Windsor Care Center Of Sacramento

Based on interview and record review, the facility failed to ensure one out of 26 sampled residents (Resident 102) received trauma-informed care (a framework of care for helping people who have experienced trauma) in accordance with professional standards of practice and accounting for residents' experiences when Resident 102's trauma trigger(s) was not identified and her Post-traumatic stress disorder (PTSD-a mental health condition that can develop after a person experiences or witnesses a traumatic event) diagnosis was not care planned. This failure placed Resident 102 at risk for re-traumatization (re-experience/relives a traumatic event or experiences causing similar stress reactions to a new event), and to not achieve her highest physical, mental, and psychosocial well-being. Findings: Resident 102 was admitted in October of 2024 and had diagnoses that included dementia a progressive state of decline in mental abilities), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and PTSD. 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.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 26 sampled residents (Resident 91), when: 1. Resident 91 did not receive spironolactone (medication used for high blood pressure) for four days (four scheduled doses) due to the medication not being re-ordered timely (Within 3-5 days of medications running out); and, 2. Resident 91 did not receive the full dose of the antidepressant medication (medication used for depression) for four days due to medication not being ordered timely. These failures had the potential for not meeting the resident's therapeutic needs or worsening of her medical conditions. Findings: 1. Resident 91 was admitted to the facility in late 2024 with diagnosis of hypertension (HTN-high blood pressure) and depression. During a review of Resident 91's physician order (PO), dated 12/19/24, the PO indicated, Spironolactone .tablet .25 MG (milligrams) .Give 1 tablet by mouth one time a day related to .HYPERTENSION . During a review of Resident 91's Medication Administration Record…

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 26 sampled residents (Resident 6) was free of unnecessary medications, when Resident 6 was prescribed a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication without adequate indication or a target behavior. This failure resulted in the use of unnecessary psychotropic medication that could potentially cause adverse reactions and consequences. Findings: Residents 6 was admitted in the middle of 2024 with diagnoses which included vascular dementia (a progressive state of decline in mental abilities). During a review of Resident 6's Psychiatrist Consult Note dated 9/26/24, the note indicated, Bedside staff report that [Resident 6] is very calm with no behavioral issues, easy to manage. Talks a lot but doesn't make any sense. During a review of Resident 6's care plan (CP) initiated 9/27/24, the CP indicated there were no behavioral interventions attempted or included for Resident 6's of aggressive behavior of yelling out for needs. During a review of Resident 6's…

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

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled correctly for a census of 111, when: 1. One opened vial and three bottles of perishable medications were not labeled with an open or use by date in the medication room; and, 2. One bottle of glucose strips, one inhaler and one insulin pen were not labeled with an open or use by date in the medication cart. These failures had the potential for residents to receive expired medications with reduced potency. Findings: 1. During an inspection of the medication room on 12/17/2024 at 8:30 a.m. with Licensed Nurse 2 (LN 2), LN 2 verified there were three bottles of latanoprost (a medication to treat glaucoma - chronic eye disease that can lead to vision loss) eye drops and one vial of tuberculin (a protein mixture to diagnosis tuberculosis - an infectious disease caused by bacteria that affects the lungs) that were not labeled with an open date or use by date. LN 2 stated not having open date and use by date on multi dose vials and eye drops could result in residents…

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 supplies in accordance with professional standards for food service safety for the 110 residents eating facility prepared meals, when: 1. Three large steam table pans were found stored wet; and 2. A bag of frozen spinach was not closed, exposing the spinach to the environment. These failures had the potential to result in food-borne illnesses. Findings: 1. During initial kitchen tour on 12/17/2024 at 8:03 a.m., three large steam table pans were observed on the bottom shelf of the cook's station in storage. When removed, three of the large steam table pans were found with water droplets on inner and outer surfaces of the pans. During a subsequent interview with the Dietary Manager (DM) on 12/17/2024 at 8:03 a.m., the DM concurred that the pans were wet. The DM stated that the condition of the wet pans could lead to contamination. During a review of the 2022 US Food and Drug Administration (FDA) Food Code section 4-901.11, the food code indicated, Items must be allowed to drain and to air-dry before being…

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

Based on interview and record review, the facility failed to protect the right to be free from physical abuse for one out of 26 sampled residents (Resident 49) by another resident (Resident 112), when Resident 112 grabbed Resident 49 by the hair, pulled her down and hit her. This failure resulted in Resident 49 getting hurt, and had the potential for Resident 49 and all residents in the facility to experience physical and/or psychosocial harm. Findings: Resident 49 was admitted January of 2024 and had diagnoses that included dementia (a progressive state of decline in mental abilities), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 49's Minimum Data Set (MDS - a federally mandated resident assessment tool) Cognitive Patterns, dated 10/22/24, the MDS indicated, Resident 49 had a severely impaired cognition (mental process of acquiring knowledge and understanding). Resident 112 was admitted June of 2024 and had diagnoses that included dementia and other specified…

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 protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sample residents (Resident 2) when Certified Nursing Assistant (CNA) 4 slapped the face, aggressively pulled the arm, and used a gown to cover the face of Resident 2. This failure had the potential for Resident 2 to suffer physical and emotional injury. Findings: During a review of Resident 2's admission Record, dated October 2024, the admission Record indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills over time), dementia (decline in mental ability that affects memory, thinking and reasoning) and Major Depressive Disorder (mental health condition where a person experiences persistent feelings of sadness, hopelessness, and a lack of interest/pleasure in most activities.) During…

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 protect two of five sampled residents (Resident 2 and Resident 3) from abuse when Resident 1 punched Resident 2 on the face and bit Resident 3 on the right hand. These failures resulted in Resident 2 sustaining a scratch on the left lower lip and Resident 3 sustaining a skin tear on the right hand. Findings: During a review of Resident 1 ' s admission record, the record indicated Resident 1 was admitted in March 2024 with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities) and depression. Resident 1 ' s Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s care plan, initiated on 3/29/24, the plan indicated, Resident/patient exhibits, or has the potential to exhibit physical behaviors related to: Cognitive Loss/Dementia. History of behaviors .and has the potential to strike out at others. During a review of Resident 2 ' s admission record indicated Resident 2 was admitted in March 2024…

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

Based on interview and record review, the facility failed to develop a person-centered care plan for one of five sampled residents (Resident 1) when there was no care plan developed for Resident 1 ' s use of Trazodone (medication used to treat depression). This failure had the potential to result in Resident 1 not maintaining the highest practicable well-being and preventing avoidable decline. Findings: During a review of Resident 1 ' s admission record, the record indicated Resident 1 was admitted in March 2024 with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities) and depression. Resident 1 ' s Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Psychotropic Medication [drug that affects behavior, mood, thoughts, or perception] Administration Disclosure (Anti-Depressant), dated 7/31/24, the disclosure indicated, Physician order: Trazodone 50mg [milligrams, a unit of measurement] PO [by mouth] tablet QHS [hours of sleep]. During a review of Resident 1 '…

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 review, the facility failed to protect one of three sampled residents' (Resident 1) right to be free from physical abuse when Resident 2 kicked Resident 1 on the right side of his torso. This failure had the potential to result in serious physical injury to the Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses of encephalopathy (brain disease that alters brain function or structure) and alcohol dependance with withdrawal delirium (confused thinking and reduced awareness of surroundings). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/16/24, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating he had severe cognitive impairment. A Behavior Note for Resident 1, dated 7/15/24, indicated, Patient is very intrusive .he goes to other peoples' rooms .he is up multiple times in the night and is hard to redirect. Resident 2 was admitted to the facility on [DATE] with 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 follow their Policy and Procedure, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, and report an alleged abuse for one of four sampled residents (Resident 2) when Resident 3 physically harmed Resident 2. This deficient practice placed Resident 2 and other residents in the facility for potential injury from Resident 3. Findings: 1. During a review of Resident 3's admission Record, indicated, Resident 3 was admitted in the facility on 12/22/23, with diagnoses that included major depressive disorder, unspecified dementia, and with other behavioral disturbances (a pattern of disruptive behaviors). During a review of Resident 3's Brief Interview for Mental Status (BIMS, tool used to identify cognitive conditions) Section C, Cognitive Patterns showed a score of 3 which suggested severe cognitive impairment. During a review of Resident 3's SBAR, Communication Form [SBAR, Situation, Background, Assessment and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility ' s dietary services failed to recognize a food allergy for one resident (Resident 1) of three sampled residents when Resident 1 was served fish for lunch and was allergic to it. This failure resulted in Resident 1 having to take medication to prevent a severe, life-threatening allergic reaction. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included intracranial hemorrhage (bleeding within the brain) and dysphagia (difficulty swallowing). This admission record also indicated Resident 1 was allergic to fish and shellfish. A review of a health status note authored by a licensed nurse, dated 11/30/23 at 8:05 p.m., indicated, [Resident 1] .admitted from [hospital] at [2:30 p.m.] via gurney .Allergies= Fish, Shellfish . A review of an allergy audit report indicated a Registered Nurse (RN) created an allergy status for Resident 1 ' s allergy to shellfish on 11/30/23 at 3:02 p.m. and fish on…

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

Based on interview and record review, the facility failed to complete annual performance evaluations for eight of eight sampled certified nursing assistants (CNAs), CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, and CNA 9 for a census of 109. This failure increased the risk for residents to receive poor quality of care from the CNAs. Findings: During a review of the facility's electronic time keeping system, the time system indicated the following dates of hire (DOH): CNA 2 - 4/3/18 CNA 3 - 10/21/16 CNA 4 - 2/19/20 CNA 5 - 6/20/16 CNA 6 - 6/10/05 CNA 7 - 1/29/18 CNA 8 - 6/25/13, and CNA 9 - 7/1/19. During a concurrent interview and record review, on 11/15/23 at 9:48 a.m., with the Administrator (ADM), the ADM indicated the personnel records for the CNAs were reviewed and no performance evaluations (PEs) were completed in 2023. The ADM stated if the PEs were not completed annually, the staff skills could be decreased and could affect the CNAs competency to provide care for the residents. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations,…

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

Based on observation, interview, and record review, the facility failed to ensure that food was prepared in a form to meet individual needs for 24 of 109 residents when Minced and Moist (MM) diets received bowtie pasta and green beans that were not modified to ¼ inch or less, and Soft and Bite-size (SB) diets received regular size bow-tie pasta that were not cut to ½ inch or smaller size. This failure had the potential to create a choking hazard for 24 residents (including Resident 14, Resident 460, Resident 83, Resident 84, Resident 161, Resident 103, Resident 54, Resident 25, Resident 3, Resident 5, Resident 49, Resident 213, Resident 210, Resident 106, Resident 63, Resident 52, Resident 40, Resident 63, Resident 1, Resident 91, Resident 58, Resident 6, Resident 33, and Resident 59) eating facility prepared meals. Findings: During the initial kitchen tour on 11/13/23 at 8:34 a.m., the Dietary Supervisor (DS) explained the various diets served in the facility. These diets included textured modified diets from the International Dysphagia (swallowing difficulty) Diet Standardization…

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

Based on observation, interview, and record review, the facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety, when the facility failed to: 1. Prevent a build-up of ice around the freezer door and on the floor; and 2. Provide tray tickets with the lunch meals when the tray was delivered to the resident. These failures had the potential to compromise the safety of frozen food served to the 109 residents eating facility prepared meals, as well as to provide the wrong meal tray to the 34 residents on hallway two. Findings: 1. During a kitchen observation and interview on 11/13/23 at 9:50 a.m. with the Maintenance Supervisor (MS), an area of ice (approximately 2x 4) was noted inside the freezer door handle and towards the bottom of the freezer door, as well as on the floor. The MS indicated he replaced the gasket last August and that he did a monthly service of the freezer. The MS was observed chipping off the ice during our interview. The MS stated that someone probably did not close the door correctly. 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.

Based on observation, interview, and record review, foods brought to the facility for residents were not kept safe for consumption when resident food was labeled only with a room number. This failure had the potential of leading to foods being given to the wrong resident (who may be allergic to or unable to safely consume) as well as staff not throwing out foods that were no longer safe to eat. Findings: During an observation and interview on 11/13/23 at 1:50 p.m. with Licensed Nurse 7 (LN 7) in the locked medication room (behind nursing station one), the procedure for handling food brought in for residents from outside of the facility was discussed. LN 7 stated the process for outside food was that nursing would check the food for compliance with the resident's diet order, and if the food was found to be acceptable, it would be labeled with the resident's name and the date it was brought in. This was to ensure that the food was given to the correct resident, and that it would be thrown away when the food was considered unsafe. LN 7 opened the resident refrigerator. Inside was 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 a safe, clean and homelike environment was promoted for two of 33 sampled residents (Resident 61 and Resident 102), when: 1. Resident 61's room had a broken closet door, two missing drawers, and trash in the bottom drawer; and 2. Resident 102's immediate environment was empty and the walls were bare, and the resident had food particles in bed. These failures had the potential for the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 61 was admitted to the facility in late 2022 and readmitted in the middle of 2023 with diagnoses which included gender identity disorder and depression. During a review of a facility document titled, Work Order #4248, dated 7/10/23, the work order indicated, Drawer for [Resident 61] broken .removed. During a review of a facility document titled, Work Order #4253, dated 7/10/23, the work order indicated, Closet Door is broken . [Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) accurately reflected the residents' current status and health conditions for three of 33 sampled residents (Resident 107, Resident 15, and Resident 30), when: 1. Resident 107's discharge MDS indicated the resident was discharged to an acute hospital; 2. Resident 15's MDS assessments indicated an active diagnosis of pneumonia (PNA, infection in the lungs) on six different occasions; and 3. Resident 30's MDS assessment indicated the resident received insulin (medication used to lower blood sugar) injections. These failures resulted in the MDS data and records submitted to CMS (Centers for Medicare-Medicaid Services) being inaccurate, and had the potential to result in the residents not receiving appropriate treatment and care to maintain their highest practicable well-being. Findings: 1. Resident 107 was admitted in the middle of 2023 with diagnoses which included muscle weakness. During a review of…

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

Based on interview and record review, the facility failed to ensure care plans were reviewed and revised timely for one of 33 sampled residents (Resident 93) when his indwelling urinary catheter (a tube inserted into the bladder) and acute pain due to catheter placement care plans had not been updated at least quarterly. This failure had the potential to result in Resident 93 having unmet nursing needs. Findings: A review of Resident 93's admission record indicated he was originally admitted in 10/22 with diagnoses including obstructive and reflex uropathy (a disorder of the urinary tract that occurs when urine cannot drain from the bladder). An MDS (Minimum Data Set, an assessment tool), dated 8/22/23, indicated Resident 93 had an indwelling urinary catheter. A review of Resident 93's clinical record included the following documents: An indwelling catheter care plan, initiated on 10/17/22, was last revised on 12/14/22. An acute pain related to urinary catheter placement care plan, initiated 6/4/23, had not been since revised. In a concurrent interview and record review, on 11/15/23…

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 nail care for one Resident (Resident 8) of 33 sampled residents, when Resident 8's fingernails were long and packed with a brownish-black substance. This failure decreased the facility's potential to maintain Resident 8's nail care and prevent infection. Findings: A review of an admission record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions). A review of Resident 8's Care Plan, dated 8/21/20, indicated Resident 8 had activities of daily living self-care performance deficit related to confusion, impaired balance, and unawareness of safety needs. Care plan further indicated Resident 8 could require assistance at a dependent to extensive level for safe completion of personal hygiene. During a concurrent observation and interview on 11/13/23 at 10:05 a.m. in the activities room with Resident 8, Resident 8's fingernails were long 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 post the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for residents' care per shift on a daily basis, for a census of 109. This failure resulted in staffing information not being provided to visitors and staff. Findings: During a concurrent observation and interview on 11/14/23 at 2:20 p.m., with the Assistant Director of Nursing (ADON) in the main facility hallway where daily nurse staffing schedules were posted, the ADON confirmed the last posted daily staffing schedule was dated 11/3/23. During a concurrent observation and interview on 11/15/23 at 8:45 a.m., with the Director of Nursing (DON) in the main facility hallway where daily nurse staffing schedules were posted, the DON confirmed the daily staffing schedule had not been updated since 11/3/2023. During a concurrent observation and interview on 11/16/23 at 8:31 a.m., with the Administrator (ADM) in the main facility hallway where daily nurse staffing schedules were posted, the ADM confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to properly secure the expired or discontinued controlled medications (medications with high potential for abuse or addiction), when the storage file cabinet was not permanently affixed to a permanent structure. This failure had the potential to increase risk of drug diversion and misuse. Findings: During an observation on [DATE] at 11:08 a.m. in the Director of Nursing's (DON) office, a file cabinet with discontinued controlled medications was observed to be not securely mounted to the wall or floor. During a concurrent observation and interview on [DATE] at 11:10 a.m. with the DON, the DON confirmed the cabinet was not secured firmly to the ground or wall. The DON stated, It could be picked up and walked off with. During a review of facility policy, titled, Disposal of Medications - related supplies, dated [DATE], The DON and consultant pharmacist are responsible for facility's compliance with federal and state laws and regulations in the handling 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 the medication administration error rate of five percent or below was maintained for a census of 109, when three medication errors were observed during medication pass out of 32 medication pass opportunities. This failure resulted in medication error rate of 9.38%. Findings: 1. Resident 45 was admitted to the facility late 2022 with diagnoses which included hypertensive heart disease (high blood pressure), unspecified atrial fibrillation (irregular heartbeat) and atherosclerotic heart disease (the build-up of fats in artery walls). During an observation of medication pass on 11/14/23 at 8:55 a.m. with Licensed Nurse (LN) 2, LN 2 was observed preparing seven medications for Resident 45 which did not include Resident 45's metoprolol extended release (a long-acting medication to treat high blood pressure) 25 mg (milligrams, unit of measure). LN 2 stated, We don't have it. It's not here. During a review of Resident 45's Order Summary Report (OSR), dated 11/15/2023, the OSR indicated, metoprolol Succinate…

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 wheelchairs for two out of 33 sampled residents (Resident 20 and Resident 32) were in good repair, when Resident 20's wheelchair had a broken brake handle on the right handle, and Resident 32's wheelchair had a torn right arm rest. This failure had the potential to compromise the health and safety of the two residents. Findings: A review of the clinical record for Resident 20 indicated, an admission to the facility in 2014 with diagnoses including, a history of a stroke, and memory problems with behaviors. A review of Resident 20's Minimum Data Set (MDS, an assessment tool), dated 11/10/23, indicated Resident 20 was using a wheelchair for mobility and was able to self-propel with one leg. During an observation on 11/13/23 at 8 a.m., Resident 20 was observed self-propelling in the wheelchair on Hall 1. The wheelchair was semi-reclined and each of the handles behind the chair had brake handles. The brake handle on the right side 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 ensure the call light was within reach for four out of 33 sampled residents (Resident 93, Resident 96, Resident 106, and Resident 217). This failure decreased the potential for the residents to get assistance from staff in a timely manner when needed. Findings: In a concurrent observation and interview, on 11/13/23 at 8:16 a.m., Resident 96 and Resident 217 were awake and sitting in their beds. Resident 96's call light was hanging on the wall to the right of his bed and Resident 217's call light was on the floor to the left of her bed. Certified Nursing Assistant 1 (CNA 1) confined the call lights were out of the residents' reach and stated they were supposed to be close to them. In a concurrent observation and interview, on 11/13/23 at 9:01 a.m., Resident 93 was asleep in his bed and his call light was hanging on the wall to the left of his bed. CNA 1 confirmed the call light was out of his reach. A review of an admission record…

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 a safe, functional, sanitary, clean and comfortable environment was provided for one of 33 sampled residents (Resident 61), when Resident 61's room had a broken closet door, two missing drawers, trash in the bottom drawer, and an unclean bathroom. This failure had the potential to result in Resident 61 not attaining his highest practicable physical, mental and psychosocial well-being. Findings: Resident 61 was admitted to the facility in late 2022 and readmitted in the middle of 2023 with diagnoses which included gender identity disorder and depression. During a review of a facility document titled, Work Order #4248, dated 7/10/23, the work order indicated, Drawer for [Resident 61] broken .removed. During a review of a facility document titled, Work Order #4253, dated 7/10/23, the work order indicated, Closet Door is broken . [Resident 61's] room .removed. During a review of Resident 61's Minimum Data Set (MDS, an assessment tool), dated 10/31/23, the MDS indicated Resident 61 had memory impairment 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 interview and record review, the facility failed to submit the results of an abuse allegation investigation involving two of four sampled residents (Resident 1 and Resident 2) to the Department of Public Health within 5 working days of the incident. This failure decreased the potential for the facility to protect residents from abuse. Findings: On 10/2/23, the Department received faxed notification from the facility indicating Resident 2 had struck Resident 1 with a stick from a tree earlier that day. The Department had not received an investigative summary from the facility by the time an on-site visit was made on 10/10/23, eight working days after the alleged incident. A written summary of the investigation was not provided on site to the Department on 10/10/2023. An interview, on 10/10/23 at 2:43 p.m., the Administrator (ADM) confirmed the 5 day follow up should have been sent on 10/7/23. ADM stated no one but her would have faxed it to the Department. ADM further stated she had no fax confirmation it was sent to the Department. ADM stated the reason for a 5 day follow…

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

Based on interview and record review, the facility failed to protect one of four sampled residents (Resident 1) from unconsented sexual contact, when Resident 2 was found on top of Resident 1 engaging in the act of sexual intercourse. This failure by the facility violated Resident 1's right to be free from sexual abuse. Findings: Resident 1 was admitted early 2022 with diagnoses which included dementia (memory loss), and psychotic disorder with delusions (abnormal thinking and perception). During a review of Resident 1's Face Sheet (a document that has patient information), the Face Sheet indicated Resident 1's son was listed as the responsible party. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) completed 6/8/23, the MDS indicated severe cognitive (thinking and reasoning) impairment. Resident 2 was admitted early 2023 with diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and delusional disorder (mental health condition in which a person cannot determine reality from what is…

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

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one of 21 sampled residents (Resident 67) when: 1. Showers were not provided, as scheduled; 2. Food preferences and dislikes were not honored, and not included on the meal ticket; and 3. Physician's order for diet was not followed. These failures resulted in resident's unmet needs, and had the potential to result in the resident not attaining the highest practicable physical, psychosocial, and mental well-being. Findings: 1. Resident 67 was admitted in early 2021 with diagnoses which included morbid obesity, acid reflux disease, and depression. During a review of Resident 67's Minimum Data Set (MDS, an assessment tool) dated 9/8/21, the MDS indicated Resident 67 was total dependent with bathing. During a review of Resident 67's chart document titled, Bathing: Support Provided, dated 11/26/21 [Friday], 11/28/21 [Sunday], 11/30/21 [Tuesday], 12/2/21 [Thursday], and 12/3/21 [Friday], the document indicated showers were done, but there were no…

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 licensed nursing staff were able to describe the safe storage of medication pass supplements for a census of 101. This failure had the potential to place residents at risk for for foodborne illness. Findings: During a concurrent observation and interview on 12/7/21, at 9:18 a.m., in Hall 4 with Licensed Nurse (LN) 2, a medication pass supplement carton with an open date of 12/7/21 was found in the cooler on the medication cart. LN 2 indicated the medication pass supplement was good for the whole day and should be discarded at the end of the day. LN 2 indicated the supplement was opened at 8:00 a.m. that morning. During a concurrent observation and interview on 12/7/21 at 9:22 a.m., in Hall 2 with LN 4, a medication pass supplement carton with an open date of 12/7/21 was found in the cooler on the medication cart. LN 4 indicated the medication pass supplement was good for the whole day and should be discarded at the end of the day. LN 4 indicated the supplement was opened at 8:05 a.m. that morning. LN 4…

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

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices for a census of 101, when: 1. Staff were unable to demonstrate how to effectively check for the concentration of sanitizing solution in the red buckets; 2. Staff were unable to verbalize how to properly sanitize the beverage dispenser system (BDS); 3. Health shakes were thawed in refrigerator but not discarded after two weeks per manufacturer guidelines; 4. Peanut butter and jelly sandwiches were not refrigerated per the grape jelly manufacturer guidelines; 5. Steam table pans were stored wet in the ready-for-use area, and a spatula was found wet in a drawer indicating it was ready to use; 6. A strainer was found ready to use but contained embedded rice in the rim of the strainer; 7. Multiple pans with deeps scratches were found hanging, ready to use and three oven mitts were found with large holes through the fingertips; 8. A bulk bin containing oatmeal was found with a chipped lid corner, leaving it unable to seal tightly; 9. A metal storage rack 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.

Based on observation, interview, and record review, the facility failed to protect privacy rights for one of 21 sampled residents (Resident 61), when Certified Assistant Nurse (CNA) 3 sat on Resident 61's bed while assisting the resident with eating. This failure had the potential to be seen by Resident 61 as an invasion of personal space. Findings: Resident 61 was admitted to the facility at the end of 2017 with diagnoses which included memory impairment and depression. During an observation on 12/7/21, at 12:40 p.m., in Resident 61's room, CNA 3 sat on Resident 61's bed, in the process of assisting Resident 61 to eat. Resident 61 was observed to be sitting in a chair next to the head of the bed. During an interview on 12/7/21, at 12:46 p.m., with CNA 3, CNA 3 stated, I usually don't sit on the bed but I need to be sitting down to feed her. I know I'm not supposed to sit on the bed. There's no chair. During an interview on 12/8/21, at 11:10 a.m., with the Director of Staff Development (DSD), the DSD stated, The CNA should not sit on the resident's bed. It's their personal space…

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

Based on observation, interview, and record review, the facility failed to treat one of 21 sampled residents (Resident 61) with dignity and respect, when a staff member referred to Resident 61 as a feeder in a public area. This failure had the potential to affect the emotional well-being of Resident 61, along with other residents who overheard the comment. Findings: Resident 61 was admitted to the facility at the end of 2017 with diagnoses which included memory impairment and depression. During an observation on 12/7/21, at 12:25 p.m., in a resident hallway, Certified Nursing Assistant (CNA) 3 stated, She's a feeder so I have to stay with her, after being handed a tray to pass to Resident 61. During an interview on 12/7/21, at 12:31 p.m., with CNA 3, CNA 3 stated, I didn't mean it to be derogatory. I could have said someone who needs assistance eating. I just wanted her [staff handing out trays] to know I had to stay with the resident. During an interview on 12/08/21 at 11:40 a.m., with the Director of Staff Development (DSD), the DSD stated, We train and train. We just went over…

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 needs were accommodated for four of 21 sampled residents (Resident 8, Resident 10, Resident 21, and Resident 67) when: 1. Call light was not in reach for Resident 8, 2. Showers were not provided as scheduled for Resident 10 and Resident 67, and 3. Staff did not allow Resident 21 to participate in the social dining program despite his request. These failures had the potential to result in residents' decreased independence, risks for falls, and risks for unmet needs. Findings: 1. Resident 8 was admitted to the facility in the spring of 2017 with diagnoses which included dementia (memory impairment). During a review of Resident 8's most recent Minimum Data Set (MDS, an assessment tool), dated 11/12/21, the MDS indicated Resident 8's memory was severely impaired and she required supervision and one person assistance with her Activities of Daily Living (ADLs). During a review of Resident 8's nursing care plan (CP) titled, I 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 privacy during personal care for two of 21 sampled residents (Resident 95 and Resident 48) when curtains were missing or did not cover the window area of the bedroom. This failure had the potential to result in residents' embarrassment and humiliation. Findings: 1. Resident 95 was admitted to the facility in early 2018 with diagnoses which included dementia (impaired memory), anxiety and depression. During a review of Resident 95's Minimum Data Set (MDS, an assessment tool), dated 10/24/21, the MDS indicated Resident 95 had severe memory impairment, was independent and required limited assistance for most Activities of Daily Living (ADLs). During an observation on 12/6/21, at 8:39 a.m., Resident 95 had no curtain at the foot of her bed, and no curtain on the window side of her bed to ensure privacy. During a concurrent observation and interview on 12/6/21, at 8:59 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 verified there…

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 that an accurate assessment was completed for 1 of 21 sampled residents (Resident 121). This failure resulted in Resident 121 having an inaccurate medical record. Findings: Resident 121 was admitted to the facility in summer of 2021 with multiple diagnoses which included muscle weakness, a history of falling, and chronic pain. During a review of Resident 121's Minimum Data Set (MDS, an assessment tool), dated 6/26/21, the MDS indicated Resident 121 had been discharged to an acute care hospital on 6/26/21. During a review of Resident 121's Discharge summary, dated [DATE], the Discharge Summary indicated, Discharge Disposition: Home with son. During a review of Resident 121's physician order, dated 6/25/21, and signed by the medical provider on 6/28/21, the order indicated, Resident is scheduled to discharge home with family on 6/26/21 .DC [discharge] home . During a review of Resident 121's progress notes, dated 6/26/21, the notes 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 maintain a desirable body weight for one of 21 sampled residents (Resident 7), when the weight loss was not documented. This failure resulted in a severe undesirable weight loss for Resident 7, and had the potential to result in further decline in the resident's nutritional status. Findings: Resident 7 was admitted in the middle of 2021 with diagnoses which included memory impairment, hypertension (high blood pressure), diabetes mellitus (abnormal blood sugar levels), iron deficiency anemia (low/insufficient iron in the body), hyperlipidemia (high levels of fat particles in the blood), and depression. During a review of Resident 7's, Weights and Vitals Summary (W/VS), the W/VS indicated the following: On 5/11/21, Resident 7 weighed 107.4 lbs. (pounds, a measurement of weight); On 11/11/21, Resident 7 weighed 95 lbs; and On 12/2/21, Resident 7 weighed 92.4 lbs. During a review of Resident 7's, Mini Nutritional Assessment (MNA), dated 8/11/21, the MNA indicated Resident 7 had no weight loss during the period…

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 safe and secure labeling and storage of medications and biological's for a census of 101, when: 1. Expired glucose monitoring test strips were found in the medication storage room; 2. Sterile needles were found in a box labeled with an expired date, in the medication storage room; 3. Refrigerated medications and vaccines were stored below acceptable temperature ranges; and 4. Two expired emergency medication kits (e-kits) were found in the refrigerator. These failures had the potential to negatively affect the health and well-being of the facility residents. Findings: 1. During an observation on 12/7/21, at 11 a.m., with Nursing Supervisor (NS) 1, of the medication storage room, an open box of, Professional Monitoring Blood Glucose Monitoring Strips was found on a shelf. The expiration date on the box was 10/17/21. During an interview on 12/7/21, at 11:05 a.m., with NS 1, NS 1 acknowledged that the strips were expired, and stated, It [the box of strips] should not be in here. It is expired. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident preferences were accommodated for two of 21 sampled residents (Resident 67 and Resident 21), when: 1. Resident 67's food dislikes were included in the meal tray; and 2. Resident 21 was not provided with a beverage of choice with a meal. This failure resulted in residents' emotional distress, and had the potential to result in residents' health complications. Findings: Resident 67 was admitted in early 2021 with diagnoses which included morbid obesity, acid reflux disease, and depression. During a review of Resident 67's Minimum Data Set (MDS, an assessment tool) dated 9/8/21, the MDS indicated Resident 67 had memory impairment. During a review of Resident 67's, Dietary Profile (DP) dated 1/12/21, the DP indicated Resident 67 disliked spinach and broccoli. During a review of Resident 67's Nutritional Assessment (NA) dated 1/14/21, the NA indicated [Resident 67] prefers no spinach, broccoli . During a concurrent observation…

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

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program for a census of 101, when: 1. A bench used by multiple residents was split and missing pieces of upholstery with an exposed padding; 2. Certified Nursing Assistant (CNA) 3, sat on Resident 61's bed while assisting the resident with eating; 3. Proper wearing of face masks by staff was not enforced; and 4. A nursing staff member wore a torn and soiled face mask while around residents. These failures had the potential risks to result in transmission of communicable diseases and infections. Findings: 1. During multiple observations on 12/7/21 at 3:05 p.m. and 12/8/21 at 8:08 a.m., one to three residents were seen sitting across from the small dining room on a bench which had split upholstery with part of the upholstery missing. Two splits were 8-10 inches long. One split had approximately one to two inches in width missing. During a review of the Work Orders (WO) dated 11/1/21 to 12/9/21, the WO had no request for repair of the upholstered bench. 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.