Oasis At The Keys Nursing And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, records review and facility policy review the facility failed to ensure an ongoing activities program for 7 (Residents, # 9, #52, #18, 36, #15, #55 and #61) of 9 residents reviewed for activities. The findings included: Review of the facility policy titled, Resident Activities, revised May 16, 2022, which said Purpose: To ensure residents are offered activities that are compatible with the resident's individual physical and mental capabilities. 1. On 6/27/22 at 9:57 a.m., Resident # 61 was observed wandering in hall repeatedly pacing back and forth the length of the unit. On 6/27/22 at 1:21 p.m., Resident #61 observed again wandering in hall, repeatedly pacing back and forth the length of the unit occasionally attempting to enter rooms not assigned to Resident #61. Redirected by staff when attempting to enter rooms not assigned to Resident #61. On 6/28/22 at 8:22 a.m., Resident # 61 observed doing the same wandering behavior on unit. On 6/28/22 at 3:45 p.m., Resident # 61…

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 the employee file, and staff interview, the facility failed to ensure the activities program was directed by a professional with the required qualifications. This has the potential to affect all current residents at the facility. The findings included: On 6/29/22 at 11:25 a.m., the Activities Director said she was currently working on her Activities Professional Certification. The Activities Director said she has not worked within the last five years in a social or recreational program and had no experience in long term care. She said the past eight years she was watching her grandchildren. On 6/30/22 at 4:48 p.m., review of the Activity Director with the Administrator verified the Activities Director did not have the qualifications to develop and supervise the activity program. the Administrator said, No she does not have the training. We have paid for her training, and she is working on it.

Based on staff interviews and staff record reviews, the facility failed to ensure 3 (Staff B, C, and D) of 3 nursing assistant employee records reviewed had a performance review completed at least once every 12 months/yearly. The facility failure to conduct a 12-month/yearly performance review could lead to the nursing staff not receiving the required in-service education to address areas of weakness identified in their yearly performance review. The findings included: On 6/30/2022, a review of Certified Nursing Assistant (CNA) Staff B's employee file revealed they were hired 8/28/19. There was no documentation Staff B's employee performance review was completed in 2021 with in-service education to address any areas of weakness identified. On 6/30/2022, a review of CNA Staff C's employee file revealed they were hired 9/23/2019. There was no documentation Staff C's employee performance review was completed in 2021 with in-service education to address any areas of weakness identified. On 6/30/2022, a review of CNA Staff D's employee file revealed they were hired 7/30/2020. There 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.

Based on observation, facility policy review, and staff interviews, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. The findings included: Review of facility policy titled, Controlled Substance Storage dated August 2019 stated, Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of. On 6/29/22 at 12:44 p.m., interviewed the Director of Nursing (DON) about the process for management of controlled substances after medication is discontinued or resident is discharged . The DON said, After resident discharged or the controlled substance is discontinued, the nurse brings the controlled substance and log paper to me. We both verify the log is accurate and number listed on log matches the number of medications being turned in. The nurse signs the log and I store the controlled substances in the locked file cabinet in my locked office until I can meet with the pharmacist and do the destruction. 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 record review and staff and resident interview, the facility failed to provide the resident and the representative, if applicable, with a written summary of the baseline care plan which included initial goals and a summary of current medications and dietary instructions for 4 (Resident #42, #57, #60, and #417) of 5 residents reviewed for baseline care plans. The findings included: 1. On 6/28/22 at 11:16 a.m., Resident #60's wife said she did not recall receiving a copy of a written summary of the baseline care plan or a summary of medications. On 6/30/22 at 9:50 a.m., record review showed Resident #60's admission date was 5/27/22. The clinical record lacked evidence of a written baseline care plan which included initial goals, and a summary of current medications and dietary instructions. 2. On 6/30/22 at 9:51 a.m., Resident #417 record review revealed an admission date of 6/9/22. The clinical record lacked evidence a written summary of the baseline care plan which included initial goals, and a summary…

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, staff and resident interviews and record review the facility failed to develop and implement a comprehensive resident-centered care plan for 1 (Residents #57) of 3 residents reviewed for specialized rehabilitation services. The failure to develop and implement a resident-centered care plan could lead to a decline and/or failure to meet the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: On [DATE] at 12:45 p.m., observed Resident #57 in her bed with her right arm in a sling. Resident #57 said she fell at home, broke her arm and she was here to get better so she can go home. She said since arriving at the facility she doesn't remember anyone going over their plan of care in getting her strong enough so she can go home. On [DATE] review of Resident #57's medical record revealed she was admitted to the facility on [DATE] with diagnoses not limited to a fracture to the upper end of right humerus, and generalized weakness. Further review of the…

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

Based on observations, record review, and staff interviews, the facility failed to revise, and update the resident's care plan to accurately reflect the resident's condition and needs for 1 (Resident #49) of 3 residents reviewed with pressure ulcers. The findings included: The facility Pressure Injury Prevention and Management Policy provided by the facility (undated) page 3 under the Risk Assessments heading number 4 reads: Findings from the pressure ulcer/injury risk assessment will be incorporated into the resident's plan of care. On 6/28/2022 at 11:15 a.m., Licensed Practical Nurse Staff L was observed, cleaning and changing the dressings to Resident #49's wound to the right heel and right lateral malleolus (bone segment that forms the ankle). No wound was observed to the sacrum. Review of the Advanced Practice Registered Nurse (APRN) wound report dated 5/5/22 showed Resident #49 had a pressure wound to the right heel and the right lateral malleolus which were facility acquired. Review of the clinical record for Resident #49 revealed a care plan for skin integrity revised 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.

Based on observation, record review, and staff interview, the facility failed to provide care and services to maintain or improve ability to carry out activities of daily living for 1 (Resident #47) of 3 residents reviewed for functional abilities. The findings included: Review of record for Resident #47 revealed she was admitted to facility on 8/7/20 with diagnoses including hemiplegia (Paralysis of one side of the body) and hemiparesis (weakness or partial paralysis of one side of the body) following Cerebral Infarction affecting Right Dominant side, aphasia (disorder affecting ability to communicate), and diabetes mellitus without complications. Review of the list provided by the facility showed Resident #47 was included in a Functional Maintenance Program (program designed to maintain performance after discharge from therapy). On 6/27/22 at 10:00 a.m., 6/28/22 at 9:40 a.m., and 11:15 a.m.,6/29/22 at 9:31 a.m., and 6/30/22 at 10:00 a.m., Resident #47 was observed in bed, sleeping. On 6/27/22 at 12:00 p.m., and 2:58 p.m., Resident #47 was observed in bed watching television.…

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, record review, staff, and resident interviews the facility failed to provide supervision during smoking for 1 (Resident #47) of 1 resident reviewed for smoking. This places the resident at risk for injuries. The findings included: Record review for Resident #47 revealed a smoking assessment done on 9/10/20, indicating Pt need to be supervised by staff while smoking. Pt needs an apron while smoking. Further review revealed a Smoking assessment done on 5/28/21, section D Smoking Habit Evaluation #4: someone to light/extinguishing cigarette. Care plan for smoking cigarettes under interventions indicates The Resident requires supervision while smoking. On 6/28/22 at 3:41 p.m., Resident #47 was observed in the smoking area with no staff supervision, and she was holding a lit cigarette with her left hand. No other residents smoking at the time, she was noted in this area by herself. On 6/29/22 at 3:45 p.m., Resident #47 was observed smoking outside the window of admission office, no one was in that office, she was smoking unsupervised. At 3:50 p.m., she rolled…

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

Based on observation, interview, and record review the facility failed to assist 1 (Resident #39) of 1 resident reviewed in obtaining routine dental care for missing dentures. The findings included: On 6/27/22 at 11:31 a.m., Resident #39 said earlier in the year he went out to the hospital for a pacemaker and his front teeth went missing. The resident said he was told the dentist could replace them, but he does not know what going on. He said he wants permanent front teeth. On 6/29/22 at 12:15 p.m., Unit Manager Staff P said she was not aware of the Resident #39's teeth issue. She did not realize the teeth were missing nor did she know the resident wanted them replaced. On 6/29/22 at 1:58 p.m., the Social Services Director said the facility has a designated dentist who will come to the facility within 48 hours of making an appointment. The Social Services Director said she was not aware of Resident #39's dental needs. She said the resident had not expressed a need for dental care. She said she will get a consult. The Social Services Director said the resident has his own dentist 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 observation, record review, resident and staff interview, the facility failed to obtain or provide Therapy Services for 2 (Resident #42 and #417) of 2 residents reviewed for Rehabilitation Services. This has the potential to inhibit the progress in ambulation and Activities of Daily Living. The findings included: 1. Review of the clinical record for Resident #42 revealed he was admitted to the facility on [DATE] with a diagnosis of hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction affecting left non-dominant side. The clinical record contained a physician's order dated 5/18/22 for Physical, and Occupational Therapy evaluation and treatment. On 6/28/22 at 12:15 p.m., Resident #42 stated he needed to get stronger to go home but he was not getting therapy. He tried to do exercises on his own to be active and move to an Assisted Living Facility. On 6/30/22 at 10:10 a.m., the Director of Rehabilitation reviewed Resident #42's…

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

Based on observation, record review and staff interview the facility administration failed to demonstrate effective ongoing Quality Assurance and Performance Improvement (QAPI) resulting in repeat non compliance in the areas of providing assistance with activities of daily living for dependent residents, effective administration to maintain the highest practicable well being of residents, maintaining an effective infection prevention and control program and a clean, safe environment for the residents. The findings included: Review of the facility's history revealed on 5/2/20 the facility administration failed to report suspected COVID-19 case to the Department of Health as directed by the Florida Department of Health (DOH) to coordinate the State's response to the COVID-19 pandemic. The facility also failed to enact appropriate COVID-19 precautions and observe proper social distancing placing all residents of the facility at risk of COVID-19 infection. On 5/14/20 the facility failed to ensure a dependent resident on the COVID unit received the necessary assistance for bathing and…

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

Based on staff interview and lack of minutes from any Antibiotic Stewardship meetings, the facility was not able to provide evidence of a functioning Antibiotic Stewadship Program that develops, promotes, and implements a facility-wide system to monitor the use of antibiotics. The findings included: The DON who was the identified Infection Control Preventionist could not produce any minutes from the Antibiotic Stewardship meetings or activities. She said they were Zoom calls, but minutes were never taken regarding what was talked about. The facility failed to provide evidence of a functional Antibiotic Stewardship program.

Based on staff interview and review of the Infection Preventionist required qualifications to have completed specialized training in infection prevention and control, the facility failed to have a qualified Infection Preventionist. The findings included: On 11/19/20 at 2:29 p.m., in an interview the Director of Nursing (DON), who was the designated Infection Preventionist, said I have not taken any Infection Preventionist training. No one in the facility has taken any additional infection control classes. The facility failed to have a qualified infection control preventionist to assist staff with infection control concerns and educate the staff on current infection control practices. This is evidenced by the blood glucose monitoring issues identifed during this survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to identify broken equipment on the dirty side of the laundry room. The facility failed to maintain a safe, sanitary, functional laundry area. The facility also failed to maintain clean and sanitary The findings included: On 11/16/20 at 8:45 a.m., observation of the dirty side of the laundry room revealed a very wet floor. Staff JJ said the pipes had been leaking for a while. When staff JJ turned on the faucet in the sink to wash her hands, water sprayed out of the faucet. The pipes under the sink were corroded and leaking. Four buckets were being used to catch the leaking water. On 11/16/20 9:15 a.m., the Maintenance Director said he checked for maintenance issues, and the cleaning and vacuuming of the dryer ventilation system in the laundry room on a monthly basis. At that time was not able to provide any documentation of a schedule. Prior to exit the administrator and maintenance director provided a Maintenance Cleaning and Vacuuming Monthly…

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 record review and staff interview the facility failed to ensure physician progress notes for 12 (Residents #2,# 4, #6, #12, #34, #41, #42, #53, #57, #66, #67, and #70) of 12 residents reviewed were readily accessible and available for inspection in the resident's files. The findings included: On 11/18/20 at 1:00 p.m., record review of Resident #2, admission date 2/24/20, revealed there were no physician progress notes in the facility. When asked, the Director of Nursing was unable to provide any physician progress notes. On 11/18/20 at 1:00 p.m., record review of Resident #4, admission date 3/19/19, revealed there were no physician progress notes in the facility. When asked, the Director of Nursing was unable to provide any physician progress notes. On 11/18/20 at 1:00 p.m., record review of Resident #6, admission date 7/15/20, revealed there were no physician progress notes in the facility. When asked, the Director of Nursing was unable to provide any physician progress notes. On 11/18/20 at 1:00 p.m., record review of Resident #12, admission date 9/15/20, revealed there…

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, record review, and interview, the facility failed to ensure 4 (Residents #24, #55, #58 and #65) of 4 residents on Pureed diets recieved the prescribed diet. (all foods have been ground, pressed, and/or strained to a soft, smooth consistency like a pudding). The facility failed to follow their policy for 4 (Residents #10, #11, #26, and #45) of 4 residents reviewed who were to be served double portions. The failures could potentially cause significant unintentional weight loss. The findings included: On 11/18/20 at 3:28 p.m., a review of the Exceptional Living Centers, Inc. Dietary Policies and Procedures dated 11/05, Subject: Altered Portions, 32 ELC, Inc. Dietary Policy & Procedure Manual revealed the following Policy: The dietary professional shall interview all residents upon admission and periodically as needed for food preferences and meal satisfaction. Altered portion sizes will be served upon request only with a physician's order. Procedure #3 included for double portions, serve two portions of meat, casseroles, potatoes or starch, vegetable and/or salad,…

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, record review, and interview, the facility failed to provide a nurse call system which relayed the call directly to a staff member or to a centralized staff work area on the first floor. This in the event of a resident emergency could result in staff not being aware or notified thereby endangering the resident from receiving immediate medical assistance. All residents on the first floor had the likelyhood of being effected by this practice. The findings included: On 11/16/20 at 10:30 a.m., in an interview Resident # 30 said the facility unhooked the call bell ringer at the nurse station from the light system so the nurses could no longer hear the call system. On 11/16/20 11:30 a.m., in an interview Resident #36 said the facility unhooked the call bell ringer at the nurse station from the light system so the nurses could no longer hear the call system. On 11/16/20 at 12:10 p.m., in an observation on the first floor, the nurse call light was observed on at the nurse station but there was 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.

Based on record review, observation and staff and resident interview, the facility failed to ensure retention of personal property for 1 (Resident # 18) of 1 resident reviewed for personal belongings The findings included: On 11/16/20 at 10:22 a.m., in an interview, Resident #18 was alert and oriented. She said she was missing clothes and other items including her hairbrush, personal care items and her books. She said her name was on the clothes and she was also missing blankets. Resident #18 said she had been moved to a different room downstairs and the contents of her bedside dresser was still upstairs. The content of the bedside dresser did not get moved down to her new room. She was scheduled to stay in the new downstairs room. She said she was very upset since without her books she had nothing to do in her room since group activites were limited due to Covid. She said she told several CNA's and other staff her personal items and clothes were still upstairs in her old room. She said she was frustrated and did not understand why the staff could not bring her her personal items.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living to 1 (Resident #41) of 1 resident reviewed resulting in the resident not having weekly bed baths or showers, her hair washed, and fingernails being clipped and cleaned. The findings included: Record review of Resident #41's care plan stated she needed extensive assistance of 1 to 2 staff members to assist her with her ADL care. An intervention listed on the care plan was to provide scheduled showers as needed with the option of a sponge bath on non-shower days. On 11/16/20 at 1:54 p.m., Resident #41 was observed to have contractures in both of her hands. Her fingernails on both her hands were observed to be long and with dirt and debris. The resident's hair was observed to be unwashed and unbrushed with noted visible dandruff in her hair. Resident #41 said she was not capable of taking a shower because she had to have 2 staff members assist her with a Hoyer lift, and she was told by 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.

Based on observation and staff interview, the facility failed to assure infection control practices were maintained in the managing of the urinary catheter tubing and drainage collection bag to reduce potential contamination for 1 (Resident #41) of 1 sampled residents with indwelling catheters by allowing the drainage bag and/or tubing to be in contact with the floor. The findings included: On 11/16/20 at 9:30 a.m., Resident #41's Foley Catheter's (Catheter placed in the bladder to drain urine) clear tubing was observed with brown stains giving an appearance the line was completely full. The drainage bag was in a trash bag tied to the bed rail. Resident #41 said she's had the catheter for years and several urinary tract infections. On 11/17/20 at 10:00 a.m., Licensed Practical Nurse (LPN) Staff M verified the Foley line was stained and needed to be changed. LPN Staff M verified the drainage bag was tied to the bed with a trash bag. Staff M said the bag did not have a hook to secure the bag to the bed. On 11/19/20 at 8:30 a.m., in an observation Resident #41's Foley drainage bag was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review and staff interview, the facility failed to ensure medications were secure and inaccessible to unauthorized staff, residents, and visitors and were not kept under direct observation of authorized staff for 1 (Staff L) of 2 staff assisting with review for medication storage. The findings included: Review of facility policy titled Storage of Medications Reviewed/Revised December 15, 2018 stated the following in Guideline Bullet #6: Compartments containing medications are locked when not in use. Trays or carts used to transport such items are not left unattended. (Compartments include, but are not limited to drawers, cabinets, rooms, refrigerators, carts and boxes.) On 11/17/20 at 9:52 a.m., Licensed Practical Nurse (LPN) Staff L was assisting this surveyor with review of the 1st floor west medication cart. Staff L asked if it would be ok if she opened the cart for me and then left to go do something. The Director of Nursing (DON) was passing by at the time and advised Staff L…

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.