Spalding Post Acute LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled Catheter Care, and Quality of Life-Dignity, the facility failed to promote, maintain, and protect residents' dignity for one of five residents (R) (R475) with an indwelling urinary catheter. This failure had the potential to diminish R475's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the facility's policy titled Catheter Care, dated 7/1/2024, revealed the Policy section stated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. The Policy Explanation section included, . 2. Privacy bags will be available and catheter drainage bags will be covered at all times when in use. Review of the facility's undated policy titled Quality of Life-Dignity revealed the Policy Statement…

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, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure that one of 51 sampled residents (R) (R55) was assessed for safe medication self-administration before allowing medications to be stored at the bedside. This deficient practice had the potential to place R55 at risk of self-administering medications in an unsafe manner. Findings include: Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, reviewed 1/1/2025, revealed the Policy statement included, Each resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse/Registered Nurse and physician have determined that the practice would be safe for the resident and other residents of the healthcare center. The section titled Procedure included . 2. If the resident or family member desires to self-administer medications, an…

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

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Misappropriations, the facility failed to ensure pre-employment screenings, specifically a background check for one employee and a background check and fingerprints for one employee, were obtained for two of 10 staff reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The facility census was 126 residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Misappropriations, effective date 2/1/2024, revealed the Policy Components section included A. Screening . 3. Criminal background checks will be conducted prior to permanent employment. Review of the facility employee files revealed the following: 1. The Director of Nursing (DON) was hired on 2/22/2023 with no background process completed. 2. The Dietary Manager (DM) was hired on 2/7/2023 with no background or fingerprint process completed. A review of the facility-provided Employee Roster Georgia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled Care Planning-Interdisciplinary Team, the facility failed to ensure that one of five residents (R) (R475) with an indwelling urinary catheter had a person-centered comprehensive care plan for the use of the indwelling urinary catheter. This deficient practice had the potential to place R475 at risk of not receiving treatment and/or care according to their needs. Findings include: Review of the facility's undated policy titled Care Planning-Interdisciplinary Team revealed the Policy Interpretation and Implementation section included, 1. A comprehensive care plan for each resident is developed after completion of the resident assessment (MDS) [Minimum Data Set]. Review of R475's electronic medical record (EMR) revealed diagnoses including, but not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder, generalized anxiety disorder, and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to ensure that one of five residents (R) (R475) with an indwelling urinary catheter had a qualifying medical diagnosis for the use of an indwelling urinary catheter. The deficient practice had the potential to place R475 at risk of avoidable urinary tract complications. Findings include: Review of R475's electronic medical record (EMR) revealed diagnoses including, but not limited to, hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness on one side of the body), major depressive disorder, generalized anxiety disorder, and a personal history of urinary tract infections. Review of R475's admission Minimum Data Set (MDS), dated [DATE], revealed section H (Bowel and Bladder) documented the resident had an indwelling catheter. Section I (Active Diagnoses) did not include any genitourinary diagnoses. Section M (Skin Condition) documented that there were no wounds. Review of R475's Physician's Orders revealed an order dated…

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

Based on observations, staff interviews, record reviews, and a review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. There were three errors with 29 opportunities for two of four residents (R) (R43 and R74) observed during medication administration. The medication error rate was 10.34 percent. These failures had the potential to place R43 and R74 at risk of medical complications and decreased therapeutic effects of medications. Findings include: Review of the facility's undated policy titled Medication Administration revealed the Policy section included A licensed nurse, Med Tech (medication technician), or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed. The Purpose section stated, To provide a safe, effective medication administration process. 1. Review of R43's Physician's Orders revealed an order dated 8/13/2024 for divalproex sodium oral capsule delayed release (DR) sprinkle 125 milligrams (mg), four…

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, staff interviews, record reviews, and review of the facility's policies titled Hand Hygiene and Infection Prevention and Control Policy, the facility failed to ensure infection control processes were followed during resident care for three residents (R). Specifically, during a fingerstick blood sugar (FSBS) test for one of 36 R requiring a FSBS (R8), during wound care for one of 20 R receiving wound care (R6), and for one of eight R receiving tube feeding (R91). The deficient practices had the potential to place R8, R6, and R91 at risk of avoidable exposure to infections. Findings include: Review of the facility's policy titled Hand Hygiene, effective date 2/1/2024, revealed the Policy Statement included, . Handwashing is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident contact in an effort to prevent 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, staff interviews, and review of the facility policy titled, Transfer and Discharge Including AMA [against medical advice], the facility failed to ensure the Ombudsman was notified for six of six residents (R) (R5, R1, R2, R7, R8, and R11) reviewed for discharge from the facility. Findings include: Review of the facility's undated policy titled, Transfer and Discharge Including AMA, revealed the Policy was It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. The Policy Explanation and Compliance Guidelines section included . 4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: . h. The name, address (mailing and email), and phone number of the representative 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, staff interviews, and review of the facility's policies titled, Glucometer Disinfection, and Infection Prevention and Control, the facility failed to ensure the infection control process was followed by two of three nurses observed using a glucometer (a device used to measure blood glucose) to check resident's blood sugar levels. The deficient practices had the potential to increase the potential for cross-contamination and spread of infection. Findings include: Review of the facility's policy titled, Glucometer Disinfection, dated 11/2017, revealed the Policy stated, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. The Policy Explanation and Compliance Guidelines section included 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 3. Glucometers should be cleaned and disinfected after each use and according 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 resident interviews, staff interviews, review of the facility policy titled, Patient/Resident Trust Funds, and review of the facility-provided document titled, Resident Fund Accounts, the facility failed to provide resident trust fund account quarterly statements for three of 100 residents (R) with trust fund accounts managed by the facility (R4, R6, and R9). This deficient practice had the potential to affect all residents who had a trust fund account with the facility. Findings include: Review of the facility policy titled, Patient/Resident Trust Funds, dated 2/1/2024, revealed the Procedure section included .3. At the time of admission, the resident will sign an authorization indicating understanding of the policy and giving the healthcare center authorization to handle such funds. This authorization is to be maintained in the financial file. Review of the undated document located in the resident admission packet titled, Resident Fund Accounts revealed, The center shall furnish resident/patients with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility policies titled, Grievances Policy, Missing Items (Including Misappropriation of Property), and Resident Council Meetings, the facility failed to make a prompt effort to file a grievance for two of 25 sampled residents (R) (R7 and R9) who verbally reported grievances. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner. Findings include: Review of the facility's policy titled, Grievances Policy, dated 2/1/2024, revealed the Policy Statement was It is the policy for healthcare centers to have and follow an established process whereby residents and/or other customers may have their grievances and complaints resolved in a prompt, reasonable and consistent manner. All employees will take an active part in efforts to resolve grievances voiced without discrimination or retaliation. Review of the facility's undated policy titled, Missing Items (Including…

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 interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary condition. The deficient practice had the potential to affect 122 of 136 residents receiving an oral diet. Findings include: A review of the cleaning schedule submitted by the dietary manager indicated a Sunday-to-Sunday cleaning schedule with a focus on sweeping and mopping kitchen floors under the prep tables and behind the oven, stove, and steamers every day. During an interview and initial tour of the kitchen with the Dietary Manager (DM) on 10/31/23 at 8:56 am an observation of the floor behind the deep fryer was full of debris that was noted to be black and sticky. The area was unclean and continued to be unclean throughout the survey process. The DM confirmed the findings in the kitchen. During an Interview on 11/01/2023 at 12:08 pm with DM revealed the findings as being unclean and presenting an unsanitary condition. The DM expresses it is the responsibility of the kitchen staff to ensure that the main kitchen, floors, and appliances are clean and in…

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

Based on interviews, record reviews, and the document Rules and Regulations for Criminal Background Checks the facility failed to consistently require new hires to go through a criminal background check before beginning employment. This deficient practice affected 5 out of 10 new employees. The census was 137. Findings include: Review of the document Rules and Regulations for Criminal Background Checks, no revised date noted, Licensed Healthcare Providers who are exempt from state fingerprint background check requirements as long as the employer checks with the applicable licensing board to verify that the license is in good standing, Nurses, Occupational Therapists, Physical Therapists, Social Workers. Unlicensed personnel are subject to state fingerprint background check requirements because they are not licensed Certified Nursing Assistants (CNA), Recreational Therapists. During an interview with the Human Resources Director on 11/1/2023 at 9:00 am it was revealed five new employee files reviewed out of 10 did not have a criminal background check. 1. Administrator hired 5/1/2023,…

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 interviews, record reviews, and the facility policy titled Controlled Substance Administration and Accountability the facility failed to maintain accurate records on controlled substances on four of six medication carts (Magnolia Hall, [NAME] Lane Hall, Pine Circle Hall, and Cedar Street Hall). Findings include: Review of the undated policy titled Controlled Substance Administration and Accountability revealed the policy was to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. The Policy Explanation and Compliance Guidelines section line numbered 9 stated: Inventory Verification: b. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Observation on 11/2/2023 at 10:30 am with the Director of Nursing (DON), of the controlled medication document titled Nurse Signature Sheet and located…

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, staff interviews, and facility policy titled Handwashing/Hand Hygiene Cleaning and Disinfection pt Resident - Care Items and Equipment, and Tracheostomy Care, the facility failed to maintain proper infection control practices by not performing hand hygiene between residents during meal pass on one hall of six, one resident (R) (R122) during tracheostomy care, and not properly labeling and storing of resident- care items on two of six halls. The facility census was 139. Findings included: 1.A review of an undated facility policy titled Handwashing/Hand Hygiene, revealed that all personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy also revealed that staff are to use an alcohol-based hand rub, or alternatively, soap and water before and after direct contact with residents. During observation of the lunch pass on Magnolia Lane Hall, on 10/31/2023 from 11:35 am until 11:50 am, it 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 observations, and staff interviews, the facility failed to maintain a clean and homelike environment as evidenced by the presence of dusty fans in resident rooms in two of six halls. This failure had the potential to place residents at risk for use of unsanitary and unsafe equipment and a potential for diminished quality of life.The facility census was 139. Findings included: On 10/31/2023 at 11:05 am, it was observed that a fan that was in resident room [ROOM NUMBER] was dusty. On 10/31/2023 at 11:15 am, it was observed that the fan in resident room [ROOM NUMBER] was dusty. On 10/31/2023 at 11:20 am, it was observed that the fan in resident room [ROOM NUMBER] was dusty. On 10/31/2023 at 11:23 am, it was observed that the fan in resident room [ROOM NUMBER] was dusty on the resident's overbed table and was blowing towards the resident's head. On 10/31/2023 at 11:17 am, it was observed that the fan in resident room [ROOM NUMBER] was dusty. On 10/31/2023 at 11:20 am, it was observed that the fan in…

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

Based on observations, staff interviews, record review, and a review of the facility policy titled Reporting Reasonable Suspicion of a Crime, the facility failed to report an alleged violation of misappropriation of property, specifically the medication Morphine for one of 39 residents (R) (R286) sampled, to the State Agency (SA). Findings include: Review of the policy titled, Reporting Reasonable Suspicion of a Crime, copyright 2022, section, Policy Explanation and Compliance Guidelines it was revealed that annually the facility will notify all employees, managers, agents, and contractors of the facility of the obligation to report any suspicion of a crime committed against a resident of this facility to one of more law enforcement agencies and the state survey agency. Although it remains the responsibility of each covered individual to ensure that his/her individual reporting responsibility is fulfilled in addition to reporting to law enforcement and SA it is the policy of this facility that employees report suspicion to the administrator or their designee. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and a review of the facility's policy titled, Activities of Daily Living the facility failed to ensure two of 137 residents (R) (R42 and R127) were given showers as scheduled. This failure had the potential to impact residents' quality of life and decrease functional status. Finding include: Review of the facility's policy titled the Activities of Daily Living Based on the comprehensive assessment of a patient and consistent with the patient's need and choices, the center must provide the necessary car and services to ensure that a patient's abilities in activities of daily living do not dimmish unless circumstances of the individual's clinical conditions demonstrates that such diminution was unavoidable. 1. Record review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] for R42 revealed a Brief Interview for Mental Status (BIMS) of 15, indicating the resident had intact cognition. Further review revealed R42 had no behaviors,…

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, staff interviews, record review, and a review of the facility policy titled, Enteral feeding process, the facility failed to label and date nutritional enteral feedings and failed to follow physician orders to Label each component with date and initials every night shift for two of fourteen residents (R) (R120 and R132). This failure had the potential for tube feeding to exceed the expiration date and time while administering an incorrect formula. Findings include: Observation on 11/2/23 at 1:49 pm revealed that R120 was lying in bed with tube feeding on. The formula bag and the flush bag were not labeled and dated. Observation on 11/2/23 at 1:52 pm revealed that R132 was lying in bed with tube feeding on. The formula bag and the flush bag were not labeled and dated. Review of the facility's policy titled Enteral feeding process, revealed Policy Statement: Formula order: State feeding route, formula name, rate and if continuous or bolus feeding. If it is continuous add start and end times.…

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, staff interviews, record review, and a review of the facility policy Oxygen Safety, the facility failed to provide necessary respiratory care consistent with professional standards of practice by not ensuring the oxygen equipment gauge was set on the prescribed flow rate for two of four residents (R) (R122 and R93) receiving oxygen therapy. This deficient practice has the potential to cause respiratory distress for the residents. The sample size was 39. Findings include: 1. Record review of the physician orders for R122 include Oxygen at 6 LPM (liters per minute) via tracheostomy continuous for acute respiratory failure. Record review of R122 diagnoses includes acute and chronic respiratory failure with hypoxia. Record review of the care plan for R122 a history of respiratory failure. Creates risk for altered breathing patterns, infection, and complications. Observation on 11/01/2023 at 10:34 am in R122's room Oxygen was on by tracheostomy at 7.5 liters. Observation on 11/02/2023 at 11:00…

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, staff interviews and a review of the facility policy titled Storage of Medications, the facility failed to secure drugs and biologicals in a safe, secure manner for one of six medication cart and one of one treatment cart. This failure placed residents, staff and visitors at risk for having unauthorized access to resident's medications. The facility census was 139. Findings included: Review of the policy with the revision date of August 2021 titled Storage of Medications revealed that Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On 10/31/2023 at 11:31 am, it was observed that the treatment cart was unlocked with the key in the lock. The treatment cart was observed outside a resident door with the door closed. The treatment nurse opened the door of the room and returned to the cart. She revealed that I knew I…

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.