphagia (difficulty swallowing) following cerebral…

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 the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with Order Summary Report for psychological/psychiatrist consult follow-up treatment dated 9/23/2025 and the facility's policy and procedures titled Behavior Management reviewed on 1/2025, when:1. Resident 1's exhibited episodes of aggressive behavior towards Resident 4 (roommate) and became extremely agitated, disruptive, thrashing arms, uncontrolled screaming, and yelling on 9/23/2026 at 9:30 am., and used curse words, derogatory names, and racial slurs directed at Resident 4 and Resident 4's family members.2. Resident 1 became verbally abusive, extremely agitated, and physically aggressive towards Resident 4's family members. These deficient practices risked the safety of Resident 4, Resident 4's family members, other residents and 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 interview and record review, the facility failed to treat two out of 20 residents (Residents 11 and 45) with respect, dignity and, care by failing to provide person-centered care in a manner that promotes and supports the Residents quality of life. This deficient practice had the potential to negatively affect the Residents' 11 and 45 physical, mental and psychosocial well-being. Findings: During a record review, Resident 11's medical record indicated Resident 11 was originally admitted to the facility on [DATE] with diagnoses that muscle weakness, falling, depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities.), cognitive communication deficit (disorder that affect a person's ability to communicate.), and anxiety (excessive and persistent worry, fear, and unease). During a record review, Resident 11's history and physical (H&P) dated 12/6/2024 indicated Resident 11 has the capacity to understand and make medical decisions. During a record review,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, and homelike environment for residents in the facility by failing to: 1. Maintain residents' room temperature between 71 and 81 degree Fahrenheit (° F) as required by the Federal regulation for one of three sampled residents (Resident 70) and five of five rooms checked during a facility tour. This deficient practice resulted in Resident 70 stating of being cold and feeling uncomfortable making it hard for the resident to sleep. 2. Provide a clean, sanitary and in good repair environment in one jack and [NAME] bathroom (a shared bathroom situated between two bedrooms, featuring at least two entrances (one from each bedroom),) for residents in rooms [ROOM NUMBERS]. This deficient practice had the potential to expose Residents and disease-causing pathogens/ micro-organisms that can cause infection, spread diseases. Findings: a. During an observation on 3/3/2025 at 8:55 AM, Resident 70 sleeping in bed covered…

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 to the Department of Health Services (CDPH), Licensing and Certification and the local health officer an unusual occurrence for two of six sample residents (Residents 17 and 71) an unwitnessed fall with injury within twenty-four (24) hours of confirmed occurrence per facility policy. On 12/23/2024 at around 11:35 AM, Resident 17 had an unwitnessed fall and sustained a skin tear to the right upper eyebrow. On 12/23/2024 Resident 17 was transfered to a General Acute Care Hospital (GACH) for a higher level of care and evaluation. On 2/28/2025 at 6:42 PM, Resident 71 had an unwitnessed fall and sustained a cut to the left eyebrow. On 2/28/2025, Resident 71 was transferred to GACH for higher level care and evaluation. This deficient practice resulted in a delay of an onsite inspection by CDPH to ensure Residents 17 and 71 allegation of an unwitnessed fall with a significant injury was investigated in a timely manner placing the residents at risk 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 protect one of two sampled residents (Resident 71) from repeated falls. Resident 71 fell on [DATE], 12/1/2024, 12/20/2024, and 12/27/2024. As a result, on 2/28/2025, Resident 71 fell again in the facility and sustained a cut (laceration) to the left eyebrow and first aid administered. On 2/28/2025, Resident 71 was transferred via 911 (emergency response number) to a general acute care hospital (GACH) for further evaluation and care. Findings: During a record review, Resident 71's admission record indicated was re-admitted on [DATE], with a diagnoses of history of falling and unspecified Dementia (cause of dementia cannot be determined, often used when a person's cognitive decline is present). During a record review, the facility fall list indicated Resident 71 fell 5 times in the facility on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025. During a record review, Resident 71's Fall Risk Evaluation dated 10/24/2024 at 11:51…

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 label and store medications in a locked compartment for one sampled resident (Resident 27). This deficient practice had the potential to result in: 1. Resident 27 self medicating without a physician's order. 2. Resident 27 receiving/consuming expired medication. Findings: During a concurrent observation, interview, and record review with the facility Dietary Supervisor (DS) on 3/5/2025 at 10:06 am, the residents outside food storage refrigerator was observed noted multiple food items without expiration dates on them, expired foods, and expired medication in Resident 27's food bag. DS stated, it is the license nurses responsibility to check the residents outside food items before they store it in the refrigerator. During an observation and interview on 3/5/2025 at 2:34 PM, of medication cart A with License Vocational Nurse 1 (LVN 1) medication cart noted to be clean. Stated he has been employed with the facility for 1 year. Stated all medications and biologicals are dated and stored properly in the 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.

Based on observation, interview, and record review, the facility failed to follow the food recipe when preparing lunch for the residents. These failures had the potential to result in resident receiving diets that could have made the residents sick for 81 of 81 residents. Findings: During an observation and concurrent interview on 03/03/2025 at 9:30 AM, Dietary [NAME] was observed preparing lunch for the residents and not following the recipe. Dietary [NAME] was pouring black pepper into the ground beef. Dietary [NAME] stated has worked in the facility for 8 years. Dietary [NAME] stated he did not follow the recipe for cooking ground beef. Dietary [NAME] stated if he does not use the measuring utensils and follow the recipes' when preparing meals, he could use too much seasoning that can make the residents sick. During an interview on 03/03/2025 at 9:36 AM, Dietary Supervisor (DS) stated all the Dietary Cooks are supposed to follow the recipes for all meals when preparing food for the residents. DS stated DS last in-serviced dietary staff on following the recipes two weeks ago.…

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: 1. Store, label, and date food items stored in the refrigerator, freezer in the kitchen 2. Label and date the residents outside food stored in the resident's refrigerator 3. Check, record, and maintain the appropriate temperatures for the residents' food refrigerator and freezer for 03/2025. These failures had the potential for the residents to consume expired food and spoiled foods that could result in food borne illnesses. Findings: During the initial tour of the kitchen and concurrent interview on 03/03/25 at 7:55 am with the Dietary Supervisor (DS), the following was observed: 1. Ground nut [NAME] and salt did not have the original label and did not have the expiration or used by date on containers. 2. [NAME] ground pepper did not have use by or expiration date on container. 3. Ground cinnamon no expiration or used by date on container. 4. Pumpkin spice no expiration or used by date on container. 5. Barbeque sauce with an expiration…

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 staff failed to observe infection control measures by: 1. Failing to put on and use (don) personal protective equipment (PPE-gowns and gloves) while providing Activities of daily leaving (ADL- self-care tasks necessary for daily functioning and maintaining independence) to a one of 20 sampled residents (Resident 15) who was on enhanced barrier precaution (EBP- infection control measures that expand the use of PPE, during high-contact resident care activities to reduce the spread of multidrug-resistant organisms (MDROs - microorganisms, typically bacteria, that have become resistant to multiple classes of antibiotics). 2. Failing to provide and maintain a safe, clean, and sanitary environment in a one jack and [NAME] bathroom (a shared bathroom situated between two bedrooms, featuring at least two entrances (one from each bedroom) for two of two sampled residents rooms (rooms [ROOM NUMBERS]) by failing to ensure there was no dried hard smear by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately initiate/develop and implement a baseline care plan for one of five sampled residents (Resident 31) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care planning, reviewed 1/2025. Resident 31 has a history of Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 31. Findings: During a record review, Resident 31's admission Record indicated the facility admitted Resident 31 on 12/17/2024 with diagnoses including PTSD, and hypertension (HTN - high blood pressure). During a record review, of Resident 31's history and physical (H&P - a physician's examination of the patient) dated 12/17/2024, indicated .history of present illness . PTSD. During a record review, Resident 31's…

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

Based on observation, interview, and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent a urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three residents (Resident 12) by failing to ensure resident's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times. This deficient practice had the potential to result in urinary tract infections for the resident. Findings: During a record review, Resident 12's admission Record indicated the facility admitted the resident on 4/16/2020 and readmitted the resident on 5/14/2024 with diagnoses including obstructive and reflux uropathy, chronic kidney disease (progressive damage and loss of function in the kidneys) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). During a record review, Resident 12's Risk for UTI care plan, initiated 5/26/2024, indicated…

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

Based on observation, interview and record review, the facility failed to: 1. Label tube feeding syringe and feeding tube 2. Change tube feeding set for one of five sampled residents (Resident 41). These deficient practices had the potential to cause infection and/or possible hospitalization. Findings: During a record review, Resident 41's admission Record indicated the facility admitted Resident 41 on 7/10/2024 with diagnoses including encephalopathy (a brain disorder that can cause a change in how the brain functions), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health). During a record review, Resident 41's physician order dated 10/9/2024 indicated enteral feed order, every night shift change tubing syringe daily. During a record review, Resident 41's Minimum Data Set (MDS - a resident assessment tool) dated 12/19/2024, indicated Resident 41 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide outside services as required by the physician orders in accordance with the facility's policy and procedures (P&P) titled Referral to Outside Services revised 1/2025, by failing to refer one of five sampled residents (Resident 21) to a dentist (a healthcare professional that specializes in caring for teeth, gums, and related oral health problems). This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 21. Findings: During a record review, Resident 21's admission Record indicated the facility admitted Resident 21 on 2/6/2025 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a record review, the physician order…

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, interviews and record review, the facility failed to follow their own Policy and Procedure (P&P) by failing to conduct and complete a personal property inventory for one of the three sampled residents (Resident 1). This deficient practice had the potential to leave personal property to be unaccounted for and easily be missed. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was admitted to the facility on [DATE] 3 with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and insomnia (trouble falling asleep or staying asleep). During a review of a history and physical (a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then…

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), received the necessary, care, treatment and services to maintain activities of daily living (ADLs) This deficient practice resulted in lack of mobility and incontinent care for Resident 1 and the potential for Resident 1 to decline in her abilities to achieve her highest practicable well-being and quality of life. Findings: During a review of Resident 1's admission Records, dated 1/14/2025, the admission Records indicated, Resident 1 was readmitted to the facility on [DATE] with a diagnoses including neoplasm of bone (the development of cancer in the bones), morbid (severe) obesity, muscle weakness, unspecified open wound of the abdominal wall, anxiety (a person is often worried or anxious about many things and finds it hard to control) disorder. During the review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/10/2024, the MDS indicated, Resident 1 required…

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 that one of three sampled residents (Resident 1), received care and treatment according to the professional standards of practice to meet the resident's physical and psychosocial needs: This deficient practice had the potential to increase discomfort and developing pressure injury (injury to skin underlying tissue resulting from prolonged pressure on parts of a body, skin) and psychosocial decline of Resident 1. Findings: During a review of Resident 1's admission Records, dated 1/14/2025, the admission Records indicated, Resident 1 was readmitted to the facility on [DATE] with a diagnosis of including but not limited to Neoplasm of bone (the development of cancer in the bones), morbid (severe) obesity, muscle weakness, unspecified open wound of the abdominal wall, anxiety (a person is often worried or anxious about many things and finds it hard to control) disorder. During the review of Resident 1's Minimum Data Set (MDS, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) received care and services necessary to prevent accidents and falls, by failing to accurately assess Resident 1's fall risk upon admission on [DATE]. This deficient practice placed Resident 1 at an increased risk for to not receiving care and services necessary to prevent accidents and falls. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 10/9/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anoxic brain damage, history of falling and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified convulsions. A review of Resident 1's hypertension care plan, initiated 10/10/2024 indicated the resident had high blood pressure. The care plan interventions included the facility administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure two of six sampled residents ' (Residents 4 and 6) intravenous (IV, a small tube introduced via a needle into a vein to receive medications and nutrition]) sites were properly secured, labeled and changed per physician ' s orders and the facility ' s policy and procedures. This failure resulted in Resident 4 ' s IV site not being changed as ordered by physician every 48 hours, and Resident 4 and Resident 6 ' s IV sites being improperly labeled as per policy. Findings: A review of Resident 4 ' s admission Record, dated 3/15/24, indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses including: type II diabetes mellitus (a condition where your body has trouble controlling the level of sugar in the blood), dysphagia (difficulty swallowing foods or liquids), muscle weakness, urinary tract infection (infection of any part of the urinary tract), and hypertension (high blood pressure). A review of Resident 4 ' s Minimum…

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 six sampled residents ' (Resident 3) physician order for gastrostomy (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) tube feeding were followed. This failure resulted in Resident 3 not receiving the correct amount of formula via g-tube from 3/14/24 at 10 pm until 3/15/24 at 10 am (12 hours at 70 milliliters [ml, metric unit of measurement for liquids] an hour equals 840 ml total). Findings: A review of Resident 3 ' s admission Record, dated 3/15/24, indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses including hydrocephalus (a buildup of fluid in the brain), dysphagia (difficulty swallowing foods or liquids) following cerebral infarction (stroke), and gastrostomy (G-tube). A review of Resident 3 ' s Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 2/21/24, indicated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations/interviews/record review, the facility failed to protect the resident's(s') right to be free from resident-to-resident physical abuse by failing ensure the director of nursing (DON) reviewed the general acute care hospital (GACH) admission inquiry for one of three residents (Resident 2). As a result, on 3/1/2024, Resident 2 punched Resident 1 on the face sustaining facial injuries. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with a diagnoses but not limited to chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), and epilepsy (a disorder of the brain characterized by repeated seizures). A review of Resident 1's History and Physical (H&P) dated 4/8/23, indicated Resident 1 could make needs known but could make medical decisions. A review of resident 1's Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) dated 1/9/2024,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations/interviews/record review, the facility failed to ensure the director of nursing (DON) reviewed the general acute care hospital (GACH) admission inquiry for one of three residents (Resident 2) prior to admission. As a result, on 3/1/2024, the facility's marketer reviewed, accepted and admitted Resident 2 to the facility on 2/29/2024. Cross Reference F600 Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with a diagnoses but not limited to chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), and epilepsy (a disorder of the brain characterized by repeated seizures). A review of Resident 1's History and Physical (H&P) dated 4/8/23, indicated Resident 1 could make needs known but could make medical decisions. A review of resident 1's Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) dated 1/9/2024, indicated Resident 1's [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 provide a safe and hazard free environment ensure three of eight sampled residents (Residents 11, 40, and 47) by failing to ensure. 1. Resident 40 did not keep cigarettes and a lighter at bedside/on oneself. 2. A rollator walker (a device that gives support to maintain balance or stability while walking) and a wheelchair (a manually operated device with wheels that is intended for medical purposes to provide mobility to persons restricted to a seating position) did not impede Resident 11 and resident 47's door from opening completely. This failure resulted had the potential to result in fire resulted injury, accidents, hospitalization, and death to Residents 11, 40, and 47 having an accident while smoking. Findings: 1. A review of Resident 40's admission record indicated Resident 40 was re-admitted to the facility on [DATE], with a diagnoses not limited to muscle weakness (decrease in muscle strength), lack in coordination (impairment 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 conduct and documet pain assessment to ensure adequate pain management for one of three sampled residents (Resident 33). This deficient practice had the potential to result in unrelieved or ineffective pain control for the resident receving comfort care. Findings: A review of Resident 33's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities),diabetes mellitus (a disorder in which the amount of sugar in the blood is elevated), and hypertension (HTN -elevated blood pressure). A review of Resident 33's history and physical (H&P -a medical completer and formal assessment of the patient and the problem) dated 6/21/2023, indicated Resident 33, does not have the capacity for medical decision making due to cognitive (involving mental activities such as…

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 procedures to ensure an evaluation was made by the physician within 72 hours of admission for one of 24 sampled residents (Resident 32). This deficient practice had the potential for the resident not receiving necessary care and treatment timely based on the physician's evaluations. Findings: A review of Resident 32's admission Record indicated the resident was admitted to the facility on [DATE] with medical diagnoses that included hemiplegia (paralysis that affects one side of the body), encounter for surgical aftercare following surgery on the digestive system (system that converts food eaten in its simplest forms like glucose [sugar]), and hypertension (HTN -elevated blood pressure). A review of Resident 32's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/5/2024, indicated Resident 32 had intact cognition (thought process involving learning, reasoning, remembering) and was dependent 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.

Bases on observation, interviews, and record reviews, the facility failed to ensure menu was followed to cook vegetables according to their dietary recipes. This deficient practice had the potential not to meet the residents' dietary and nutritional needs. Findings: During a tour of kitchen on 2/22/24 11:55 a.m., [NAME] 1 poured salt directly into a pan of vegetables without using a measuring device. During a concurrent interview, the [NAME] 1 stated she did not follow the recipe for cooking vegetables. [NAME] 1 also stated if the recipes are not followed, the residents could get the wrong diet. During an interview on 2/22/24 12:00 p.m., with the Dietary Supervisor (DS), the DS stated Cooks had been trained on how to measure food items during their training. The DS stated, if recipes are not followed, the residents could consume the wrong diet which could make them sick. A review of the facility policy and procedures (P&P) titled Standard Recipes with a review date of 1/2024, indicated the facility is to provide the dietary department with the guidelines for the use of standardized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for two of eight residents (Residents 13 and 68) This failure resulted in Resident 68 feeling angry and also had the potential for Residents 13 and 68 to develop skin infections, skin irritation, and foul odor. Findings: 1. A review of Resident 13's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses not limited to morbid obesity (weight of more than 80 to 100 pounds above their ideal body weight), muscle weakness (decrease muscle strength). A review of Resident 13's History and Physical (H&P) dated 6/6/23, it indicated Resident 13 had the capacity to understand and make decisions. A review of resident 13's Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) dated 12/10/23, indicated Resident 13's [cognitive skills- the core skills your brain uses to think, read, learn, remember, reason,…

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 they have procedures in place to document a resident's choices regarding issues like Cardiopulmonary Resuscitation (CPR - an emergency lifesaving procedure performed when a person breathing and/or heart stops) for one of three sample residents (Resident 12) by failing to ensure the code status ((level of medical interventions a person wishes to have started if their heart or breathing stops) ) documents (Physician order, POLST, and Advance Directives [a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury]) were on file and readily available for review in case of a medical emergency for Resident 12. This failures had the potential for the facility not to honor the wishes and delay necessary medical services during an emergency for Resident 12. Findings: A review of Resident 12's face sheet (background information;…

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 staff failed to change, label, and date nebulizers tubing and mask and store a nebulizer mask set-up bag for one of eight sampled residents. This failure had the potential for contamination of nebulizer mask and use nebulizer tubing with past open dates for Resident 24. Findings: A review of Resident 24's admission Record Resident 24 was admitted on [DATE] with a diagnoses of but not limited to pneumonia (a condition where air sacs in the lungs become inflamed and filled with fluid or pus), methicillin resistant staphylococcus aureus (MRSA - a type of bacteria that causes an infection that does not respond to certain types of antibiotics), chronic obstructive pulmonary disease (COPD - is a common lung disease causing restricted airflow and breathing problems). A review of Resident 24's History and Physical (H&P) dated 2/1/24, indicated Resident 24 had the capacity to make medical decisions. A review of Resident 24's physician orders dated 2/1/24,…

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 three facility staff were competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and had the skills set to weigh residents appropriately and accurately. This failure had the potential for inaccurate residents' weight calculation that could result in neglecting necessary and or implementing unwanted medical interventions. Findings: A record review of the facility's in-service education titled Hoyer lift (a mechanical lifting device to weigh a patient) and standing weight scale, dated 09/05/2023, indicated, Restorative Nurse Assistant 1 (RNA 1 - assists residents in performing tasks that restore or maintain physical function) attended the in-service education. The in-service lesson plan did not indicate how to appropriately use a Hoyer lift and standing weight scale when weighing residents. During an interview with RNA 1 on 02/22/2024 at 9:59 AM, RNA 1 stated, I put…

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 label food in accordance with professional standards and facility policy to ensure food service safety by failing to: 1. Label food with the resident's name and date received. 2. Discard expired food stored in the resident's refrigerator. Those deficient practices placed residents with compromised health status at risk for foodborne illnesses. Findings: During an observation on 2/20/24 at 3:08 p.m., of resident's refrigerator with the Director of Nursing (DON), several food items were observed without resident's name, dates and some were past expiration date. During a concurrent interview with the DON, the DON stated Housekeeping (HK) is responsible for cleaning the refrigerator for residents and nurses are responsible to label foods received residents' family members. The DON stated residents could get food poisoning and become very sick if they consumed expired food. During an interview on 2/20/24 at 3:24 p.m., the HK stated HK is supposed to clean the refrigerator weekly on Fridays and the nurses…

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 interviews, and record reviews the facility failed to implement its' abuse policy and procedures when the facility failed to report to the California Department of Public Health (State Agency) of an alleged abuse of one of three sampled residents (Resident 1). This deficient practice resulted in a delay for an onsite investigation of the alleged abuse and places Resident 1 to continuous verbal and mental abuse from Resident 3. Findings: A review of Resident 1's face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 diabetes (an impairment in the way the body regulates and uses glucose [sugar] as a fuel), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood. The imbalance is caused by an illness or organs that are not working as well as they should. When the imbalance affects the brain, it can lead to personality changes) and hemiplegia & hemiparesis of the left side (loss 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 medical records requested upon written request on 12/8/24 within two working days per facility's policy and procedures (P&P) titled Resident Access to PHI, for one of three sampled residents (Resident 1). This deficient practice denied Resident 1 and the representative (RP) the right to have access to their medical records as indicated in their P&P. Findings: A review of Resident 1's admission Record (FS) for Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included, PUs of the left and right ankles stage 3 (Stage I: Intact skin with redness, Stage II: partial thickness, Stage III: full thickness skin loss, Stage IV: full thickness tissue loss, Suspected deep tissue injury, Unstageable: full thickness skin or tissue loss), diabetes mellitus 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and cognitive communication deficit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of two sampled residents (Resident 4) by failing to ensure: 1. Resident 4 ' s right buttock Pressure Ulcer (PU- skin and soft tissue injuries that form because of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body) was care planned. 2. Resident 4 ' s right first and fifth metatarsal (a group of 5 long bones in the middle of your foot. They connect the back part of your foot to your toes) Arterial Ulcer (a painful, deep sore or wound in the skin of the lower leg or foot. The ulcer doesn't heal as you'd expect an ordinary sore to heal. That's because there isn't enough blood flowing to the area. Blood supplies oxygen and nutrients to the tissues) was care planned. These deficient practices had the potential to result negative impact on Resident 4 ' s wounds healing thereby…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals for one of four sampled residents (Resident 4) by failing to: 1. Ensure physician orders were carried out. 2. Initial skin assessment was completed upon admission. This deficient practice had the potential to place Resident 4 and an increased risk for worsening of the Pressure Ulcers (PU- skin and soft tissue injuries that form because of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body) and/or new PU development. Findings: A review of the Resident 4's admission Record indicated Resident 4 was readmitted on [DATE] indicated Resident 4 was admitted with diagnosis that included, PUs of the left and right ankles stage 3 (Stage I: Intact skin with redness, Stage II: partial thickness, Stage III: full thickness…

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.