Pavilion Of South Shore

Based on observation, interview and record review, the facility failed to follow plan of care and physician order to apply hand roll or splint on right hand for 1 (R29) resident. This failure could potentially affect 1 (R29) resident reviewed for range of motion in a sample of 23. The findings include: R29's admission record documented initial admission date on 12/3/18 with diagnoses not limited to Chronic obstructive pulmonary disease with (acute) exacerbation, Dysarthria following cerebral infarction, Ataxia following cerebral infarction, Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Unspecified osteoarthritis, Age-related osteoporosis without current pathological fracture, Foot drop right foot, Chronic kidney disease stage 3, Essential (primary) hypertension. On 2/4/25 at 11:03 AM Observed R29 sitting up on wheelchair in the dayroom, alert and verbally responsive, right hand contracted, fist closed, no device in placed. On 2/5/25 At 1:01pm V2 (Director Of Nursing/ DON) stated splint / any device should be applied as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that smoking materials (cigarette and lighters) were kept by staff for safety. This failure could potentially affect 3 (R28, R84, R93) residents reviewed for smoking in a sample of 23. The findings include: R28's admission record showed admission date on 11/7/2023 with diagnoses not limited to Interstitial pulmonary disease, Unspecified asthma, Chronic obstructive pulmonary disease, Anemia, Essential (primary) hypertension. MDS (Minimum Data Set) dated 11/6/2024 showed R28's cognition was moderately impaired. R84's admission record showed admission date on 7/31/2023 with diagnoses not limited to Unilateral primary osteoarthritis right hip, Anemia, Pain in right lower leg, Pain in left lower leg, Opioid dependence. MDS dated [DATE] showed R84's cognition was intact. R93's admission record showed admission date on 3/4/2024 with diagnoses not limited to Type 1 diabetes mellitus with hyperglycemia, Essential (primary) hypertension,…

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 oxygen use and no smoking signage was posted on a resident's (R213) door who's on continuous oxygen, failed to date humidifier bottle for oxygen concentrator and nebulizer mask for 1 (R71) resident, and failed to follow physician order for oxygen liter flow and provide humidification for continuous use of oxygen for 1 (R28) resident out of 3 residents reviewed for respiratory care in a final sample of 23. Findings Include: On 2/04/25 at 11:24 AM, R213's sleeping in bed observed on oxygen at 3 liters per minutes (LPM) via nasal cannula. Surveyor did not observe oxygen in use and no smoking signage posted on R213's door or over R213's bed. On 2/05/25 at 11:22 AM, R213's lying in bed alert and able to verbalize needs. R213 was using oxygen via nasal cannula set to 3 LPM. R213 stated that [R213] has heart failure and [R213's] oxygen saturation goes down at times. There was no oxygen in use and no smoking signage posted on R213's door or…

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 assess the risk versus benefits of using a bed rail and review them with the resident prior use, and failed to implement person-centered comprehensive care plan addressing the use of the bed rail. These failures have the potential to affect 1 (R213) out of 4 residents reviewed for bed rails in a final sample of 23. Findings Include: On two separate occasions on 2/04/25 at 11:24 AM and on 2/05/25 at 11:22 AM, R213 was observed resting in bed and noted with one full bed rail up on the right side of R213's bed. On 2/05/25 at 1:50 PM, interviewed V14 (Restorative Licensed Practical Nurse) and stated that restorative does the residents' bed rail assessments, and they need to be completed before using the bed rail. V14 stated that the purpose of the bed rail assessment is to determine the need for use of bed rails prior to use. V14 stated [V14] will first explain to the resident or representative what rails are used for and the complications.…

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 assess eligibility and offer pneumococcal vaccine to three (R39, R48, R72) of five residents reviewed for pneumococcal immunization. These failures had the potential to affect 3 (R39, R48, R72) residents eligible to receive the Pneumococcal vaccinations in a sample of 23. The findings include: 1. R39's admission record showed admission date on 5/19/2020 with diagnoses not limited to End stage renal disease, Malignant neoplasm of prostate, Cardiac tamponade, Hypothyroidism, Secondary malignant neoplasm of bone, Malignant neoplasm of colon, Secondary malignant neoplasm of liver and intrahepatic bile duct, Secondary malignant neoplasm of unspecified lung, Essential (primary) hypertension, Dependence on renal dialysis. R39's MDS (Minimum Data Set, dated [DATE] showed cognition was intact. MDS showed Pneumococcal vaccine was not up to date. Reviewed R39's immunization record, no documentation found for pneumococcal vaccine. R39's Covid-19 vaccine consent…

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 follow facility's policy and procedure, the facility failed to assess eligibility and offer covid-19 vaccine to three (R39, R48, R72) of five residents reviewed for covid-19 immunization. These failures had the potential to affect 3 (R39, R48, R72) residents eligible to receive the covid 19 vaccinations in a sample of 23. The findings include: 1. R39's admission record showed admission date on 5/19/2020 with diagnoses not limited to End stage renal disease, Malignant neoplasm of prostate, Cardiac tamponade, Hypothyroidism, Secondary malignant neoplasm of bone, Malignant neoplasm of colon, Secondary malignant neoplasm of liver and intrahepatic bile duct, Secondary malignant neoplasm of unspecified lung, Essential (primary) hypertension, Dependence on renal dialysis. MDS (Minimum Data Set, dated [DATE] showed R39's cognition was intact. MDS showed R39's covid vaccination was not up to date. Reviewed R39's immunization record, no documentation found for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the call lights of residents are accessible as stated in the care plans. This failure has the potential to affect 2 residents ( R1 and R2). Findings include: On 12/4/24 between 10:10am and 11:05am during observation on the third floor, the following were observed: At 10:18am, R1 was observed in bed with call light not accessible. The surveyor asked R1 if R1 knows how to use the call light to call staff for help, R1 stated that he tries to use the call light. R1 looked up and down the side of the bed and there was no call light within reach. The surveyor asked V5(CNA/Certified Nurse Assistant) V5 to help R1 find the call light. V5 looked behind the bed and stated, It's on the floor. At 10:50am, R2 was observed sitting on the edge of the bed in the room and looking and trying to bend towards the wall where the call light was supposed to be. The surveyor asked R2 for the call light and R2 stated I don't see it. The surveyor…

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 the fall prevention interventions as stated in the care plans for residents with diagnoses of Dementia who are also at risk for falls. This failure has the potential to affect two residents (R3 and R4) reviewed for proper footwear as a fall prevention intervention. Findings include: On 12/4/24 between 10:10am and 11:05am during observation on the third floor, the following were observed: At 10:25am, R3 was observed sitting in the wheelchair in the day room with white socks that are smooth on the bottom. The surveyor notified V3 (Assistant Director of Nursing/ADON) who confirmed the resident's name. V3 stated I will find non-skid socks for him. This is not okay for fall prevention. At 10:55am, R4 was observed in the room sitting in the wheelchair with blue socks that are smooth on the bottom. V6(CNA/Certified Nurse Assistant) was notified. V6 stated I will ask the ADON for the non-skid socks. The socks need to grip to prevent…

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 provide transportation for a resident (R1) who required daily methadone clinic visits. This failure affected one of three residents reviewed for quality of care. Findings include: R1's face sheets shows that R1 admitted to the facility on [DATE] R1's progress note dated May 24, 2024, authored by V5 (Social Service Director) documents in part that R1 discharged from the facility Against Medical Advice (AMA) on May 24, 2024. R1 has a diagnosis which include but not limited to opioid dependence, uncomplicated, psychoactive substance abuse, depression, and chronic diastolic congestive heart failure. R1's Minimum Data Set (MDS) dated [DATE] shows that R1 did not have a Brief Interview for Mental Status score and indicated that R1's memory was ok. R1's hospital record Physician Order Sheet (POS) dated 05/18/24 shows that R1 has orders to receive Methadone HCl Oral Tablet 10 MG by mouth starting May 19, 2024. On 06/11/24 at 11:03 am, V2 (Director of Nursing,…

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 a.) ensure food items were labeled and dated per facility policy, b.) discard expired and/or rotten foods, c.) keep food storage areas clean, d.) conduct hand washing in between handling dirty and clean plateware/equipment. These failures have the potential to affect all 110 residents receiving food prepared in the facility's kitchen. Findings include: On 04/16/24 at 9:18 AM, during initial kitchen tour V5 (Dietary Manager) stated all food items need to be labeled with a in date or delivery date, an open or prepared date and a use by date or expiration date. Depending on what the food is determines its expiration or use by date. V5 pointed to a documented posted outside the walk-in cooler and stated that piece of paper has the use by dates on it organized by the item. V5 stated it is the responsibility of the staff member who puts the item in the cooler to label and date the item and it is V5's responsibility to monitor expiration dates and throw out any expired or items beyond the use by date. V5 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to follow their policies and procedures to (a) ensure there was signage outside of the resident's (R74) room indicating Enhanced Barrier Precaution (EBP); (b) provide readily available personal protective equipment (PPE) supplies outside of the resident's (R74) room; (c) use PPE in isolation rooms (R74, R28, R85, R410); (d) maintain infection control practices during medication administration (R4, R93, R105); (e) ensure a resident's (R85) urinary catheter bag remained off the floor; and (f) contain soiled linens in sealed bags during transport. This has the potential to affect 111 residents residing in the facility. Findings include: R85's physician order sheets (POS) documents in part: Single Room Strict Contact Isolation for (ESBL [Extended-spectrum beta-lactamases], Herpes) (ordered 04/09/2024), resident on enhance barrier precautions due to [history of] ESBL, [urinary] Catheter (ordered 04/05/2024), and [urinary] catheter care every…

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 follow standards of professional practice to maintain resident dignity by standing over four residents (R7, R22, R57, R91) during feeding assistance out of a sample of 26 total residents. Findings: On 04/17/24 at 8:54 AM, R57 was observed sitting in his wheelchair in his room. V29 (CNA) was observed standing next to wheel chair feeding R57 breakfast. On 4/18/2024 at 12:42 PM, V16 (CNA) was observed standing in the room of R57 with his lunch tray in front of R57 giving R57 liquid from a cup. On 04/16/24 at 12:35 PM, V16 (CNA) was observed standing over R22 while V16 assisted R22 with eating lunch. On 04/18/24 12:38 PM V29 (CNA) was observed standing over R91 feeding him lunch. When surveyor asked the resident's name, V29 provided the name and stated I'm helping him because he has trouble with his vision. Policy titled Resident Rights dated 12/2012 and revised 11/2013, 4/2014 and 4/2017 states in part: Policy Statement: Employees shall treat…

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 follow facility policy by not providing residents going to dialysis during mealtimes with a sack lunch for four (R29, R40, R45, R101) out of four residents reviewed for dialysis services in a sample of 26. Findings include: On 04/16/24 at 11:30 AM, R45 stated R45 goes out to dialysis three times a week on Monday-Wednesday-Friday. R45 stated they don't send me to dialysis with a meal or snack. R45 stated R45 usually leaves the facility at 10:00 AM and returns between 4:30-5:00 PM. R45 stated on dialysis days R45 eats breakfast and dinner at the facility. R45 stated R45 does not eat lunch or anything in between breakfast and dinner on dialysis days because the facility does not send him to dialysis with a sack lunch or snacks. R45 stated by the time R45 returns to the facility after dialysis it is time for dinner. R45 complains about being hungry on dialysis days because R45 eats breakfast around 8:00 AM and then does not consume anything…

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 the facility [A] failed to label individual resident's insulin medications with an open date, [B] failed to dispose expired insulin, [C] failed to refrigerate unopened insulin in 3 of 5 medication carts reviewed for medication storage and labeling in a sample of 26. On 4/16/23 at 9:22 AM, V18 [Licensed Practical Nurse] and surveyor conducted inventory of the third-floor medication cart, observed the following: R72's [1] Open Novolog Flex Pen was opened and used, no open or expiration date. [2] Open Lantus insulin pen with an open date of 3/14/24, expiration date of 4/12/24, and [3] Open [NAME] pen with no open date. R72's physician orders: 12/14/23-Novolog Solution 100 units/ml, inject 10units three times per day. 9/6/22-Lantus Solution 100 unit/ml, inject 25 units at bedtime. R2's [1] Unopened Levemir Flex Insulin Pen read on the package Refrigerate Until Open. [2] Insulin Aspart Flex Insulin Pen with open date of 3/7/24, expiration date of 4/7/24. R2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to determine self-administration of medication was appropriate for three (R5, R57, R69) out of three residents observed with medication at bed side in a sample of 26. Findings Include: On 04/16/24 at 10:41 AM, surveyor entered R69's room and observed one medication in a medication cup on R69's bed side table. R69 stated the nurse left the medication on R69's table this morning, but R69 does not want to take the medication. At 10:45 AM, R69 triggered the call light, and V30 (Registered Nurse/RN) entered R69's room, V30 picked up the medication, V30 identified the medication as Colace 100 MG capsule administered at 9:00 AM. V30 stated V30 usually stay with R69 to ask if R69 wants the medication, but V30 did not ask R69 today because V30 went out of R69 to attend to other residents. V30 stated V30 should have stayed with R69 to take medication and that the medication should not have been left on R69's bed side table. R69's Minimum Data Set (MDS)…

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

Based on observations, interviews, and record reviews, the facility failed to place a resident's (R410) call light in a position that allowed the resident to utilize it for one out of a total sample of 26 residents reviewed for call lights. Findings include: R410's comprehensive care plan documents in part that R410 has Activities of Daily Living (ADL) self-care performance deficit due to paraplegia (paralysis of the lower body) and multiple diagnoses (initiated 04/25/2023). R410's care plan also documents in part that R410 is at risk for falls related to multiple diagnoses (initiated 07/17/2023). Interventions initiated 07/17/2023 documents in part: Call light in reach and answer in a timely fashion. On 04/16/2024 at 10:37 AM, R410 was alert and oriented to person, place, and year. R410 laid in bed which was the furthest from the hallway. R410 was laying towards right side with a pillow under right forearm. R410 had contracted hands. R410 stated I'm burning up and asked the surveyor to remove R410's blankets. R410 stated uses call light to call staff but cannot reach it. Call light…

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 reviews, the facility failed to ensure the low air loss mattress was available for 1 (R74) resident with Stage IV pressure ulcer and failed to ensure the low air loss mattress was in the correct setting for 1 (R56) resident. These failures affected 2 (R56 and R74) of 2 residents reviewed for pressure ulcer in a sample of 26. The findings include: R74's health record documented admission date on 9/8/2021 with diagnoses not limited to Multiple sclerosis, Pressure ulcer of sacral region stage 4, Dementia in other diseases classified elsewhere, Bipolar disorder, Cannabis abuse, Other psychoactive substance abuse, Strange and inexplicable behavior, Major depressive disorder, Delusional disorders, Insomnia, Anemia. On 4/16/24 at 12:41pm Observed R74 sitting on the side of the bed, alert and verbally responsive. R74 stated he has wound on his bottom and not sure how he got it. He said he has a wound when he was admitted to the facility. R74 had no air mattress in place. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the left-hand splint and left AFO (Ankle Foot Orthosis) were in place. These failures affected 2 (R38 and R54) residents reviewed for limited range of motion in a sample of 26. The findings include: R38's health record documented admission date on 12/15/2020 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Aphasia following cerebral infarction, Personal history of covid-19, Chronic fatigue, Multiple and bilateral precerebral artery syndromes, Repeated falls, Rhabdomyolysis, Hereditary and idiopathic neuropathy, Ataxia, Major depressive disorder, Essential (primary) hypertension, Alcohol abuse, Cannabis use, Hyperlipidemia. R54's health record documented admission date on 12/15/2019 with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Unspecified chronic bronchitis, Low back pain, Age-related…

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, interview, and record reviews, the facility failed to ensure fall precautions were in place for a resident (R18) at risk for falls for one out of a total sample of 26 residents. Findings include: R18's Fall Risk Evaluation dated 02/06/2024 documents in part that R18 is at risk for falls. R18's comprehensive care plan documents in part that R18 is at risk for falls/accidents related to medical complexities, impaired mobility, and multiple medications (initiated 08/08/2023). R18 had an unwitnessed fall on 02/04/2024. Interventions to prevent further falls document in part: floor mats down while resident is in bed (initiated 02/05/2024) and Resident's bed at the lowest position at all times (initiated 02/05/2024). On 04/16/2024 at 10:13 AM, R18 was lying in bed. There were large, blue, floor mats to each side of the head of the bed. The one on the left side of R18 was folded in half and not laid flat. The one on the right side of R18 was folded in half and standing on its side-not laid flat on the floor next to R18's bed. On 04/17/2024 at 10:20 AM, V24 (Certified…

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 place oxygen cannula tubing in a bag when not in use for one (R103) resident of three residents reviewed for respiratory care in a sample of 26. Findings include: On 04/16/24 at 11:48 AM, observed in R103's room oxygen cannula tubing attached to R103's oxygen concentrator hanging across the top of the concentrator. Cannula oxygen tubing was not stored in a bag or covered in anyway. The oxygen concentrator was not turned on and R103 was not in R103's room at this time. On 4/16/24 at 11:57 AM, observed R103 sitting on R103's bed. Next to R103's bed was R103's wheelchair with a portable oxygen tank on the back with oxygen cannula tubing attached and draped over a pole coming from the portable oxygen tank. The oxygen cannula tubing attached to the portable oxygen tank was not stored in a bag or covered in anyway. Observed R103 wearing the oxygen cannula tubing attached to the oxygen concentrator which was infusing oxygen at two liters 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.

Based on interviews and record reviews the facility failed to obtain medication consents and care plan for the use of an antidepressant for R85, in a total sample of 26. Findings include: R85's face sheet documents in part an admission date of 01/20/2023. R85's physician order sheets (POS) documents in part an order for Nortriptyline HCl (hydrochloride) Capsule 10 MG (Milligram) Give 1 capsule by mouth at bedtime for depression. R85's progress notes and Medication Administration Records (MARs) document in part that R85 received the medication since admission. R85's January 2023 MAR documents in part that the first dose was on 01/21/2023. R85's November 2023 MAR documents in part that facility discontinued Nortriptyline on 11/22/2023 and reordered it on 11/29/2023. R85's March 2024 MAR documents in part that the medication was discontinued on 03/21/2024. R85's April 2024 MAR documents in part that it was reordered on 04/02/2024. Surveyor verbally requested R85's psychotropic consents multiple times on 04/18/2024 and via electronic mail on 04/18/2024 at 10:20 AM. Facility provided 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 interviews and record review the facility staff failed to report an elopement and unusual occurance (unscheduled hospitalization) to the Illinois Department of Public Health for 1 (R2) of 3 residents reviewed for reporting. R2 eloped from the facility, was located with the assistance of the local police department , taken to local the hospital and recieved treatment for hypothermia. The facility also failed to follow the facility policies for reporting an accident, incident or unusual occurrence. This deficient practice was evidenced by the following: Findings Include: On [DATE] R2 was observed to be missing from the facility-by-facility staff. R2 was not found after a facility and community search was conducted by the facility. Per facility documentation the Chicago Police department was notified and participated in the community search. R2 was later identified at the Hospital after arriving via EMS (Emergency Medical Services) and admitted with a diagnosis of hypothermia. R2 was admitted to 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, interview and record review the facility failed to ensure that 1 (R3) of 4 residents received treatment and care in accordance with the professional standards of practice, according to the side rail assessment, and the comprehensive person-centered care plan, as evidenced by: Findings Include: R3 has diagnosis not limited to Paraplegia, Asthma, Epilepsy, Insomnia, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Unspecified Lower Extremity, Malignant Neoplasm of Colon, Neuromuscular Dysfunction of Bladder, Schizoaffective Disorder and Long Term (Current) Use of Anticoagulants. R3 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Assist Rail Screening dated 10/23/23 document in part: D. Recommendation: This facility uses assist rails which may be in a horizontal or vertical position. 1. The resident has been assessed and it is recommended to use: 3. Two assist rails. Care plan document in part: Focus: R3 has decreased mobility skills (roll to side) due to Paraplegia. Intervention:…

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 the facility failed to ensure that resident's medications are administered as ordered by the physician. This failure affected two residents (R1 and R2) of seven residents reviewed for quality of care and administration of prescribed medications. Findings include: On 11/14/2023 at 3:00pm V2(Assistant Director of Nursing) presented R2's MARs (medication administration records) and POS (Physician Order Summary Report) to the surveyor, which were reviewed. There were missing entries of nurses' signatures or codes on the MARs for August 2023(8/1/2023 to 8/31/2023), September 2023 (9/1/2023 to 9/30/2023) and October 2023(10/1/2023 to 10/31/2023) for the following dates, times, and medications: 1. 8/17/2023 at 0600 Pantoprazole Sodium Oral Tablet Delayed Release 40mg-Give 1 tablet by mouth one time a day. 2. 8/17/2023 at 0600 Brimonidine Tartrate Ophthalmic Solution 0.2%- Instill 1 drop in both eyes three times a day. 3. 8/19/2023 at 1400 Brimonidine Tartrate Ophthalmic Solution 0.2%- Instill 1 drop in both eyes three times a day. 4. 8/17/2023 at 0600…

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, that facility failed to ensure that one resident (R3) was free from pain, after a suspected unwitnessed fall. This failure affected one of 7 residents reviewed for pain management. Findings include: R3 is [AGE] year old with diagnosis including but not limited to: History of falling, Intervertebral disc degeneration, Cervical disc degeneration, Muscle wasting and atrophy, Ataxic gait and Hypertension. R3 has a BIMS (Brief Interview of Mental Status) score of 3 which indicates severe cognitive impairment. On 11/13/23 during investigation, V2 (Assistant Director of Nursing) said, R3 was discharged after going out to the hospital. She (R3) was complaining of pain and the family requested that she (R3) be sent to hospital for further evaluation. On 11/15/23 at 10:45 AM, V8 (Director of Nursing) said, I was not aware of R3 stating that she had a fall or complaining of pain. Surveyor inquired about the expectations regarding falls and pain management. On 11/15/23 at 10:45 AM, V8…

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 discard food items stored in the walk-in refrigerator and dry storage room by the use-by date; failed to follow proper food storage practices and labeling of food to prevent food-borne illnesses; failed to don a hairnet while in the kitchen; failed to ensure sanitizing buckets had the required amount of sanitizing solution needed for proper sanitizing per the manufacturer's recommendation; failed to ensure cleanliness of kitchen and storage refrigerator and failed to isolate dented cans from non-dented cans to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 113 residents receiving an oral diet in the facility. Findings include: On 03/12/23 at 9:13 am, Surveyor entered the facilities kitchen area. Surveyor observed V17 (Dietary Cook) at the cook station handling foods not wearing a hairnet. At 9:15 am, Surveyor and V17 toured the facilities kitchen with the following observations: Nine Ready Care health shakes observed in the walk-in refrigerator on 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 interview and record review, the facility failed to track, and ensure 100% of staff were vaccinated with Covid vaccine to help prevent the spread of Covid-19 as required by CDC (Centers for Disease Control and Prevention). These failures have the potential to affect all 114 residents in the facility. Findings include: On 03/12/22 at 11:00 am, V1 (Administrator) stated that the official facility census is 114 residents. On 03/12/22 at 1:00 pm, Surveyor requested the facilities staff vaccination matrix from V2 (Director of Nursing, DON). V2 was unable to provide the facilities staff vaccination matrix to surveyor. V2 stated, The Infection Preventionist is out on maternity leave. Surveyor asked V2 to complete the Covid-19 Staff Vaccination Matrix created by the Department of Health and Human Services Centers for Medicare and Medicaid Services. On 03/13/22 at 9:10 am, V2 gave surveyor a copy of employee immunization list with missing documentation for 12 employees. Surveyor inquired if the employees with undocumented Covid vaccinations have any exemptions. V2 stated, 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 observation, interview and record review, the facility failed to provide a resident room identifier outside of 11 resident rooms on the first floor. This failure has the potential to affect all 22 residents residing in the affected rooms. Findings include: On 03/12/23 at 10:27 AM, this surveyor observed 11 out of 18 rooms on the first floor with no signage outside of the door to identify which room it is, or which residents reside in the room. On 03/12/23 at 11:58 AM, another surveyor verified that the following rooms did have a sign with the room number outside the door: 106, 108, 109, 115, 116, 117, 118. Therefore, according to the facility floor plan, the following rooms were missing room identifiers: 100, 101, 102, 103, 104, 105, 107, 110, 111, 112, and 114. On 03/12/23 at 11:38 AM, the surveyor inquired about the missing room number signs. V26 (Maintenance Assistant) stated, They supposedly ordered signs. The surveyor inquired who ordered the signs. V26 stated, The administrator or regional maintenance director. V26 added, They supposed to have them (doors) marked.…

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 residents who depend on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive shaving. This affects four residents (R13, R20, R24, and R106) out of 45 residents reviewed for ADL care and grooming. Findings include: On 03/12/23 at 10:10 am, Surveyor observed R13 in R13's room awake, alert in bed. Surveyor observed R13 ungroomed, unshaved with a facial beard, mustache (hair above upper lip). When R13 was asked when was the last time R13's facial hairs (beard and mustache) were shaved, R13 stated, I (R13) don't remember. I (R13) look rough. The girls (referring to the CNA's) come in when they come in to shave me (R13). On 03/12/23 at 10:12 am, Surveyor observed R24 in R24's room awake, alert in bed. Surveyor observed R24 ungroomed, unshaved with facial beard, mustache (hair above upper lip) and long nasal hairs coming from both nostrils reaching down to R24's beard. R24 was asked when was the last time R24's facial hairs (beard and mustache) and nasal hairs were…

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

Based on observation, interview and record review, the facility failed to ensure incoming and outgoing nurses counted the controlled medications at the end of the shift, failed to maintain an accurate account of controlled medication for 1 (R22) resident, and failed to document administration of as needed controlled medication for 1 (R22) resident. These failures affected 1 resident (R22) reviewed for medication labeling and storage and have the potential to affect all 35 residents in the 3rd floor. Findings include: The (03/12/2023) census in 3rd floor was: 35. On 03/13/2023 at 11:25am, during the medication storage and labeling task with V27 (Licensed Practice Nurse), surveyor observed the (03/2023) Controlled Substance Check form with an entry in column 'Nurse Off' on Date: 13, Time: 3. This observation was pointed out to V27. V27 stated, I (V27) just sign both in and out after I (V27) counted the meds. This surveyor inquired if V27 counted the controlled medications with another nurse. V27 stated, She (V32) was already gone when I (V27) came in. On 03/13/23 at 11:28am, observed…

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 dispose of loose pills in the bottom of 1st floor medication cart, failed to remove expired house stock medications from 1st floor medication cart, and failed to remove expired insulin for 2 residents (R4, R88) residing on the 3rd floor receiving insulin from 3rd floor medication cart. This failure has the potential to affect all 16 residents receiving medication from the 1st floor medication cart and 35 residents receiving medication from the 3rd floor medication cart. Findings: On 3/13/2023 at 11:27am surveyor observed 24 loose pills in the bottom of the medication cart that provides medication for the residents residing in the odd room numbers. At 11:36am surveyor observed 2 bottles of Aspirin 325mg with an expiration date of 2/2023 in the top drawer of the medication cart. On 3/13/2023 at 11:38am V28 (LPN) stated that medication from those bottles should not be given, and those bottles should be discarded. On 3/14/2023 at 1:51pm V2 (DON) stated that it's the 11:00 pm to 7:00 am nurse's responsibility 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 observation, interview and record review, the facility failed to post isolation signs on the door of positive covid residents rooms; failed to have isolation equipment available prior to entering an isolation room, failed to ensure that staff don PPE (Personal Protective Equipment) face mask covering the nose and the mouth for prevention and control of Covid-19, and failed to change and date oxygen tubing and humidification bottle in an effort to prevent the spread of infectious microorganisms including COVID-19. These failures affected five resident (R16, R23, R72, R 213, and R214) and has the potential to affect all 39 residents on the second floor and all 36 residents on the third floor in the facility. Findings include: The (3/12/23) Facility Census was 114. On 3/12/23 at 9:45 am surveyor toured the third floor and noted all staff walking in the hallway and going in and out of resident's rooms with N95 mask on and no eye shields. On 3/12/23 at 9:50 am surveyor observed an isolation cart outside of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure facility handrail on the first floor was firmly secured to the wall. This failure has the potential to affect all 38 residents residing on the 1st floor. Findings include: 3/12/2023 resident census on the first floor was 38. On 3/12/2023 at about 12:05pm surveyor observed the hand railing on the first floor between rooms [ROOM NUMBERS] to be loose, and when touched the screws were visible. On 3/14/2023 at 9:52am V26 (Maintenance Assistant) stated, I tighten up the handrail on the first floor; it was loose. V26, further stated, Yes, the loose handrail on the first floor could be harmful to the residents. On 3/14/2023 at 12:05pm surveyor observed that the handrail between rooms on 111 and 115 was repaired and was no longer loose once this was brought to the attention of V26. Undated Maintenance Service Request documents, in part, 3/14/2023 handrail by RM [ROOM NUMBER] loose. Job description dated 8/2018 titled Maintenance Director…

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 the call light was within reach for two residents (R10, R28). This failure has the potential to affect two residents (R10, R28) in a sample of 45 residents. Findings: R10 is a [AGE] year-old female with a diagnosis of but not limited to Parkinson Disease, Type 2 Diabetes Mellitus with Proliferative Diabetic Retinopathy, Lymphedema, Major Depressive Disorder, Bilateral Primary Osteoarthritis of Knee, Syncope and Collapse and Asthma. R10 has a Brief Interview of Mental Status score of 10 that suggests moderately impaired. On 3/12/2023 at 10:33am surveyor observed R10's call light on the floor underneath the bed not within reach. Surveyor asked R10 if R10 could locate her call light. R10 said, They gave me this new bed, so I don't have the call light anymore. On 3/12/2023 at 10:43am V11 (CNA) stated, The call light is right here on the floor and no, ma'am I (R10) cannot reach it. V11 stated that the call light is supposed to be attached…

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 provide the monthly trust fund allowance to one resident (R77) out of a sample of 45 residents residing in the facility. Findings: R77 is an [AGE] year-old female with a diagnosis of but not limited to Muscle Wasting and Atrophy (Left Shoulder), Hypertensive Heart Disease with Heart Failure, Left Ventricular Failure, Major Depressive Disorder and Anxiety Disorder. R77 has a Brief Interview of Mental Status score of 10 that suggests moderately impaired. On 3/12/2023 at 10:00am R77 stated that she does not get the monthly trust fund benefit and does not know why. On 3/13/2023 at 1:00pm surveyor reviewed the Withdrawal Record (Trust Fund Account) dated 2/15/2023 that does not include R77 as receiving an allowance amount. Trust Fund form for February 2023 does not list R77. Surveyor also reviewed the Trail Balance (Trust Fund Account) as of 3/13/2023 that indicates R77 has a balance and is entitled to an allowance of $30.00. On 3/13/2023 at 2:15pm surveyor…

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 implement pressure ulcer prevention interventions as per resident care plan and failed to provide and document wound treatments as ordered for one resident (R14) with a Stage III pressure ulcer in the total sample of 45 residents. Findings include: On 03/12/23 at 10:57 AM, R14 was observed lying on a regular bed with a standard mattress. The surveyor inquired if R14 had any pressure sores. R14 answered, Yes, I do, and added that she (R14) gets wound care, Once a week. On 3/12/23 at 11:11 AM, the surveyor inquired if R14 has any wounds. V21 (LPN/Licensed Practical Nurse) stated, No. I don't believe she (R14) does. The surveyor requested to see R14's back side which R14 agreed to. V21 and V22 (LPN Orientee) turned R14 to the right side. V21 stated, It looks like she (R14) does have a wound. No dressing was observed over R14's coccyx wound. The surveyor inquired what was on the cloth incontinence pad. V21 stated, Looks like a little discharge. Like blood. The surveyor inquired if R14 was on a standard 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.

Based on observation, interview, and record review the facility failed to provide ordered oral nutritional supplements, for one resident (R213) reviewed for nutrition in a sample size of 45 residents. Finding include R213 has a diagnoses of but not limited to osteoarthritis, malignant neoplasm of stomach, anemia, hypertension, and chronic fatigue. R213's (3/6/23) BIMS (Brief Interview of Mental Status) score is 8 (Moderately impaired). On 3/12/23 at 10:15 am R213 stated that R213 has not been getting any dietary supplement for 2 weeks. R213 stated that the supplement helps R213 get up, walk and give R213 energy. On 3/12/23 at 12:35 pm observed R213 lunch tray with rice, ground meat, carrots, cake, and juice. No dietary supplement noted on R213's tray. R213's diet ticket reviewed, no dietary supplement on R213's diet ticket. On 3/13/23 at 12:25 pm observed R213's lunch tray with chicken broccoli casserole, mash potatoes, fruit cocktail and juice. No dietary supplement noted on R213's tray. R213's diet ticket reviewed, no dietary supplement on diet ticket. R213's order summary report,…

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 residents' call device was functioning to allow resident to call for staff assistance. This failure affected 1 resident (R28) reviewed for functioning resident call device in a total sample of 45 residents. Findings include: On 03/12/2023 at 10:36 AM, R28 was in the room by herself (R28). This surveyor requested R28 to activate the call device. Surveyor checked if the overhead call device indicator was lit. Surveyor observed the overhead call light was not lit. On 03/12/2023 at 10:40am, V10 (CNA) checked R28's call device, per surveyor's request and stated, It is not working. This surveyor inquired how R28 would be able to call for assistance if needed. V10 stated, If the roommate is here, the roommate will be able to call for help, but the (roommate) is not here. On 03/12/2023 at 10:55am, V8 (HK/Laundry/Maintenance Director) checked R28's call device, per this surveyor's request. V8 stated, It is not working. V8 checked the cord and stated, The cord is cut. I (V8) think what happened was, 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.