Stanley Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the availability of the prescribed medications for one of five sampled residents (Resident 5) reviewed for unnecessary medications. * Resident 5 had a physician's order for Cobenfy (psychotherapeutic medication). The licensed nurse was unable to administer the evening dose of Cobenfy on two consecutive days, due to the unavailability of the medication. This failure posed the risk for inhibiting the therapeutic effects of the medication.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber orders, including any required time frame. Medical record review for Resident 5 was initiated on 4/6/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Order Summary Report showed a physician's order dated 2/20/26, 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 interview, medical record review, and facility document review, the facility failed to follow up the MRR recommendation for one of five sampled residents (Resident 6) reviewed for unnecessary medications. * The facility failed to implement the pharmacy recommendations approved by physician to change the ibandronate (medication to prevent bone weakening) administration time for Resident 6. This failure placed Resident 6 at an increased risk for developing preventable adverse effects of the medication. Findings: Medical record review for Resident 6 was initiated on 4/6/26. Resident 6 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 10/26/25, showed the resident had no capacity to understand and make decisions. Review of Resident 6 's Order Summary Report showed the following physician order dated 10/26/25, may administer ibandronate 150 mg one tablet once a month on every 28th day of the month, give with eight ounces of water…

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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. One of three licensed nurses (LVN 2) was found to have made errors during the medication administration to one final sampled resident (Resident 4). * LVN 2 failed to administer the cholecalciferol (supplement) and fluticasone (medication to treat allergies) medications as ordered for Resident 4 due to the unavailability of the medications. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delays in interventions. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. 1. On 4/7/26 at 0834 hours, a medication…

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

Based on observation, interview, and facility P&P, the facility failed to provide the necessary pharmacy services to ensure the proper storage of medications for one of three medication carts (Medication Cart 1) inspected. * The facility failed to ensure the treatment supplies were stored properly. This failure had the potential to alter the efficacy of the stored treatment supplies and pose the risk of infection to the residents.Findings: Review of the facility's P&P titled Storage of Medication Labeling and Storage revised 2/2023 showed the nursing staff is responsible for maintaining the storage and preparation areas in a clean, safe and sanitary manner. On 4/6/25 at 1046 hours, an observation of Medication Cart A and concurrent interview was conducted with the DON. The following was observed:- one individual pack of sterile gauze bandage roll open with package's description showed it contained sterile in unopened, undamaged package.- three individual pack open Medi strip reinforced wound closure, with package's description showed it was a single use only dressing. During 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 facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpster. This failure had the potential to attract pests and rodents that carry diseases.Findings: Review of the facility's P&P titled Miscellaneous Areas, Garbage and Trash dated 2023 showed the garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. According to the 2022 FDA Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 4/6/26 at 0740 hours, an observation of the facility's one outside garbage dumpster was conducted. The garbage dumpster was observed with the lid partially propped open by the garbage bags, preventing the lid from fully closing. On 4/6/26 at 1529 hours, an interview was conducted with the DSS. The DSS was shown a photograph of the dumpster taken on 4/6/26 at 0740 hours. The DSS verified the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately documented for four of 13 final sampled residents (Residents 2, 6, 8, and 11). * The facility failed to ensure the safety assessment for siderails usage for Residents 2, 6, and 11 were accurate in accordance with the physician's orders. * The facility failed to ensure Resident 6's informed consent for buspirone (medication to treat anxiety), and citalopram (medication to treat depression) were maintained in the residents' medical record. * The facility failed to ensure Resident 8's blood pressure access site was accurately documented in the medical record. * The facility failed to ensure Section D of Resident 11's POLST (Physician Orders for Life-Sustaining Treatment) was signed and dated by the physician. These failures have the potential for the residents care needs not being met as their medical information were inaccurate and incomplete.Findings: 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.

Based on interview, and facility document review, the facility failed to ensure an employee working as a CNA (a healthcare professional who provides basic resident care and support) at the facility held a valid and up-to-date license and met competency evaluation requirements for training. This failure had the potential to result in an unlicensed CNA providing direct care to the residents without proper the certification and training, and placing the residents' safety at risk.Findings:On 1/28/26, CDPH, L&C Program was forwarded a complaint from the CNA Misconduct, which showed CNA 1 picked up an afternoon shift on 1/26/26, at the facility. However, the person who showed up and claimed to be CNA 1 was male. The complainant alleged CNA 1 stole a TV out of the utility closet and left the scheduled shift. Upon further investigation by the facility, showed CNA 1 was a female individual and the male individual who showed up for the afternoon shift was unlicensed and working under CNA 1's license. On 2/4/26 at 1021 hours, an interview and facility document was conducted with the DON.…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for four of four sampled residents (Residents 1, 2, 3 and 4). * The facility failed to ensure Resident 1 had an order to suction secretions. * The facility failed to ensure Resident 2's oxygen nasal cannula was stored in the bag according to the facility's P&P. * The facility failed to ensure Resident 3's nebulizer administration set-up was changed every seven days according to the facility's P&P. * The facility failed to ensure Resident 4's CPAP washable filter, mask, nasal pillows and tubing were cleaned according to the manufacturer's guideline and facility P&P while the resident was in the facility. These failures had the potential to negatively affect the residents' medical conditions. 1. Review of the facility's P&P titled Suctioning Upper Airway (Oral Pharyngeal Suctioning) revised on 10/2010 showed to verify there is a physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 2) had the physician's orders for the indwelling urinary catheter use, care, and maintenance. This failure had the potential for the resident to develop indwelling urinary catheter related infection and/or complications. Findings: Medical record review for Resident 2 was initiated on 5/15/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's physician orders failed to show any orders for the indwelling urinary catheter use, care, and maintenance. On 5/15/25 at 1510 hours, Resident 2 was observed lying in bed, with a urinary drainage bag hanging on the left side of the resident's bed. On 5/15/25 at 1511 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 2 had an indwelling urinary catheter, and catheter care should be done every shift and documented in the TAR. LVN 1 reviewed Resident 1'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, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the microwave utilized to warm up the food was maintained in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 3/3/25, showed 23 of 23 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation dated…

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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed and implemented as evidenced by: * Residents 2, 6, 9, 18, and 22's physicians were not notified when the residents' infections did not meet the McGeer's criteria. * The facility failed to ensure Resident 627 had contact isolation precautions in place due to the clostridium difficile infection. * The Infection & Control Surveillance Log of Infections for February 2025 was inaccurate. Resident 627's CAI infection was not included in the log. * The blood pressure wrist machine used for the residents did not have a cleanable surface (Velcro with cloth material). * The facility failed to ensure the hospice licensed staff practiced EBP when providing wound care treatment for Resident 20 who was on the EBP. * CNA 3 did not wear gown when provided dressing and hygiene to Resident 7 who was on the EBP. These failures posed the risk 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 facility P&P review, the facility failed to ensure the services provided met the professional standards of care when LVN 2 failed to properly obtain the blood pressure for one of three residents (final sampled resident, Resident 3) observed for medication administration. This failure had the potential for the residents requiring blood pressure checks to have inaccurate readings. Findings: Review of the facility's P&P titled Blood Pressure, Measuring revised 2010 showed the steps in the Procedure section as follows: - To expose the resident's arm by rolling the sleeve up about five inches above the elbow. - To wrap the blood pressure cuff evenly around the upper arm, approximately one inch from the elbow. - When you locate the pulsation, place the diaphragm of the stethoscope firmly against the skin. Hold diaphragm in place with your hand. - With your free hand, pump air into the cuff by squeezing the bulb until you can no longer hear the pulsation. (Note: You must be watching the mercury level on the manometer while you are pumping the air 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 8) who had limited mobility and ROM functions received the appropriate treatment and services to maintain or improve their ROM functions and prevent further decline in their ROM functions. This failure had the potential for Resident 8 to experience a decline in her physical abilities. Findings: Review of the facility's P&P titled Resident Mobility and Range of Motion revised July 2017 showed the residents will not experience an avoidable reduction in ROM. Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. In addition, resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. On 3/3/25 at 0856 hours, an observation and concurrent interview was conducted with Resident 8. When asked about…

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, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 3) reviewed for smoking remained free from accident hazards. * The facility failed to ensure Resident 3' smoking assessment was completed upon admission to the facility to determine if the resident was safe to smoke. This failure had the potential for the resident to sustain accidents and/or injuries. Findings: Review of the facility's P&P titled Smoking Policy revised July 2017 showed the residents who smoke must be assessed upon admission with a safe smoking assessment tool. On 3/3/25 at 1201 hours, an interview with was conducted with Resident 3 about his smoking privileges in the facility and how the facility staff had accommodated him. Resident 3 stated, they (the facility staff) take me out to the smoking area and wait with me while I smoke, there's an ashtray and they put the cover over me to keep me clean. On 3/3/25 at 1215 hours, an observation 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, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 13 and 17) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 13 and 17's oxygen therapy. This failure had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify there is a physician's order for this procedure, review the physician's orders or facility protocol for oxygen administration. On 3/3/25 at 0907 hours, during the initial tour of the facility, Resident 13 was observed lying in bed and receiving oxygen at 5 liters per minute via nasal cannula which was attached to the oxygen machine concentrator . Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 12 final sampled residents reviewed for the side rail use (Residents 1, 12, 13, and 20) remained free from the accident hazards due to the use of side rails. * The facility failed to ensure the Facility Verification of Informed Consent for Resident 13 was accurately completed. The consent form had no physician's signature and date. Furthermore, the facility failed to ensure the physician's order was obtained for the use of the bilateral half side rails for Resident 13. * The facility failed to ensure a care plan was initiated for the use of the bilateral half side rails for Resident 20. * The facility failed to provide the manufacturer's manual for Resident 12's bed to show compatibility for the bed's side rails. In addition, Resident 12's assessment for the use of the side rails was not completed. * Resident 1's assessment for the side rails to attempt the least…

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, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of medications for one of three residents (final sampled resident, Resident 8) observed for medication administration when: * LVN 1 failed to assess Resident 8's bowel status prior to administering a laxative (promotes bowel movements) medication as per the physician's order. This failure had the potential to negatively affect the resident's health conditions that could posed the risk for possible complications. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with the prescriber orders. On 3/4/25 at 0816 hours, a medication administration observation for Resident 8 was conducted with LVN 1. LVN 1 prepared and administered Resident 8's medications which included polyethylene glycol (laxative) powder 17 gm and Senna (laxative) 8.6 mg. LVN 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's identified drug recommendations were addressed for two of 12 final sampled residents (Residents 1 and 17). This failure posed the risk for the residents to have adverse consequences related to their medications. Findings: Review of the facility's P&P titled Medication Regimen Review revised 5/19 showed: - The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. - The attending physician documents in the medical record that the irregularity has ben reviewed and what (if any) action was taken to address it. 1. Medical record review for Resident 17 was initiated on 3/5/25. Resident 17 was admitted to the facility on [DATE]. a. Review of Resident 17's Order Summary Report showed a physician's order dated 9/6/24, to administer Preparation H (temporarily relieve swelling, burning, pain, 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, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 11.11%. Two of two licensed nurses (LVNs 1 and 2) observed during the medication administration were found to have made an errors. * LVN 1 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 8. LVN 1 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per the physician's order. * LVN 2 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 3. LVN 2 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per the physician's order. In addition, LVN 2 failed to administer Resident 3's vitamin B12 (supplement) medication as ordered. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 1 and 13) reviewed for hospice services received the necessary care and services. * The facility failed to ensure the hospice visit calendar was available in Resident 1's medical record and provide accurate documentation of the hospice staff visits for Resident 1. The facility also failed to ensure the care plan were updated and available in the resident's medical record. * The facility failed to ensure the hospice visit calendar was available in Resident 13's medical record. Additionally, the facility failed to ensure a care plan was initiated for the hospice services provided for Resident 13. These failures posed a risk of delayed communication and the provision of hospice care between the hospice provider and the facility. Findings: Review of the facility's P&P titled Hospice Program dated 7/2017 showed the facility has designated the DON…

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 review, and facility P&P review, the facility failed to ensure the QAPI committee developed and implemented action plans to include monitoring the effectiveness of those plans in achieving and sustaining the improvement for a repeated deficient practice cited at F756. This was not in accordance with the facility's POC from the last recertification survey completed on 3/14/24. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: Review of the facility's P&P titled Quality Assurance and Performance Review dated 2/2020 showed the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: - Tracking and measuring performance; - Establishing goals and thresholds for performance measurement; - Identifying and prioritizing quality deficiencies; - Systematically analyzing underlying causes of systemic quality deficiencies; - Developing and implementing corrective action or performance improvement activities; and - Monitoring or…

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 facility document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the quality control record for February and March 2025 reflected on the glucometer with the serial number 1040-4333929. This failure had the potential for the residents requiring glucose checks to have inaccurate readings. Findings: On 3/4/25 at 1339 hours, a concurrent review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for February and March 2025 and inspection of the glucometer with the serial number 1040-4333929 was conducted with LVN 1. The log showed the glucometer quality control was completed for February and March 2025. However, when the glucose quality control results documented on the log were compared to the glucometer device's saved results (memory), it showed the glucose quality control results documented for 2/1 through 2/4, 2/6, 2/8 through 2/13, 2/16 through 2/20, 2/23 through 2/27, and 3/3/25, were not observed on the glucometer device. For…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurately completed for four of 12 final sampled residents (Residents 1, 12, 13, and 20). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and 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, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The facility failed to ensure the handwashing sink was used for handwashing only. * The facility failed to ensure proper labeling and dating of food in the refrigerator used for resident foods. * The facility failed to ensure the kitchen utensils were clean and stored in sanitary condition. * The facility failed to ensure the cutting boards were kept in sanitary condition. * The facility failed to ensure the kitchen utensils and equipment were kept in good repair. * The facility failed to ensure the kitchen equipment were air dried. * The facility failed to ensure the dented cans were removed. These failures had the potential to cause foodborne illness in a highly…

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, facility P&P review, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to show documentation of Legionella testing protocols. * The facility failed to ensure the personal items and food were not stored in the laundry room with clean linens for the residents. In addition, the facility failed to ensure the laundry soap, fabric softener, and Clorox were stored properly and in clean condition in the laundry room. * The facility failed to ensure CNA 1 performed hand hygiene after assisting Resident 19 with lunch and doffing her gloves. * The facility failed to ensure the urinals, basins, and tubs stored in a shared bathroom shelf were labeled. These failures had the potential to result in the transmission of infection to the vulnerable population of residents in the facility.…

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, facility document review, and facility P&P review the facility failed to implement their Antibiotic Stewardship Program when the facility failed to conduct an accurate assessment for the McGeer's criteria for one of 14 final sampled residents (Resident 3) and one nonsampled resident (Resident 6). This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization cites…

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, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs for one of 14 final sampled residents (Resident 130) and one nonsampled resident (Resident 25). * The facility failed to ensure the call lights for Residents 25 and 130 were within the resident's reach. This failure had the potential to negatively impact the resident's physical and psychosocial well-being or would result in delayed provision of care. Findings: Review of the facility's P&P titled Call System, Resident dated 9/22 showed each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 1. During the initial tour of the facility on 3/11/24 at 0850 hours, Resident 25 was observed lying in bed. The call light was observed to be wrapped around the bed's side rail and on the floor. On 3/11/24 at 0900 hours, a concurrent observation and interview with Resident 25 was conducted with CNA 1 in Resident 25's room. Resident 25's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary timely assistance with the execution of an advance directive for healthcare and failed to ensure the POLST and Advance directive acknowledgement form was obtained for two of 14 final sampled residents (Residents 12 and 18). * Resident 18 was admitted to the facility on [DATE] and she informed the facility on 1/16/24, that she wished to execute an advance directive for health care. The facility attempted to contact the Ombudsman on 1/19/24, to schedule a time in which the Ombudsman could sign Resident 18's advance directive; however, the facility failed to follow up with the Ombudsman and Resident 18 had yet to formulate an advance directive. * The facility failed to ensure the POLST and Advance directive acknowledgement form were obtained from Resident 12's responsible party. These failures had the potential for the residents' decisions regarding their healthcare and treatment options to not 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 medical record review, the facility failed to obtain the physician's order for the discharge to home as well as documentation of the physician's notification upon leaving the facility for one of two closed medical records reviewed (Resident 28). This failure had the potential to affect the health and safety of the resident during the transition of care. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation last revised on 12/2016 showed the details of the transfer/discharge will be documented in the medical record and appropriate information will be communicated to the provider. On 3/13/24 at 0956 hours, closed medical record review was conducted for Resident 28 and showed Resident 28 was admitted to the facility for respite care from 12/10/23 to 1/3/24, and discharged home on 1/3/24. However, there was no physician's order for the resident's discharge in the closed medical record. Further review of Resident 28's Discharge summary dated [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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for two of 14 final sampled residents (Residents 16 and 19). * Resident 16 was evaluated to have blanchable redness to his left hip on 1/19/24. Resident 16 developed with DTI on the left hip on 2/11/24. The facility failed to ensure Resident 16's left hip was reassessed per the physician's order. The facility failed to provide the appropriate and necessary services to ensure Resident 16 did not develop a pressure ulcer in the facility. * The facility failed to ensure the LAL mattress setting was consistent with Resident 19's weight. These failures had the potential for the residents to develop the pressure ulcers or worsening of existing pressure ulcers. Findings: Review of the facility's P&P titled Prevention of Pressure Ulcers/Injuries revised 1/2017 showed to evaluate, report and document…

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, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 22) and one nonsampled resident (Resident 8) remained free from accident hazards. * The facility failed to ensure CNA 1 locked the wheelchair brakes during a transfer for Resident 22 on 1/23/24, resulting in Resident 22 falling to the ground. * The facility failed to ensure the tab alarm was in place as per the physician's order for Resident 8. These failures had the potential to not prevent further falls for these rresidents. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed according to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT for one of 14 final sampled residents (Resident 23). * The facility failed to ensure Resident 23's HOB was elevated during the enteral feeding to reduce the risk of aspiration. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 23. RNA 1 was observed to turn off the GT feeding to assist with repositioning for Resident 23. These failures posed the risk for complications related to the use of GT for Resident 23. Findings: Review of the facility's P&P titled Enteral Feedings- Safety Precautions revised 11/2018 showed all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. Under the section preventing aspiration showed to elevate the HOB at least 30 degrees during tube feedings. Medical record review for 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 observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for four of 14 final sampled residents (Residents 1, 2, 16, and 18). * The facility failed to follow the physician's order for administering the oxygen at 2 LPM instead of 3.5 LPM for Resident 1. * The facility failed to ensure the oxygen tubing was stored and labeled properly for Resident 2. In addition, the facility failed to obtain a physician's order for the oxygen therapy for Resident 2. * The facility failed to ensure the oxygen nebulizer mask and tubing were stored properly and labeled for Resident 16. * Resident 18's nasal cannula was improperly stored. These failures posed the risk for the residents' safety and respiratory related complications including infection. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify that there is a physician's order for this procedure; review the physician's orders or facility…

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, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 14 final sampled residents (Resident 2). * The facility failed to monitor and accurately document Resident 2's fluid intake. * The facility failed to show evidence Resident 2's monthly weight was monitored and recorded. * The facility failed to update Resident 2's comprehensive plan of care to reflect the current dialysis access site. These failures had the potential to result in health complications for Resident 2. Findings: Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident revised 9/2010 showed the residents with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 12) remained free from accident hazards related to the use of elevated side rails. * Resident 12 was observed with elevated side rails in place. The facility failed to review the risks and benefits of the side rails with Resident 12 and/or responsible party and failed to obtain the informed consent for the use of the side rails. * Resident 1 was observed in bed with the elevated side rails. However, there was no physician's order, care plan, and informed consent for the use of side rails. These failures had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed the consent for using restrictive devices will be obtained from the resident and legal representative per facility protocol. The consent for the side rail use will be obtained…

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, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 14 final sampled residents (Resident 2). * The facility failed to administer Sevelamer Carbonate (medication to treat too much phospate in the blood in residents with chronic kidney disease who are on dialysis) with meals as ordered by the physician. * The facility failed to monitor and document the blood pressure prior to administration of Midodrine (medication to increase blood pressure) as ordered by the physician. These failures had the potential to negatively affect the resident's health. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019, showed medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 2 was initiated on 3/11/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination…

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, medical record review, and facility document review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one of 14 final sampled (Resident 10). This failure had the potential for the resident not receiving the necessary care and services. Findings: Medical record review for Resident 10 was initiated on 3/11/24. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Physician Orders for 3/2024, showed a physician's order dated 1/19/24, to administer metoprolol tartrate 25 mg tablet PO (by mouth/orally) two times a day for hypertension (high blood pressure); and to hold if the heart rate less than 60 beats per minute or systolic blood pressure greater than 110 mmHg. Review of the facility document titled Medication Regimen Review Report dated 1/2024 showed a medication review completed by the Pharmacist Consultant for Resident 10. The recommendation showed for metoprolol tartrate (blood pressure medication) to be given with food 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, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 12) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the informed consent was obtained from Resident 12's responsible party for the use of Remeron (an antidepressant drug which can be taken as an appetite stimulant). This failure posed the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed the residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternative. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12'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 Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medications in the Medication Cart. The facility failed to ensure treatment supplies were not expired in the Treatment Cart. The Facility failed to ensure the expired hand sanitizer bottles were discarded. * Discontinued prednisone (steroid) tablets were observed in the Medication Cart. * The facility failed to ensure a container of germicidal alcohol wipes was stored separately from the residents' medications. * An unlabeled and unpackaged vial of ipratropium and albuterol (combination medication that relaxes muscles in the airways and increase air flow to the lungs) inhalation solution was observed lying in the Medication Cart. * Within the Medication Cart, two 30-ounce bottles of wild cherry Pro-Stat (protein supplement) and one 16-ounce bottle of Milk of Magnesia (laxative & antacid) were observed with an unknown substance accumulated on the outside of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccine was administered to one of 14 final sampled residents (Resident 17). This failure put Resident 17 at risk for pneumonia. Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised 10/2019 showed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provisions of such education shall be documented in the resident's medical record. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. Medical record review for Resident 17 was initiated on 3/14/24. Resident 17 was admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents. Findings: Review of the facility P&P titled Sanitization revised 12/08 showed ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the ice machine instruction manual titled Automatic Ice Maker undated, under the section for Cleaning and Maintenance, showed the ice machine must be cleaned by use of a water jet; for interior cleaning, the ice storage bin should be sanitized occasionally by wiping down the interior with a sanitizing solution made of 28 grams (g) of household bleach or chlorine 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.