Rossmoor Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident received the necessary respiratory care in accordance with professional standards of practice when facility failed to provide in a timely manner, the missing connector for the appropriate-sized BIPAP (bilevel positive airway pressure, a machine used to treat sleep apnea [a sleep-related breathing disorder]) mask used by one of two sampled residents (Resident 1). This failure resulted in Resident 1's inconvenience, discomfort, several nights of interrupted sleep, skin breakdown to nose bridge (related to use of unfit, temporary BIPAP mask), anxiety, and mood swings. This failure also had the potential to result in serious harm and potential death to the resident. Findings: A review of Resident 1's admission Record, printed 11/12/24, indicated Resident 1 was admitted to the facility on [DATE], with multiple diagnoses that included acute respiratory failure with hypoxia (when the lungs are unable to provide oxygen in 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.

Based on observation, interview, and record review, the facility failed to have oxygen safety signage posted on Resident 1 ' s room as Resident 1 used an oxygen concentrator (a portable medical device used to deliver oxygen to those who have a condition that causes or results in low levels of oxygen in their blood). This failure had the potential of not having safety precautions in place necessary to care for Resident 1 who required oxygen use. Findings: During a record review of Resident 1 ' s face sheet, undated, Resident 1 had a diagnosis of acute respiratory failure with hypoxia (a medical condition that occurs when the lungs have difficulty exchanging oxygen and carbon dioxide with the blood). During an interview on 7/31/24, at 8:55 a.m., with Nurse Supervisor (NS), NS stated a resident who uses oxygen should have a magnetic oxygen signage posted on the door. During an observation on 7/31/24, at 12:10 p.m., Resident 1 had an oxygen concentrator located at the bedside. During a concurrent observation and interview on 7/31/24, at 12:26 p.m., NS stated Resident 1 did not have an…

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

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure a suspicion of sexual abuse, including injuries of unknown origin, was reported to appropriate authorities within the required regulatory timeframe when the Ombudsman received a telephone call from the facility ' s Master of Social Work (MSW) on 2/20/24, at 3 pm., regarding a concern that had been brought up by Certified Nursing Assistant 1 (CNA 1) during Resident 1 ' s Care Conference. This failure resulted in the facility's ability to ensure a complete investigation was initiated timely and ensure interventions were initiated to protect Resident 1 as well as all other residents of the facility, from protection from abuse. Findings: A review of Resident 1's admission Record, printed date 3/14/24, indicated Resident 1 was admitted to the facility in 2019 with diagnoses of Alzheimer ' s Disease (a decline in memory, thinking, learning, and organizing skills over time) and failure-to-thrive (state of decline in health and ability). A review of Resident 1's Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had adequate services to improve or maintain mobility when Resident 1 was discharged from physical therapy services after seven days out of a 60 day physical therapy plan and did not have recommendations at physical therapy service discharge to the physician or nursing staff to maintain or improve mobility. This failure placed Resident 1 at risk of impaired mobility and falls. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy after a right hip hemiarthroplasty (surgical replacement of the hip with an artificial hip). Resident 1 had a diagnosis of right femur fracture, artificial right hip joint and muscle wasting. During a record review of Resident 1's Hospitalist Discharge Summary, dated 1/4/24, Resident 1's hospitalization prior to admission to the facility was reviewed. The summary 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 interview and record review, the facility failed to ensure ongoing nursing assessments for one of three residents (Resident 1) involving: 1. admission Evaluation did not include skin condition of buttock area that had Mepilex (absorbent foam dressing) for protection. 2. When pressure injury was evaluated, Pressure Ulcer Report was not completed until four days after admission and Skin and Wound Evaluation Report was completed after an additional three days. 3. Care plans for rashes and pain were not personalized for Resident 1. 4. Treatment Administration Record (TAR) did not have entries for nine tasks related to skin monitoring and wound care. This failure resulted in Resident 1 not receiving ongoing assessments and the delay in having updated status of pressure injury (a localized damage to the skin and underlying tissue usually over a bony prominence or related to a medical or other device) may potentially affect Resident 1's care and well-being. Findings: A review of Resident 1's face sheet, undated, indicated Resident 1 was admitted to the facility in July 2023 with…

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

Based on observation, interview, and record review, the facility failed to ensure all staff wore the proper personal protective equipment (PPE, protective clothing, gloves, face masks, goggles and other garments used to protect the wearer's body from injury or infection) required during the facility's COVID-19 (coronavirus disease 2019, a sickness caused by a virus called severe acute respiratory syndrome coronavirus 2) outbreak when the Receptionist wore a surgical mask (a loose-fitting disposable device that creates a physical barrier between mouth and nose of wearer) instead of the required N95 mask (Non-0il with 95% efficiency, a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). This deficiency had the potential to place residents, visitors, and other staff at risk for serious respiratory illnesses. Findings: During an observation on 11/8/23, at 1:30 p.m., upon entrance to the building, a sign was posted at the entrance door that indicated there was currently a respiratory outbreak which required staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to establish criteria for registered nursing staff to follow for assessment and determination of irreversible death for one of two sampled residents (Resident 1). This failure resulted in Registered Nurse 1 (RN 1) using her personal judgement to assess Resident 1 as dead, instead of immediately calling 9-1-1 for emergency medical services or starting cardiopulmonary resuscitation (CPR, any medical intervention used to restore blood circulation or breathing functions that have ceased) as per Resident 1's physician order to provide full emergency medical treatment in the event Resident 1 stopped breathing, or Resident 1's heart stopped beating. This failure had the potential to result in residents being denied life-saving measures in the event death was reversible. Findings: During a review of Resident 1's admission Record Report, undated, the admission Record Report indicated Resident 1 was admitted to the facility in [DATE] with diagnoses of hemiplegia…

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 three of three sampled residents (Resident 47, 1 and 21) were provided privacy when staff did not draw the curtain during wound care for Residents 47 and 1, and Resident 21's Foley catheter bag (a urine drainage bag that collects urine. The bag is attached to a catheter (tube) is inside the bladder) was not covered and was visible. This failed practice had the potential to jeopardize Residents 47, 1 and 21's dignity. Findings: A review of Resident 1's admission Record Report and order details indicated, Resident 1 was admitted to the facility with diagnose of uterus (the womb) cancer and Resident 1 was treated for pressure injury (breakdown of skin integrity due to pressure) on her sacrococcygeal (tailbone). A review of Resident 47's admission Record Report and order details indicated, Resident 47 was admitted to the facility with diagnose of Alzheimer's disease (progressive mental deterioration) and was treated for pressure injury on sacral (tailbone). During an observation on 11/30/22 at 10:00 a.m.,…

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 four of nine sampled residents (Residents 488, 39, 633, and 8 received showers, bed baths and nailcare when Residents 488, 633, and 39 did not receive timely showers and Residents 8 and 39 did not receive nail care. This failure placed residents at risk for getting infections from lack of proper hygiene, injuring themselves with long fingernails, and compromising residents' physical and psychosocial wellbeing. Findings: During a review of Resident 488's admission Record printed on 12/01/22, the admission Record indicated Resident 488 was originally admitted to the facility on [DATE] and had medical diagnoses including traumatic subarachnoid hemorrhage (bleeding in the brain). During a record review of Resident 488's, Social Services Evaluation- V2, dated 11/22/22, indicated, Resident 488 was alert and oriented to time, place and person and had a BIMS score of 12 out of 15 and indicated moderate mental impairment. During an interview…

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 a review of Resident 633's admission Record Report printed on 11/28/22, the record indicated Resident 633 was admitted to the facility on [DATE]. During a record review of Resident 633's Minimum Data Set, dated 11/16/22, the assessment indicated Resident 633 had a BIMS score of 14 out of 15 and indicated intact mental status. During a concurrent observation and interview on 11/28/22, at 10:43 a.m., Resident 633 was sitting at the edge of the bed and stated, Both my legs are swollen, and they burn and [NAME], for two weeks; no one has come in to help me. During a concurrent observation and interview on 11/28/22, at 12:13 p.m., Minimum Data Set Coordinator (MDSC, a Registered Nurse responsible for conducting the resident assessments) assessed Resident 633's legs and stated Resident 633 had 2+ pitting edema. During an interview and record review on 11/28/22, at 12:20 p.m., with the MDSC, Resident 633's admission assessment and nursing progress notes from 11/12/22 through 11/28/22 were reviewed. The MDSC…

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: 1. Medications were administered according to physician's orders for 1 of 30 sampled residents (Resident 639); 2. Controlled medications awaiting final destruction were securely stored; 3. Random controlled medication use audits for four of five residents (Residents 3, 11, 57, and 442) were not reconciled. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents, or documented in the MAR and not signed out of the CDR; and 4. Physician was notified of missed doses of anti-seizure medication for 1 of 30 sampled residents (Resident 102) placing the resident at risk for seizures. These failures had the potential for Residents 639 and 102 to not receive their therapeutic dose of medications and medication diversion. Findings: 1. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure pharmacy storage and labeling procedures were followed when: 1. Medication refrigerator (#) temperature was not monitored and recorded twice daily; 2. Expired medications in the medication refrigerator were not discarded; 3. Expired medications in the medication carts were not discarded; 4. Resident 90's medication was not labeled; 5. Treatment material was left unattended at Resident 29's bedside. These failures had the potential for impaired medication integrity or to administer expired medication to residents. Findings: 1. During a review of the refrigerator temperature monitoring log on 11/28/22, at 9:29 a.m., the log dated November 2022, indicated temperature monitoring was not completed twice daily on nine days. The facility was unable to provide additional temperature monitoring logs upon request on 11/28/22 and 11/29/22, for August 2022 through September 2022. Licensed Vocational Nurse (LVN) 3 stated vaccines were to 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.

Based on observation, interview, and review of facility documents, the facility failed to ensure food service safety when multiple food items with no open date were found in the refrigerators. This failure placed the residents at risk for food borne illnesses. Findings: During a concurrent observation and interview on 11/28/22, at 9:15 a.m., with Director of Food Services (DFS), in the kitchen during the initial tour, it was observed in Refrigerator (Ref) 1, an opened package of butter, and a bag of cheese omelet with five pieces remaining with no date open indicated on the packaging. In Ref 2, there was an open bag of lettuce and an open bag of ham with no date open indicated on the packaging. DFS stated an open date should be placed on each packaging to know when it needed to be discarded. During a review of the facility's policy and procedure (P&P) titled, Labeling Food and Date Marking, dated 11/2020, the P&P indicated, Foods are labeled following deliver, preparation or opening to identify the item and to provide date, time and, or temperature information. The P&P also…

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 A review of Resident 76's admission Record Report and order summary report indicated Resident 76 was admitted to the facility with diagnose of Acute respiratory failure and was receiving 2 liter oxygen via nasal cannula every shift. During an observation on 11/28/22 at 10:44 a.m., Resident 76 was in bed and was receiving oxygen via nasal cannula. The nasal cannula and sterile water chamber (humidifier) connected to the oxygen tank was not dated or labeled. Resident 76's treatment mask connected to the nebulizer was dated 9/19/22. During an interview on 11/28/22 at 10:48 a.m., with LVN 6, LVN 6 confirmed the oxygen tube and humidifier were not properly dated, LVN 6 stated did not know when nurses changed them and confirmed the date on treatment mask was 9/19/22. LVN 6 stated Resident 76 used the treatment mask for breathing treatment. LVN 6 further stated oxygen tubes, mask and humidifier should be change weekly due to infection control. Based on observation, interview, and record review, the facility failed 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 Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 86), had physician's orders for Oxygen (O2) for more than six-months, when O2 was being administered around the clock. This failure resulted in Resident 86 receiving O2 without a physician order. Findings: During a record review of Resident 86's admission Record Report printed on 12/2/22, the record indicated Resident 86 was admitted to the facility on [DATE]. During a record review of Resident 86's Minimum Data Set (MDS- an assessment used to guide care) dated 10/24/22, the assessment indicated Resident 86 had a Brief Interview of Mental Status (BIMS, an assessment of mental status) score of 15 out of 15 and indicated intact mental status. During an observation on 11/28/22, at 11:05 a.m., with Licensed Vocational Nurse (LVN) 9, LVN 9 stated Resident 86 was receiving O2 via nasal cannula (thin plastic tube inserted in nostrils to provide oxygen) at 2 Liters/minute (L/min). During an additional…

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, nursing services did not communicate a doctor's therapy order in a timely manner for Resident 112. This failure resulted in a delay of services needed to maintain Resident 112's physical well-being. Findings: During a concurrent observation and interview on 11/28/22 at 11:00 a.m., Resident 112 laid in bed. Resident 112 stated she did not get physical therapy as her doctor ordered. Resident 112 stated therapy no longer worked with her and the facility was trying to discharge me home without my equipment, I need a bed, walker, and wheelchair. Resident 112 stated her legs were starting to stiffen and complained her legs and feet hurt because no one comes to help get her out of bed into her wheelchair or to walk or move around, I just lay here, and they do not check on her needs. Resident 112 stated she knows of the COVID-19 (a serious respiratory disease) restrictions and not leaving her room, but wanted to walk back and forth from her bed to the door. Review of Resident 112's physician order dated 11/21/22, indicated, 1. Continue…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to protect and promote the rights of four (Residents 184, 98, 112 and 117) of seven sampled residents when the following occurred: 1. Resident 184 was not given a shower when requested. 2. Resident 98 could be seen from the hallway exposed in her brief. 3. Resident 112 was not provided privacy and exposed when her Gastronomy Tube (GT - a tube surgically inserted into the stomach to provide nutrition, medication and water) was assessed. 4. Resident 117 was not asked for permission before staff removed her linen/covers. These failures resulted in unnecessary exposure for Residents 184, 98, 112, and 117 and had the potential for them to feel humiliated, disrespected, and disregarded. Findings: 1. Review of the medical record showed Resident 184 was admitted to the facility on [DATE] with a fractured left femur (thighbone) and an injury to his right leg. Further review of Resident 184's last comprehensive Minimum Data Set (MDS - an assessment…

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 properly store food in the refrigerators. This deficient practice had a potential for residents to consume food with food-borne pathogens. Findings: During an observation on 4/22/19 at 2:10 p.m. while in the presence of the Registered Dietician (RD 2), refrigerator #2 had an opened paper container of Wholesome Farms Scrambled Egg Mix-Liquid Egg Product without an opened date or used by date labeled. During an interview on 4/22/19 at 2:13 p.m., RD 2 stated everything in the refrigerators should have an opened date marked on it. During an observation on 4/22/19 at 2:17 p.m., the walk-in refrigerator had three clear pitchers without the name, open date, or use by date labeled. Further observation showed the first pitcher had an amber colored liquid, the second pitcher had a dark brown liquid, and the third liquid had an orange liquid. During an interview on 4/22/19 at 2:18 p.m., RD 2 stated, I do not know what kind of juices they are. Maybe they are apple, watermelon, and orange juice. They should be labeled…

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 assist one (Resident 184) of three sampled residents to the bathroom which resulted in Resident 184 defecating on himself. This failure resulted in Resident 184 feeling embarrassed and ignored. Findings: Review of the medical record showed Resident 184 was admitted to the facility on [DATE] with a fractured left femur (thighbone) and an injury to his right leg. Further review of Resident 184's last comprehensive Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 2/21/19 showed Resident 184 had a Brief Interview for Mental Status score (BIMS - a screening tool used to assess cognition) of 15 (cognitively intact). The MDS further showed Resident 184 was continent of urine and bowel, however required one person to assist him when transferring from one surface/area to another. During an interview on 4/22/19 at 11:37 a.m., Resident 184 stated, Day shift took about one and a half hours to respond to my call light…

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 call light was functioning for one (Resident 95)of three sampled residents. For Resident 95, his call light went non-functioning for three days before the facility addressed this need. This failure resulted in Resident 95 feeling frustrated he could not directly contact the staff for his care needs. Findings: A review of Resident 95's admission Minimum Data Set (MDS- an assessment tool used to help direct health care needs) dated on 4/4/19 showed Resident 95's Brief Interview for Mental Status (BIMS- a screening tool that aims to determine a person's attention, level of orientation, and ability to recall information) scored Resident 95 at 15, which meant Resident 95 was able to understand and be understood by others. Further review of the MDS showed Resident 95 required extensive assistance with one-person to physically assist Resident 95 when moving to or from his bed, a chair, his wheelchair, to a standing position, and for toilet use. During an observation and concurrent interview on 4/22/19 at…

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.