Courtland, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, it was determined that the facility's staff failed to track proper diet orders, to process the repeat insufficient proportion requests from residents and to honor residents' right to meet personal dietary proportion needs. This was evident for 1 (Resident #12) out of 2 residents reviewed for food during an annual survey.The findings include:Observation, on 07/15/2025 at 1:30 PM, Resident #12 finished everything on the lunch tray and yelled, I'm hungry and they did not bring enough food, Geriatric Nursing Assistant Staff #34 in the hallway stated that she notified the kitchen for additional food which it has been on-going for a while.Observation, on 07/16/2025 at 8:30 AM, this resident's main dish consisted of 3 parts of thin watery pureed food on a plate. Overheard this resident yelling out later, I'm hungry and need food. Observed the breakfast tray meal was completely finished by this resident. Record review, on 07/16/2025 at 01:08 PM, of this…

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 medical record, review of a complaint, and interview of facility staff, it was determined that the facility's Medical Director failed to ensure adequate implementation of resident care intervention and/or policy review. This was found evident for 1 (Resident #98) of 1 resident reviewed for insulin use. The findings include: On 7/16/25 at 12:32 PM, the surveyor interviewed Resident #98. During the interview Resident #98 described that when he/she was admitted to the facility he/she was prescribed a glucose monitoring device that was utilized to monitor blood glucose levels without the use of a finger stick. Resident #98 stated he/she was very happy with the use of the device but shortly after the device was ordered it was discontinued. On 7/23/25 at 11:35 AM, the surveyor reviewed Resident #98's medical record. The review revealed an order was placed for 3/27/24 for Resident 98 to have a continuous glucose monitoring device. On further review, Nurse Practitioner (NP) #42 documented, on 4/6/24 in a progress note, that the patient was seen for a follow-up. Patient 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 review and interview with staff it was determined the facility staff failed to maintain complete and accurately documented medical records by:1) Failing to document the disposition of a discharged residents personal property. This was evident for 1 (#163) of 1 resident reviewed for Misappropriation of Property. 2) Failing to document resident behavior. This was evident for 1 (#176) resident reviewed for 1 of 16 abuse reports reviewed. The findings include:1) Resident #163's medical record was reviewed on 7/15/25 at 11:55 AM due to complaints which included but were not limited to an allegation that the resident's wheelchair was stolen and was replaced by the facility with a broken chair. The resident was admitted to the facility from an acute care hospital in Maryland. According to the hospital Discharge summary dated [DATE], he/she had resided in a Long Term Care facility in another state prior to the hospitalization. During an interview on 7/16/25 at 12:20 PM Staff #10 the Rehabilitation…

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 interviews, it was determined that the facility failed to maintain practices to help prevent the transmission of infections. This was found evident on 2 out of 3 observations of the laundry area. The findings include: On 7/15/25 at 10:51 AM, the surveyor observed the clean laundry room. The door to a linen closet was opened and linens were not covered. Additionally, two carts in the clean laundry room, in which the staff had just folded and placed laundry, were left uncovered and exposed to the sewer water on the floor. Staff #1 stated that all the linens would be re-washed and the room terminally cleaned after this was brought to his attention. On 7/18/25 at 10:51 AM, the surveyor again observed the door to a linen closet was opened and linens were not covered. The surveyor interviewed the Laundry Staff #40. Staff #40 stated that currently the clean laundry bin in the closet was prohibiting the door from closing but that she would be folding them next and after the bin was removed the the door would be closed. Next the surveyor went into the hallway where…

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.

Number of residents sampled: Number of residents cited: Based on record review, and interview it was determined that the facility failed to document the rationale for non-administration of the influenza and pneumococcal immunization. This was found evident of 1 (Resident #66) of 5 residents reviewed for vaccinations during an annual survey. Influenza (flu) immunizations are usually offered during the flu season, which is considered October 1 through March 31 annually. The findings include: On 7/22/25 at 1:50 PM, the surveyor reviewed Resident #66's medical record. The review revealed that Resident #66 refused all vaccinations offered to him/her on 4/4/25. On Resident #66's influenza vaccination form it was documented that Resident #66 declined to have the influenza vaccination administered. Further on the form no rationale was given for the refusal even though the form asks for the reason to be indicated. The form was signed by the resident, indicating it was offered, and did not state that the refusal was due to the recently ending flu season. On further review the pneumococcal…

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 reviews of facility documents and medical records, it was determined that the facility staff failed to 1) ensure that the dishwasher hot water temperatures are frequently checked to ensure cleanliness and sanitation of dishware, and 2) store food in accordance with professional standards for food service safety, and 3) ensure meals were provided in a manner that maintained safe quality control temperatures to meet the individual needs of dialysis residents. This was evident for 2 (Residents #51 and #111) of 17 residents reviewed during an LTCSP recertification survey for food quality and kitchen practices. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: 1) An initial environmental kitchen food services inspection was conducted on 1/23/23 at 8:15 AM. Dishwasher temperature logs were not found/observed in the dishwashing machine area or any other area in the kitchen. A male dietary worker (staff #28) was asked about the dishwashing temperature log, and he…

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, reviews of medical records, and staff interviews, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by;1) failing to screen tuberculosis (TB) for new admit residents, this was evident for 2 (Resident #125 and #142) of 5 residents TB screening reviewed; 2) failing to order contact precautions for a resident who diagnosis E. coli infection, this was evident for 1 (Resident #343) of 6 residents review for infection disease; 3) failing to follow infection control practices in residents' rooms, this was evident for 2 (Resident #2 and #205) of residents reviewed; 4) failing to implement Enhanced Barrier Precautions (EBP), and 5) failed to implement measures to prevent contamination of resident care products for 1 (#65) of 8 residents reviewed for Pressure Ulcer/Injury. These practices had the potential to affect all…

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 surveyor observation and interview with staff it was determined the facility staff failed to treat each resident with respect and dignity by 1) ensuring residents were treated with respect and dignity by labeling residents who required physical assistance with meals as feeders and this was evident for 11 residents listed on 2 of 3 posted staffing assignment boards in the facility, 2) identifying, labeling and posting the residents level of dependency on others on 1 of 3 nursing units in the facility, and 3) failing to have an effective process in place to assist the residents to obtain and wear personal clothing for 2 (#70 and #137) of 78 residents reviewed during an LTCSP recertification survey. The findings include: 1) A lunchtime meal test tray observation was conducted with the Food Service Director staff #20 in the 1st-floor unit on 2/3/23. A review of the unit staffing assignment board revealed the word feeders at the bottom left corner, with room numbers (indicating the residents requiring assistance with eating) listed across the row under each GNA assignment. 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, medical record reviews, and staff interviews, it was determined that facility staff failed to develop and initiate comprehensive, resident-centered care plans with measurable objectives and goals for residents residing in the facility. This was evident for 6 (#14, #30, #131, #52, #51, #35) of 78 residents reviewed during the LTCSP recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) Resident #131's care plans were reviewed on 2/10/23. A care plan problem initiated on 2/6/23 related to functional maintenance was reviewed. Two goals were written as resident will be able to make basic needs known with use of GoTalk device, and Resident will demonstrate effective use writing skills with use writing skills with use of white board to copy letters/simple words. The only intervention was written as communication 3 x a week for 53 weeks The one…

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 medical record reviews and interviews with facility staff, the facility failed to update residents' care plans after each assessment and failed to consistently conduct quarterly care plan meetings. This was found to be evident for 4 (Resident #48, #131, #23, #35) of 78 residents reviewed during an LTCSP recertification survey. Findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents (regardless of payer) of long-term care facilities certified to participate in Medicare or Medicaid. Each care plan provides a framework for guiding the review of trigger areas and clarifying a resident's functional status and related causes 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 complaints, reviews of medical records, and interviews, it was determined that the facility failed to 1) ensure staff followed physician orders as evidenced by failing to apply Multi Podus boots and hand splints to a resident, and 2) to ensure ordered consults were addressed, 3) follow a consult physician's dressing change orders, 4) provide care for a resident who had shortness of breath, including failing to ensure the resident's x-ray was taken STAT (immediately) per the Physician's order, and 5) delay care regarding critical lab results. This was evident for 5 (Resident #53, #199, #297, #403, #405) of 78 residents reviewed during an LTCSP recertification survey. This noncompliance resulted in no actual harm to the residents, it has a potential for more than minimal harm if the practice is not corrected. The findings include: 1) On [DATE] at 12:00 PM, Resident # 53 was observed in room and not wearing hand splints and/or Multi podus boots. A follow-up observation was made on [DATE] at 12:26 PM.…

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, reviews of medical records, and staff interviews, it was determined that the facility staff failed to 1) initiate nursing interventions to prevent further falls, and 2) implement measures to minimize the residents' risk of injury. This was evident for 2 (Residents #65, and #129) of 11 residents reviewed for accidents during an LTCSP recertification survey. The findings include: 1) Resident #65 was observed on 1/25/23 at 10:08 AM lying in his/her bed. His/her bed was in an elevated position approximately 3 feet above the floor, no fall mats were observed in the room. Another observation on 1/27/23 at 12:35 PM revealed the resident was again observed in his/her bed which was elevated approximately 3 feet above the floor. When asked at that time if he/she adjusted the height of the bed, the resident stated I don't do shit with it. Another observation was made on 1/30/23 when the surveyor entered Resident #65d room with Staff #52 the wound nurse and #53 a GNA (Geriatric Nursing Assistant) 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 reviews of the medical records and interviews with staff, it was determined that the facility staff failed to 1) conduct accurate ongoing assessments and oversight of the resident before and after dialysis treatments, and also failed to develop a resident-centered plan of care for a resident receiving dialysis. This was evident for 2 (Residents #51, and #297) of 5 residents reviewed for Dialysis during an LTCSP recertification survey. The findings include: 1) Dialysis Communication Forms are utilized by the facility and dialysis center to assess and communicate the residents status before, during and after dialysis treatments. The facilities Dialysis Communication form consisted of 3 sections. The first section FN1, provided space for the facility nurse to document any communication to the dialysis nurse, and space to record the residents most recent vital signs and blood glucose with the date and time each were obtained. The second section DN provided space for the dialysis nurse to post dialysis vital…

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, administrative policy review, and interviews, it was determined that the facility failed to have a system in place to ensure that appropriate alternatives are attempted prior to installation of side rails, assess residents for risk of entrapment from bed rails, obtain informed consent, and ensure bed rails were properly installed prior to the utilization of side rails for any resident. This was evident for 3 (Resident #30, #48, #131) of 3 residents reviewed for accident hazards during the annual survey. The findings included. The intent of this requirement is to ensure that prior to the installation or use of bed rails, the facility attempts to use alternatives. If the attempted alternatives were not adequate to meet the resident's needs, the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative. The facility must ensure the bed is…

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 it was determined that the Physician failed to 1) review the resident's total plan of care as evidenced by the physician continuing to write orders related to a condition no longer existed, and 2) reconcile the correct dose, or the amount of the medication the resident received per day, of Depakote. This was evident for 2 (Resident's #35, #49) of 5 residents reviewed for Unnecessary Medications during an LTCSP recertification survey. The findings include: 1) Resident #35's medical record was reviewed on 2/2/23 at 11:52 AM. The review revealed a physician order written 11/26/22 for Enhanced Barrier Precautions (EBP) every shift. In an interview on 2/2/23 at 1:28 PM the Director of Nursing (DON) who was also the acting Infection Preventionist, was asked why the resident was on EBP. She indicated that the resident had a wound on their leg and thought that the wound was resolved in December. Resident #35's most recent Skin and Wound record dated 12/5/22 revealed that a left calf wound was resolved on 12/5/22. Further review of Resident #35'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 reviews of medical records and staff interviews, it was determined that the facility staff failed to 1) have a process to ensure the clinical pharmacist's monthly medication reviews were reviewed by the physician with a documented response in the resident's medical record, 2) to ensure that monthly medication regimen review was completed by the facility pharmacist, and 3) ensure the physician reviewed and addressed irregularities identified by the clinical pharmacist. This was evident for 6 (Residents #48, #30, #93, #35, #129, and #33) of 6 residents reviewed for unnecessary medications during an LTCSP recertification survey. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough monthly evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve…

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, staff interview, and documentation review it was determined that facility staff failed to 1) keep medication carts locked when unattended, 2) discard multi-dose vials which have been opened or accessed (e.g., needle-punctured) within 28 days, 3) label medications upon opening, and 4) dispose of expired medications. This was evident in 2 of 3 nursing units observed during the annual recertification survey. The findings include: 1) 01/31/23, at 12 noon, during an observation of the lunch meal on the 100 hall, an observation was made of an unlocked medication outside room [ROOM NUMBER]. The surveyor waited approximately 5 minutes for the nurse to return and lock the medication cart. 02/13/23, at 10:05 AM, during an observation of the second floor nursing unit, an observation was made of an unlocked medication outside room [ROOM NUMBER]. The surveyor notified the charge nurse who locked the medication cart. 02/13/23, at 2:01 PM, during an observation of the second floor nursing unit, an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility staff failed to document that resident and/or their Responsible Parties (RPs) were provided education regarding the benefits, risks, and potential side effects of Influenza and Pneumococcal vaccines before requesting consent, and document residents' vaccination consent form including agree to receive the vaccine or refuse it. This was evident for 4 (Resident #51, #128, #133, and #142) of 5 residents reviewed who were eligible for Influenza and Pneumococcal vaccines during the annual survey. The findings include: Pneumococcal vaccine helps prevent pneumococcal disease, which is any type of illness caused by streptococcus pneumonia bacteria. The Centers for Disease Control and Prevention (CDC) recommends a pneumococcal vaccine for age [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions or risk factors. (Centers for Disease Control and Prevention- vaccines and preventable disease) Flu is a…

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

Based on medical record review and staff interview, it was determined the facility failed to document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents. This was evident for 2 (Resident #51 and #128) of 5 residents reviewed for COVID-19 vaccination during the annual survey. The findings include: On 01/25/23 at 01:45 PM, randomly selected five residents COVID-19 vaccination medical records were reviewed. Resident #51 has resided in the facility since August 2021 and received the first dose of COVID-19 vaccines on 03/08/22. The second dose of COVID-19 vaccine was documented as consent refused under the electronic medical record immunization tab. However, no COVID-19 vaccine refusal form was filed under his/her medical records. Also, no documentation was found to support the facility educating the resident regarding the vaccine. A review of Resident #128's medical records on 01/25/23 at 2:00 PM revealed that the resident has resided in the facility since August 2022 and had been refused COVID-19 vaccine.…

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 documentation review and interview, it was determined that the facility failed to ensure nurse aide competency training (including dementia management and resident abuse prevention training) occurred no less than 12 hours per year. This was evident for 3 (GNAs #48, #49, and #50) of 3 employee training records reviewed and had the potential to affect all residents. The findings include: A review was conducted of GNA personnel files on 2/14/23 at 11:25 AM. A review of GNA #48's personnel file revealed GNA #48 was hired on 1/9/19. A review of GNA #49's personnel file revealed GNA #49 was hired on 8/16/19. A review of GNA #50's personnel file revealed GNA #50 was hired on 9/17/19. An interview was conducted with the Human Resources director (staff #38) on 2/14/23 at 11:35 AM. She was asked about education transcripts and the process of monitoring. She indicated that the facility does not control the electronic system that is utilized for employee education. She indicated that employees are sent emails to notify each employee of due education requirements and the expected date…

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 with staff it was determined the facility staff failed treat residents with dignity and respect by failing to encourage and assist residents to dress in their own clothing. This was evident for 1 (#90) of 78 residents reviewed during the survey. The findings include: Resident #90 was observed on 1/27/23 at 10:08 AM walking in the hallway toward the nurses' station wearing a hospital gown in his/her bare feet the gown was open in the back and the residents brief was visible. He/She was observed again on 1/31/23 at 12:20 PM sitting on the side of his/her bed wearing a hospital gown and nonskid socks. Review of Resident #90s medical record on 1/31/23 at 12:31 PM revealed an inventory of belongings list dated 9/19/19 which listed 2 shirts. Resident #90 was observed again on 2/3/23 at 8:57 AM sitting on the side of his/her bed wearing a hospital gown and nonskid socks. A blanket was wrapped around his/her shoulders and back. An observation of Resident #90's room was made with Staff #19 on 2/15/23 at 8:49 AM. Resident #90 was in his/her room wearing 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 reviews of a medical record and staff interview, it was determined that the facility staff failed to 1) notify a resident's physician and family member when a significant weight loss was identified, and 2) notify a resident's Surrogate Decision Maker when changes were made in the residents' psychotropic medications. This was evident for 2 (Resident #35 #93) of 78 residents reviewed during an LTCSP recertification survey. The findings include: 1) A review of the facility Change in Resident Condition, physician notification policy on 02/06/23 at 11 AM revealed the purpose of the policy was to ensure that resident care problems are communicated to the medical staff in a timely, efficient and effective manner, and to ensure that all significant changes in resident condition are assessed and documented in the medical record. The policy for notifying a resident's physician for non-immediate resident changes, that includes a weight change of 5% or more within 30 days, should be minimally notified the next…

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 it was determined the facility staff failed to 1) have an effective process in place to protect resident's property from loss or theft. This was evident for 1 (#43) of 3 residents reviewed for Personal Property, and 2) failed to have a safe clean and comfortable environment on 1 of 3 units observed throughout the survey. The findings include: 1) In an interview on 1/24/23 at 11:22 AM Resident #43 was asked if he/she had any belongings go missing. He/she indicated that he/she had clothing go missing over the past 4 years, that he/she had been reimbursed for some things but not everything. The Resident indicated that a [NAME] blanket had been missing for the past month. When asked if it was reported to anyone the resident indicated that he/she had spoken to the Administrator who said that they can't afford to keep replacing his/her items. In an interview on 1/31/23 02:11 PM Staff #19 the Unit Manager was asked to explain the protocol for resident inventory of belongings. She…

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 complaints, reviews of medical records, and interviews, it was determined that the facility failed to 1) ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued, and 2) promptly resolve resident grievances. This was evident for 2 (Resident #131 and #43) of 3 residents reviewed for the grievance process during the LTCSP recertification survey. The findings include: 1) On 1/30/23, a phone interview was conducted with resident #131's representative at 2:48 PM reporting various concerns with the facility and not receiving written responses/notifications related to grievances filed with 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 a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 1 (Resident #9) out of 16 residents reviewed for abuse during an LTCSP recertification survey. The findings are: A review of facility-reported incident MD00151687 on 02/06/23 revealed that the facility reported an allegation of staff-to-resident abuse on 02/20/20 which was observed by another staff member. The facility also reported the incident to the local police who conducted an onsite investigation. The resident's physician and responsible party were also made aware of the allegations. A review of the facility abuse and resident reporting policy on 02/01/23 revealed the purpose of the policy was to comply with the entire measure and intent of Article 43, Section 565 A of the Patients' [NAME] of Rights law to ensure the protection of patients entrusted to our care. The first line of the [NAME] of Rights reiterates the resident's right to be…

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

Based on complaint, reviews of the facility investigation, and staff interview, it was determined that the facility failed to implement abuse prevention polices as evidenced by staff's failure to, 1) immediately notify the facility administrator of an allegation of resident abuse, 2) immediately initiate an investigation into the allegation of resident abuse, and 3) report an allegation of resident abuse to the State Regulatory Agency (Office of Health Care Quality). This was evident for 1 of 16 (Resident #57) residents reviewed for abuse during an annual recertification survey. The findings include: During the initial stages of the LTCSP survey, the surveyor interviewed Resident #57's family member who stated that Resident #57 was kicked in the chest by his/her former roommate 1.5 years ago. Resident #57's family member stated that the facility had taken care of the incident immediately. Review of the facility abuse, resident reporting policy on 02/01/23 revealed the purpose of the policy was to comply with the entire measure and intent of Article 43, Section 565 A of the Patients…

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 medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#48) of 14 residents reviewed for nutrition during the annual survey. The findings include. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Resident #48 was interviewed on 1/25/23 at 2 PM. During the interview resident, #48 revealed he/she did not have any teeth as he/she wore dentures. The resident's medical record was reviewed on 1/27/23. A review of the annual MDS assessment with an assessment reference date (ARD) of 11/16/22 revealed a miscoding at L0200 (B) as Z none of the above was coded. The 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 medical record review and staff interview, it was determined that the facility failed to screen a resident to determine if the resident had or may have had a mental disorder (MD), intellectual disability (ID), or related condition. This was identified for 1 of (Resident #9) of 2 residents reviewed for pre-admission screening and resident review (PASSR) requirements during an LTCSP recertification survey. The findings include: A review of Resident #9's medical record on 01/25/23 revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that include: end stage renal disease on hemodialysis, hypertension, diabetes, peripheral vascular disease, and anemia. An admission PASSR was not available in the medical record. In an interview with he nursing unit manager on 01/25/23 at 2:14 PM, the unit manager stated that Resident #9's admission PASSR was located on a facility computer hard drive. Further review of Resident #9's medical record revealed that Resident #9 was sent to the hospital 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 review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission. The facility did not have records to show the Preadmission Screening and Resident Review (PASARR) Level 1 screening was completed prior to admission. This is evident for 2 (#30, #9) of 34 residents in the initial sample of the annual survey. The findings include: The PASARR level 1 screening is federally mandated and must be completed for all applicants to nursing facilities which participate in the Maryland Medical Assistance Program regardless of an applicant's payment source. The purpose of the screening is to help ensure that residents are not inappropriately placed in nursing homes for long term care. The program assists in the placement and provision of services for individuals with severe mental illness and/or intellectual disability. 1) 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.

Based on interviews and record review, it was determined that the facility failed to provide residents and or residents' responsible party (RP) a copy of their baseline care plan along with a copy of their admission medications. This was evident for 1 (#131) of 1 resident interviewed about baseline care plans during the annual survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1) On 1/25/23 at 4:15 PM an interview was conducted with Resident #131. When he/she was asked if the facility provided a baseline care plan or medication list, resident #131 responded no. A phone interview was conducted with the resident's responsible party (RP) on 1/30/23 at 2:48 PM. The RP responded that the resident nor the family…

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 complaints, medical record reviews, and interviews with residents and facility staff, it was determined that the facility failed to provide a resident with a shower during the past four weeks of his/her stay. This was evident for 2 (Residents #52, and #195) of 6 residents reviewed for activities of daily living (ADL) during an LTCSP recertification survey. The findings include: 1) A complaint was obtained during the survey regarding Resident #52, on 02/06/23 at 1:30 PM, with an allegation that the nursing staff is not providing showers to Resident #52 for the past four weeks. It was also alleged that the nursing staff is instructing Resident #52 to bathe himself/herself. In an interview with Resident #52 on 02/08/23 at 2:40 PM, Resident #52 stated S/he is to receive a shower once a week and that the last shower that S/he received was 3-4 weeks ago. Resident #52 stated that the facility shower chair is not big enough for/him/her. A review of Resident #52's shower/bathing records on 02/09/23 revealed that the nursing staff documented that Resident #52 did not receive a bath…

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 complaint, reviews of a medical record, and interview, it was determined that the facility failed to provide treatment/services to maintain vision (Resident #52). This is evident for 1 out of 5 residents reviewed for vision/hearing during the annual LTCSP recertification survey. The findings include: A complaint was obtained during the survey regarding Resident #52, on 02/06/23 at 1:30 PM, with an allegation that the nursing staff are not providing any type of vision support. The complainant stated that Resident #52 is blind and that the nursing staff do not assist Resident #52 were his/her personal items are located or where the food items are located on his/her meal tray. A review of Resident #52's medical record on 02/06/23 revealed that Resident #52 was admitted to the facility on [DATE] with diagnoses that include diabetes, unspecified cataracts, hemodialysis, and amputations of the right and left below the knee/lower legs. In an interview with Resident #52 on 02/08/23 at 2:40 PM, Resident #52…

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 complaints, observation, reviews of medical records, and interviews, it was determined that the facility staff failed to 1) cleanse a wound with the prescribed solution, 2) implement measures to minimize the residents' risk of injury, 3) ensure a wound consult was completed timely, and 4) monitor and document treatments and services to promote healing of pressure ulcers. This was evident for 2 (Residents #65, #401, and #405) of 10 residents reviewed for pressure ulcers during an LTCSP recertification survey. The findings include: 1) On [DATE] at 9:23 AM the surveyor observed Staff #52 the Wound Nurse perform wound care for Resident #65. Staff #52 gathered supplies including Optiform dressing, Aquacel, skin prep, cotton tipped swabs, sterile 4 x 4 gauze pads, a drape, and a 16 ounce spray bottle of Skintegrity wound cleanser. Upon entering Resident 65's room, Staff #52 placed the supplies onto the drape on the residents overbed table. She cleansed her hands and applied gloves. She removed the old…

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 medical record review, and staff interview, it was determined facility staff failed to follow up on Podiatry consultation report recommendations. This is identified for 1 (resident #131) of 1 resident reviewed for foot concerns. The findings include: Podiatry is a branch of medicine devoted to the study, diagnosis, and medical and surgical treatment of foot, ankle, and lower extremity disorders. A review of resident #131's medical record on 2/13/23 revealed a physician's order for Podiatry Consult was written on 10/19/2022. A review of the medical record did not reveal if resident #131 had been seen by a Podiatrist. An interview was conducted with the unit manager/nurse (staff #37) at 11:45 PM on 2/13/23. When asked if the resident was seen by podiatry, she indicated that the resident was seen. She was informed that the podiatry consultation report was not in the medical record. She looked in a binder and found the original Health Dive initiation on the podiatry consult dated 10/19/22. She could not find the podiatry consult or documentation of when resident #131 was seen…

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 a medical record review and staff interview, it was determined that the facility failed to monitor a resident's body weight, who had potential nutritional risks due to tube feeding. This was evident for 1 (Resident #33) of 14 residents reviewed for nutrition during the annual survey. The findings include: A PEG (percutaneous endoscopic gastrostomy) feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach. Parenteral and enteral feedings are considered in patients with insufficient oral intake or contraindications to anything by mouth. A review of the medical record for Resident #33 on 01/31/23 at 11:30 AM revealed that the resident had a PEG tube since his/her origin admission in August 2022 for Resident #33's history of poor oral intakes. Resident #33 had an order of 1800ml total volume of nutrients and a regular texture thin liquids consistency diet. A review of Resident #33's care plan revealed that the intervention, obtain/ monitor/document weight as ordered, was placed under risk for a deficient…

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 review of residents medical records and interview with staff, it was determined that the facility failed to develop a plan of care that addressed the needs of a resident with dementia. This was evident for 1 (#129) of 2 residents reviewed for dementia care. The findings include: Dementia is a general term that describes symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function caused by the permanent damage or death of the brain's nerve cells. Resident #129's electronic and paper medical record was reviewed on 1/30/23 at 2:02 PM. During the review, it was found that the resident was diagnosed with unspecified dementia without behavioral disturbance, Parkinson's disease. Resident #129 was receiving medications such as Carbidopa-Levodopa or Nuplazid (discontinued on 11/23/22) that were used in treating those diagnoses. Further review of the resident's care plan and interventions revealed that the care plan failed to address the needs of a dementia resident to achieve the highest practicable physical, mental, and psychosocial…

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 with staff it was determined the facility staff failed to ensure adequate rationale for increasing antianxiety and antidepressant medications and monitoring of behaviors, behavior interventions and effectiveness for a resident receiving psychotropic medications for anxiety and depression. This was evident for 1 (#35) of 5 residents reviewed for Unnecessary Medications. The findings include: Review of Resident #35s medical record on 2/2/23 at 11:52 AM revealed diagnoses which included but were not limited to Dementia, Psychotic disturbance, Mood disturbance and Anxiety. A Psychiatric Nurse Practitioner (NP) progress note dated 9/19/22 at 9:44 PM indicated that Resident #35 was irritable, anxious, loud, yelling at staff and complained of anxiety. The note indicated: Medication intervention with rationale: Start Buspar (also known as Buspirone, an anxiety medication) 5 mg (milligrams) twice per day. The physicians' orders reflected an order written on 9/19/22 for Buspirone 5 mg…

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 medical record review and staff interviews, it was determined that facility staff failed to ensure residents were free from significant medication errors, as evidenced by administrating overdose of psychotropic medication with the same ingredient but different forms (tablet and sprinkles capsule) for two days. This was evident for 1 (#49) of 5 residents reviewed for an unnecessary medication review during the annual survey. The findings include: The medication Depakote (divalproex sodium) is an anticonvulsant. It is prescribed to treat seizure disorders and to manage the manic phase of bipolar disorder. Depakote has three different forms: Depakote (delayed-release tablets), Depakote ER (extended-release tablets), and Depakote Sprinkle Capsules (delayed-release Capsules). Depakote Sprinkle Capsules work the same way as Depakote Delayed-Release tablets, although they are in capsule form instead of a tablet. Some patients (for example, those with difficulty swallowing) may find it easier to take Depakote Sprinkle Capsules because they can be swallowed whole or opened and 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 a complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to obtain a STAT urine sample when a resident was observed with a change in condition. This was evident for 1 (Resident #195) of 36 complaints reviewed during an LTCSP recertification survey. The findings include: A review of complaint MD00161773 on 02/14/23 revealed an allegation that Resident #195 was not provided with care while residing in the facility. A review of Resident #195's closed medical record on 02/14/23 revealed that Resident #195 was observed with increased confusion on 10/20/20 at 4:48 PM. The nurse notified Resident #195's physician who instructed the nurse to obtain a STAT urinalysis and urine culture. Bloodwork was also ordered at this time on a routine basis. Further review of Resident #195's closed medical record revealed a nurse's progress note, dated 10/20/20 at 5:31 PM, that indicated the nurse was unable to obtain a STAT urine specimen to send to the lab. In an interview with Resident #195's 10/20/20 evening shift charge nurse,…

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 with staff it was determined the facility failed to have sufficient dietary support personnel to provide social dining services in the dining room. This was evident throughout the survey and had the potential to affect all residents. The findings include: 1) Observations were made of the facility's only dining room, located on the first floor of the building, from approximately 7:00 AM - 3:00 PM on 1/23/23-1/27/23 and 1/30/23-2/3/23. Group activities were observed taking place however no dining services were provided during that time frame. Review of the Resident Council meeting minutes on 1/26/23 at 10:31 AM revealed that the Administrator shared with the council on 1/4/23 that dining room service would return ASAP when the new director starts in the beginning of January. Minutes from a Special Resident Council Meeting held 1/19/23 to discuss Food complaints revealed that the new Food Service Manager, Staff #20 indicated that service in the main dining room would resume when staffing allows. In an interview on 2/3/23 at 10:10 AM Staff #20…

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 complaint, observation, resident, and staff interviews, it was determined that the facility staff failed to develop, prepare, distribute, and serve menus that reflect a resident's nutritional wishes. This was evident for 1 (Resident #96) of 78 residents reviewed during the recertification survey. The findings include: In an interview with Resident #96 on 1/25/2023 at 12:36 PM, Resident #96 complained that the food was usually cold, and s/he was not given a menu to choose from. Resident # 96 added that what was served did not match what they had on the meal ticket, and they don't give you alternate food choices. While the surveyor was in the resident's room, Geriatric Nursing Assistant (GNA #27) brought in Resident #96's lunch tray. Surveyor observed that the food items on the lunch tray did not match what was written on the meal ticket. Resident #96 refused the meal and stated that s/he did not like the food. GNA #27 took the tray out without offering the resident any alternate food choice or substitute. Surveyor immediately interviewed GNA #27 who confirmed that the meal…

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 complaint, observation, resident, and staff interviews, it was determined that the facility staff failed to provide food that accommodates resident preferences and/or appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice. This was evident for 2 (#96, #342)) of 78 residents reviewed during the recertification survey. The findings include: 1) In an interview with Resident #96 on 1/25/2023 at 12:36 PM, Resident #96 complained that the food was usually cold, and s/he was not given a menu to choose from. Resident # 96 added that what was served did not match what they had on the meal ticket, and they don't give you alternate food choices. While the surveyor was in the resident's room, Geriatric Nursing Assistant (GNA #27) brought in Resident #96's lunch tray. Surveyor observed that the food items on the lunch tray did not match what was written on the meal ticket. Resident #96 refused the meal and stated that s/he did not like the food. GNA #27 took the tray out without offering 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 a complaint, reviews of a closed medical record, and staff interview, it was determined that the facility staff failed to correctly evaluate and provide a resident with a full cognitive workup as recommended by a speech-language pathologist (SLP). This was evident for 1 (Resident #195) of 36 complaints reviewed during an LTCSP recertification survey. The findings include: A review of complaint MD00161773 on 02/14/23 revealed an allegation that Resident #195 was not provided with care while residing in the facility. A review of Resident #195's closed medical record on 02/14/23 revealed that Resident #195 was admitted to the facility on [DATE]. At that time, Resident #195's physician instructed the staff to obtain a Speech-Language Pathology screen and to treat as indicated. A review of the 10/08/20 SLP, staff member #60, screening criteria noted that Resident #195 had a mental status change, having problems with memory, orientation, or problem-solving, and a change in the resident's condition. 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, record review and interview it was determined the facility staff failed to ensure 1) accurate documentation of oxygen administration for 1 (#111) of 1 resident reviewed for respiratory care, and 2) failed to maintain complete and accurate inventory of belongings for 3 (#70, #137, and #90) of 78 residents reviewed during the survey. The findings include: 1) Review of Resident #111's medical record on 2/13/24 at 8:37 AM revealed a physician order written 12/27/22 for Oxygen via Nasal Cannula at 2-3 LPM (liters per minute) Goal O2 saturation greater than 95%. Review of the TAR (Treatment Administration Record) for January and February 2023 revealed the physicians order for oxygen. The spaces provided for administration times were labeled PRN (as needed). The oxygen was not signed off by the nursing staff as administered to the resident nor did it reflect how many liters of oxygen were administered. Staff #19 the 2A Unit Manager was interviewed on 2/13/23 at 12:41 PM. She was shown the TAR and made aware that the order indicated a range of 2-3 liters, the TAR…

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 medical record review and interview with the facility staff it was determined that the facility staff failed to ensure the information used to complete the Annual and Quarterly Minimum Data Set (MDS) assessment for 1) Functional Status; Activities of Daily Living and 2) Bladder and Bowel were accurate. This was found to be evident for 3 out of 4 residents (Resident #119, Resident #44 and Resident #26) reviewed for activities of daily living and 1 out of 1 (Resident #26) reviewed for bladder and bowel during the investigation stage of the survey. The findings include: MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Activities of Daily Living or ADL's are basic self-care tasks. They include bed mobility, toileting, grooming, maintaining continence, putting on clothes,…

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, resident interview, record review, and staff interview it was the determined that the facility staff failed to provide a resident-centered care plans to address: 1) the the resident's choice to not have facial hair shaved and 2) the care of a resident's Permacath (a catheter used for dialysis). This was found to be true with 2 of 2 residents (Resident #31 and Resident #96) reviewed for patient centered care plans during the survey. The findings include: An interview was conducted with Resident #31 and their Resident Representative (RR) on 12/11/18 at 1:41 PM. During the interview the resident alerted surveyor to an area on the right side of their cheek near the mouth. Surveyor noted several small white raised bumps clustered reaching from the corner fold of the mouth to just under the right nostril. Also observed were 5 to 6 clusters of flat white circles and numerous short strands of thick hair along the cheek, jawline, and upper neck of the resident. Several of the strands were curled toward their skin. Resident #31 rubbed the raised bumps and stated that…

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, medical record review and interviews with facility staff it was determined the facility failed to update care plans to 1) meet the specific needs for a resident with a history of falls and 2) a resident diagnosed with anemia (a condition where the patient does not have enough red blood cells to carry oxygen to parts of the body). This was found to be evident for 2 of 30 residents (Resident's #109 and #131) that were investigated during the facility's annual survey. The findings include: 1. A medical record review was conducted on Resident #109 on 12/18/18 at 2:30 PM and it revealed the resident had an unwitnessed fall on 12/8/18 and 12/9/18 resulting in a cervical fracture and laceration to head. Review of Resident #109's medical record revealed a history of resisting care and agitation at times and impulsivity. Review of the Incident/Accident report indicated that on 12/8/18 Resident #109 was observed sitting on the floor close to his/her bed and wheel chair, in his/her room bleeding from forehead. Additionally, on 12/9/18 Resident #109 was noted on the floor…

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, record review, resident and staff interview it was determined that the facility staff failed to put a system in place to ensure that food and beverages are healthy and satisfying to residents. This deficient practice has the potential to affect all residents in the facility. The findings include: During a meeting with the facility's Resident Council on 12/13/18 at 9:21 AM, members stated that they have expressed concerns in several council meetings regarding the temperature, appearance, and taste and timeliness of meals. Residents stated that for the past several months, the meal trays and service carts arrived late to the units and dining rooms resulting in cold food. They added that the dinner meal services have arrived at least 1 to 2 hours late and that the previous evening (12/12/18) the first of the delivery carts for the 2nd floor unit did not come until 6:30 PM. Because of the delays, the servers in the dining room are rushed which resulted in food served cold, and/or burnt, and messily plated. During an interview with the Food Service Director and 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, record review, resident and staff interviews it was determined the facility failed to: 1) follow resident's meal tickets and 2) provide foods that are consistent with the resident diet plan and 3) provide meals on time 4) put a system in place to provide food and drink that was attractive, appetizing, at acceptable temperatures, and assure that food is stored in a way to maintain its nutritional value for residents. This was found to be evident for 3 out of 3 residents (Resident #41, Resident #95 and Resident #110) investigated for food concerns and has the potential to affect all residents in the facility. The findings include: 1. An interview was conducted with Resident #41 on 12/11/18 at 2:00 PM and s/he complained that the food is not correct when it is brought to them by dietary. The resident went on to say that the dietary department is unable to read the dietary slips and stated that if they are reading the diet slips correctly, why was s/he served a pureed diet, when my diet slips reads regular? An observation was made of Resident #41's plate of food…

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, record review, resident and staff interview it was determined that the facility staff failed to put a system in place to ensure that residents meals and snacks were offered at scheduled times. This deficient practice has the potential to affect all residents in the facility. Findings include: During a meeting with resident representatives on 12/13/18 at 9:21 AM it was revealed that they have expressed concerns in the past several months regarding the lack of timeliness of the delivery of meals and snacks in the facility. The dinner meal services have arrived at least 1 to 2 hours late and that the previous evening (12/12/18) the first of the delivery carts for the 2nd floor unit did not come until 6:30 PM. The residents added that snacks are not provided consistently and that they must request several times during the evening to receive them. Residents stated that on 12/12/18 evening snacks for Diabetic residents were not delivered at all. During an interview with the Food Service Director and the Administrator on 12/13/18 at 11:00 AM, the FSD admitted that…

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, record review, and staff interview it was determined that the facility staff failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. This deficient practice has the potential to affect all residents in the facility. Findings include: An observation of the kitchen on 12/18/18 at 12:46 pm was conducted. Surveyors noted several food tray lids were on the floor. Additional observation revealed that Staff #31 bent down, pick the trays off the floor, placed then on a nearby food prep counter, then proceeded to grab clean plates and continued to serve meals without removing gloves, sanitizing their hands or removing the tray lids from the service area. The Administrator was alerted to surveyor's findings and redirected staff after surveyor's intervention. (Cross Reference F 880) Further observation at 12:51 pm revealed that the bin containing individual milk cartons for lunch distribution failed to have ice in it. Additional observation revealed that the temperature of the milk in one of the cartons was 48 degrees.…

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, medical record review and interview with facility staff, it was determined that the facility staff failed to: 1) promote care for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect by failing to provide a privacy cover to a resident with Foley drainage bag and 2) failure to knock and wait for permission to enter a resident room. This was found to be true for 2 out of 4 residents (Resident #44 and Resident #31) reviewed for dignity. The findings include: A Foley catheter is a urinary collection system consisting of a tube inserted into the bladder. The urine then drains through the tubing into a drainage bag that is attached to the side of the bed or chair. A privacy cover is placed over the drainage bag to hide the contents thus ensuring privacy and preventing embarrassment for the resident, roommate or visitors. 1. During a tour of unit 2 on 12/10/18, Resident #44 was observed from the hallway with his/her Foley drainage bag exposed. Review of the medical records on 12/10/18 revealed that Resident #44…

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 staff interview it was determined the facility failed to promote care for a resident in a manner that would ensure the resident's dignity. This was found to be evident for 1 out of 44 residents (Resident #44) reviewed during the survey. The findings include: An observation was made on 12/12/18 at 12:50 PM of Staff #21, a Geriatric Nursing Assistant (GNA), assisting Resident #44 with his/her lunch in their room. The GNA stood above the resident and fed him/her their lunch. Staff #22, a nurse, walked into the resident room at that time to check on the resident. As Staff #22 exited the room, at 12:52 PM, the surveyor asked Staff #22 if there was a reason why the GNA was standing and feeding Resident #44 and s/he responded that there was no chair in the resident room. The nurse, Staff # 22, went into another room and retrieved a chair and took it into Resident #44's room and the GNA, Staff #21 sat down and continued to assist the resident with his/her meal. During the interim while the nurse retrieved the chair, the GNA Staff #21 continued to stand above 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, record review and interview with staff and family members, the facility failed to ensure that resident bathing areas were free of hazards that may cause injury to the residents. This has the potential to affect any resident that utilized the shower in Hall 1A. The facility also failed to provide reasonable accommodation of resident needs and preferences for Resident #2. This was evident for 1 out of 45 Residents reviewed during the survey. The findings include: 1. On 12/18/18 at 1:40 PM during an environmental tour of Hall 1A with Staff #23, the residents' shower area floor (first shower stall) had a 4 inch x 2 inch area of cracked and peeling paint with raised edges that may cause injury to a resident while barefoot. Staff #23 and the administrator did acknowledge the surveyor's concerns during the tour. 2. A family interview was conducted on 12/10/18 at 9:30 AM with Resident #2's spouse and child. Family members stated that for months they have talked to the laundry staff and the unit manager and repeatedly requested that the facility not do the resident'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.

Based upon resident interviews, record review and staff interview it was determined that facility staff failed to consider or act upon Resident Council's grievances regarding food service. This deficient practice has the potential to affect all residents receiving food/meal services in the facility. The findings include; Resident Council is a group of residents that meets regularly on behalf of all residents in the facility to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider residents' views and act upon grievances and recommendations. Facility staff must consider these recommendations and attempt to accommodate them, to the extent practicable. On 12/13/18 at 9:21 AM a meeting with the facility's Resident Council was conducted. Members stated that they have expressed concerns in several council meetings regarding the temperature, appearance, taste and timeliness of meals. Residents stated that for the past several months, the meal trays and service carts arrived…

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 medical record review and interview with staff it was determined that the facility failed to ensure that residents and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 2 of 4 residents (Resident #103 and Resident #119) reviewed for hospitalization during the investigative stage of the survey. The finding includes: 1. Review of the medical record for Resident #103 on 12/12/18 at 2:45 PM revealed that the resident was admitted to the facility in November 2018 and then discharged to the hospital within the first few weeks of admission to the facility. During an interview with the resident on 12/12/18 the surveyor asked if he/she received any documentation from the facility indicating why the resident was being transferred/discharged to the hospital. The resident's response was that they did not give me anything. Further review of the medical records failed to reveal any documentation that the facility provided a copy of the notice of reason for transfer/discharge 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 administrative manual review, medical records review and interview with staff and residents, it was determined that the facility failed to provide residents and or their resident representative (RP) with the documentation of the facility's bed-hold policy. This was evident for 2 of 4 residents (Resident #103 and Resident #119) reviewed for planned and unplanned hospitalizations during the investigative stage of the survey. The findings include: Review of the facility bed-hold policy revealed that the resident and his/her surrogate decision maker or court appointed legal representative would be provided written and or verbal information regarding the bed-hold policy at the facility 1. On 12/12/18 Resident #103's medical records were reviewed. This review revealed that the resident had an unplanned transfer to the hospital 2 weeks after admission. Further review of the medical records revealed that the facility failed to provide the resident or RP with a copy of the bed-hold policy upon transfer/admission to the hospital. During an interview with the Director of Nursing(DON)…

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 medical record review and interviews with facility staff it was determined the facility failed to develop a care plan for a resident at risk for pressure ulcers. This was found to be evident for 1 of 4 residents (Resident #99) reviewed for pressure ulcers. The findings include: Resident #99 was admitted to the facility on [DATE] and has the following but not limited diagnosis: Peripheral Arterial Disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). A medical record review was conducted for Resident #99 on 12/14/18 at 10:45 AM. Review of the resident care plan revealed the resident had a care plan in place for actual pressure ulcer related to disease process, history of ulcers and immobility that was initiated on 5/18/18. Another care plan for an actual arterial ulcer related to history of ulcers, limited joint mobility and peripheral arterial disease that was initiated on 9/26/18. Further review revealed the facility failed to have a potential for pressure…

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.

2. Blood glucose level is the amount of glucose (sugar) in the blood. The amount of glucose in the blood is measured in units of mg/dl or mmol/l. Blood sugar levels that are too high or too low can be a dangerous condition and without immediate treatment can cause serious complications. A review of the medical for Resident #96 was conducted on 12/10/18 at 10:00 AM. Review of a physician order dated 10/17/18 stated to check the resident's blood sugar level twice a day and notify the physician if the resident's blood sugar level was below 80 mg/dl or above 250 mg/dl. However, review of the October 2018 Treatment Administration Record (TAR) conducted on 12/13/18 indicated that the order was started on 10/22/18. Further review of the resident's TAR revealed that from October 2018 to December 2018, there were five entries by staff that indicated blood sugar levels above 250 mg/dl and one entry the level was below 80 mg/dl. However, there was no documentation to support that the physician was notified about the levels as ordered. The Director of Nursing was made aware of surveyor'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.

Based on record review, staff and family interview, it was determined that the facility failed to adequately monitor behaviors for a resident who was prescribed antipsychotic medication. This was evident for 1 out of five residents (Resident #2) reviewed for unnecessary medications. The findings include: A family interview was conducted on 12/10/18 at 10:10 AM with Resident #2's spouse. Spouse stated that he/she felt the Resident was less interactive and had slowly been declining in awareness of his/her surroundings since the Resident was first admitted . A record review conducted on 12/10/18 at 2:20 PM revealed Resident #2 had a diagnosis of depression and had been prescribed two medications for this condition prior to admission and continued on both medications after admission. Record review conducted on 12/12/18 at 1:30 PM revealed a physician order dated 7/11/18 for a third medication for depression and a physician order dated 7/31/18 for an antipsychotic medication for agitation. Record review on 12/13/18 at 10:45 AM of behavioral health progress notes from the previous 6…

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 with a resident and facility staff, it was determined the facility failed to provide what was on the menu for a resident who was served lunch. This was found to be evident for 1 resident (Resident # 41) while observing lunch being served during the facility's annual survey. The findings include: An interview was conducted with Resident #41 on 12/11/18 at 2:00 PM and s/he complained that the food was not correct when it is brought to them by dietary. The resident went on to say that the dietary department is unable to read the dietary slips and stated that if they are reading the diet slips correctly, why was s/he served a pureed diet, when my diet slips reads regular? An observation was made of Resident #41's plate of food and there was a serving of pureed spinach on his/her plate. The resident also stated that dinner is sometimes served as late as 7:00 PM at times. Review of Resident #41's diet slip that was on his/her tray indicated a regular diet. An interview was conducted with the Nursing Home Administrator (NHA) and Dietary Manager (DM) on 12/17/18. The DM…

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, and staff interview it was determined that the facility staff failed to 1) follow infection control practices and guidelines while performing duties and caring for residents and 2) provide sanitary storage conditions to prevent the development and transmission of disease by not providing proper storage of resident mattress and fall mats after disinfection by central supply. This deficient practice has the potential to affect all residents in the facility. 1a. During an observation of the 1A Unit on 12/11/18 at 01:26 pm, surveyor noted Geriatric Nursing Assistant (GNA) (Staff #33) enter room [ROOM NUMBER] with a white Styrofoam cup labeled Rm #120 and placed on top of a dispenser to care for a resident in the room. The GNA exited the room, sat the cup on a nearby medication cart, poured water into cup from a pitcher and took it to room [ROOM NUMBER]. The GNA was interviewed immediately after the observation in the presence of their Unit Manager (UM) (Staff #5). The GNA acknowledged 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.