Landmark Of Rayne

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to esnure: 1. S6TXN (Treatment Nurse) wore proper PPE (Personal Protective Equipment) while providing wound care to Resident #11, and S10CNA (Certified Nursing Assistant) wore proper PPE while providing care to Resident #83 who was on Enhanced Barrier Precautions; 2. S6TXN appropriately removed and discarded soiled PPE; after completing wound care. This deficient practice had the potential to affect a census of 96 residents. Findings: Review of facility policy and procedure titled Enhanced Barrier Precautions (EBP) with a review date of 01/29/25, read in part .enhanced barrier precautions require the use of gown and gloves only for high-contact resident care activities. The following…

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 notify the State Long Term care Ombudsman of facility-initiated transfer for 1 (#7) resident in a final sample size of 33. The deficient practice has the potential to affect a census of 96. Findings: Review of Resident #7's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, epilepsy, hemiplegia and hemiparesis, urinary tract infection, major depressive disorder, anxiety disorder, and abnormalities of gait and mobility. Review of Resident #7's nurse's notes revealed on 12/13/2024 at 1:20 p.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 12/15/2024 at 2:20 p.m., the resident returned from the hospital back to the facility. Review of Resident #7's nurse's notes revealed on 12/24/2024 at 8:15 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 12/24/2024 at 1:02 p.m.,…

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 accurately code the resident's Minimum Data Set (MDS) assessment for restraint use for 1 (#28) of 33 sampled residents whose records were reviewed. Findings: Review of Resident #28's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diabetes mellitus, acquired absence of right leg below knee and acquired absence of other left toes. A review of Resident #28's December 2024 Physician's Orders revealed no order for a restraint. Further review of resident #28's medical record revealed an Annual MDS assessment with an ARD (Assessment Reference Date) of 12/12/2024, which read in part . Section P. Restraints and Alarms .Used in Chair or Out of Bed .Trunk restraints .were indicated. On 04/09/2025 at 4:29 p.m., an interview and record review was conducted with S5MDS who confirmed Resident #28 did not have an order for a restraint. She reviewed the referenced MDS, and confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop a comprehensive centered care plan for a Level II PASRR (Preadmission Screening and Resident Review) for 1 (Resident #47) out of 33 sampled residents. This deficient practice had the potential to affect a census of 96. Findings: Review of Resident #47's medical record revealed she was admitted on [DATE] with a diagnosis that included, but not limited to, Schizoaffective Disorder, Depressive Type. Review of Resident #47's Notice of Medical Certification dated 08/28/2024 read in part, Section II. H. Approved for admission by Level II Authority for a temporary period effective 09/07/2024 through 09/06/2025. Review of OBH-PASRR (Office of Behavioral Health-Preadmission Screening and Resident Review) Evaluation Summary and Determination Notice Evaluation and Placement Recommendations read in part, the individual has a serious mental illness and is recommended nursing home admission. Review of Resident #47's comprehensive person-centered care plan…

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 resident was invited to the resident's care planning meetings for 1 (Resident #54) out of a sample of 33 residents. This deficient practice had the potential to affect a census of 96. Findings: A review of the facility's policy titled Care Plan Process with a review date of 01/29/2025, read in part: Baseline Care Plan and Summary: The facility must provide the resident and the resident representative, if applicable, with a written summary of the baseline care plan by completion of the comprehensive care plan. Step 3: Obtain and consider input from resident and/or family/resident's representative regarding the care area. The IDT (Interdisciplinary Team) will minimally include in part the resident and the resident's representative. If the participation of the resident and their representative is determined to be not practicable for the development of the resident's care plan, and explanation shall be included in the resident's medical…

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's Quality Assurance and Performance Improvement (QAPI) Program failed to measure its success and track performance after identifying an area of improvement as evidenced by failing to have documented evidence of monitoring the effectiveness of the proposed plan of action. This deficient practice had the potential to affect a census of 98 residents. Findings: Review of the facility's form titled, Corrective Action Plan, dated 02/12/2025 revealed: 1. Problem Identified: Tasks not firing correctly due to facility changed from 12 hour shifts to 8 hour shifts. 12 hour shifts continued to fire to tasks in addition to 8 hours. Several time code discrepancies resulted in facility wide tasks audit to make corrections. 2. Plan of Action: Immediate action of Task audits of each resident correcting each task time code. Audit of Every individual task for each resident audited and corrected. Nursing staff were in-serviced on task time codes (8 hours) and correct body audit schedules must be verified on each new admit and hospital…

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, observations and interview, the facility failed to ensure that residents received the necessary treatment consistent with professional standards of practice to identify, prevent and promote the healing of a pressure area for 2 residents (#2 and #3) out of a total of 6 (#1, #2, #3, #R4, #R5 and #R6) sampled residents. This deficient practice was evidenced by the facility staff failing to: 1. Conduct weekly body audits for Resident #3; 2. Identify a Stage 2 Pressure Ulcer for Resident #3; and 3. Provide ordered treatments for Resident #2. Findings: A review of the facility's policy titled, Weekly Body Audit, with a latest review date of 08/2021 revealed, in part: To be completed weekly for all residents to identify any new alterations in skin integrity. On a designated day of the week, per facility schedule as developed by the DON (Director of Nursing), a body audit will be performed. The Licensed Nurse completes a head to toe inspection of the skin with notation of no new problem or new…

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 store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Discard expired foods from the kitchen refrigerator, freezer, and dry storage area; 2. Label opened foods with the date they were opened; 3. Remove compromised cans from the dry storage area; 4. Clean the inside of oven and outside of refrigerator and freezer; and 5. Ensure staff wore hair restraints in the kitchen. This deficient practice had the potential to affect the 92 residents who consumed food from the kitchen from a census of 93 Residents., Findings: On 03/18/2024 at 3:00 p.m., a review was conducted of the facility's policy titled, Storage of Refrigerated Food with a revision date of 01/25/2024. This Policy read in part, The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure .5. All non-hazardous, opened foods are labeled with name of food, date stored .11. Food shall be stored base 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 provide respiratory care consistent with professional standards as evidenced by: 1.Failing to ensure oxygen equipment was stored appropriately when not in use for Resident #5 and Resident #68; 2.Failing to ensure oxygen equipment was changed for Resident #53, Resident #68, and Resident #80; 3.Failing to ensure oxygen equipment was properly dated for resident #80. Findings: On 03/19/2024, a review of the facility's policy titled Infection Control Oxygen Equipment Cleaning with a last reviewed date of 01/25/2024 read in part . 5. Pre-filled humidifiers are to be dated .6. Refillable humidifiers should be washed and refilled every 72 hours with distilled or sterile water and dated. 7. Tubing should be replaced every 7 days. 8. Masks should be replaced every 7 days. 9. Cannulas should be replaced every 7 days. 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Resident #5 Review 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 observation and interview, the facility failed to ensure that menus met the nutritional needs of residents according to established guidelines, as evidenced by the kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to decreased intake, altered nutritional needs, and weight loss for the 9 residents who consumed pureed diets. 92 residents consumed foods from the kitchen. Findings: On 03/18/2024 at 9:50 a.m., an observation of the pureed procedure was conducted. S12Diet (Dietary) scooped 5 large unmeasured cooking spoons of macaroni noodles into the food processor, and used the same spoon to scoop 2 large spoons of melted cheese. S12Diet poured water from a large pitcher into the food processor without measuring, then poured an unmeasured portion of a white powder from a cup on the counter into the food processor. She turned the food processor on, then stopped and poured more water and white powder in the food processor and blended again. On 03/18/2024 at 9:55 a.m., an interview…

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, interviews, and policy and procedure reviews the facility failed to ensure resident rights by not acting promptly upon resident grievances received during monthly resident council meetings and demonstrate the facility's response for such grievances in the facility. Findings: On 03/21/2024, a review of the facility's policy, Resident Council, with a last reviewed date of 01/25/2024, revealed in part, the following, Policy: A Resident Council will be organized within the facility with regularly scheduled meetings (at least quarterly). If a formal Resident Council cannot be established within the facility, an alternate process is established . Purpose: To provide a forum for residents to share in the governance of the facility by providing opinions, suggestions, and problem solving in relation to areas of concern or community issues. Procedures: . 8. The facility must consider the views of the group and act promptly upon recommendations regarding issues of resident care and life in the facility. The Grievances-Residents process shall be followed. The grievance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure residents were free from unnecessary physical restraints for 1 (#76) resident out of 2 (#75, #76) residents investigated for physical restraints. Findings: On 03/20/2024, a review of the facility's policy titled Restraints and Safety Devices with a last reviewed date of 01/25/2024 read in part .The use of a restraint will require a determination of need to be completed by a licensed nurse, a signed consent and a physician's order prior to applying restraints Before a restraint may be use, the following steps must be followed unless it is an emergency situation: 1. Identify reason for symptoms that indicate the need for a restraint. 2. Remove, if possible, the causes of these symptoms. This may include taking care of special needs, increased rehabilitation and restorative nursing, modifying the environment and increasing supervision .4. Restraints should be used only after practicable alternatives have failed. The least restrictive…

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, record review ,and policy review the facility failed to implement the resident's care plan by failing to administer medications per physician's orders for 1 ( #94) out of a total sample of 30 residents. Findings: On 03/20/2024, review of the facility's policy, Drug Administration and Documentation, last reviewed on 01/25/2024, revealed in part, the following . Routine medications must be administered no more than sixty (60) minutes before or after the prescribed time. Review of Resident #94's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Malignant Neoplasm Of Colon Unspecified, Neoplasm Related Pain (Acute) (Chronic), Hyperlipidemia, Other Specified Arthritis, Unspecified Site, and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms. Review of Resident #94's physician orders dated 03/01/2024 revealed: 1. Clarithromycin 500 mg (milligram) tablet give one tablet by mouth twice daily for 12 doses 2. Pravastatin 10…

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 a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for 1 (#18) out of 2 (#18, #69) residents investigated for ADLs out of a total sample of 30 residents. Findings: On 03/20/2024, a review of the facility's policy titled Activities for Daily Living with a last reviewed date of 01/25/2024 read in part .Procedure .7. CNAs will document completion of resident assignments every shift by marking with their initials or by entering in electronic charting system 9. CNA's will initial indicating completion of assignments for the specific date and shift at the end of the ADLs or enter electronically. Review of the Nursing Assistant-Certified Job Summary read in part .Responsibilities .16. Follows baths and whirlpool schedules as outlined for each resident. Review of Resident #18's EHR (Electronic Health Record) revealed the resident was admitted to the facility 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 record review and interview, the facility failed to ensure residents were re-evaluated for the continued use of PRN (as needed) antipsychotic medications after 14 days for 1 (#75) resident out of a final sample of 30 residents. Findings: On 03/20/2024, a review of the facility's policy titled Anti-Psychotic-Use of Anti-Psychotics with a last reviewed date of 01/25/2024, read in part .The facility will not use Antipsychotic medications, unless it is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use antipsychotic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to safely reduce and discontinue these drugs .PRN orders for antipsychotic drugs are limited to 14 days and require the evaluation of the attending physician or prescribing practitioner to renew. Review of Resident #75's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which…

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 and interview the facility failed to maintain an infection prevention and control program as evidenced by staff failing to sanitize reusable resident care equipment after use and between residents. The deficient practice had the potential to effect a census of 93. Findings: On 03/19/2024 at 4:30 p.m., a review of the facility's policy titled Infection Control Policy for General Cleaning and Maintenance of Equipment reviewed on 01/25/2024 read in part . It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. Further review of facility's policy titled Blood Glucose Quality Control reviewed on 01/25/2024 read in part #18. Clean the meter using a disinfectant wipe. Maintenance of Blood Glucose Monitoring Systems, Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe per facility policy. On 03/19/2024 at 8:14 a.m., during medication pass, S9LPN (Licensed Practical Nurse) was observed using a tray…

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

Based on observations, record review and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects and rodents. The deficient practice had the potential to affect 87 residents who resided in the facility. Findings: Review of the facility's policy Pest Control, read in part a pest management program is used to prevent pests from entering . Procedure 1 . c. Gaps and cracks in doorframes and thresholds are sealed with weather stripping . Review of resident #2's Grievance/Complaint form dated 6/29/2023 revealed the resident complained that she had bugs in her room. The summary of pertinent findings or conclusions revealed the fields surrounding the facility were recently cut and the bugs from outside were drawn to the inside light. Insects were entering the door on the hall where the resident resides. The corrective action taken revealed that on 6/29/2023 maintenance sealed the door where the insects were likely coming inside. On 6/30/2023, resident #2 stated the bugs were still coming inside. Review of resident…

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 review and interviews, the facility failed to maintain a clean and homelike environment as evidenced by the presence of cobwebs, sediment observed on the wall, and stained privacy curtain for 1 (#3) of 6 (#1, #2, #3, #4, #5 and R1) sampled residents. Findings: Review of facility's policy titled, Resident Environment, revealed: It is the policy of this facility to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his/her personal belongings to the extent possible. Review of form titled, Housekeeping Hall Job Duties, revealed in part: Task to be completed each shift .Clean spider webs .When cleaning rooms please make sure you are moving everything and cleaning behind them . Review of form titled, Detail Cleaning Checklist, revealed in part .Disinfect corners .Spot clean walls .Conduct final inspection . Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent…

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 that service was provided as outlined in the comprehensive plan of care for 1 (#2) of 6 sampled residents (#1, #2, #3, #4, #5, and R1) by failing to ensure that weekly body audits were conducted for Resident #2. Findings: Review of the facility's policy titled, Weekly Body Audit revealed in part: Policy: To be completed weekly for all residents to identify any new alterations in skin integrity .1. On designated day of the week, per facility schedule as developed by the DON, a body audit will be performed .5. The Licensed nurse completes a head to toe inspection of the skin with notation of no new problem or new problem noted . Resident #2 was admitted to the facility on [DATE] with diagnoses in part: Pressure Ulcer of Sacral Region, Unspecified Protein-Calorie Nutrition, Spinal Stenosis. A review of the Resident #1's care plan revealed that he had a pressure ulcer, with an intervention for weekly body audits. A review of the resident's July and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all residents received care and treatment in accordance with professional standards of practice to meet the highest practicable physical well-being of residents when the facility failed to have the required size of a curved tip urinary catheter available to replace the resident's current catheter when it had become occluded and was causing pain for 1 (#3) of 3 (#2,#3 and #R1) residents with urinary catheters out of a total 6 (#1, #2, #3, #4, #5 and #R1) sampled residents. Findings: Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Quadriplegia, Anxiety Disorder, Major Depressive Disorder- Recurrent, Moderate, Neuromuscular Dysfunction of Bladder, Dysuria and Other Specified Rheumatoid Arthritis, Multiple Sites. Review of Resident #3's significant change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS…

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.