Idylwood Care Center

Based on observation, interview, and record review, the facility failed to follow its policy and procedure when Registered Nurse I (RN I) did not use a pair of gloves while preparing a hazardous drug (medications that pose potential health risks to individuals who handle them). This failure had the potential to expose RN I to hazardous drug. Findings: During the medication administration observation on 4/8/25 at 9:04 a.m., Registered Nurse I (RN I), was observed preparing five medications for Resident 139. One of the medications was finasteride (used to treat symptoms of Benign Prostatic Hyperplasia (BPH, a benign [not cancerous] condition in which the prostate gland [prostate is a gland in the male reproductive system] is larger than normal) 5 mg (milligrams, unit of measurement). The finasteride medication blister pack (packaged doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles.) was labeled with a red sticker stating, Hazardous drug. RN I prepared the finasteride medication without using gloves. During a concurrent interview and 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 to provide adaptive equipment (a device specifically designed to assist with drinking/eating) with meals to one of two sampled residents (Resident 10). This failure had the potential to affect the swallowing ability, fluid intake, health, and well-being of Resident 10. Findings: Review of Resident 10's face sheet (FS, a document that gives a resident's information at a quick glance) indicated Resident 10 was admitted to facility on 1/31/2002 with diagnoses including dysphagia (difficulty swallowing). Review of Resident 10's physician orders indicated, Nosey cup TID (three times per day) with meals for adaptive equipment . dated 11/5/2021. Review of Resident 10's meal tray card for lunch on 4/8/2025 indicated, Nosey Cup (an adaptive drinking cup with a U-shaped cut out on one side, designed to maintain proper head and neck position when drinking for safe swallowing liquids) highlighted in yellow color. During lunch meal observation and interview with certified nursing assistant K (CNA K) in Resident 10's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 10. Review of Resident 27's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including COPD and pericardial effusion (build up of extra fluid in the space around the heart.) Review of Resident 27's physician order, dated [DATE], it indicated he had an order for continuous supplemental oxygen at 2 to 5 liters per minute. During an observation on [DATE] at 9:48 a.m., Resident 27 was receiving oxygen via nasal cannula being delivered via an oxygen concentrator. The filters on both sides of the oxygen concentrator machine were dusty, with an accumulation of whitish gray substances on the filter sponges. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on [DATE] at 10:07 a.m., he confirmed both filters on Resident 27's concentrator were dirty and he stated the filters should be changed. During an interview with the director of nursing (DON) on [DATE] at 7:30 a.m., she stated the concentrator filter should be cleaned every week and replaced 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.

Based on interview and record review, the facility failed to follow up on diagnostic results timely for two of three residents (Resident 1 and 2) when: 1. Resident 1's dual-energy x-ray absorptiometry (DEXA or DXA, bone density scan used to diagnose osteoporosis [bone disease that causes a loss of bone density, weakens bones, and increases the risk of fractures]) scan results were not followed up timely. 2. Resident 2's order to schedule a DEXA scan was not followed up timely. This failure resulted in Resident 1's DEXA scan results not reported to the physician timely and a delay in starting medication to treat Resident 1's osteoporosis. This failure had the potential to result in Resident 2 not receiving necessary treatment/medication timely. Findings: 1. Review of Resident 1's clinical record indicated she was admitted to the facility with schizophrenia disorder that affects a person's ability to think, feel, and behave clearly) and benign neoplasm (abnormal but noncancerous tumor) of meninges (membranes that protect the brain and spinal cord). Review of Resident 1's Change 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, facility document and policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to retransmit Minimum Data Set (MDS) assessments within required timeframes for 8 (Residents #86, #67, #121, #108, #136, #22, #56, and #65) of 29 residents reviewed for MDS requirements. Findings included: A review of a facility policy titled, MDS, Minimum Data Set/Resident Assessment Instrument, effective on 05/27/2015, revealed, It is the policy of this facility to complete the Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) in accordance with the regulations, timeframes and guidelines set forth by OBRA [Omnibus Budget Reconciliation Act]-required and Medicare-required assessments. A review of the CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.18.11, revised in October 2023, revealed in Chapter 2: Assessments for the RAI that a Significant Correction to a Prior Quarterly (SCQA) must be transmitted no later than the MDS Completion Date +…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure podiatry care, specifically toenail care, was provided for 1 (Resident #130) of 2 sampled residents reviewed for activities of daily living (ADLs). Findings included: A review of a facility policy titled, Fingernails and Toenails, Care of, effective 09/01/2013, revealed, Fingernails and toenails are cleaned and trimmed regularly. Only podiatrists, physicians or licensed nurses provide nail care to diabetic residents, or residents with severe circulatory impairment. A review of an admission Record revealed the facility admitted Resident #130 on 09/27/2023. According to the admission Record, the resident had a medical history to include a diagnosis of need for assistance with personal care. The admission Record did not reflect a diagnosis of diabetes, circulatory impairment, or any nailbed abnormalities. A review of Resident #130's Care Plan revealed a Focus area, initiated 09/27/2023, that indicated the resident had an ADL self-care performance deficit related to impaired…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the head of bed (HOB) was elevated 30 degrees during the infusion of enteral feeding as ordered by a physician for 1 (Resident #68) of 2 sampled residents reviewed for tube feeding management. Findings included: A review of a facility policy titled, Enteral Therapy (Tube Management, Feeding, Medications), effective on 09/01/2013, revealed, POLICY Enteral nutrition is provided in a safe and effective manner to promote nutritional well-being and prevent complications of enteral therapy, as ordered by the physician. The section of the policy titled II. Administration of Enteral Feeding / Nutrition, C. Procedure for Feeding Pump Method: specified, 3. Ensure head of bed is elevated minimum of 30-45 degrees before starting the feeding. A review of an admission Record revealed the facility admitted Resident #68 on 01/20/2022. According to the admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) and pneumonitis due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 8. During an observation on 5/3/21 at 10:07 a.m., Resident 78 had signage outside his door and one pair of used gloves and two disposable gowns were exposed outside the garbage lid. During a concurrent observation and interview on 5/3/21 at 10:08 a.m., with LVN M, he confirmed the above observation and stated the garbage can was overflowing and the housekeeper should empty the garbage can. He further stated that Resident 78 is on contact isolation precaution and staff should have disposed the used gowns and pair of gloves inside the garbage can with fully covered by the lid. During an observation on 5/6/21 at 8:25 a.m., Resident 78 had signage outside his door and two pairs of used gloves, two disposable gowns were expose outside the garbage lid cover. During a concurrent observation and interview on 5/6/21 at 8:30 a.m., with LVN K, he acknowledged the above observation. He stated the garbage can was full and the housekeeper should empty the garbage can. He further stated that the overflowing of used gloves 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 respect and dignity was maintained for 3 of 25 sampled residents (38, 91, and 106) when: 1. Resident 38's privacy curtain was not drawn while she was voiding (passing urine from the body) on a toilet seat; 2. Resident 91 did not have appropriate covering or clothing and was exposed to view from her room; and 3. Resident 106's urinary catheter drainage bags (a urinary catheter is a thin, flexible tube used to drain urine from the bladder) was left uncovered. These failures had the potential to affect the emotional and psychosocial well-being of the residents. Findings: 1. During an observation on 5/4/21 at 3:15 p.m., Resident 38 was on a toilet seat beside her bed. Her privacy curtain was not drawn and the resident's door was open to the hallway where other residents and staff passed by. Two activity staff were present in the room. Resident 38's lower body part was exposed naked from waist level to lower legs. During an interview with LVN J on 5/4/21 at 3:35 p.m. , LVN J stated the curtain should be…

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 properly store medications and biologicals when: 1. An expired bottle of loperamide (anti-diarrhea) was found in one of the medication carts in Station B; 2. A bottle of Haloperidol (used to treat mental disorder) not kept in its original carton to protect from light was found in medication cart in Station A; 3. A Zioptan (sterile eye drop solution) single use containers not stored in refrigerator was found in the medication cart in Station A; and 4. Two boxes containing normal saline (NS, a mixture of sodium chloride in water that has a number of uses in medicine) were left outside the building. This failure had the potential to affect the efficacy and potency of the drugs. Findings: 1. During an observation on [DATE] at 2:40 p.m., in Station B, there was a bottle of Loperamide HCl (anti-diarrhea) containing several pills which had an expiration date of 11/2020 found in the top drawer of the medication cart. During an interview with 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.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Ten dietary staff did not cover their hair completely with a hairnet; 2. Two cans of dried peas in the dry storage room were dented; 3. Chopping boards 2 of 7 had deep cuts; and 4. Two dietary staff used the same potholder that was dropped on the floor to hold the hot tray and pots. These failures had the potential to result in a food borne illness outbreak among a population of vulnerable residents with complex medical conditions. Findings: 1. During an initial kitchen tour with the dietary manager (DM) on 5/3/21 at 9:15 a.m., the DM, registered dietitian (RD), dietary aide (DA) DA Q, DA R, DA S, DA T, DA U, DA V, DA W and DA X, worked in the kitchen. Their hair on the sides and back were not completely covered with a hair net. During an interview with the DM on 5/3/21 at 9:25 a.m., she confirmed the above observation and she stated dietary staff should have covered their hair completely with a hair net. Review of the facility's policy, DRESS CODE 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 interview and record review, the facility failed to complete a significant change in status assessment (SCSA) in the minimum data set (MDS, an assessment tool) for one of 25 sampled residents (87) when the resident had significant weight loss, had declined in activities of daily living (ADL, daily self-care tasks, e.g., bathing, toileting, and transferring) and had declined bowel continence. These failures had the potential to result in Resident 87 unable to achieve or maintain optimal status of health, function and quality of life. Findings: Review of Resident 87's face sheet (summary page of a patient's important information) indicated he was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty of swallowing), major depressive disorder (mood disorder that interferes with daily life) and schizoaffective disorder (a mental illness that can affect your thoughts, mood and behavior). During a concurrent interview and record review on 5/7/21 at 1:41 p.m., with registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan with measurable objectives, goal and person-centered interventions, for one of 25 sampled residents (118). This deficient practice had the potential to result not meeting the resident's needs. Findings: During an observation on 5/3/21 at 10:21 a.m., Resident 118 was lying in bed, with a fall mat on the floor next to his bed and had a low bed. Resident 118 had unclear speech, slurred and mumbled words. A review of Resident 118's face sheet indicated he was readmitted to the facility on [DATE], with diagnoses that included Schizophrenia (chronic brain disorder characterized by hallucinations, disorganized thoughts and speech, and trouble thinking), Alzheimer's (a progressive disease that destroys memory and mental functions), dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Anxiety disorder (medical condition…

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 2. Review of Resident 117's admission record indicated he was admitted to the facility on [DATE] with chronic obstructive pulmonary disease (COPD, a disease that causes airflow blockage and breathing-related problems.) Review of Resident 117's physician order indicated he had an order for oxygen 2 liter (L, a metric unit of volume) per minute (LPM) to 5 LPM as needed every shift related to COPD. During an observation with licensed vocational nurse C (LVN C) on 5/3/21 at 10:25 a.m., Resident 117 was lying in bed and was administered oxygen at 1.25 LPM. During a concurrent interview with LVN C, she confirmed Resident 117 was administered oxygen at 1.25 LPM. LVN C stated it should have been 2LPM. Review of the facility's 9/1/13 policy, Physician Orders indicated Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented. Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standards for two of 25 sampled…

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 the necessary care to maintain good grooming and personal hygiene for one of four residents (84). This failure resulted in Resident 84 having long and dirty fingernails and long toenails. Findings: Review of Resident 84's admission record indicated he was admitted to the facility on [DATE] with diabetes diagnosis (a disease in which the blood sugar levels are too high.) Review of Resident 84's Minimum Data Set (MDS, a clinical assessment tool), dated 12/28/2020, indicated Resident 84 needed extensive assistance with one-person physical assistance for personal hygiene. During an observation on 5/3/21 at 11:46 a.m., Resident 84 was lying in bed. His fingernails and toenails were long, and his fingernails were dirty. During a concurrent interview with supervisor A (SUP A), she confirmed Resident 84's fingernails and toenails were long, and his fingernails were dirty. SUP A stated sometimes Resident 84 refused to have his nails cut.…

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 bladder care was provided for one of five residents with indwelling urinary catheter (hollow tube that is inserted into your bladder to drain urine) when Resident 329's urinary collection bag was not emptied. This failure had the potential to cause resident's urinary tract infection (when bacteria gets into urine and travels up to bladder). Findings: During an observation on 5/4/21 at 3:30 p.m., Resident 329's urinary collection bag was full, bulky and hanging beside the bed. It contained more than 1000 ml of amber urine . During an interview with LVN K on 5/04/21 at 3:32 p.m., LVN K stated the urinary collection bag was not emptied since this morning and should have been emptied on every shift to avoid it becoming too full and heavy, which may pull on the catheter. This should occur every 2 to 3 hours or when the bag is about half to three-quarters full. Review of Resident 329's physician order dated 1/25/21, indicated Catheter care daily (per facility protocol) - AM every day shift. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation on 5/3/21 at 9:59 a.m., Resident 87's was lying in bed with his breakfast tray untouched and uncovered on top of his bedside table. During an observation and concurrent interview with LVN M on 5/3/21 at 11:17 a.m., he confirmed the above observation. He stated the CNA assigned to Resident 87 did not ask for food replacements and/or offer a food substitute; and lunch would be served soon. During an observation on 5/3/21 at 12:30 p.m., Resident 87's was lying in bed with his lunch tray untouched and uncovered on top of his bedside table. During an observation and concurrent interview with LVN M on 5/3/21 at 1:15 p.m., he confirmed the above observation. He stated the CNA assigned to Resident 87 did not ask for a food substitute and the lunch tray was served around 12:40 p.m. He further stated the food was already cold and needed to be replaced. During multiple observations on 5/4/21 at 8:15 a.m., 5/5/21 at 8:49 a.m., 5/6/21 at 8:45 a.m., and 5/7/21 at 10:00 a.m., Resident 87's was lying in…

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

Based on observation, interview, and record review, the facility had 10.71 percent medication error rate when three (3) medication errors of 28 opportunities were identified during a medication pass for three of seven residents. These failures had the potential to result in an ineffective drug therapy and possible adverse events. Findings: 1. During an observation on 5/4/21 at 8:45 a.m., LVN E poured 15 ml of Centrum liquid (Multivita.m.in & Mineral liquid) over piston (irrigation) syringe to Resident 46's gastrostomy (G-tube, feeding tube placed through the abdomen into the stomach). The medication was not fully administered when there was about one-third back flow of the multivita.m.in liquid spilled out from the piston syringe that was orange colored. During an interview with LVN E on 5/04/21 at 9:00 a.m., LVN E stated only about three-fourth of the multivita.m.in liquid was given to Resident 46 because the medication spilled out from the syringe. Review of Resident 46's physician order for 5/2021, indicated Multivita.m.in & Mineral liquid. Give 15 ml via G-tube one time a day…

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 documentation was complete for two of six residents (84 and 94) when Resident 84 and Resident 94 restorative nursing assistance (RNA) order were not transcribed to the Restorative Flow Sheet (RFS). These failures resulted in Residents 84 and 94 not receiving a RNA as ordered. Findings: 1. Review of Resident 84's admission Record indicated he was admitted to the facility on [DATE] with muscle weakness diagnosis. Review of Resident 84's physician order indicated he had an RNA order for active assisted range of motion (AAROM) or passive range of motion (PROM) of bilateral upper extremity in all planes while supine in bed as tolerated three times a week for three months, dated 4/23/21. However, this order was not on Resident 84's 5/2021 RFS. During an interview with minimum data set coordinator D (MDSC D) on 5/7/21 at 1:35 p.m., he confirmed the order was not on Resident 84's 5/2021 RFS, and therefore Resident 84 had not received this RNA service.…

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 outlet wall plates for two of 12 residents (Residents 8 and 329), were installed in a way to protect residents from potentially dangerous open electrical outlets. Findings: During an observation on 5/03/21 at 11:55 am, Residents 8 and 329's outlet wall plates facing towards the head of the residents bed were broken. During an interview with maintenance supervisor (MS) on 05/04/21 at 3:35 p.m., The MS acknowledged the findings and stated these were not logged in for repair or replacement. During an interview with LVN K on 5/04/21 at 3:45 p.m., LVN K stated if that's were not replaced that can present an electrical shock risk and potential fire hazard to residents' in this room. The facility's undated policy and procedure titled, Maintenance Log Procedure, procedure indicated 1. Fill out the Maintenance Request Form or maintenance log. Clearly state the issue or problem. Also note the urgency (if urgent). 2. Maintenance request form will be checked by Maintenance Dept. on a regular basis to address 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.