Avalon Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice by failing to ensure fluid restrictions were followed and implemented as ordered for 1 (#3) of 1 sampled residents who were reviewed for dialysis. Findings: Review of the medical record revealed resident #3 was admitted on [DATE]. Her diagnoses included end stage renal disease, hypertensive heart disease and unspecified psychosis. Review of the October 2024 physician orders revealed the resident received dialysis on Monday, Wednesday and Friday and had a 1000 cc fluid restriction. There was no documentation in the medical record that resident #3's fluid intake was being monitored. On 10/15/2024 at 1:55 p.m., interview with S5Certified Nurse Aid (CNA) revealed she worked in the memory care unit where resident #3 resided. S5CNA reported they did not keep a fluid intake log for resident #3. On 10/25/2024 at 2:15 p.m., interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to the installation of bed rails for 4 (#5, #12, #17, and #38) of 5 (#5, #12, #17, #38 and #52) residents reviewed for bed rails. Findings: Review of the facility's undated Physical Restraints, Side Rails policy revealed: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines 3. As assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails, when used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are…

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 of medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 10.71% medication error rate with 3 medication errors out of 28 opportunities. Findings: Resident #43 An observation of the medication administration for resident #43 on 10/15/2024 at 8:33 a.m. with S4Licensed Practical Nurse (LPN) revealed S4LPN administered Furosemide 20 milligrams (mg) 1 tablet by mouth and administered Gabapentin 100 mg 1 capsule by mouth. Review of the October 2024 Physician's orders for resident #43 revealed the following orders: 02/13/2024 Gabapentin 300 mg capsule by mouth 2 times per day (BID) at 9:00 a.m. and 5:00 p.m; and 09/23/2024 Furosemide 40 mg tablet: take 1 tablet by mouth (40 milligrams total dose) at 8:00 a.m. every Tuesday, Thursday, Saturday, and Sunday. An interview on 10/15/2024 at 1:30 p.m. with S2Assistant Director of Nursing (ADON) confirmed that S4LPN should have administered Furosemide 40 mg by mouth and Gabapentin 300 mg by mouth to resident #43…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 3 (#18, #28, and #35) of 3 (#18, #28, and #35) residents reviewed for enhanced barrier precautions. Findings: Review of the Enhanced Barrier Precautions (EBP) policy and procedure dated 04/01/2024 revealed the following in part: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: -colonization with a Center for Disease Control and Prevention (CDC)- targeted Multidrug-resistant organism (MDRO) when Contact Precautions do not otherwise apply; or -wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Indwelling medical devices examples include central lines, urinary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure 1) the resident's representative was notified after resident #69 had a fall, and 2) staff notified the nurse when resident #6 was found to have bruises for 2 (#6 and #69) of 2 residents reviewed for notification of change. Findings: Review of the facility's Change in a Resident's Condition or Status Policy undated revealed: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). Resident #69 Review of the medical record for resident #69 revealed an admission date of 06/25/2024 with diagnoses including pulmonary edema, hypertension, dementia, muscle weakness, and cerebral infarction. Review of the current 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#25, #52 and #70) of 3 residents reviewed for restraints. The facility failed to have documented evidence of monitoring the release of the lap trays for residents #25, #52 and #70 and failed to have physician orders for the lap trays for residents #25 and #70. Findings: Review of the facility's Use of Restraints policy and procedure, revised December 2007, revealed the following, in part: Policy Interpretation and Implementation 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e., side rails put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman for 1 (#12) of 1 (#12) reviewed for hospitalizations. Findings: Review of the Emergency Transfer Logs for June 2024 and July 2024 revealed resident #12 was discharged to the hospital on the dates of 06/23/2024 and 07/17/2024. Further review revealed there was no documented evidence of the Ombudsman being notified of resident #12 being transferred to the hospital on [DATE] and 07/17/2024. On 10/16/2024 at 5:12 p.m., during a telephone interview with the local Ombudsman assigned to the nursing facility, she confirmed that she had not been notified of resident #12's transfers to the hospital on the dates of 06/23/2024 and 07/17/2024. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator 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 record reviews and interview, the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 2 (#25 and #27) of 2 residents sampled for Minimum Data Set (MDS) Assessments. Findings: Resident #25 Review of resident #25's record revealed an admission date of 09/01/2017. Further review of the record revealed the resident's last Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 06/25/2024 and no documented Quarterly MDS for resident #25. Resident #27 Review of resident #27's record revealed an admission date of 08/31/2021. Further review of the record revealed the resident's last Quarterly MDS Assessment with ARD of 06/04/2024 and no documented Quarterly MDS for resident #27. An interview on 10/16/2024 at 7:45 a.m. with S2Assistant Director of Nursing (ADON) confirmed that the Quarterly MDS Assessments for resident #25 and resident #27 were not completed within 3 months of the previous Quarterly MDS Assessments.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 (#72) of 3 (#72, 73, 74) residents selected for closed record reviews. Findings: Review of the discharge Minimum Data Set (MDS) assessment for resident #72 revealed the resident was discharged to the hospital on [DATE]. Review of the nurse's notes revealed resident #72 was discharged to home. On 10/16/2024 at 4:05 p.m., an interview with S2Assistant Director or Nursing confirmed the resident was discharged home. On 10/16/24 at 4:15 p.m., an interview with S6Licensed Practical Nurse confirmed the MDS incorrectly indicated resident #72 was discharged to the hospital rather than to home.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's needs by not having documentation of the character of urine every shift for 1 (#18) of 1 residents reviewed for urinary catheters. Findings: Review of the Catheter Care Urinary Policy and Procedure updated 01/12/2024 revealed the following in part: Documentation The following information should be recorded in the resident's medical record: 1. Date and time catheter care was given. 2. The name and title of the individual giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. Review of resident #18's medical record revealed an admission date of 09/03/2024 with diagnoses including urinary retention, fibromyalgia, hypertension, paroxysmal atrial…

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, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 (#52) of 5 (#6, #28, #30, #52, and #67) residents investigated for activities of daily living. The facility failed to ensure resident #52's fingernails were kept trimmed. Findings: Review of the Care of Fingernails/Toenails Policy (Undated), included the following, in part: General Guidelines: 1. Nail care includes daily cleaning and regular trimming. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given 2. The name and title of the individual(s) who administered the nail care 3. The condition of the resident's nails and nail bed, including: a. Redness or irritation of skin of hands and feet 6. If the resident refused the treatment, the reason(s) why and the intervention taken 7. The signature and title of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure that a resident with limited range of motion receives appropriate treament and services to increase range of motion and /or to prevent further decrease in range of motion for 1 (#52) of 1 residents reviewed for Position/Mobility. The facility failed to ensure hand rolls were provided for resident #52's hand contractures. Findings: Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including dementia without behavioral disturbance, schizophrenia, mood affective disorder, anxiety disorder, and pseudobulbar affect. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed resident #52 had a documented brief interview for mental status score of 99 which indicated the resident had severe cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #52 had limitation in range of motion to her upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor edema for a resident who received a diuretic for 1 (#17) of 5 (#17, #35, #38, #52, and #68) residents reviewed for unnecessary medications. Findings: Review of the medical record for resident #17 revealed an admit date of 08/26/2022 with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness and anemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #17's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition for daily decision making. Resident #17 required assistance with activities of daily living. Review of the current care plan revealed the resident had the potential for hypertension /hypotension related to medication use. The interventions were to monitor blood pressure, administer medications as ordered and obtain labs and diagnostic tests as ordered.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 5 (#4, #49, #57, #80 and #82) of 6 (#4, #7, #49, #57, #80, and #82) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for side effects for residents #4, #49, #57, #80 and #82 while receiving psychotropic medications. Findings: Resident #4 Review of the Facility's Behavioral Assessment, Intervention and Monitoring Policy revealed in part: The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, and or recurrent falling. Review of the facility's Pharmacy Services: Medication Regimen Review (MRR) Policy and Procedure revealed in part: 5. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 2 (#4 and #80) of 6 (#4, #7, #49, #57, #80, and #82) sampled residents reviewed for unnecessary medications. The facility failed to monitor resident #80 for edema while receiving a diuretic and failed to monitor lab for resident #4 while taking Keppra and Divalproex. Findings: Resident #4 Review of the record for resident #4 revealed an admission date of 06/24/2022 with diagnoses including other seizures, bipolar disorder, hypertension, hyperlipidemia, depression, unspecified dementia, blindness both eyes, and metabolic encephalopathy. Review of the current Physician's Orders for resident #4 revealed the following: 08/29/2022- Divalproex Sodium DR 250 milligram tablet give 1 tablet by mouth 3 times per day (seizures) 09/02/2022- Keppra 500 milligram tablet give 1 tablet by mouth 2 times per day (seizures) Further review of the Physician's Orders revealed no order for monitoring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure that each resident was free from unnecessary medication use for 5 (#4, #49, #57, #80 and #82) of 6 (#4, #7, #49, #57, #80, and #82) residents reviewed for unnecessary medications. The facility failed to monitor side effects for residents #4, #49, #57, #80 and #82 that received psychotropic medications. Findings Resident #82 Review of the Facility's Behavioral Assessment, Intervention and Monitoring Policy revealed in part: The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, and or recurrent falling. Review of the medical record for resident #82 revealed an admission date of 04/27/2023 with diagnoses including vascular dementia, encephapathy, hypertension, depression, Alzheimer's disease, heart disease, hyperlipidemia, and hypothyroidism. Review of the current Physician's Orders for resident #82 revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance wtih professional standards for food service safety by storing resident and staff's personal belonging in the kitchen food preparation and supply storage areas. Findings: During a tour of the kitchen on 10/09/2023 at 8:15 a.m., an observation revealed one large rolling cart that was located near to 7DM (Dietary Manager's) office. Observation of the inside of the cart revealed there a Christmas [NAME], 3 individual packages of table clothes, one thirty ounce bottle of old spice body wash, three bars of old spice soap, one ten ounce bottle of men's care exfoliating deep cleanser, and one seven ounce can of equate shaving gel. Further observation revealed one pair of tennis shoes and one cell phone that were sitting the tops of storage containers that was located in a small section of the kitchen and was designated supplies for food services. S7DM confirmed the items should not have been strored in…

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

Based on record review and interview the facility failed to coordinate and evaluate activities under the Quality Assessment and Assurance QAA / Quality Assurance Performance Improvement (QAPI) program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary. Findings: Review of the facility's Quality Assurance binder revealed there was no documented evidence the facility addressed issues or concerns identified on a quarterly basis. Further review of the binder revealed no documented evidence of minutes from the April, July and October 2023 quarterly meetings. On 10/11/2023 at 4:15 p.m., an interview with S1Administrator revealed he only had sign in sheets for the April, July, and October 2023 QA (Quality Assurance) meetings and did not have any meeting minutes or any documentation of tracking, trending or QAPI issues the facility addressed during the April, July, and October quarterly meetings.

Based on observation and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition, by having a grease build-up on the internal components of the deep fryer. Findings: On 10/09/2023 at 8:15 a.m., an observation revealed one large gas deep fryer located in the kitchen. Observation of the deep fryer revealed a grease build-up on the internal components that were housed inside of the fryer's lower compartment. S7Dietary Manager was present during the observation and confirmed that the fryer was a gas operated fryer. She further confirmed the deep fryer was not in safe operating condition due to the grease build-up on the internal components of the fryer. On 10/11/2023 at approximately 9:40 a.m., S1Administrator was notified of the above findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#18) of 2 (#8, #18) residents reviewed for limited range of motion. The facility failed to ensure staff placed a splint device to resident #18's contracted right hand. Findings: Review of the medical record for sampled resident #18 revealed an admission date of 06/08/2022 with diagnoses of diabetes mellitus, hypertension, spastic hemiplegia, right hand contracture and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired and needed assistance with activities of daily living. Further review of the Minimum Data Set revealed documentation of functional limitation of upper extremity on one side. On 10/09/2023 at 1:10 p.m., observation revealed resident #18 had a contracture to the right hand…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the provider failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical specialist of laboratory results that fall outside of clinical reference ranges for 1 (#1) of 1 (#1) residents who received seizure medications. Findings: Review of resident #1's medical record revealed a physician's order dated 05/13/2023 for Dilantin 100 milligrams; give one capsule by mouth every a.m. at 9:00 a.m. Further review revealed a second order dated of 05/13/2023 for Phenytoin (Dilantin) 100 milligrams; give one capsule by mouth at bedtime every day at 9:00 p.m. Review of a hand written physician's order dated 09/26/2023 revealed an order to increase Dilantin to 200 milligrams every p.m. and 100 milligrams every a.m. Further review revealed a second order to check a Dilantin level in one week. Review revealed diagnosis as history of seizures and recent seizure activity. Review of the medical record further revealed a laboratory final 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.