Irving Park Living & Rehab Ctr

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards for a PICC (Peripherally Inserted Central Catheter) line for 1 (R130) of 3 (R17, R132) sampled residents related to the maintenance of intravenous access devices. Findings Include: R130 has diagnosis not limited to Encounter for Other Orthopedic Aftercare; Primary Generalized (Osteo)Arthritis; Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Falling, Hyperlipidemia, Hypothyroidism, Polycythemia Vera, Bipolar Disorder, Effusion, Right Knee, Pyogenic Arthritis, Klinefelter Syndrome, Spinal Stenosis, Testicular Hypofunction, Depression, Retention of Urine, Morbid (Severe) Obesity, Iron Deficiency Anemia and Muscle Spasm. R130's Care Plan document in part: Focus: Intravenous Therapy: Antibiotic therapy. Resident has a need for IV (Intravenous) antibiotic therapy ceftriaxone 2-gram solution due to osteomyelitis. IV site will remain free of signs and symptoms of infection. R130's Resident Medication Administration Record…

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 ensure a resident with a tracheostomy had the required emergency equipment at the bedside for 1 (R17) resident reviewed for respiratory care in a sample of 48. Findings Include: R17 has diagnosis not limited to Tracheostomy, Chronic Respiratory Failure, Gastrostomy, Dysphagia, Morbid Obesity, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Major Depressive Disorder, Anxiety Disorder, Hypertensive heart disease, Epilepsy, Shortness of Breath Type 2 Diabetes Mellitus and Primary (Essential) Hypertension. R17's Physician's Orders document in part: Tracheostomy tube changes every 3 months and prn (as needed). (Tracheostomy tube) 6 as needed. Change Inner Cannula (Tracheostomy tube) 6 once daily and prn. R17's Care Plan document in part: Focus: Tracheostomy: Resident with tracheostomy r/t (related/to) dx (diagnosis) of chronic respiratory failure. On 01/14/25 at 01:12 PM Enhanced Barrier Precaution signage was observed on R17's entrance door. Upon entering R17's room, 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.

Based on observation, interview, and record review the facility failed to a.) ensure the accurate shift change reconciliation accountability record for controlled substance and b.) ensure an accurate accountability for 2 controlled substances (Clonazepam/Tramadol) by resolving discrepancies in a timely manner. This deficient practice was identified for 1 of 3 medication carts used to store controlled narcotics. Findings Include: Document titled Shift Change Accountability Record for Controlled Substance document in part: 2nd Month-Year January 2025: nurse Initials were missing for 01/13/25 second shift, third shift and 01/14/25 first shift. R9's Control Drug Receipt/Record/Disposition Form: document Date received 07/19/24, Drug Name/Strength: Tramadol HCL Tab 50 mg (Milligrams), Directions: One tablet by mouth every 6 hours as needed for pain. Quantity Received: 30. Amount Left: 16. R9's Bingo Medication Card contain a total of 15 Tramadol HCL Tabs indicating one missing tablet. R59's Control Drug Receipt/Record/Disposition Form: document Date received 10/31/24, Drug Name/Strength:…

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 ensure a resident received the prescribed amount of insulin for 1 (R25) resident reviewed for significant medication error in a sample of 48. Findings Include: R25 has diagnosis not limited to Paraplegia, Essential (Primary) Hypertension, Atrial Fibrillation, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hyperlipidemia, Peripheral Vascular Disease, Polyneuropathy, Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in Right Knee, Pain in Left Knee, Foot Drop, Right Foot, Obstructive and Reflux Uropathy, Chronic Kidney Disease, Urethral Stricture, Retention of Urine, Hyperkalemia, Schizoaffective Disorder and Shortness of Breath. R25's Physician Order document in part: Basaglar Kwik Pen U-100 Insulin 100 unit/ml (milliliter) (3 ml) subcutaneous, inject 15 units by subcutaneous route Twice a day. Monitor Blood Sugar AC/HS (before meals/hour of sleep. R25's Care Plan document in part: Focus: Diabetes Mellitus: Resident has elevated blood glucose level secondary to diagnosis of NIDDM…

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 a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerators, c.) ensure resident refrigerators are in proper working order. This has the potential to effect one resident (R53) out of six residents reviewed for personal food storage in a total sample of 48. Findings include: On 01/14/25 at 12:21 PM, R53 gave surveyor permission to look in R53's personal refrigerator at bedside. The inside of R53's refrigerator was warm, not cold, or cool. All items inside felt warm to the touch. Thermometer located inside R53's refrigerator read 58 degrees Fahrenheit (F). The temperature log on the outside of R53's refrigerator documented in part that on 01/14/25 the refrigerator temperature was 38 degrees F. Inside R53's refrigerator found the following items: 1.) Two unopened 2-ounce packages labeled Smoked Ham and printed on packaging use by September 25, 2024 by manufacturer. 2.) In freezer compartment of refrigerator found fully defrosted box labeled…

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 records and interviews the facility failed to protect the rights of every resident to be free from verbal or physical abuse for 1 out of 4 residents (R1) reviewed for resident rights to be free from abuse. These failures do not conform with the abuse policy of the facility. Failures affected 1 resident (R1) that had directed verbal aggression and was poked in the hand by R2. Findings include: R1 an [AGE] year-old resident, with intact cognition based on brief interview of mental status (BIMS) dated 12/02/2024, scored 13. R1 is alert. R1's diagnosis includes dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R2 [AGE] year-old resident, with intact cognition based on brief interview of mental status (BIMS) dated 12/03/2024, scored 14. R2 is alert. R2's diagnosis includes dementia, psychotic disturbance, major depressive disorder. Per facility's incident report investigation with initial date of 12/02/2024, and final date of 12/06/2024, it…

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 and review of records, facility failed to follow their policy to ensure family members were notified of resident's change in condition for one (R1) out of three residents reviewed for right to be notified of changes, in a total sample of 3. Findings include: On 11/30/2024, at 9:30 AM, V3 (R1's POA/Complainant) stated that she is R1's POA (Power of Attorney) with her husband. V3 stated that she had requested a report from the facility on what happened to R1 the night he was sent to the hospital. V3 stated that she requested R1's report of the transfer to the hospital on November 5th, 2024, and still has not received an update. On 11/30/2024, at 9:50 AM, V1 (Administrator) stated that V3 requested a report from them on 11/5/2024, regarding what transpired with R1 on 10/31/2024; he was sent to the hospital. V1 stated she notified V2 right away. On 11/30/2024, at 10:00 AM, V2 (Director of Nursing) stated that R1 was a resident on the 3rd floor. V2 stated that on Thursday, sometime in October, R1 was sent out to the hospital because he said he wanted to jump out of…

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

Based on interview and record review, Facility failed to follow their policy to be free from sexual abuse by not providing necessary care and services. This failure resulted in a male resident (R4) sexually assaulting another male resident (R3). This failure affects two (R3 and R4) out of three residents reviewed for sexual abuse. Findings include: R3's MDS (Minimum Data Set) dated (10/1/2024) documents in part R3's BIMS (Brief Interview for Mental Status) score is 15. R3 is cognitively intact. R3's face sheet documents the medical diagnoses: Generalized epilepsy, viral hepatitis, spinal stenosis, chronic pain, hypothyroidism, gastroesophageal reflux disease, metabolic encephalopathy, essential hypertension, depression, type 2 diabetes mellitus, osteoarthritis, anxiety disorder. R4's is only alert and oriented to person and place. R4 is not alert. R4's face sheet documents the following medical diagnoses: dementia with behavioral disturbances, cognitive communication deficit, cerebral infarction with residual deficits, bipolar disorder and Schizophrenia. On 11/20/2024, at 11:10 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and record review, the facility failed to thoroughly and timely investigate a situation of potential staff-to-resident abuse for one resident (R1) reviewed for physical abuse in the sample of three. Findings include: On 8/20/2024 at 2:00 PM, V3 stated I got a call from the R1 family, and she reported that V5 struck R1 in the penis on 8/6/2024 while giving patient care, and nothing was being done. She also informed me the facility has not started working on R1 discharge planning. After speaking with the family, I immediately came out to visit R1 and informed the facility Administrator on 8/15/2024. On 8/20/2024 at 11:36 AM, R1 states on the evening of 8/6/2024, the CNA(V5) came to my room. I pulled the call light because I needed to be changed. I told the CNA I think I had a bowel movement. The CNA came over to check to see if I was wet and struck me in my private area, and I yelled. I was yelling because I didn't understand why he would check me like that, and I have a urinary catheter…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a as needed (PRN) dose of pain medication was administered to a resident for breakthrough pain which affected one (R3) resident in the total sample of 8 residents reviewed. Findings include: On 5/28/24 at 1:41 pm, R3 stated, There was a mix up, and the nurses were not giving me (R3) the PRN medication for pain when I was receiving the scheduled pain medication every 8 hours. They (nurses) were not wanting to give me the PRN medication if it hadn't been a lapse of 4 hours after my scheduled dose. That means that I would only be able to have 3 PRN doses per day (24 hours) when I should be able to get 4 PRN doses. R3 stated that R3's doctor wrote instructions for the nurses not to wait until 4 hours after the scheduled dose to give the PRN. R3 stated that the instructions also restrict the total doses of the PRN pain medication to 4 doses every 24 hours. R3 stated that R3 requests for the PRN pain medication, if I (R3) hurt in between…

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 ensure that the residents' rooms temperature are within the required comfortable and safe degrees Fahrenheit of between 71 to 81 degrees for 37 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10,11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, and R37) reviewed for comfort and safe environment. This failure affected (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10,11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, and R37) residing on the 2nd and 3rd floor and has the potential to affect all 86 residents residing in the facility. Findings include: On 01/23/23 at 12:58pm, V5 (Wound Care Nurse) stated that most of the residents have been complaining that their rooms are cold. V5 stated this was reported to V4 (Maintenance Director). V4 identified R13 as one of the residents actively complaining…

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 ensure that the facility temperature in the common areas on the 2nd and 3rd floor meet the required temperature of between 71-degree Fahrenheit to 81-degree Fahrenheit. This failure has the potential to affect all residents residing on the 2nd and 3rd floor of the facility. Findings include: On 01/23/23 at 12:56pm, V5 (Wound Care Nurse) stated that most of the residents have been complaining that the dining rooms are cold, and the staff can feel it in the hallways and dining area. V5 stated this was reported to V4 (Maintenance Director). V4 identified R13 one of the residents actively complaining about the room temperature. V5 stated R13 has being complaining since sometime last week. On 01/23/23 between 1:00pm to 2:00pm, during environmental rounds with V4 (Maintenance Director) regarding facility temperature. The following observations were made: At 1:00pm-Temperature measures on the 3rd floor the [NAME] Hallway 69.2-degree Fahrenheit, South Hallway 67.1-degree Fahrenheit, Dining room =69.0-degree…

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 follow physician's orders and apply hand splint/brace for two of six residents (R2 and R4) with limited range of motion and failed to provide documentation related to application refusal of splint/brace. This failure affected R2 and R4 reviewed for assistive devices in the total of 86 residents. Findings include: On 01/23/23 1:41pm, R2 was noted lying in bed using the right hand to lift left hand trying to make sure it did not get caught up in the linen. R2 complained that the staff is not helping in applying the hand sling/brace. At 1:48pm, when this observation was brought to V12 CNA (Certified Nurse's Aide) assigned to R2 attention, V12 stated that I don't know about the hand splint, whether R2 is to wear it. V12 looked for the device in R2's bed side dresser drawer and V12 stated they are not in here (referring to the hand device splint/brace). V12 stated that the restorative devices are applied by the restorative aides. At 1:49pm V13 (Restorative Coordinator) who was on the floor at the time was called 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.

Based on observation, interview, and record review the facility failed to ensure that the residents environment remains free of accidental hazard by not leaving sharp items, disposable shaving razor and scissors that could harm the residents at the bedside. This failure affected R2 who had scissors on the bed and visible to the hallway and R12 who had disposable shaving razor on the bedside table. This has potential to affect all the residents residing on the 2nd and 3rd floor of the facility. Findings include: On 01/23/24 at 1:41pm, R2 noted in bed with four blankets covering, a pair of scissors was noted upon entering the room on R2's bed and visible to the hallway. R2's electronic medical record Face Sheet showed listed diagnosis information that includes but not limited to Cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Cerebral atherosclerosis, Major depressive disorder, Mild intermittent asthma, Dementia in other diseases classified elsewhere, unspecified severity with psychotic disturbances, Pain unspecified,…

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 provide enough staffing to meet the needed restorative services for two of six residents (R2 and R4) with limited ROM/range of motion and who are dependent on staff assistance in applying hand splint/brace devices. This failure affected R2 and R4 whose splint/braces are not applied, and this has the potential to affect all 74 residents identified as residents on restorative program and 22 residents on splint program. Findings include: On 01/23/24 between 1:00pm to 2:00pm, R2 and R4 were noted in their rooms with their splint/braces not in use as ordered by their physician. On 01/23/24 at 1:50pm V13 (Restorative Coordinator) who was on the floor at the time was called to R2's room and V13 stated that the R2's sling should be applied in the morning at least at 9:00am the staff for restorative called off, there are not enough people to work. So, I have not being able to apply any splint for any of the resident. I'm working on getting this assessment done I'm trying to catch up on the new admissions too. V13…

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 ensure that medication is stored in a locked cart when not in proximity of the nurse for two of three residents (R2 and R3) in the sample reviewed for medication administration. This failure affected R2 and R3 whose medications were left at the bedside without physician order to do so and has the potential to affect all 30 residents residing on the 3rd floor. Findings include: On 01/23/24 at 1:41pm, R2 noted in bed with four blankets covering, a pair of scissors noted upon entering the room on R2's bed and visible to the hallway. An open bottle of medication Methyl Salicylate Camphor (Menthol counter irritant) not labeled with name and directions noted on the overbed side table. R2 stated I use that for my leg pain. The medicine is from Philippines. During the same observation, R3 observed in bed with albuterol inhaler, artificial tears, fluticasone propionate, and deep-sea nasal spray noted on the bedside table visible to the hallway. R3 stated the nurse gave it to me (referring to self) and I (R3) use them.…

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, interviews, and record reviews, the facility failed to label/date food items, failed to dispose of food items beyond the use by date, failed to ensure freezer' and cooler' temperatures were monitored and logged, failed to ensure staff' lunch bag was not stored in the Kitchen cooler, and failed to ensure the test strips used to check the solution in the sanitize sink was not expired in an effort to prevent food borne illnesses. These failures have the potential to affect all 73 residents receiving oral nutrition at the facility. Findings include: The (11/30/2023) email correspondence with V1 (Administrator) documented that there were 3 residents not taking oral nutrition at the facility. On 11/27/2023 at 9:31am, the reach in cooler labeled C had a tub of cottage cheese dated 11/5/23 and 11/20/23; and had 3 pieces of pancakes on styro foam plate dated 11/22/23. V5 (Dietary Manager) stated the tub of cottage cheese should have been thrown out on 11/20/23 and the pancakes are good for 3 days only. The pancakes should have been thrown out on 11/25/23. On 11/27/2023…

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 observation, interview and record review the facility failed to ensure the outside dumpsters' lids were closed in an effort to prevent pest and rodents from migrating into the dumpster. This failure has the potential to affect all 76 residents at the facility. Findings include: On 11/27/2023 at 9:52am, one of the two small outside dumpsters was open with overflowing trash and 1 of the 6 lids of the big outside dumpster was open with overflowing trash. V5 (Dietary Manager) attempted to close the dumpsters to no avail. V5 stated these are nursing staff. Housekeeping should ensure the lids are close. V5 pointed out to this surveyor the space available in the big dumpster and stated (V5) I don't know why they keep on throwing stuff here (pointing to the open part of the dumpster) when there's more space (pointing to the rear of the big dumpster) on that side of the dumpster. On 11/28/23 at 3:18pm, V5 stated everybody is using the dumpster. Anyone who uses the dumpster must make sure to close the lids to keep pests and rodents out of the dumpster. On 11/28/2023 at 9:53am, V12…

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 provide thermometers for resident's personal refrigerators for 2 residents (R56 and R70), failed to discard expired food from resident's personal refrigerator for 1 resident (R56), and failed to properly log refrigerator temperatures for 3 residents (R56, R74, and R181). These failures affected 3 (R56, R74, and R181) residents reviewed for personal food items in a total sample of 41 residents. Findings include: On 11/27/2023 at 11:00AM, during observation of R56's personal refrigerator, the following were observed: The refrigerator was without a temperature thermometer. The refrigerator was without a temperature log. The 4-ounce rice pudding located in the refrigerator had an expiration date of 11/02/2023. On 11/27/2023 at 11:05AM, this surveyor inquired how often staff are checking temperature readings and contents of the refrigerator. R56 stated they hardly ever come in to check this refrigerator. This refrigerator is from the kitchen. On 11/27/2023 at 11:10AM, V7 (Certified Nursing Assistant) was informed…

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

Based on observation, interview and record review, the facility failed to ensure a homelike environment for one resident (R59) in the sample of 41 residents. Findings include: R59's diagnosis includes but are not limited to, Parkinson's disease, neurocognitive disorder with Lewy bodies, cerebral ischemia, hyperlipidemia, insomnia, essential hypertension, neuralgia and neuritis, spinal stenosis, hypothyroidism, vitamin D deficiency, contracture (right ankle) and contracture (left ankle). R59's Brief Interview for Mental Status (BIMS) dated 9/20/2023 documents that R59 has a BIMS score of 10 which indicates that R59 has some cognitive impairments. On 11/28/2023 at 10:05 am surveyor observed chipping paint located behind the head of R59's bed, the chipping paint was observed to be on the wall extending the entire length of R59's headboard. On 11/29/2023 at 12:15 pm V12(Maintenance/ Housekeeping Director) stated the paint chips are behind the bed because the head of the bed is constantly pushing and digging into and against the wall. V12 stated the Maintenance Director is responsible…

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 interviews and record review, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed quarterly for one resident (R64) reviewed in a sample of 41 residents. Findings include: R64 is [AGE] year-old with diagnosis including but not limited to: Anxiety disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Idiopathic Epilepsy and Hypertension. On 11/29/23 during investigation, Surveyor requested R64's previous MDS from V19 (MDS Coordinator). On 11/29/23, at 2:03 PM, V19 said, I just started here. I believe that the last MDS is in the old charting system. We recently converted over to a new charting system. I will check for you. On 11/29/23 at 2:35 PM, V19 presented Surveyor with MDS documentation for R64. Surveyor reviewed R64's MDS and inquired about the deadlines regarding MDS assessments. On 11/29/23 at 2:35 PM, V19 said, the MDS assessments are supposed to be completed on a quarterly basis, for insurance purposes. I'm not sure why it was not done in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive mouth care, grooming and showers as scheduled. These failures affected two residents (R25 and R33) out of 4 residents reviewed for ADL care and grooming, in a total sample of 41 residents. Findings include: R25's face sheet shows diagnoses include but are not limited Pressure Ulcer of Sacral Region, Cerebral Infarction, and Osteoarthritis. On 11/27/23 at 10:40am, R25 was observed in the day room with other residents. R25's mouth was dry and sticky with thick secretions, and the teeth had visible accumulation of creamy brown material. Again at 11:30am, R25 was observed in the same condition. At this time, V20(CNA/Certified Nurse Assistant) was notified. V5 stated I will make sure he (R25) gets cleaned up now. V 9(LPN/Licensed Practical Nurse) was also notified and V9 stated that R25's mouth and face should have been…

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 interviews and record review, the facility failed to ensure that an abnormal lab and abnormal blood glucose were relayed to the Medical Doctor for one resident (R41). This failure has affected one of 41 residents reviewed for nursing care. Findings include: R41 is [AGE] year-old with diagnosis including but not limited to: Type 2 Diabetes Mellitus with Diabetic Neuropathy, Diabetes Mellitus due to underlying condition, Non-Pressure Chronic Ulcer of Other Part of Left Foot with Necrosis of Muscle, Pure Hypercholesterolemia, Polyneuropathy and Hypertension. R41 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. On 11/27/23 during investigation, Surveyor observed R41 sitting in his room. On 11/27/23 at 10:45 AM, R41 said, Sometimes my blood glucose is uncontrolled. I have not seen an Endocrinologist. My blood sugar was 43 on last Saturday. At that time, R41 pulled out his cellular device to show Surveyor blood glucose recording of 43 (mg/dL- Milligrams per…

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 have low air loss mattress at the correct weight settings for a resident with pressure ulcer who is at high risk for further pressure ulcers. This failure affected one resident (R56) of two residents, reviewed for pressure ulcer prevention interventions, in a total sample of 41 residents. Findings include: On 11/27/23 at 11:00am during observation, R56 was observed on a low-air-loss mattress (LALM) with the machine weight setting at 300 pounds. Again on 11/28/23 at 10:10am, R56's LALM was still at a weight setting of 300 pounds. R56's weight records show that R56 only weighs 120 pounds. On 11/28/23 at 11:55am, V16 (Wound Care Nurse) was interviewed and requested to observe R56's LALM wrong settings and change the weight setting to the correct weight. V16 stated (R56) should be on air mattress for pressure ulcers, and the weight setting should always be at the patient's weight. I usually go round every week to check the air mattress…

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, interviews and record review, the facility failed to ensure that oxygen tubing was replaced for two residents (R58 and R19). This failure has the potential to affect 13 other residents who receive oxygen or nebulizer treatments in the facility. Findings include: R19 is [AGE] year-old with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Unspecified Cough, Hypertension and Hyperlipidemia. R58 is [AGE] year-old with diagnosis including but not limited to: Chronic Pulmonary Embolism, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, Hyperlipidemia and Morbid Obesity. On 11/27/23 R19 and R58 were both observed in their bedroom, which they shared. On 11/27/23 at 11:40 AM, Surveyor observed R58's breathing treatment tubing and mask on the bedside stand next to his bed. R58's oxygen tubing and mask were not contained and was noted with a date of 10/16/23 on it. At that time, R19's breathing treatment tubing and mask 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 observations, interviews, and record reviews, the facility failed to label with date a resident central venous line dressing in an effort to prevent infection. This failure affected R180 reviewed for infection control in a total sample of 41 residents. Findings include: On 11/27/23 at 11:07 am, there was an empty bag of IV (intravenous) medication with R180's identifiers. R180 stated the reason is because when I (R180) was in the hospital, they said I (R180) have bacteria in my (R180) blood. I (R180) need to get antibiotic for 35 days. I (R180) started getting the antibiotic on November 3. On 11/27/2023 at 11:09am, R180 had a central venous line on the left arm; dressing was not dated. R180 stated the dressing was applied 1-2 weeks ago. On 11/27/23 at 11:30 AM, V6 (Licensed Practice Nurse) checked R180's central venous line dressing per this surveyor's request and stated I (V6) don't see a date. It is not dated. On 11/29/2023 at 12:12pm, V2 (Director of Nursing) stated the expectation for the PICC (peripherally inserted central catheter) line dressing, that it has to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record reviews the facility failed ensure 1 [R1] of 3 residents pain medication was available on 1 of 3 medication carts. Findings include: R1's clinical record indicates in part: R1 is a [AGE] year-old, admitted on [DATE], with medical diagnosis of but not limited to paraplegia, injury to cervical spinal cord, neuralgia, type II diabetes, lumbago sciatica, heart disease, anxiety disorder, morbid-server obesity, major depression, essential hypertension, and acute respiratory failure. R1's Physician orders: -9/11/23 - acetaminophen 300 mg-codeine 30 mg tablet: 1 tablet by mouth every 4 hours as needed for pain. -9/11/23- gabapentin 800 mg tablet 3x daily for pain -9/11/23- lidocaine 5% topical patch daily for pain. -9/11/23- baclofen 10mg give 1/2 tablet [5mg] every 8hrs for pain. R1's minimum data set [MDS] Brief Interview Mental Status Score [ 15] indicates R1 is cognitively intact. On 10/10/23 at 11:40 AM, R1 stated, This past weekend, I ran out of my acetaminophen 300…

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, interviews, and record reviews, the facility failed to ensure the high temperature dish machine reached a temperature of 180F during final rinse and failed to ensure the high temperature dish machine was monitored two times daily. These failures have the potential to affect all 78 residents taking oral nutrition at the facility. Findings include: The (09/01/2023) Facility census was 81 residents. The (09/02/2023) Residents who are NPO (nothing per-mouth) documented that there were 3 residents on NPO. On 09/01/2023 at 1:17pm, V9 (Dietary Manager) stated we (facility) are using high temp dish machine. V9 pointed the round thermometer attached to the dish machine. The number on the thermometer attached to the dish machine was barely visible. V9 stated I (V9) don't know; it is hard to see the number on the thermometer. We (facility) use temperature strip to check it. On 09/01/2023 at 1:19pm, Requested to see the August 2023 temperature log for the dish machine. The temperature log was noted with bar on the temperature strips not completely turning bright orange…

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, interviews, and record reviews, the facility failed to provide podiatry services for a resident (R9) and have services done every 60 days. These failures affected 9 (R4, R6, R9, R22, R27, R32, R39, R53, R64) residents out of a final sample of 18 residents reviewed for podiatry services and potentially affecting all residents in the facility who require podiatry services. Findings include: R9's face sheet documents in part an initial admission date of 5/12/2022. R9's medical diagnoses include but are not limited to Paraplegia and type 2 Diabetes Mellitus. R9's physician order sheets document in part: May see podiatrist ordered 08/09/2022. On 12/06/2022 at 11:12 AM, R9 stated the facility's podiatrist has not evaluated R9. R9 stated [R9] needs to see the podiatrist due to history of diabetes. R9 stated [R9's] nails need cutting because they are so long, they are starting to grow to the side. On 12/06/2022 at 12:26 PM, surveyor entered R9's room with V6 (Nurse) to conduct feet assessment. V6 removed R9's left sock. V6's eyes widened. V6 stated yes, podiatrist…

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, interviews, and record reviews, the facility failed to provide adequate staffing to provide individual needs such as providing escorts to assist a resident (R68) to appointments. This has the potential to affect all the residents that reside on the third floor. Findings include: On 12/06/22 at 10:53 AM, surveyor entered R68's room for an interview. R68 was oriented to person, place, and time. R68 stated [R68] missed a few appointments to outside physicians' services because staff can't find an escort to take [R68]. R68 stated staff repeatedly reschedules [R68's] appointments because of escort issues. R68 stated [R68] was supposed to go to an appointment this week but staff rescheduled it again. On 12/06/2022 at 10:56 AM, V6 (Nurse) stated R68 was supposed to go out on appointment yesterday but did not go. V6 stated I informed [V1 (Administrator)] about [R68] needing to go out on an appointment but [V1] said since we were running out of time to send [R68], we should just reschedule it. On 12/06/2022 at 12:17 PM, V6 stated a CNA (Certified Nurse Aides) usually…

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, interviews and review of records the facility failed to account all narcotics medication including those provided by hospice for 1 out of 2 medication storage room reviewed for 2 residents (R232 and R233). Failed to follow policy on administration of medication via gastrostomy route to 1 resident (R27). These failures have the potential to affect all 35 residents on the 3rd Floor as it relates to accounting of narcotic medications. And 1 resident (R27) receiving medication via Gastrostomy. Findings include: On [DATE] at 11:21 AM. With V6 (Licensed Practical Nurse) Inside the medication room the following narcotic medication were found: R232, R233, R73 Lorazepam 2MG per ML. V6 stated that R232 and R233 are not in the facility because they were already expired. V6 was asked how nursing staff account for these narcotics since during review of narcotics it was not found on both narcotic books. V6 said that these narcotics should have been discarded. And that he (V6) in his experience does not…

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, interviews, and review of records the facility failed to follow their policy for storage of medications for 2 out of 3 medication carts and 1 out of 2 medication room for not dating insulin for 1 resident (R40). Failed to maintain medication cart free from expired insulin medication for 1 resident (R31). Failed to lock refrigerator that contains narcotic medication for 3 residents (R73, R232, R233). These failures have the potential to affect 35 residents on the 3rd Floor and 1 resident (R31) on the 2nd Floor receiving insulin. Findings include: On [DATE] at 10:40 AM. V6's (Licensed Practical Nurse) medication cart was reviewed. R40's Insulin Aspart that was opened did not have any date written. V6 said, Yea, it is open. I think who ever open this insulin forgot to place open and expiration date. It should have been dated. On [DATE] at 11:21 AM. With V6 in the Medication Room was reviewed, there was a refrigerator that had padlock hanging and was not locked. V6 stated that the padlock does…

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 ensure the appropriate use of personal protective equipment (PPE) worn by visitors while visiting a resident (R55) with an infectious disease. This failure had the potential to affect all ten residents residing on the first floor of the facility. Findings include: On 12/06/2022 at 11:14am, surveyor observed V12 (Case Manager) sitting in a chair inside of R55s' room. V12 observed inside of R55s' room without gloves or a gown on. On 12/06/2022 at 11:14am, surveyor observed sign outside of R55s' room door that read Contact Isolation, prior to entering rooms, clean hands, wear gown, wear gloves eye protection, and clean hands after leaving the room. Surveyor also observed an isolation cart located outside of R55s' room with gowns and gloves inside of the cart. On 12/06/2022 11:16am, V12 observed exiting R55s' room and did not perform hand hygiene upon exiting R55s' room. V12 stated I do not work here and this is my first time coming here. I do not know why R55 is on isolation and no one told me R55s' status 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 interviews and record reviews, the facility failed to provide an escort to assist a resident (R68) to outside appointments for 1 of 1 resident reviewed for appointments in a total sample of 18 residents. Findings include: R68's face sheet documents in part medical diagnoses that include but are not limited to interstitial pulmonary disease, malignant neoplasm of stomach, chronic obstructive pulmonary disease, and monoclonal gammopathy. On 12/06/22 at 10:53 AM, surveyor entered R68's room for an interview. R68 was oriented to person, place, and time. R68 stated [R68] missed a few appointments to outside physicians' services because staff can't find an escort to take [R68]. R68 stated [R68] is not allowed to go to the appointments on own. R68 stated staff repeatedly reschedules [R68's] appointments because of escort issues. R68 stated [R68] was supposed to go to an appointment this week but staff rescheduled it again. On 12/06/2022 at 10:56 AM, V6 (Nurse) stated R68 was supposed to go out on appointment yesterday but did not go. V6 stated I informed [V1 (Administrator)] about…

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

Based on observations, interviews, and record reviews, the facility failed to replace R39's wheelchair in a timely manner and ensure R72's call light was within reach affecting 2 of 18 residents reviewed for accommodation of needs. Findings include: On 12/06/2022 at 11:24 AM, surveyor entered R39's room for interview. Observed R39's wheelchair with multiple rips and tears. Left hand rest with two large tears exposing the foam underneath. There was a missing left side panel underneath the armrest. R39 also had a specialized cushion on the wheelchair with tears. R39 was alert and oriented to person, place, and time during the interview. R39 stated the facility is supposed to get [R39] a new wheelchair but staff have been saying that for months. On 12/07/2022 at 9:55 AM, R39 stated facility told [R39] around August that they were going to provide R39 with a new wheelchair. R39 stated the left armrest started ripping a few months ago. R39 stated facility already replaced the armrest before but they need to replace it again. On 12/07/2022 at 11:24 AM, V14 (Restorative Nurse/MDS, Minimum…

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, interviews and record review of records the facility failed to follow policy on restraint for 2 of 2 residents (R4 and R27) for a total of 18 reviewed for restraint use. Findings include: R4 was [AGE] years old, with medical diagnosis of hemiplegia affecting left dominant side. R4's brief interview for mental status dated 10/4/2022 was 2. That means R4's cognitively impaired. On 12/06/2022 at 12:25 PM. R4 was seen sitting in his wheelchair, R4 had a light brown helmet that covered up the ears area. R4 was wearing it while being in the dining room. R4 unable to be interviewed due to not responding to questions when asked. V3 (Acting Director of Nursing/Nurse Consultant) was informed by surveyor that upon review of R4'2 medical records, no assessment was seen to determine if the helmet R4 was using was restraining him because it might cover both of his ears and impede his hearing. V3 stated she will review and will provide restraint assessment if available. On 12/07/2022 at 10:02 PM. Per V3…

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, interviews and review of records the facility failed to follow policies for 2 out of 2 residents (R27 and R30) for a total number of 18 residents reviewed for enteral feeding. Failures include 1 resident (R27) Gastrostomy Tube patency check for administering medication was not checked. And failed to determine the need for a Gastrostomy Tube of 1 resident (R30). Findings include: On 12/07/2022 at 08:40 AM. R30 was not reviewed for medication administration via Gastronomy Tube because V6 (Licensed Practical Nurse) informed writer that R30 takes his medication and food by mouth and not via Gastronomy Tube (G Tube). V6 said, We give R30's medicine by mouth. He (R30) takes food and medication by mouth. But he (R30) still has his G Tube (Gastrostomy Tube). At 08:45 AM with V29 (Licensed Practical Nurse) in lieu of R30 was observed administering medication for R27 via Gastrostomy Tube. Before administering medication V29 did not checked R27 for patency. Then using a syringe, V29 mixed the medications with water and administered it to R27via Gastrostomy Tube. At 10:45…

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 call light for 1 (R22) of 6 residents reviewed in a total sample of 18 for call lights. Findings include: On 12/6/22 at 11:13 AM, observed R22 lying in bed with no call light within reach and no call light cord or hardware in the electrical socket or switch with cord attached on the walls for R22's bed. V8 (Infection Preventionist) acting as interpreter to conduct interview with R22. R22 stated that he (R22) uses the call light when he (R22) has access to it. R22 stated that he (R22) could not see a call light during the time of the interview and stated that since there was no call light available, he (R22) would have to call out for the nurse to get help. On 12/6/22 at 11:16 AM, V8 stated that she (V8) did not see a call light for near R22 to use and that there was no call light for R22 attached to the wall. V8 stated that V8 should have a call light in place for him to use. V8 stated that the potential problem with R22 not having…

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.