Civita Care Sheriden Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews for two of six sampled residents (Resident #9 and Resident #79) reviewed for advance directives, the facility failed to ensure a physician's order was in place and consents were obtained regarding the resident's wishes regarding advance directives and decisions related to cardiopulmonary code status. The findings include: Resident #9's diagnoses included systemic lupus erythematosus, depression and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #9 was cognitively intact and was independent with dressing, personal hygiene, bed mobility, transfers and ambulation. The care plan dated [DATE] identified Resident #9 had an established advance directive with a wish to be a DNR (do not attempt cardiopulmonary resuscitation)/ DNI (do not intubate)/RNP (Registered Nurse may Pronounce death) with interventions that directed to not administer cardiopulmonary resuscitation…

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, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #114) reviewed for mistreatment, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #114's diagnoses included neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder.The quarterly MDS assessment dated [DATE] identified Resident #114 was moderately cognitively impaired, had no behaviors, required limited assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment further identified the resident utilized a wheelchair for mobility. The care plan dated 10/3/25 identified Resident #114 was at risk for refusing care and not waiting for assistance with transfers related to behavior problems with interventions that included assistance of two staff for care and transfers, introduce self to resident, explain what you are going to do, use calm,…

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, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #114) reviewed for abuse, the facility failed to ensure the allegation of abuse was reported to the state survey agency in a timely manner. The findings include: Resident #114's diagnoses included neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder.The quarterly MDS assessment dated [DATE] identified Resident #114 was moderately cognitively impaired, had no behaviors, required limited assistance for bed mobility, transfers, dressing, and personal hygiene. The assessment further identified the resident utilized a wheelchair for mobility. The care plan dated 10/3/25 identified Resident #114 was at risk for refusing care and not waiting for assistance with transfers related to behavior problems with interventions that included assistance of two staff for care and transfers, introduce self to resident, explain what…

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, review of facility documentation, review of facility policy/procedures and interviews for one of two sampled residents (Resident #45) reviewed for medication administration, the facility failed to ensure medications were passed on time. The findings include: Resident #45's diagnoses included hypertension, type 2 diabetes, cirrhosis of liver, seizures. The quarterly MDS assessment dated [DATE] identified Resident #45 was cognitively intact, had no behaviors, required limited assistance with bed mobility, transfers, dressings and personal hygiene. The assessment further identified the use of a walker for mobility. The care plan dated 1/21/26 identified Resident #45 was at risk for seizures with interventions that included caution patient to lie down and push call button if experiencing a prodromal or aural warning, keep call light within reach, medications as ordered. Review of the active physician's orders for March 2026 directed to administer Keppra Oral tablet 500mg 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 observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one sampled resident (Resident #2) who was incontinent, dependent on staff for care, and had a pressure injury, the facility failed to ensure the timely provision of care allowing the resident to go without incontinent care for over five hours. The findings include:Resident #2 was readmitted to the facility in September 2025. Diagnoses included Type 2 diabetes mellitus without complications, Sjogren syndrome, chronic combined systolic (congestive and diastolic (congestive) heart failure. The Norton Plus Assessment (determines the risk of developing pressure ulcers), dated 10/6/25 identified Resident #2 scored 11 which indicated Resident #2 was at high risk. The annual MDS assessment dated [DATE] identified Resident #2 had moderately impaired cognition, utilized a wheelchair, was dependent for transfers, showering and toileting hygiene, was always incontinent of bladder…

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, clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #79) reviewed for foot care, the facility failed to ensure the resident received podiatry services for trimming of toenails. The findings include:Resident #79 was admitted to the facility in November of 2025 and had diagnosed that included type 2 diabetes mellitus, multiple sclerosis, and paraplegia. The admission MDS assessment dated [DATE] identified Resident #79 was cognitively intact, dependent on staff for dressing, personal hygiene, putting on/taking off footwear, transfers and was non-ambulatory. The care plan dated 11/21/25 identified Resident #79 had diabetes with interventions that directed podiatry consult as ordered and skin audits per facility protocol. The care plan further identified the resident requires assistance with dressing, bathing hygiene, transfers, total care except feeding, oral care and dressing with interventions directed assist…

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, review of facility policy/procedures and interviews for one sampled resident (Resident #102) reviewed for pain, the facility failed to ensure the resident received pain medication timely. The findings include: Resident #102's diagnoses included primary osteoarthritis left shoulder, pain disorder with related psychological factors, chronic pain syndrome, unilateral primary osteoarthritis right knee. The quarterly MDS assessment dated [DATE] identified Resident #102 was cognitively intact, had no behaviors, required limited assistance with bed mobility, independent to supervision or touching assistance with transfers, partial to moderate assistance with dressing and independent with personal hygiene. The assessment further identified that the resident utilized a walker and a wheelchair for mobility.The care plan dated 2/26/26 identified Resident #102 was at risk for pain related to being on pain medication therapy with interventions that included administer analgesic…

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 clinical records, review of facility documentation, review of facility policy/procedure, and interviews for one of five sampled residents (Resident #5) reviewed for immunizations, the facility failed to ensure that the resident was offered and/assessed for pneumococcal and influenza immunization upon admission as per facility's policy. The findings include:Resident #5 was admitted to the facility in January of 2026 and had diagnoses that included chronic kidney disease, type 2 diabetes mellitus and chronic obstructive pulmonary disease. The admission MDS assessment dated [DATE] identified Resident #5 was cognitively intact and had not received the influenza vaccine as it was not offered. Review of Resident #5 immunization and clinical records with the Infection Preventionist (IP) nurse (RN #6) on 2/24/26 at 12:31 PM failed to identify that the influenza and the pneumococcal vaccine was offered and/or assessed for past immunization. Interview with RN #6 on 2/24/26 at 12:31 PM identified that he…

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 one (1) of three (3) sampled residents (Resident #1) who required staff assistance with transfers and ambulating, the facility failed to review and revise the mobility care plan when there was a change with the physician's order. The findings include:Resident #1's diagnoses included osteoarthritis (the most common type of arthritis that occurs when the cartilage that lines the joints is worn down or damaged and the bones rub together when the joint is used) of the knee, rheumatoid arthritis (when the immune system attacks the tissue lining the joints causing joint inflammation and pain), and generalized anxiety disorder. A physician's order dated 3/2/25 and remained a currant order directed to provide the resident with bed mobility assistance of two (2) and transfer assistance of two (2) with a rolling walker. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental…

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) sampled residents (Resident #1) who had sustained an injury, the facility failed to administer pain medication following observations of pain to keep the resident comfortable. The findings include:Resident #1's diagnoses included osteoarthritis (the most common type of arthritis that occurs when the cartilage that lines the joints is worn down or damaged and the bones rub together when the joint is used) of the knee, rheumatoid arthritis (when the immune system attacks the tissue lining the joints causing joint inflammation and pain), and generalized anxiety disorder. A monthly physician's order that was initially ordered on 1/26/24 directed to administer acetaminophen 325 milligrams (mg), give three (3) tablets by mouth every six (6) hours as needed for pain. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score 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 review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #32) reviewed for palliative care, the facility failed to administer medications as prescribed by the physician. The findings include: Resident #32's diagnoses included Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive. A significant change in status MDS assessment dated [DATE] identified Resident #32 had severely impaired cognitive skills for daily decision making and was dependent on staff with all activities. The care plan dated [DATE] identified Resident #32 was admitted to hospice on [DATE]. Interventions directed to administer pain medications according to the physician order. The hospice narrative note dated [DATE] identified Resident #32 had a significant decline, was not eating and had difficulty swallowing. On assessment, the resident was minimally responsive, breathing was labored, and moaned in pain when moved. Recommendations included discontinue 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 documentation, and interviews for 1 of 3 residents (Resident #32) reviewed for palliative care, the facility failed to ensure that clinical record documentation was accurate by documenting medications that were not actually given. The findings include: Resident #32's diagnoses included Alzheimer's disease, dementia, anxiety, chronic kidney disease and adult failure to thrive. A significant change in status MDS assessment dated [DATE] identified Resident #32 had severely impaired cognitive skills for daily decision making and was dependent on staff with all activities. The care plan dated 2/16/25 identified Resident #32 was admitted to hospice on 1/28/25. Interventions directed to administer pain medications according to the physician order. Further review of the care plan identified the resident had episodes of anxiety and history of anxiety. Interventions included anti-anxiety per order and monitor for effectiveness. The hospice narrative note dated 2/25/25…

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 one of three sampled residents (Resident #1), the facility failed to ensure a comprehensive care plan to include known smoking incidents. The findings include: Resident #1's diagnoses included chronic obstructive pulmonary disease and nicotine dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and was independent for mobility with a wheelchair. The Resident Care Plan (RCP) dated 6/12/24 identified Resident #1 had a smoking history. Interventions directed to instruct about the facility smoking policy, smoking materials locked in the medication room, offer nicotine patch and address smoking cessation. Clinical record review of the nursing progress notes identified the following: a. Nursing note dated 7/18/2024 at 10:28 PM identified Resident #1 stated…

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 one of three residents (Resident #1), reviewed for accidents, the facility failed to ensure known resident smoking incidents were investigated timely. The findings include: Resident #1's diagnoses included chronic obstructive pulmonary disease and nicotine dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact and was independent for mobility with a wheelchair. The Resident Care Plan (RCP) dated 6/12/24 identified Resident #1 had a smoking history. Interventions directed to instruct about the facility smoking policy, smoking materials locked in the medication room, offer nicotine patch and address smoking cessation. Clinical record review of the nursing progress notes identified the following: a. Nursing note dated 7/18/2024 at 10:28 PM identified 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 clinical record reviews, review of facility documentation and policies, and interviews for two (2) sampled residents (Resident #1 and #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure the residents' controlled medications and the controlled disposition sheets were not removed from the facility. The findings include: 1. Resident #1's diagnoses included Alzheimer's disease and malignant neoplasm of the colon. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, received scheduled pain medication, experienced shortness of breath, and was on hospice services. The Resident Care Plan dated 6/11/24 identified Resident #1 had the potential for pain. Interventions directed to administer pain medications as ordered and assess the characteristics of the pain, location, and severity. A physician's order dated 7/12/24 directed to administer Morphine Sulfate (concentrate) oral…

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 one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of mistreatment, the facility failed to treat the resident in a dignified and respectful manner. The findings include: Resident #1's diagnoses included knee replacement, difficulty walking, and pain. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time and required substantial/maximal assistance with personal hygiene, transferring in and out of the bed and chair and dressing, was frequently incontinent of urine and always incontinent of stool. The Resident Care Plan dated 10/21/24 identified Resident #1 was incontinent of bowel and bladder. Interventions directed to provide incontinent care every two (2) hours, provide privacy and dignity while providing care, and offer bedpan and toileting assist every two (2) hours. The nurse's note dated 11/12/24 at 12:44…

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 two (2) residents (Resident #2), reviewed for misappropriation of funds, the facility failed to ensure a resident was free from misappropriation from a facility staff member. The findings include: Resident #2 was admitted to the facility with diagnoses that included peripheral vascular disease and deep vein thrombosis (blood clot) of the left lower extremity. The quarterly MDS dated [DATE] identified Resident #2 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive staff assistance with activities of daily living (ADL's). The care plan dated 6/12/24 identified Resident #2 had episodes of anxiety with interventions included to observe for behaviors as indicated, offer support and reassurance to the resident and family, and provide a calm quite environment. Review of the accident and incident form (A & I) dated 8/30/24 identified Resident #2 told his/her niece…

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 two (2) residents (Resident #1) reviewed for impaired skin integrity, the facility failed to document completed weekly skin evaluation forms in accordance with facility policy. The findings include: Resident #1 was admitted to the facility with diagnoses that included dementia and coronary artery disease. Physician's treatment order dated June 2024 directed weekly skin checks on bath/shower day Thursday every evening shift (3:00 PM - 11:00 PM shift). The Norton_assessment dated [DATE] identified Resident #1 was at moderate risk of developing pressure ulcers/injuries. A weekly skin evaluation form dated 6/6/24 identified Resident #1 had no new skin impairments since the last review. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, was occasionally incontinent of bladder, and required assistance of one staff member for bed mobility, transfers and toilet use. The care…

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 of three sampled residents (Resident #6) who were reviewed for an allegation of abuse, the facility failed to ensure the resident was free from verbal and physical abuse when a staff member pushed resident into a seated position with force and used profanity directed towards the resident. The findings include: Resident #6's diagnoses included dementia, schizoaffective disorder, and generalized muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #6 rarely or never made decisions regarding tasks of daily life, required extensive assistance of one (1) staff member for most activities of daily living including locomotion on unit, and a wheelchair was utilized for mobility. The social service progress note dated 3/23/22 at 11:13 AM identified on this date the social worker witnessed a 7AM-3PM charge nurse use inappropriate language towards Resident #6 and aggressively pulled…

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 of three sampled residents (Residents #1 and #10) who were reviewed for an allegation of misappropriation of the resident's medication, the facility failed to ensure Residents #1's medications were not consumed by a licensed nurse and Resident #10's narcotic medication was not missing and unaccounted for. The findings include: 1. Resident #1's diagnoses included dementia, chronic pain syndrome, and type 2 diabetes mellitus. A physician's order dated 2/21/23 directed Gabapentin also known as Neurontin 300 milligrams (mg) one (1) capsule two (2) times per day for neuropathy, weakness, numbness and pain from nerve damage usually in the hands and feet. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life and required cueing or supervision. The Resident Care Plan dated 4/24/23 identified Resident #1 had pain. Interventions directed to administer…

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 of three sampled residents (Residents #1 and #10) who were reviewed for allegations of misappropriation of medications the facility failed to report the allegations timely and did not remove the involved staff member from the facility immediately. The findings include: 1. Resident #1's diagnoses included dementia, chronic pain syndrome, and type 2 diabetes mellitus. A physician's order dated 2/21/23 directed Gabapentin also known as Neurontin 300 milligrams (mg) one (1) capsule two (2) times per day for neuropathy, weakness, numbness and pain from nerve damage usually in the hands and feet. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life and required cueing or supervision. The Facility Reported Incident report dated 5/10/23 at 1:40 PM identified on 5/6/23 at 11:00 PM the Nursing Supervisor consumed 900 mg of Gabapentin from a resident'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 clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #9) who were reviewed for the administration of medication, the facility failed to ensure a licensed nurse followed standards of practice when administering insulin. The findings include: 1. Resident #9's diagnoses included diabetes with diabetic neuropathy and diabetic retinopathy without macular edema. A physician's order dated 2/7/22 directed to administer a long-acting medication to lower the blood sugar, Levemir FlexTouch solution Pen Injector 100 units/ml, inject 56 units subcutaneously (under the skin) two (2) times a day, hold for blood sugar under 130. The annual Minimum Data Set assessment dated [DATE], identified Resident #9 made reasonable and consistent decisions regarding tasks of daily life and received insulin daily. A physician's order dated 3/4/22 directed to give a short acting medication that lowers the blood sugar, Insulin Lispro Solution Pen-injector 100…

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 reviewed for dignified treatment, (Resident 1) , the facility failed to ensure a resident was treated with dignity. The findings include: Resident #1 was admitted to the with diagnoses that included post-polio syndrome and dementia. The physician's orders dated 1/11/24 directed an assist of one staff for Activities of Daily Living (ADL's) and toileting and assist of two staff for transfers with hoyer lift. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, and was frequently incontinent of bowel and bladder. The care plan dated 4/12/24 identified Resident #1 had mobility deficits and was a hoyer list with assist of two (2) staff for transfers with interventions that included to provide assistance with mobility as ordered and allow the resident sufficient time to complete a task. The care plan further identified Resident #1 required assistance…

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 reviewed for transfer status, (Resident #1) , the facility failed to ensure a resident was transferred in care plan and physician orders. The findings include: Resident #1 was admitted to the with diagnoses that included post-polio syndrome and dementia. Physician's orders dated 1/11/24 directed an assist of one staff for activities of daily living (ADL's) and assist of two staff for transfers with hoyer lift. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, and required extensive assistance with Activities of Daily Living (ADL's) The care plan dated 4/12/24 identified Resident #1 had mobility deficits and was a hoyer list with assist of two staff for transfer with interventions included to provide assistance with mobility as ordered, and allow the resident sufficient time to complete a task. The care plan further 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 reviews, review of facility policy and interviews for five of twenty-four sampled residents (Residents #33, #51, #69, 78, &107) reviewed for Advanced Directives, the facility failed to ensure the physician's orders and the signed advanced directive forms were congruent. The findings include: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting non-dominant side, bipolar disorder, and schizophrenia. Review of the clinical record identified an Advanced Directive form dated [DATE] that identified Resident #33 elected a code status of Do Not Resuscitate (DNR), which means if the resident stops breathing or if the resident's heart stops beating cardiopulmonary resuscitation will not be provided. The admission MDS assessment dated [DATE] identified the Resident #33 had intact cognition and required substantial/maximal assistance with activities of daily living. The Care Plan 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 clinical record review, review of facility documentation, review of facility policy and interviews for one of four sampled residents (Resident #11) observed during the medication administration, the facility failed to ensure that the consultant pharmacist identified a discrepancy in a written physician's order. The findings include: Resident #11's diagnoses included dementia, psychotic disturbance, type 2 diabetes mellitus without complications, and pain. The quarterly MDS assessment dated [DATE] identified Resident #11 had moderately impaired cognition and was independent with ambulation and transfers but required assistance with bathing, dressing, and toileting. The physician's order dated 4/18/2024 (origination date of order was 1/19/24) directed: administer Gabapentin capsule 300 mg give 100mg by mouth two times a day for pain. The care plan dated 4/22/2024 identified resident had pain/potential for pain related to generalized discomfort and recent falls with interventions that included 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 clinical record review, observations, review of facility policy and interviews for sample one of two sampled residents (Resident #24) who required total assistance with activities of daily living, the facility failed to ensure that the resident's nails were trimmed. The findings include: Resident #24's diagnoses included dementia, anxiety, contracture of right hand, and macular degeneration. The quarterly MDS assessment dated [DATE] identified Resident #24's cognition was severely impaired, required total assistance for toileting, transfers, personal hygiene, transfers, and was non-ambulatory. The care plan dated 3/11/24 identified Resident #24 had an ADL deficit due to dementia diagnosis with interventions that included explain tasks to resident, breakdown tasks into simple subtasks as able if necessary. The care plan further identified Resident #24 required assistance with grooming with interventions with an intervention for weekly skin inspections. The physician's orders for April/2024 included an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review, and interviews for one of two sampled residents (Resident #113) with a non-pressure related wound, the facility failed to ensure the wound was assessed by a registered nurse upon initial observation, and failed to ensure the wound was assessed on a weekly basis. The findings include: Resident #113 's diagnoses included heart failure, lymphedema, chronic embolism, venous insufficiency, and chronic pain. The admission MDS assessment dated [DATE] identified Resident #113 had intact cognition and required limited assistance with toileting, hygiene, bed mobility, transfers, and ambulation. The Resident Care Plan (RCP) dated 3/14/24 identified Resident #113 was at risk for skin breakdown related to impaired mobility and lower extremity edema. Care plan interventions directed to inspect skin for redness, irritation and breakdown during care, weekly skin inspections, treatment as ordered, and pressure reducing mattress/cushion as needed. The 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 clinical record review, review of facility policy, and interviews for one of two sampled residents (Resident #27) reviewed for pressure ulcers, the facility failed to ensure that the initial and weekly assessments of the wound were completed by a registered nurse. The findings include: Resident #27's diagnoses included type 1 diabetes mellitus, adult failure to thrive, weakness, anemia, and hyperlipidemia. The admission MDS assessment dated [DATE] identified Resident #27 had intact cognition, required extensive assistance with bed mobility, transfers, toileting, and personal hygiene. The assessment further identified Resident #27 was at risk for the development of pressure ulcers and was admitted with an unstageable pressure injury. The care plan dated 2/22/24 identified Resident #27 was at risk for skin breakdown related to mobility, nutrition, and incontinence with interventions that included weekly skin inspections, off-load heels, and pressure reducing cushion or mattress as needed. The Wound…

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 sampled resident (Resident #58) reviewed for a resident-to-resident interaction, the facility failed to ensure the resident's dignity was maintained. The findings include: Resident #58's diagnoses included schizophrenia, hypotension, anxiety, and chronic obstructive pulmonary disease (COPD). The quarterly MDS assessment dated [DATE] identified Resident #58 had severely impaired cognition, and required supervision with toileting hygiene, transfers, and ambulation. The care plan dated 2/19/24 identified Resident #58 had impaired cognition related to long term and short memory loss with interventions that included: encourage socialization and recreational activities, identify self, speak slowly and clearly, and explain all procedures. The care plan further identified Resident #58 had a history of trauma with potential of traumatization with interventions that included social services to provide…

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, review of facility policy, and interviews for one sampled resident (Resident #58) reviewed for an allegation of mistreatment, the facility failed ensure timely notification of an allegation of inappropriate behavior to the State Survey Agency. The findings include: Resident #58's diagnoses included schizophrenia, hypotension, anxiety, and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #58 had severely impaired cognition, required moderate assistance with toileting hygiene, personal hygiene, and transfers. The assessment further identified the resident was ambulatory. The care plan dated 2/19/24 identified Resident #58 had impaired cognition related to long term and short memory loss with interventions that included: encourage socialization and recreational activities, identify self, speak slowly and clearly, and explain all procedures. The care plan further identified…

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 sampled resident (Resident #58) reviewed for an allegation of resident-to-resident mistreatment, the facility failed to ensure a timely investigation was initiated. The findings include: Resident #58's diagnoses included schizophrenia, hypotension, anxiety, and chronic obstructive pulmonary disease (COPD). The quarterly MDS assessment dated [DATE] identified Resident #58 had severely impaired cognition, required moderate assistance with toileting, hygiene, and transfers. The assessment further identified the resident was ambulatory. The care plan dated 2/19/24 identified Resident #58 had impaired cognition related to long term and short memory loss with interventions that included: encourage socialization and recreational activities, identify self, speak slowly and clearly, and explain all procedures. The care plan further identified Resident #58 had a history of trauma with potential 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 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 abuse. The findings include: Resident #1 was admitted to the facility with diagnoses that included major depressive disorder, and anxiety. A nursing admission assessment dated [DATE] at 7:13 PM identified Resident #1 was alert and oriented, and required staff supervision for toileting, transfers, and ambulating with a walker. The A Resident Care Plan (RCP) dated 1/23/2024 identified Resident #1 was at risk for falls due to decreased endurance. Interventions directed to instruct Resident #1 to ask for assistance prior to attempting to transfer or ambulate, and to assist with transfers. A facility grievance form dated 1/24/2024 identified the Administrator received a phone call from Resident #1 and indicated no staff assisted for toileting on the second and third…

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 clinical record was complete and accurate to include an assessment after reported pain. The findings include: Resident #1 was admitted to the facility with diagnoses that included status post fracture of the left femur, closed reduction. A nursing admission assessment dated [DATE] at 7:13 PM identified Resident #1 was alert and oriented, and had a left thigh surgical incision with bruising notes. A MDS assessment screening tool dated 1/23/2024 identified Resident #1 was independent for range of motion for upper extremities and dependent for range of motion for lower extremities. The A Resident Care Plan (RCP) dated 1/23/2024 identified Resident #1 was at risk for falls due to decreased endurance. Interventions directed Physical Therapy as ordered. A facility grievance form dated 1/24/2024 identified the Administrator…

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, facility documentation review and interviews for kitchen review, the facility failed to ensure bread was labeled with an expiration date. The findings include: Interview and tour of kitchen on 11/15/2021 at 10:20 AM with the Director of Dining Services (DoD) identified although four (4) loaves of bread were marked with an expiration date of 11/10/2021, over twelve (12) loaves of bread had no manufacturer's label with expiration dates. Further, the loaves of bread were not marked to identified when it was received or an expiration date. The DoD indicated that the loaves of bread should be marked to indicate an expiration date. Interview with Director of Kitchen on 11/10/2021 at 11:47 AM identified the facility receives bread is delivered frozen and kept frozen until time for use. Then it is thawed overnight for use the next day and is usually deemed good for 72 hours after being thawed. Per the Director of Kitchen, the bread should be labeled with a green sticker to identify the date of thawing, and it was an oversight that the observed loaves of breads had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation and interviews for two of three sampled residents (Resident #191 and #588) who were reviewed for a change in condition, the facility failed to notify a physician at the time the residents experienced a decline in their health status. The findings include: 1. Resident #191's diagnoses included atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] identified Resident #191 made reasonable and consistent decisions regarding tasks of daily life and required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The nurse's note dated 3/22/20 at 5:15 PM identified the charge nurse notified the Nursing Supervisor that Person #2 stated Resident #191 had slurred speech while talking. The charge nurse stated Resident #191 had weakness earlier in the day and upon assessment Resident #191 was sitting up in bed unassisted, watching TV, and eating a fish sandwich using both hands. Resident #191'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 clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #190) who was discharged home, the facility failed ensure the Inter-Agency Patient Referral Form had the correct demographic information and an order for oxygen therapy. The findings include: Resident #190's diagnoses included chronic obstructive pulmonary disease, COVID-19, anxiety and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #190 had short and long-term memory problems, had modified independence with cognitive skills for daily decision making, required extensive assistance with bed mobility, and received oxygen therapy while not a resident. A physician's order dated 1/6/21 directed oxygen via nasal cannula at three (3) liters per minute as needed to maintain an oxygen saturation level greater than or equal to 92%, may titrate if needed and check the pulse oximetry every shift. The physician's progress noted dated 1/28/21 identified 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 clinical record review, facility documentation review, and interviews, for one sample resident (Resident #22) reviewed for dialysis, the facility failed a comprehensive care plan to include resident refusals to attend dialysis appointments. The findings include: Resident # 22 was admitted to the facility on [DATE]with diagnosis that included End Stage Renal Disease (ESRD) that required hempdialysis A physician's order dated 6/2/2021 directed hemodialysis three times a week. The nursing admission assessment dated [DATE] identified Resident #22 received dialysis treatments. The admission Minimum Data Set (MDS) dated [DATE] identified that Resident #22 was alert and oriented, refused care during the last 1-3 times during the last 7 days, received hempdialysis and refused care at times. The quarterly Minimum Data Set (MDS) dated [DATE] identified that Resident #22 was alert and oriented, refused care one to three times during the last seven days, and received hemodialysis, and refuses care at times. 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 reviews, review of facility documentation and interviews for one of three sampled residents (Resident #588) who was a new admission, the facility failed to transcribe onto the Medication Administration Record the correct frequency a medication was to be administered . The findings include: Resident #588's diagnoses included diabetes mellitus. The Inter-Agency Patient Referral Form dated 10/5/21 directed aspart protamine-insulin aspart (70-30) units/milliliter injection, inject 15 ml (15 units total) under the skin 2 (two) times a day before meals. A physician's order dated 10/5/21 directed insulin aspart prot and aspart suspension (70-30) 100 unit/ml, inject 15 units subcutaneously before meals for diabetes. Review of the October 2021 Medication Administration Record (MAR) identified the transcribed order read insulin aspart and aspart suspension 15 units administer three (3) times a day before meals at 7:30 AM, 11:30 AM and 4:30 PM. Upon further review, the MAR identified the insulin was administered three (3) times on 10/6/21 instead of only twice.…

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 documentation and interviews for one of three sampled residents (Resident #588) who was a new admission, the facility failed to obtain a physician's order when the resident required oxygen therapy. The findings include: Resident #588's diagnoses included COVID-19, chronic congestive heart disease, and pleural effusion. The nurse's note dated [DATE] at 2:09 PM identified Resident #588's family was notified Resident #588's oxygen saturation level dropped to 84% on room air (normal level 95-100%) and oxygen at two (2) liters per minute was initiated. Upon further review, the clinical record failed to reflected documentation a Registered Nurse assessed Resident #588 when his/her oxygen level dropped to 84% and oxygen was required and that an order was obtained for the oxygen. The nurse's note dated [DATE] at 8:02 AM identified at 4:45 AM an nurse aide reported Resident #588 did not look good, Resident #588 was immediately assessed by the Licensed Practical Nurse…

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.