Bloomfield Center For Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for 1 of 2 residents, (Resident #95), reviewed for nutrition, the facility failed to obtain daily weights for a resident with Congestive Heart Failure (CHF) per the physician's order. The findings include: Resident #95 was admitted to the facility in July of 2024 with diagnoses that included hypertension, Congestive Heart Failure (CHF), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #95 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment, and required maximum assistance for toileting, personal hygiene, bed mobility, and transfers. A Resident Care Plan (RCP) in effect for the month of December 2024 identified Resident #95 with a potential for altered cardiac status related to CHF and hypertension. Interventions included monitoring changes in lung sounds on auscultation (i.e. crackles) and evaluating respiratory status for signs of shortness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #66) reviewed for hydration, the facility failed to ensure the correct intravenous solution was administered per the physician's order. The findings include: Resident #66's diagnoses included dementia, acute kidney failure, and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #66 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment, and was independent with eating and bed mobility, required supervision with transfers, and once standing could ambulate 150 feet independently. The Resident Care Plan dated 5/1/2025 identified Resident #66 was at risk for dehydration secondary to infection and poor PO (by mouth) intake. Interventions included peripheral IV fluids, staff were directed to administer IV medications per MD order, and to monitor signs and symptoms of dehydration. APRN #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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #90) reviewed for hemolytic treatment, the facility failed to follow a fluid restriction for a resident on hemolytic treatment. The findings include: Resident #90 was admitted to the facility in April of 2025 with diagnoses that included end stage renal disease, dependence on renal hemolytic treatment, congestive heart failure (CHF) and anemia. The admission Minimum Data Set assessment dated [DATE] identified Resident #90 had a Brief Interview for Mental Status (BIMS) score 14 indicating no cognitive impairment, required substantial/maximum assistance for personal hygiene and bed mobility, was dependent on toileting and transfers and was receiving hemolytic treatment. The Resident Care Plan (RCP) in effect for April and May 2025 identified Resident #90 was on hemolytic treatment due to end stage renal failure. Interventions included checking and changing 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 clinical record review, review of facility policy, and interviews for 1 of 5 sampled residents (Resident #46) reviewed for medication administration, the facility to ensure medications that had been dispensed and were going to be administered were safely stored. The findings include: Resident #46 was admitted to the facility in July of 2024 with diagnoses that included hypertension, congestive heart failure (CHF), and diabetes. The annual Minimum Data Set (MDS) assessment dated MDS 5/2/2025 identified Resident #46 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, and was independent for eating, required moderate assistance with personal hygiene, and maximum assistance for toileting transfers. A Resident Care Plan in effect for the month of May of 2025 identified Resident #46 with Potential for altered cardiac status related to CHF and hypertension. Interventions included monitoring changes in lung sounds on auscultation (i.e. crackles), evaluating respiratory status: signs of dyspnea (shortness of breath), dyspnea on exertion,…

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, clinical records, staff interviews, and policy review for 1 of 2 sampled resident, (Resident #60), reviewed for infection control, the facility failed to ensure staff wore the appropriate Personal Protective Equipment (PPE) when providing resident care. The findings include: Resident #60 was admitted in April of 2024 with diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure, and quadriplegia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #60 had a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition, was dependent with personal hygiene and rolling left and right and used a motorized wheelchair. The Resident Care Plan (RCP) dated 4/29/2025 identified Resident #60 had COPD. Interventions included monitoring for signs and symptoms of respiratory insufficiency and to monitor/document/report any signs and symptoms of respiratory infection. Nurse progress notes dated 5/7/2025 identified Resident #60 was 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 clinical record reviews, reviews of facility documentation, facility policies, and interviews for three (3) sampled residents (Residents #1, #2, and #3) who were reviewed for misappropriation of funds, the facility failed to ensure funds from the residents' accounts were not withdrawn and misappropriated without the resident's knowledge or approval. The findings include: 1. Resident #1's diagnoses included schizophrenia and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, time and situation. The social worker note dated 4/4/25 at 1:00 PM identified Resident #1 reported that he/she went to the front desk on 4/4/25 to withdraw funds and was informed the balance was twenty-six (26) dollars. Resident #1 reported that he/she withdrew twenty dollars ($20) and his/her balance at that time should have been one hundred and sixty-six dollars and fifteen cents (166.15) and after the withdrawal it should have been one…

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 clinical record reviews, review of facility policies and procedures, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure a staff member would not retaliate towards the resident. The findings include: Resident #1's diagnoses included bipolar disorder and vascular dementia with behavioral disturbance. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was alert and oriented to person, place and time, was independent with most Activities of Daily Living and utilized a walker as an assistive device. The nurse's note dated 1/23/25 at 1:14 PM identified Resident #1 reported an incident had occurred with a nurse aide and the nurse aide stated, if Resident #1 hits her, she was going to hit Resident #1 back. The Facility Reported Incident report dated 1/23/25 at 12:00 PM identified Resident #1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of staff to resident abuse, the facility failed to ensure a witnessed allegation of verbal abuse was reported within two (2) hours to the Administrator or designee. The findings include: Resident #1's diagnoses included bipolar disorder and vascular dementia with behavioral disturbance. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #1 was alert and oriented to person, place and time, was independent with most Activities of Daily Living and utilized a walker as an assistive device. The nurse's note dated 1/23/25 at 1:14 PM identified Resident #1 reported an incident had occurred with a nurse aide and the nurse aide stated, if Resident #1 hits her, she was going to hit Resident #1 back. 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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include: 1) Resident #2's diagnoses included malignant neoplasm of the frontal lobe (cancerous brain tumor), epilepsy (seizure disorder), anxiety disorder and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, exhibited no behaviors, and required moderate assistance with bed mobility and was dependent on staff with transfers. The Resident Care Plan (RCP) dated 10/23/24 identified that Resident #2 has a behavior problem including accusatory behaviors related to malignant neoplasm of the frontal lobe with interventions that included to have two (2) caregivers at all times, encourage the resident to express…

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 review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and #2) reviewed for mistreatment, the facility failed to ensure the State Agency was notified of allegations of abuse/neglect timely. The findings include: 1. Resident #1's diagnoses included a fracture of the right fibula (the outer shin bone), congestive heart failure and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required maximal assistance with bed mobility and was dependent on staff for toileting hygiene. The Resident Care Plan (RCP) dated 11/12/24 identified that Resident #1 had bladder incontinence with interventions that included to check the resident every two (2) to three (3) hours for incontinence and clean the peri-area with each incontinence episode. Interview with Person #1 on 12/20/24 at 10:10…

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 review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) residents (Resident #1 and #2) reviewed for abuse and neglect, the facility failed to provide evidence that allegations of abuse and/or neglect were thoroughly investigated in accordance with facility policy. The findings include: 1. Resident #1's diagnoses included a fracture of the right fibula (the outer shin bone), congestive heart failure and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required maximal assistance with bed mobility and was dependent on staff for toileting hygiene. The Resident Care Plan (RCP) dated 11/12/24 identified that Resident #1 had bladder incontinence with interventions that included to check the resident every two (2) to three (3) hours for incontinence and clean the peri-area with each incontinence…

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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to follow the resident's plan of care directing to provide two (2) caregivers at all times. The findings include: Resident #2's diagnoses included malignant neoplasm of the frontal lobe (cancerous brain tumor), epilepsy (seizure disorder), anxiety disorder and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, exhibited no behaviors, and required moderate assistance with bed mobility and was dependent on staff with transfers. The Resident Care Plan (RCP) dated 10/23/24 identified that Resident #2 has a behavior problem including accusatory behaviors related to malignant neoplasm of the frontal lobe with interventions that included to have two (2) caregivers at all…

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 review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for incontinent care, the facility failed to complete a bladder evaluation on admission for a resident admitted to the facility with urinary incontinence. The findings include: Resident #1's diagnoses included a fracture of the right fibula (the outer shin bone), congestive heart failure and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required maximal assistance with bed mobility and was dependent on staff for toileting hygiene. Additionally, the MDS reported that Resident #1 was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 11/12/24 identified that Resident #1 had bladder incontinence with interventions that included to check the resident every two (2) to three (3) hours for incontinence 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 review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents, (Resident #1 and #2), reviewed for mistreatment, the facility failed to ensure the residents were provided social services support timely after an allegation of abuse/neglect. The findings include: 1. Resident #1's diagnoses included a fracture of the right fibula (the outer shin bone), congestive heart failure and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required maximal assistance with bed mobility and was dependent on staff for toileting hygiene. The Resident Care Plan (RCP) dated 11/12/24 identified that Resident #1 had bladder incontinence. Interventions included to check the resident every two (2) to three (3) hours for incontinence and clean the peri-area with each incontinence episode. Interview with Person #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 clinical record reviews, facility documentation, facility policy and interviews for three (3) of four (4) sampled residents (Residents #2, #3, and #4) who were reviewed for resident-to-resident physical abuse, the facility failed to ensure Resident #1 did not have physical contact with Residents #2, #3, and #4. The findings include: 1. Resident #1's diagnoses included Alzheimer's Disease, anxiety, and psychotic disorder with delusions. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had short- and long-term memory deficits, had not exhibited any behaviors in the past seven (7) days, was independent with ambulating, and received antipsychotic, antianxiety, and antidepressant medications. The Resident Care Plan dated 9/12/24 identified Resident #1 had an altered thought processes and the potential to become physically aggressive due to a history of aggression towards another resident and dementia. Interventions directed to provide one (1) to one (1) support as needed 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 clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was recently readmitted , the facility failed to update the Resident Care Plan when the resident returned from the hospital to include the hospitals' recommendation for wound care and a non-weight bearing status of the right foot. The findings include: Resident #1's diagnoses included type 2 diabetes with foot ulcer, amputation right great toe, end stage renal disease on dialysis, acute embolism and thrombosis of deep veins of right lower extremity, osteomyelitis. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, made reasonable decisions regarding tasks of daily life and had an infected diabetic foot ulcer that required dressings changes. The Resident Care Plan dated 8/19/24 identified Resident #1 had a self-care deficit and a potential for skin breakdown. Interventions directed to utilize pressure…

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 clinical record reviews, facility documentation, facility policies and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) who required wound care, the facility failed to obtain physician orders for the wound care they were providing and for Resident #2 the facility failed to follow professional wound care standards by not dating and timing the dressing when changed daily. The findings include: 1. Resident #1's diagnoses included type 2 diabetes with foot ulcer, amputation right great toe, end stage renal disease on dialysis, acute embolism and thrombosis of deep veins of right lower extremity, osteomyelitis. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, made reasonable decisions regarding tasks of daily life and had an infected diabetic foot ulcer that required dressings changes. The Resident Care Plan dated 8/19/24 identified Resident #1 had a self-care deficit and a potential for skin breakdown. Interventions…

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 clinical record reviews, facility documentation, facility policies and interviews for one (1) of four (4) sampled residents (Resident #3) who had severe contractures of the bilateral elbows and hands, the facility failed to ensure the proper application of a splint in accordance with the physician's order. The findings include: Resident #3's diagnoses included subarachnoid hemorrhage, seizures, and contractures of the bilateral hands and elbows. A physician's order dated 7/17/24 directed to trial bilateral hand splints by the Occupational therapist. The Resident Care Plan dated 7/18/24 identified Resident #3 had a self-care deficit and was dependent on staff for assistance with all activities of daily living and an alteration in skin integrity. Interventions directed dietary evaluation as needed, monitor for signs of infection, follow physician orders, and weekly wound rounds until resolved. Upon further review, the resident care plan failed to reflect documentation Resident #3 had bilateral hand…

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 clinical record review, facility documentation review, facility's policy review, and interviews for two of three residents (Resident #1 and Resident #3) reviewed for care and services, the facility failed to ensure consults were obtained in accordance with physician orders. The findings include: 1. Resident #1 was admitted with diagnoses that included dementia, hemiplegia and hemiparesis after a stroke, depression, and bell's palsy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment. A Resident Care Plan (RCP) dated 4/17/2023 identified Resident #1 was a long-term resident and had impaired cognition and communication. Interventions directed to monitor lab/diagnostic work as ordered and to report results to MD, following up as needed. Further record review identified Resident #1 had a Power of Attorney for financial and medical decisions. A physician's order dated 7/17/2023 directed to obtain a follow up consultation with gastroenterology in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of mistreatment. The findings include: Resident #1's diagnoses included femur fracture, Peripheral Vascular Disease, benign neoplasm of the brain and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, was incontinent of bowel and bladder, and required extensive assistance with bed mobility, transfers, and toileting. The Resident Care Plan (RCP) dated 11/15/2023 identified a communication problem. Interventions directed to anticipate and meet needs, ensure/provide a safe environment, speak on an adult level, speak clearly and slower than normal. Interview with the Administrator on 12/26/2023 at 12:54 PM identified on 11/29/2023 Resident #1's family member reported the roommate's family informed…

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 clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure a comprehensive investagation was completed timely after an allegation of mistreatment. The findings include: Resident #1's diagnoses included femur fracture, Peripheral Vascular Disease, benign neoplasm of the brain and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition, was incontinent of bowel and bladder, and required extensive assistance with bed mobility, transfers, and toileting. The Resident Care Plan (RCP) dated 11/15/2023 identified a communication problem. Interventions directed to anticipate and meet needs, ensure/provide a safe environment, speak on an adult level, speak clearly and slower than normal. Interview with the Administrator on 12/26/2023 at 12:54 PM identified on 11/29/2023 Resident #1's family member reported 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #3) reviewed for accidents, the facility failed to ensure the physician, the DON and the local police were notified timely when a resident eloped from the facility. The finding included: Resident #3's diagnoses included Alzheimer's and Parkinson's disease. Clinical record review identified Resident #3 had a court appointed Conservator of Person. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had impaired cognition for decision making, was independent with transfers and ambulation. Review of an elopement risk assessment dated [DATE] identified Resident #3 had was not at risk for elopement. Review of progress notes for the period of 7/1 to 7/12/2023 identified that the resident had no exit seeking behaviors. a. Review of a nurse's note dated 7/13/2023 identified that at approximately 2:00 AM the front door alarm was sounding and when 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 clinical record review, facility documentation review, facility policy review, and interviews for one sampled resident (Resident #2), reviewed for a change in condition, the facility failed to ensure neurological assessments were completed timely after resident fall. The findings include: Resident #2 was admitted to the facility during 12/2020 with diagnoses that included syncope and collapse, and dementia. The nursing admission assessment dated [DATE] identified Resident #2 was independent with transfers and ambulation. Fall risk assessment dated [DATE] identified Resident #2 was a high risk for falls with interventions that directed appropriate footwear when ambulating. The Resident Care Plan (RCP) dated 12/6/2020 identified Resident #2 had an ADL self-care performance deficit and was at risk for falls. Interventions directed limited assistance of staff for transfers and that the resident was independent to walk, and to use appropriate footwear when ambulating. Facility incident report form 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 clinical record review, facility documentation, facility policy and interviews for 1 of 1 sampled resident (Resident #41) reviewed for a hemolytic treatment, the facility failed to ensure notification to the physician/APRN concerning refusal of medications, in order to have the opportunity to alter the times of administration for missed medication. The findings include: Resident # 41's diagnoses include chronic obstructive pulmonary disease, end stage renal disease, and Diabetes Mellitus with neuropathy. A Resident Care Plan dated 1/16/22 and updated quarterly identified the need for dialysis related to renal failure. Interventions included to change the access dressing at dialysis, coordinate meals, snacks, medications, therapy and treatments in accordance with dialysis days (Monday, Wednesday and Friday). The annual MDS assessment dated [DATE] identified Resident #41 had intact cognition, required supervision with set up help for bed mobility and transfers. The MDS further identified Resident #41…

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 review of the clinical record, facility policy and interview for 3 of 5 residents (Resident #23, 157, and 158) reviewed for advance directives, the facility failed to ensure the resident's wishes regarding advance directives was discussed, addressed and documented timely, per facility policy. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive pulmonary disease, and diabetes. The nurses note dated [DATE] at 4:11 PM identified Resident #23 had arrived in a private car to the facility around 12:30 PM accompanied with his/her conservator. Review of the admission physician's orders failed to reflect a code status. A physician's note dated [DATE] at 1:00 AM identified, in the past, in the event of cardiopulmonary arrest, Resident #23 requested cardiopulmonary resuscitation (CPR) be performed. The care plan dated [DATE] identified in the event of a cardiopulmonary arrest, the residents code status was (full code) meaning…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #38 and 79) reviewed for abuse, for Resident #38, the facility failed to protect the resident from sexual abuse, and for Resident #79, the facility failed to protect the resident from abuse. The findings include: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that included dementia, left hand contracture, late onset Alzheimer's and abnormalities of gait and mobility. Court of Probate paperwork dated 7/3/19 identified the following for Resident #89, Conservator of Estate was terminated, and the Conservator of Person (COP) shall remain. Resident #89 was admitted [DATE] with diagnoses that included dementia, schizoaffective disorder bipolar type, schizoaffective disorder depressive type and moderate cognitive impairment with independent mobility. A nurse's note dated 7/29/21 at 1:36 PM identified Resident #38 was observed entering Resident #89's room and 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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident #45 and 79) reviewed for abuse, the facility failed to report the allegations of abuse according to facility policy and established timeframes. The findings include: 1. Resident #45 was admitted to the facility with diagnoses that included diabetes and osteomyelitis. A physician's order dated 9/19/22 directed to get Resident #45 out of bed via a mechanical lift to an adaptive power wheelchair with pelvic positioning belt to maintain upright posture. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition and required extensive assistance for personal hygiene, dressing, toileting, bed mobility, and transfers. Further, the MDS identified Resident #45 was occasionally incontinent of bladder and frequently incontinent of bowel and used a motorized wheelchair. The care plan dated 10/27/22 identified Resident #45 was dependent on staff for meeting physical needs.…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 6 residents (Resident #45) reviewed for abuse, the facility failed to investigate an allegation of abuse in a timely manner. The findings include: Resident #45 was admitted to the facility with diagnoses that included diabetes and osteomyelitis. A physician's order dated 9/19/22 directed to get Resident #45 out of bed via a mechanical lift to an adaptive power wheelchair with pelvic positioning belt to maintain upright posture. The quarterly MDS dated [DATE] identified Resident #45 had intact cognition and required extensive assistance for personal hygiene, dressing, toileting, bed mobility, and transfers. Further, the MDS identified Resident #45 was occasionally incontinent of bladder and frequently incontinent of bowel and used a motorized wheelchair. The care plan dated 10/27/22 identified Resident #45 was dependent on staff for meeting physical needs. Interventions included all staff to converse 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #45) reviewed for participation in care planning, the facility failed to ensure the resident was able to attend and participate in the care plan meetings on a quarterly basis. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included diabetes and osteomyelitis. The significant change MDS dated [DATE] identified Resident #45 had intact cognition. The care plan dated 6/8/22 identified Resident #45 was independent for meeting emotional, intellectual, and social needs. Interventions included to invite resident to scheduled activities. Additionally, establish a pre discharge plan with Resident #45 and evaluate progress and revise plan. Interview with Resident #45 on 12/14/22 at 9:01 AM indicated he/she has not been invited to the quarterly care plan meetings and is not told when or where they occur. Resident #45 indicated he/she would attend and would…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #8) reviewed for edema, the facility failed to ensure the compression stockings were applied daily per the physician's order, and for 2 residents (Resident #23 and 59) reviewed for accidents, the facility failed to ensure neurological assessments after a fall were completed per facility policy, for 1 resident (Resident #38) reviewed for glucose monitoring, the facility failed to ensure the resident did not get unnecessary fingersticks for blood sugar, and for 1 of 2 residents (Resident #47) reviewed for urology services, the facility failed to follow the physician order and book a urology consultation in a timely manner. The findings include: 1. Resident #8 was admitted to the facility with diagnoses that included diabetes, hypertension, and chronic obstructive pulmonary disease. A physician's order dated 4/15/22 directed to apply compression stockings in the morning at 6:00 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interview for 1 of 3 residents (Resident #87) reviewed for pressure ulcers, the facility failed to ensure the appropriate settings for a low air loss (LAL) mattress, failed to monitor for function and placement of the LAL and failed to notify the Dietitian when Resident #87 developed a pressure ulcer. The findings include: Resident #87's diagnoses included dysphagia, dementia without behavioral disturbance, adult failure to thrive and protein calorie malnutrition. A Resident Care Plan dated 4/11/22 identified Resident #87 being at increased risk of skin breakdown secondary to compromised nutritional status, poor po (food by mouth) intake, decreased ability to perform activities of daily living (ADL's), decreased mobility and decreased level of consciousness. Interventions included a pressure reducing mattress, avoid constrictive clothing, offloading of the heels per a physician order and dietary supplements as ordered. The annual MDS…

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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #45) reviewed for accidents, the facility failed to ensure the mechanical lift was in good repair prior to use resulting in the lift tipping over with the resident in it. The findings include: Resident #45 was admitted to the facility with diagnoses that included diabetes and osteomyelitis. The significant change in condition MDS dated [DATE] identified Resident #45 had intact cognition and required extensive assistance for personal hygiene, dressing, toileting, bed mobility, and transfers. Additionally, the resident had 5 stage 2 pressure ulcers. A reportable event form dated 6/11/22 at 10:50 AM indicated that the mechanical lift tipped over while Resident #45 was being transferred and the resident landed on the floor. A statement by NA #1 indicated the resident was in the mechanical lift, and it tipped over to the left and fell. A statement by NA #5 identified she and NA #1 were using…

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 staff interview, review of the clinical record and facility policy for 2 of 2 sampled residents (Resident #58 and Resident #87) reviewed for weight loss, the facility failed to notify the Dietitian when nutritional supplements were omitted because they not available (Resident #58 and Resident #87) and failed to complete quarterly nutritional assessments per facility policy for Resident #87. The findings include: 1. Resident #58's diagnoses included cerebral vascular disease, dementia, glaucoma, dysphagia following cerebral infarction, and diabetes. The Resident Care Plan dated 5/23/22 identified a problem with being at risk for altered nutrition related to a diagnosis of diabetes, dietary restrictions of low concentrated sweets, no added salt diet, mechanically altered diet due to dysphagia and total dependence for eating. Interventions included Glucerna supplements as ordered, provide and serve diet as ordered, monitor intake and record every meal, monthly weights, Registered Dietician (RD) to evaluate…

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 review of facility documentation, facility policy, and interviews, the facility failed to ensure licensed nurses had the specific competencies and skill sets to care for residents including competencies in IV therapy, and the facility failed to ensure nurse aides demonstrated competency in mechanical lift transfers. The findings include: 1. Interview with (Staff Development) ADNS on 12/14/22 at 2:02 PM and review of facility documentation failed to reflect documentation that licensed nurses and nurse aides had been provided competency training in intravenous therapy (IV) for the year 2022. Interview with the DNS on 12/14/22 at 5:59 PM identified he was not aware that the licensed nurses and nurse aides did not have yearly education, in-service, and competencies for IV therapy for the year 2022. The DNS indicated he was under the impression that the ADNS was providing the in-service and competency for the IV therapy. Interview with (Staff Development) ADNS on 12/14/22 at 6:02 PM identified that since she has been in the ADNS/Staff Development position she has been working as…

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

Based on review of facility documentation, facility policy, and interviews the failed to ensure a mechanical lift was in safe operating condition and maintenance checks were completed per facility policy and manufacturer recommendations. The findings include: Interview with the Director of Maintenance on 12/20/22 at 1:30 PM indicated he was made aware when the mechanical lift had tipped over and Resident #45 fell to the floor and indicated that lift was broken and was removed. The Director of Maintenance could not remember what was broken on the lift and because the lift is gone, could not be observed. The Director of Maintenance indicated many times the nurse aides complained about the lift wheels not moving but every time he looked at that lift, he never found anything wrong with the wheels. The Director of Maintenance indicated all those types of lifts are discontinued and the facility has 2 machines for parts in the maintenance area. The Director of Maintenance indicated he would check every mechanical lift for safety every Friday and if nursing had a problem with a lift 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, review of facility documentation, review of facility policy, and interview, the facility failed to maintain a sanitary, comfortable, and homelike environment. The findings include: Observations on 12/21/19 at 11:00 AM through 12:20 PM and 12/22/19 at 2:20 PM with the Director of Maintenance and the Administrator identified the following: 1. Damaged, chipped and/or marred bedroom walls on C unit in rooms 1, 2, 3, 4, 9, 11, 15, 19, 20, and 23. 2. Damaged and/or brown stains on bedroom ceiling tile on C unit in rooms 1, 4, 5, 9, 18, and 23. 3. Damaged and/or brown stains on bathroom ceiling tile on C unit in rooms [ROOM NUMBERS]. 4. Damaged, broken and/or bent window blinds in bedroom on C unit in rooms [ROOM NUMBERS]. 5. Dirt, dirt particles, webs and/or stains identified on C unit bedroom window in room [ROOM NUMBER]. 6. Damaged, broken and/or stain radiator cover in bedroom on C unit in rooms [ROOM NUMBERS]. 7. Dirt and/or stains on bathroom hand railing on C unit in rooms 4, 5, Bathing…

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 clinical record review, review of facility documentation, and interview, for one of two residents, (Resident #67), reviewed for pressure ulcers, the facility failed to ensure weekly skin monitoring was completed per facility policy. The findings include: Resident #67's diagnoses include cerebral infarction and respiratory failure. An admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 required total assistance of two staff with Activities of Daily Living (ADLS) and no pressure ulcers. A quarterly MDS dated [DATE] identified Resident #67 with a stage 3 pressure ulcer. The resident care plan dated 8/2/19 identified Resident #67's skin was intact and the resident was at risk for future breakdown. The care plan dated 9/26/19 identified Resident #67 with a stage 3 pressure ulcer of the coccyx. Review of the weekly skin integrity check sheets from 9/2019 to 12/24/19 identified sheets were not completed for the months of 9/2019, 11/2019, and 12/2019, (10/2019 sheets were…

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 observations, review of facility documentation, review of facility policy, and interview, the facility failed to maintain the kitchen in a clean and sanitary manner. The findings include: During a tour of the kitchen on 12/21/19 at 10:29 AM with the Director of Nursing the following was identified: 1. The juice station bottom shelf was noted with a moderate amount of stains and/or debris. 2. Underneath the juice station the floor was noted with debris. 3. One muffin pan was noted on floor underneath the steamer station. 4. The steamer bottom shelf was noted with debris. 5. The spice shelf was noted to have spice debris, debris and/or dust. 6. The convection oven compartment had an accumulation of grease film and/or dry food debris. 7. The grill was noted with dried stains. 8. The hot plate warmer was noted with stains and/or debris. 9. Four food carts were noted with clean trays and was noted with stains and/or food debris. 10. The refrigerator with milk and thickened liquids was noted with stains on the inside panel and/or bottom shelf. 11. The dry food storage room floor…

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, clinical record review, review of facility documentation, and interviews, for one of five Residents (Resident #50) observed for medication administration, the facility failed to ensure that medications were stored and administered according to manufacturer's and pharmacy's guidelines. The findings include: Resident #50 had diagnoses including an eating disorder. A current physician's order identified that Resident #50 was to receive Lactinex one packet twice a day. On 12/22/19 at 10:37 AM, Registered Nurse (RN) #1, was observed administereing medications. RN #1 was preparing medicaitons for Resident #50 and retrieved from the third drawer of the medication cart, the medication Lactinex Granules, prepared it, and administered the Lactinex Granules to Resident #50. The drawer not not noted to be refrigerated. Review of the box containing the packets of Lactinex Granules was noted with a clear label reading Keep Refrigerated. At 10:55 AM on 12/22/19, at 10:55 AM when asked when and where he/she retrieved the box of Lactinex Granules, RN #1 identified he/she did…

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.