King David Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility staff failed to clarify a physician's order, failed to follow a physician's order, and failed to ensure a resident received their medication as ordered. This deficient practice was evidenced in 1 (#9) of 5 medical records reviewed during the complaint survey.The findings include:1. On 02/25/26 at 11:38 am a review of Resident #9's electronic health record (EHR) revealed a change in condition note was written on 12/23/25 at 1:38 pm indicating the resident was diagnosed with Influenza A. An order was written on 12/23/2025 1:27 pm for Tamiflu Oral Capsule 30 MG Give 1 capsule by mouth two times a day (BID) for Flu for 5 Days; the order was discontinued on 12/23/2025 10:51 pm. The resident never received the medication. The surveyor received a note indicating the physician was made aware on 12/23/25 at 10:50 pm. Another order was written on 12/23/25 at 10:51 pm Tamiflu 30 MG Give 1 capsule by mouth two times a day for Flu for 5 Days. According…

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.

On the review of the electronic health record and interview it was determined that the facility staff failed to document when a resident received activities of daily living (ADL) assistance. This deficient practice was evidenced in 1 (#6) of 5 resident records reviewed during the complaint survey.The findings include:On 02/25/26 at 8:39 am a review of Resident #6 ADL tasks for the months of December 2025 and January 2026 revealed there were multiple GNA tasks that were not completed during both months. On 12/24 & 12/25/25 (11 pm - 7 am), 12/26/25 (7am- 3 pm), and 12/31/25 (11 pm - 7am) there was no documentation to verify if the resident received personal hygiene care. On 12/24 & 12/25/25 (11 pm - 7am) 12/26/25, (7am-3pm), and 12/31/25 (11pm-7am) there is no documentation to verify the resident was turned and repositioned. On 01/03/26 (3pm-11pm) there was no documentation to verify the resident was turned and repositioned. On 01/03, 01/11, 01/18 during 11pm - 7am shift there was no documentation to verify if the resident was bathed. There was no documentation on 01/03, 01/11, 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 observations and interviews it was determined that the facility staff failed to maintain infection control practices. This deficient practice was discovered during three observations of linen carts and shower rooms during the complaint survey.The findings include:On 02/18/26 at 8:31 am during observation rounds the surveyor observed a linen cart outside of room [ROOM NUMBER] with a tube of cream, shower gel, a fan, and a bag of wash cloths on top on the linen cart.On 02/18/26 at 8:43 am the surveyor observed an uncovered linen cart outside of room [ROOM NUMBER].On 02/20/26 at 10:25 am the surveyor made Unit Manager #5 aware of the uncovered linen cart and the linen cart with items on top. LPN Unit Manager #5 verbalized the linen cart should have been covered and the items should not have been on top of the linen cart.On 02/20/26 at 10:30 am while in the shower room on Sudbrook with LPN Unit Manager #5 the surveyor observed a used washcloth on the grab bar in the shower stall and two used washcloths and…

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

Based on record review and interview it was determined the facility staff failed to make prompt efforts to resolve grievances and keep the resident/representative appropriately apprised of progress toward resolution. This was evident for 1 (#8) of 6 residents reviewed for neglect.The findings include:A complaint involving Resident #8, and Resident #8's medical record were reviewed on 9/15/25 at 11:44 AM.Resident #8 was evaluated by 2 physicians on 3/31/25 and certified to lack mental capacity to make informed medical decisions. The residents' children became his/her surrogate decision makers.The complaint indicated that on the evening of 6/4/25, one of Resident #8's children was concerned that the Residents' condition was deteriorating. They asked Staff #12 a Licensed Practical Nurse (LPN) to call an ambulance. They reported that Staff #12 refused, told them to make the call themselves, argued with the family and failed to check on the resident following their request. The complaint also indicated that an email was sent to the facility's management team and Social Worker that night…

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 the facility staff failed to report an allegation of neglect to the State Survey Agency. This was evident for 1 (#8) of 6 residents reviewed for neglect.The findings include:Resident #8's medical record and a complaint involving Resident #8, were reviewed on 9/15/25 at 11:44 AM.The complaint indicated that on the evening of 6/4/25, Resident #8's family members were concerned that the Residents' condition was deteriorating. They asked Staff #12 a Licensed Practical Nurse (LPN) to call an ambulance. The complaint indicated that Staff #12 refused, told them to call 911 themselves, argued with the family and failed to check on the resident following the request to call 911. The complainant also indicated s/he sent an email to the facility's management team and Social Worker later the same night. Review of the email revealed it was sent by Resident #8's family member on 6/5/25 at 4:18 AM to the Director of Rehab as well as Staff #6, the Social Work Director. Staff #6 forwarded the email to the Administrator on 6/5/25 at 12:12 PM.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 medical record review and interview with resident and facility staff, it was determined that the facility failed to put interventions in place to prevent the future occurrence of abuse and neglect allegations. This was evident during the review of 2 of 2 allegations of abuse reported by Resident #2.The findings include:1. Medical record review of Resident # 2 on 9/16/25 at 10:30 AM revealed allegations of abuse that occurred during the rendering of activities of daily living (ADL) that was being provided to Resident #2 on 8/23/25 and then again on 9/7/25. Resident #2 first made allegations that his/her rights were violated on 8/23/25 when s/he reported that staff changed and dressed him/her without permission. Resident #2 even stated that s/he had told the staff 'No', but they continued to change his/her shirt anyway. Resident #2 alleged that s/he was held down by the wrists and made to change his/her shirt.Resident #2 was interviewed on 9/16/25 at 12:15 PM regarding what occurred on the night of 8/23/25. S/he stated that his/her regular GNA was not scheduled, and another…

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 that upon resident admission to the facility the physician failed to address a hospital discharge plan to provide CPAP (Continuous Positive Airway Pressure) at night and to wean a resident off supplemental oxygen. This was evident for 1 (#8) of 8 residents reviewed for Quality of Care.The findings include:Resident #8's medical record was reviewed on 9/15/25 at 11:44 AM. The resident was admitted to the facility from the hospital on 3/28/25. Their diagnoses included but were not limited to Obstructive Sleep Apnea and acute respiratory failure with hypercapnia (excessive carbon dioxide in the blood).The hospital Discharge summary dated [DATE] reflected post discharge plans which included but were not limited to: continue to wean off O2 (oxygen) continue with supplemental O2 in the meanwhile Continue with CPAP at night.A CPAP (Continuous Positive Airway Pressure) machine delivers a steady stream of air through a mask to keep the users airway open…

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 it was determined the facility failed to develop and implement a comprehensive person-centered plan to meet the residents' needs. This was evident for 1 (#8) of 8 residents reviewed for Quality of Care.The findings include: Oxygen weaning involves the gradual reduction of supplemental oxygen to determine a patient's ability to maintain adequate oxygen saturation on room air. A common approach includes decreasing oxygen flow rates in small increments, observing for symptoms and SpO2 (blood oxygen saturation level) at rest and during activity and ensuring the patient can sustain the target SpO2.A CPAP (Continuous Positive Airway Pressure) machine is a common treatment for sleep apnea, delivering a steady stream of air through a mask to keep the patients airway open during sleep and prevent pauses in breathing.Resident #8's medical record was reviewed on 9/15/25 at 11:44 AM. The resident was admitted to the facility from the hospital on 3/28/25. Their diagnoses included but were…

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

Based on medical record review and interview with resident and facility staff, it was determined that the facility failed to revise a care plan related to a resident's specific identified and individualized needs. This was evident during the review of 1 of 3 (Resident #2) resident care plans reviewed for facility self-reports.The findings include:Medical record review of Resident # 2 on 9/16/25 at 10:30 AM revealed multiple comorbidities including concerns with chronic pain, mood and adjustment disorder, cancer and a history of respiratory failure. Resident #2 also recently had 2 allegations of abuse reported to the facility regarding treatment during ADL care.A review of Resident #2's care plans on 9/16/25 revealed care plans initiated on admission in 2024 for said medical diagnosis' including shortness of breath with interventions for example to include proper positioning.However, the care plans related to Resident #'2's mental health, mood disorder and depression, initiated 2/5/24 and 10/29/24 respectively state to administer medications, see a psychiatrist/behavioral health 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 it was determined the facility staff failed to ensure hospital discharge treatment plans for supplemental oxygen weaning and CPAP use were implemented upon the residents' admission to the facility and failed to have an effective process to wean residents off supplemental oxygen. This was evident for 1(#8) of 8 residents reviewed for Quality of Care.The findings include:Resident #8's medical record was reviewed on 9/15/25 at 11:44 AM. The resident was admitted to the facility from the hospital on 3/28/25. Their diagnoses included but were not limited to Obstructive Sleep Apnea and acute respiratory failure with hypercapnia (excessive carbon dioxide in the blood). The hospital Discharge summary dated [DATE] included post discharge plans which included but were not limited to: continue to wean off O2 (oxygen) continue with supplemental O2 in the meanwhile continue with CPAP at night. Oxygen weaning involves the gradual reduction of supplemental oxygen to determine a patient'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 observation and interview it was determined the facility failed to ensure bed rails were securely affixed to the bed frame to limit entrapment zones. This was evident for 1 (#1) of 1 resident reviewed for Physical Environment.The findings include:An observation of Resident #1's room was made on 9/12/25 at 9:00 AM. 1/4 bed rails were located on both sides of the bed near the head of the bed. The rails were not firmly affixed to the frame, were loose and easily tilted away from the mattress creating a gap approximately 4-5 inches wide between the mattress and the rail. The bed was observed again on 9/15/25 at 9:33 AM, the rails remained loose.On 9/15/25 at 11:15 AM the Administrator was asked to provide the facility's bed rail inspection logs for the past 6 months. He indicated that an inspection was in progress and was asked to provide documentation of the current inspection as well.At approximately 12:00 PM the Administrator provided 1 bed rail audit dated 9/26/24 and indicated that the facility completed bed rail safety audits yearly. He did not provide evidence of the…

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

Based on observations and interviews it was determined that the facility failed to provide a resident with a reasonable accommodation of need. This was found evident of 3 out of the 4 observations made in Resident #1's room. The findings include: On 4/10/25 at 11:42 AM, the surveyor interviewed Resident #1. During the interview Resident #1 stated that his/her clock was not working and that the time had been off for some time. He/She further stated that he/she had asked a staff member to fix it but they had not fixed it yet. On 4/11/25 at 12:48 PM, the surveyor observed Resident #1's clock not working again. The surveyor asked the Nursing Home Administrator (NHA), who was in the hallway, to observe the clock not working. The NHA stated that he would have the clock fixed. On 4/14/25 at 12:17 PM, the surveyor observed Resident #1's clock. Again, the clock was not working. The surveyor informed the Director of Nursing (DON) about the Resident #1's clock not working. The DON stopped the Maintenance Director in the hall and informed him about the clock. The Maintenance Director stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident for 2 ([NAME] view and [NAME]) of 4 units observed during the annual survey. The findings include: 1a) On 4/10/25 at 9:36 AM, the surveyor observed crumbs, debris, and mouse dropping along the back corner wall for Resident #68's room located on the [NAME] View Unit. On 4/11/25 at 12:31 PM, the surveyor interviewed the Nursing Home Administrator (NHA). The surveyor asked if housekeeping had cleaned the resident's room yet. He stated he believed so. Next the surveyor escorted the NHA to Resident #23's room. The NHA observed the crumbs, debris, and mouse droppings that the surveyor observed the day before. The NHA stated he would have the room cleaned up immediately. 1b) On 4/10/25 at 11:25 AM, the surveyor observed room [ROOM NUMBER] in the [NAME] Unit and noted a rectangular cardboard like plank…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, it was determined the facility failed to notify the Ombudsman of resident's transfers. This was found evident of 3 (Resident #4 #16 & #96) of 3 residents reviewed for hospitalization during the survey. The findings include: 1a) On 4/11/25 at 8:11 AM, the surveyor reviewed Resident #4's medical record. The review revealed that Resident #4 had a change in condition on 1/12/25 and was sent to the hospital. On 4/15/25 at 12:21 PM, the surveyor asked the Nursing Home Administrator (NHA) for records to demonstrate that the Ombudsman was notified of Resident #4's transfer. On 4/17/25 at 8 AM, the surveyor conducted a follow-up interview with the NHA. During the interview the NHA confirmed that there was no notification made to the Ombudsman for Resident #4's transfer. 2a) On 4/14/25 at 9:27 AM, a review of Resident #16 and #96's chart was conducted. Resident #16 was transferred to the hospital on [DATE] and 12/24/24. Resident #96 was transferred to the hospital on 3/13/25. 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.

Based on record review and staff interview, it was determined that the facility failed to comprehensively assess a resident who has had a significant change in status using the CMS-specified Resident Assessment Instrument (RAI) process and weight change. This was evident for 2 (Resident #101 and #16) out of 55 residents reviewed for change of condition. The findings include: The Resident Assessment Instrument (RAI) helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. 1a) Review of Resident #101's medical record on 4/11/25 at 8:45 AM revealed that Resident #101 had two significant functional changes: significant weight loss and a decrease in functional feeding ability from independent to dependent. Continued review of Resident #101's medical record on 4/11/25 at 9:30 AM revealed the MDS record showed no significant changes in the resident's functional ability at any time during the resident's stay. MINIMUM DATA SET The MDS is a federally mandated assessment tool used by nursing home…

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 interviews it was determined that the facility failed to ensure that a resident received treatment to promote healing of a pressure ulcer. This was found evident in 1 (Resident #4) out of 2 Residents reviewed for pressure ulcers. The findings include: On 4/15/25 at 9:34 AM, the surveyor reviewed Resident #4 ' s medical record. The review revealed that Resident #4 had two, Stage 4 pressure ulcers. (Stage 4 being the most severe type of pressure ulcer, characterized by full-thickness skin and tissue loss, with exposed or fascia, muscle, tendon, ligament, cartilage, or bone) One to the right hip and the other in the sacral area. Next the surveyor reviewed a wound note written by the in-house wound consult physician Staff #13 dated 4/7/25. The note described that a debridement (procedure to remove dead, damaged, or infected tissue from a wound to promote healing) was completed to the sacral wound. The note ends with treatment goals and treatment recommendations: The sacral wound to be cleansed with 0.5% of Dakin solution and given the change of…

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

Based on observations, medical record review and interviews it was determined that the facility failed to 1) ensure that a resident's room was free from hazards and 2) adequately monitor a resident with known behaviors. This was found evident for 1 (Resident #68) out of 3 residents reviewed for accidents and 1 (Resident #23) out of 3 Residents reviewed for behaviors. The findings include: 1) On 4/10/25 at 9:36 AM, the surveyor observed Resident #68 ' s bed plugged into an outlet on the other side of the room. On further observation a power-strip was plugged into the second plug and was resting on the floor. An extension cord was then plugged into the power strip. Next the surveyor interviewed Resident #68. During the interview the Resident #68 stated that approximately 4 months ago the outlet on his/her side of the room blew and that he/she had not been able to use the outlet since. Resident #68 stated that currently his/her roommate was in the hospital so he/she could use the outlet, however he/she needed the extension cord to plug charging cords into. On 4/11/25 at 12:31 PM, 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 record review and interviews, it was determined that the physician failed to document a note addressing a resident's significant weight loss. This was evident for 1 out of 2 residents reviewed for nutrition. The findings include: On 4/11/25 at 9:18 AM, Resident #16's weights were reviewed. On 10/11/2024, the resident weighed 135.8 lbs. On 04/02/2025, the resident weighed 109 pounds which is a 19.73 % loss over 6 months. On 4/14/25 at 10:21 AM, a review of Resident #16's progress notes was conducted. A Dietitian progress note dated 10/29/2024 at 10:59 AM, stated Resident #16 had a new weekly weight on 10/25/24 of 125.4 pounds with a Body Mass Index of 22.2. The dietician stated that the weight loss was significant and documented that the interdisciplinary team, Medical Director, and Resident Representative was made aware of the significant weight loss. On 4/14/25 at 10:28 AM, a review of Resident #16's physician notes was conducted. There were no physician's notes in Resident #16's chart that addressed the resident's weight loss from 10/25/24. On 4/14/25 at 11:00 AM, 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.

Based on record reviews, and interviews from resident and staff, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for Resident #62 in 2 out of the 4 months reviewed for Metformin administrations. The findings include: On 4/10/25 at 1:53 PM the surveyor conducted an interview with Resident #62. During the interview Resident #62 stated that on several occasions he/she was not provided his/her prescribed metformin (a medication used to treat type 2 diabetes) due to the facility running out. On 4/16/25 at 1:16 PM, the surveyor reviewed Resident #62 ' s Medication Administration Records (MAR) in 2025. The review revealed that on Resident #62 ' s February MAR, the medication metformin was marked 9 on 2/11/25 and 2/12/25 and on the March MAR, metformin was marked 9 on 3/14/25, 3/15/25, and 3/16/25. The code for 9 was, see progress notes. The surveyor asked the Director of Nursing (DON) for the corresponding progress notes for the dates marked as 9. On 4/16/25 at 1:59 PM, the surveyor conducted a follow-up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews it was determined that the facility failed to have an effective pest control program. This was found evident in one room on the [NAME] View Unit. The findings include: On 4/10/25 at 9:36 AM, the surveyor observed crumbs, debris, and mouse dropping along the back corner wall for Resident #68's room. On 4/11/25 at 12:31 PM, the surveyor took the NHA to Resident # 68's room. The NHA observed the crumbs, debris, and mouse droppings that the surveyor observed the day before. The NHA stated he would have the room cleaned up immediately. The surveyor requested pest management documentation. Next the surveyor reviewed the pest problem log book for the [NAME] View unit. The log book revealed that Resident #68's room was reported to have mice concerns in September of 2024 and treated. On 4/15/25 the surveyor reviewed the treatment invoices for the pest management company that serviced the facility for 2025. The treatments were described at weekly service to inspect and treat for mice…

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 facility failed to inform and give written notice for the reason for a room change to a Resident's Representative (RP). This occurred on 3 out of 3 bed reassignments made for Resident #23. The findings include: On 4/17/25 at 12:54 PM, the surveyor reviewed Resident #23's room census. The review revealed that on 10/16/23, 10/15/25 and 1/28/25 Resident #23 was relocated to a different bed assignment. On 4/17/25 at 2:32 PM, the surveyor requested from the Nursing Home Administrator (NHA) the written notice with reason for room change for Resident #23. On 4/18/25 at 8:41 AM, the surveyor conducted an interview with the NHA. During the interview the NHA stated that when a resident bed assignment is going to change the resident or the RP is told about the room change. However, confirmed that there was no documentation to validate that Resident #23's RP was notified with the reason on any of the bed reassignments.

Based on record review and interviews, it was determined that the facility failed to protect a resident from abuse from another resident. This was found evident of 1 (Resident #47) out of 8 Residents reviewed for abuse allegations during an annual and complaint survey. The findings include: On 4/16/25 at 10:35 AM, the surveyor reviewed a complaint. The complainant alleged that Resident #23 was witnessed sexually harassing his/her roommate and nothing was being done about it. On 4/17/25 at 2:13 PM, the surveyor reviewed Resident #23's medical record. The review revealed a progress note written by Licensed Practical Nurse (LPN) #8 on 4/9/24 at 12:44 PM that stated, Resident was observed as touching and exposing his/her private part and was also inviting the roommate to participate on it with him/her. A care plan was initiated on 4/10/24 that stated Resident #23 has a behavior problem related to sexual inappropriateness with a female staff. One of the interventions listed was, intervene as necessary to protect the rights and safety of others. Another was, remove from the situation and…

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

Based on a complaint, medical record review and interviews with a resident and staff, it was determined the facility staff failed to report an allegation of abuse to the regulator agencies and Office of Health Care Quality (OHCQ). This was found evident in 1 (Resident #47) out of 8 residents reviewed for abuse. The findings include: On 4/16/25 at 10:35 AM, the surveyor reviewed a complaint. The complainant alleged that Resident #23 was witnessed sexually harassing his/her roommate and nothing was being done about it. On 4/17/25 at 12:43 PM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the NHA confirmed that the facility did not have any investigation in regard to Resident #23. On 4/17/25 at 2:13 PM, the surveyor reviewed Resident #23's medical record. The review revealed a progress note written by Licensed Practical Nurse (LPN) #8 on 4/9/24 at 12:44 PM that stated, the Resident was observed as touching and exposing his/her private part and was also inviting the roommate to participate on it with him/her. On further review a progress note…

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 a complaint, review of facility investigations, record review, and interviews it was determined that the facility failed to: 1) prevent potential abuse after a documented incident occurred and 2) failed to complete a thorough investigation and maintain the records of their investigation. This was found evident of 1 (Resident #47) out of 8 residents reviewed for abuse and 1 (Resident #68) out of 9 residents reviewed in facility reported incidents. The findings include: 1a) On 4/16/25 at 10:35 AM, the surveyor reviewed a complaint. The complainant alleged that Resident #23 was witnessed sexually harassing his/her roommate and nothing was being done about it. On 4/17/25 at 2:13 PM, the surveyor reviewed Resident #23's medical record. The review revealed a progress note written by Licensed Practical Nurse (LPN) #8 on 4/9/24 at 12:44 PM that stated, the Resident was observed as touching and exposing his/her private part and was also inviting the roommate to participate on it with him/her. 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.

Based on medical record review and interview, the facility failed to accurately document medical information in a resident's medical record and in accordance with acceptable professional standards and practices by keeping complete documentation. This was evident for 2 (Resident #104 and #23) out of 57 residents reviewed during a facility's complaint survey. The findings include: 1a) Surveyor review of Resident #104's medical record on 4/15/25 at 11:00 AM revealed the facility nursing staff failed to document Activities of Daily Living (ADL) care for the resident on 11/10/24 after 7:00 AM. The documentation stated that the resident was not available for nursing staff to provide adl care. Continued review of the resident's medical record on 4/15/25 at 11:30am revealed that the resident was in the facility all day on 11/10/24. Surveyor interview of the administrator on 4/17/25 at 8:30 AM confirmed that the resident was in the facility on 11/10/24 and the Administrator was also unable to explain why the nursing staff failed to document adl care after 7:00 AM on 11/10/24. 2a) On 4/18/25…

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 surveyor observation throughout the annual recertification survey it was determined that the facility staff failed to maintain a sanitary, orderly, and comfortable interior in four locations: Resident #211's room, the dining room, Resident #3's oxygen concentrator, and the facility's parking lot. The findings include: On 4/22/2021 at 9:22 AM a gap was observed between room [ROOM NUMBER]'s air conditioning unit and the surrounding wall. On 4/22/2021 at 10:00 AM the dining room revealed the two right-most windows was had holes in the screens. On 4/23/2021 at 8:11 AM observation of Resident #3's oxygen concentrator revealed the presence of small, brown liquid stains. Further observations of the resident's oxygen concentrator on the following dates and times: 4/16/2021 at 1:14 PM, 4/27/2021 at 8:32 AM and 12:30 PM, 4/28/2021 at 8:15 AM, 4/29/2021 at 8:40 AM, and 4/30/2021 at 8:15 AM confirmed the presence of the same brown stain observed on 4/23/2021. On 4/29/2021 at 2:00 PM, over one dozen discarded…

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 clinical record review, observation, and staff interview it was determined that the facility staff failed to prevent unplanned weight loss for 1 out of the 45 residents that were part of the survey sample (Resident #21) and failed to promptly address a significant weight loss for 1 of 45 residentw that were reviewed as a part of the survey sample (Resident #39). The findings are: 1. On 4/22/21 a review of Resident #21's clinical record revealed that the resident weighed 138.4 pounds on 2/24/21. On 4/15/21 Resident #21 weighed 108.4 pounds. This represents a 21.68% loss in weight. On 4/22/21 at 8:45 AM surveyor observed that Resident #21's breakfast tray was untouched. The food was undisturbed and the silverware had no food debris on it. The Geriatric Nursing Assistant (GNA) documented that the resident ate 26-50% of the meal. On 4/26/21 at 8:14 AM Resident #21's food tray had all of the menu items on the tray. The food was undisturbed and the silverware was clean. At 9:24 AM the tray was observed to have been removed. A muffin and two cookies were left on Resident #21'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 observation, clinical record review, and staff interview it was determined that the facility's staff failed to adequately monitor oxygen use for 1 of 48 residents in the survey sample Resident #383). The findings include: A review of Resident #383's clinical record revealed that the resident had an order to apply oxygen at 2 LPM [liters per minute] via NC [nasal cannula] continuous for COPD [Chronic obstructed pulmonary disease]. Resident #383 was observed on 4/22/21 at 11:34 AM. The resident did not have the nasal cannula for the oxygen placed in the nose as appropriate. The cannula was in the resident's lap. This surveyor observed the resident on 4/26/21 at 8:20 AM. The nasal cannula was not in the resident's nose. Upon return at 1:14 PM the nasal cannula was not in the resident's nose. The Resident's oxygen concentrator was covered in plastic. The resident was observed on 4/27/21 at 8:32 AM and 12:30 PM to not having the nasal cannula place in the nose.

Based on observation, medical record review and interview with resident and staff it was determined that the facility failed to initiate a pain regimen timely for a resident with reported and verbalized pain. This was evident for 1 of 5 residents reviewed for pressure ulcers (#47) The findings include: Review of the medical record on 4/23/2021 at 12:39 PM, Resident #47 was noted with a stage 3 pressure area on his/her genital area. Medical record review of Resident #47 at 7:40 AM revealed an order for Tylenol as needed for pain. Surveyor observed wound care for Resident #47 on 4/26/2021 at 11:23 AM. Resident #47 yelled out in pain and reported that when his/her genital area is touched it caused discomfort. A change in condition nursing note completed on 4/26/2021 at 12:15 PM documented that the resident's primary physician was notified of the observation that morning. The resident was interviewed and stated that it only hurts when they touch it. The physician decided because the area did not appear infected no new medications were ordered. Review of the medical record on 4/27/2021…

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 ensure staffing information was posted in clear, readable, and complete manner. This was evident for 1 out of 3 shifts. The findings are: On 4/22/21 at approximately 8:55 a.m. observation revealed the nursing staff's information was posted on a letter sized piece of paper on the counter of each nursing station. The posted information was not accessible to visitors because the visitor would have to visit each nursing station to obtain then required information. The Director of Nursing (DON) was interviewed on 4/30/21 at 11:33 AM. The findings were discussed. 04/30/21 a review of the staffing sheets revealed that the [NAME] staffing sheets did not match hours the facility indicated they paid staff. The facility posted one nurse worked on the staffing sheet, but other records indicate two nurses were paid to work. They posted that they had two Geriatric Nursing Assistants (GNA) working but they claimed they paid for 1.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews it was determined that the facility failed to 1) Ensure medications requiring refrigeration were stored safely 2) Ensure medications were stored and labeled properly 3) Ensure expired medications were properly disposed and; 4) Ensure medications were kept in secured locations. This was found to be evident in 1 out of 2 medication storage rooms, 4 out of 4 medication carts and 2 out of 2 treatment carts during observation of medication storage and labeling and has the potential to affect all residents. The findings include: 1. On 04/23/2021 at 12:05 PM the surveyor and RN #6 (unit manager) conducted an observation of the locked medication storage room and locked medication cart located on the Mt. [NAME] nursing unit. On 04/23/2021 at 12:06 PM, during the observation of the medication storage room, the surveyor observed the medication refrigerator thermostat temperature at 49 degrees Fahrenheit. The Mt. [NAME] Temperature Log dated 04/19/21, 04/20/21, 04/21/21,…

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, it was determined the facility staff failed to provide the most practical dignified existence for 4 of 45 for resident's reviewed during the survey by: 1) Entering Resident #36's room without knocking and waiting for an invitation to open the door; 2) Allowing Resident #44 to wait a minimum of 12 minutes after the resident's roommate was served prior to serving Resident #44; 3) Standing over (Resident #1) during assistance with a meal; providing care to Resident #36 in manner that did not provide full privacy for the resident. This was evident for 4 of 4 residents selected for review of dignity, a total of 45 residents were reviewed during the survey. The findings include: 1. Surveyor observation of Resident #36 on 4/22/21 at 9:45 AM revealed Staff #14 entered Resident #36's room to collect the resident's breakfast tray; however, staff failed to knock on the resident's door, then wait for permission to enter the room. On 4/22/21 at 9:45 AM and interview with Staff #14 at that the employee was aware of the need to knock on resident's door and wait…

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, it was determined the facility staff failed to notify the physician of a resident's ongoing refusal to take medication. This was evident for 1 of 45 residents selected for review during the survey process (Resident #333). The findings include: On 4/23/21 at 12:00 PM a review of Resident #333's, medical record revealed on 3/11/20 a physician ordered: Lopressor 50 milligrams, 1 tablet by mouth two (2) times a day, hold the medication for blood pressure less than 110/60 mm Hg or heart rate less than 60 beats per minute. Lopressor is a medication that lowers the blood pressure and heart rate. A continued review of Resident #333's medical record revealed that on 8/4/2020 a the physician ordered: Miralax powder, 17 grams by mouth once a day for the resident. Miralax is a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements. Miralax is used as a laxative to treat occasional constipation or irregular bowel movements. On 4/23/21 a review of the Medication Administration Record (MAR) revealed…

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, it was determined that the facility staff failed to notify the residents or their responsible party in writing of the reason for a resident's transfer to the hospital (Residents #69). This was evident for 1 of 3 residents reviewed for hospitalization during the annual recertification survey. The findings include: 1. A review of Resident #69's medical revealed the resident was transferred to an acute care facility on 3/24/2021. There was no documentation found in the medical record to show the resident and or the resident's responsible party was given written notice of the reason for the resident's transfer in a language and manner that they understand. On 4/23/21 11:27 AM in an interview, the Director of Nursing was made aware there was no documentation found in Resident #69's medical records that the residents or the resident's responsible party was given written notice of the Resident's transfer in a language and manner they understand. This finding was confirmed by the Director of Nursing.

Based on resident record review and staff interview it was determined that the facility failed to conduct a comprehensive assessment within 14 days of a significant change for 1 of 48 residents reviewed during the complaint survey (Resident #66). The findings include: A significant change is a major decline or improvement in a resident's status that will not normally resolve itself without further intervention. Comprehensive Assessments provide insight to a resident's status and includes measurements such as vital signs and symptoms, medical history and physical examinations. On 4/22/2021 at 11:45 AM a review of Resident #66's medical record revealed a weight loss of 15.12% of the resident's body weight between 12/31/2020 to 4/2/2021. Generally, a 7.5% weight loss in a three (3) month period is considered significant. A review of the Facility's Policy for Weights, on 4/29/2021 at 11:49 AM, revealed the facility defines a 7.5% change over a three (3) month period as a significant change in a resident's weight. The policy also stated For significant weight gain or loss, the dietician…

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, it was determined the facility staff failed to initiate a care plan to address hearing impairment/bilateral hearing aids for Resident (#69). This was evident for 1 of 1 resident selected for care plan review during the annual survey process. 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. The Long-Term Care Minimum Data Set (MDS) is a health status screening and assessment tool used for all residents of long-term care nursing facilities that are certified to participate in Medicare or Medicaid. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. A Care Area Assessment (CAA) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual…

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 it was determined the facility staff failed to provide grooming and personal hygiene services (Resident #56 ). This is evident for 1 of 4 residents selected for review for ADL care during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. The MDS 3.0 captures information about the residents' comorbidities, physical, psychological and psychosocial functioning in addition to any treatments (e.g., hospice care, oxygen therapy, chemotherapy, dialysis) or therapies (e.g., physical, occupational, speech, restorative nursing) received. Observation of Resident #56 on 4/25/21 at 12:45 AM revealed Resident #56 have elongated fingernails with brown-black matter under them. Interview with the resident at that time revealed the 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 medical record review, observation, and interview, it was determined the facility's staff failed to provide care for 3 of 45 residents in accordenance with professional standards of practice (Residents #2, #68, and #69). In regards to Resident #2, the faciliy failed to: 1) Administer medications to the resident as ordered, Administer the lesser pain medication based on the resident's stated level of pain, and Provide the resident with un-interrupted care. In regards to Resident #68, the facility failed to: 2) Document the outcome of finger sticks as ordered by the resident's physicians. In regards to Resident #69, the facility failed to: 3) Arrange routine pacemaker checks for the resident. The findings include: 1 A. The facility staff failed to administer medications as ordered by the physician. On 4/26/21 at 10:00 AM a review of Resident #2 revealed that on 8/25/20 a physician in conjunction with the a Dietician ordered: Enternal Bolus feeding, 237 cc, 1 can, Osmolite 1.5 Bolus feeding x 5 cans daily for the resident. Enteral feeding may mean nutrition taken through 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 and interview, it was determined the facility staff failed to provide treatment/services to prevent potential pressure ulcer to (Resident #2). This is evident for 1 of 5 residents selected for review of pressure ulcers during the annual survey process and 1 of 45 residents selected for review during the annual survey. The findings include: A pressure ulcer also known as pressure sore or decubitus ulcer as any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Observation of Resident #2 on 4/28/21 at 12:00 PM revealed the resident in bed. Further observation of the resident at that time revealed the residents upper thighs crossed and in a fixed position, knee to knee. Further observation revealed the facility staff failed to apply any items to separate the legs to prevent friction, moisture and the potential for breakdown. Although the resident's legs are fixed in a tight position; a pillow case, towel or folded sheet could be used to separate the resident's legs to relieve pressure from them and to absorb any moisture. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility failed to ensure resident safety when the resident was transferred from the floor to bed. This was found to be evident for 1 out of 1 resident observed for transfer (resident #74). The findings include: The Minimal Data Set (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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. On 04/29/2021 at 8:43 am Resident #74 was observed on the floor, unclothed, sitting upright on his/her buttocks approximately 18 inches from the foot of the bed in his/her assigned room. Surveyor observed Assistant Director of Nursing (ADON) #3, Translator/Social Worker #5, Unit Manager # 10,…

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

Based on medical record review, observation, and interviews with facility staff it was determined the facility staff failed to provide support and security for indwelling urinary catheters. This was evident for 2 of 5 residents reviewed for indwelling urinary catheters during the annual survey (Residents #47 and #27). The findings include: 1. On 04/26/2021 a review of Resident #47's medical record revealed the presence of a urinary catheter related to neurogenic bladder (a urinary condition in people who lack bladder control due to a brain, spinal cord, or nerve problem). Further review of the medical record for Resident #47 revealed a stage 3 pressure ulcer to the genital area. Surveyor observed wound care for Resident #47 on 4/26/2021 at 11:23 AM. Resident #47 yelled out in pain and reported that when his/her genital area is touched it caused discomfort. At this time, it was also noted that the foley catheter was not secured to the resident's leg. On 4/26/2021 at 11:37 AM the Unit Manager, Staff #10, and Staff #16, were interviewed regarding the lack security on the foley…

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, it was determined the facility's staff failed to consistently administer medication according to vital sign parameters as outlined in physician's orders. The facility's staff also failed to report the outcome of a resident's vitals signs to the physician as ordered. This was evident for 1 of 5 residents selected for medication review (Resident #11). The findings include: On 4/29/21 at A review of Resident #11's record revealed that on 8/21/20 a physician ordered Atenolol 50 milligrams by mouth two (2) times a day, with instructions to hold this medication when the resident's systolic blood pressure (SBP, systolic/diastolic) is less than 110/60 mm Hg and the resident's heart rated is less than 55 beats per minute. Atenolol is used with or without other medications to treat high blood pressure and can also lower the heart rate. On 8/21/20 the physician ordered Lisinopril 20 mg every day, with instructions to hold the medication when Resident #11's SBP is less than 110/60 mm Hg or heart rate is less than 55 beats per minute. Lisinopril 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 medical record review and interview, it was determined the facility staff failed to clearly identify target symptoms for the administration of psychotropic medications and establish a plan for the ongoing monitoring of those symptoms for Resident 2 of 5 residents selected for review of unnecessary medication and 1 of 45 residents selected for review during the annual survey process (Residents #68 and #93). The findings include: 1. On 4/28/21 a review of Resident #68's medical record revealed the following note from a psychiatric nurse medication review: [Patient] was [discharged ] without Nuplazid (not clear why) and Seroquel. during the visit [patient] looks calm, confused more then usual, weak but denies to have hallucinations, change diagnosis for Seroquel, it is given for Hallucinations due to Parkinson's disease. Further review of Resident #68's orders revealed that on 3/28/21 the psychiatric nurse ordered: Quetiapine Fumarate Tablet 25 milligrams 1 time a day via G-tube (gastrostomy tube, a tube inserted through the abdomen that brings nutrition directly 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 medical record review, observation and interview it was determined the facility staff failed to obtain a medication error rate less than 5%. This was evident for 2 medication errors out of 26 medication observation opportunities. This resulting in an error rate of 7.69%. The findings include: On 4/29/2021 a review of Resident #10's medical record revealed that on 8/17/20 a physician ordered: Trajenta Tablet 5 milligrams by mouth one time a day related to Diabetes for the resident. Trajenta is used to lower blood sugar levels in patients with type 2 diabetes mellitus. Observation of medication pass on 4/28/21 at 9:33 AM revealed Staff #9 failed to administer the Trajenta to Resident #10. Further review also revealed the facility staff failed to obtain the medication and administer it later in that day. Interview on 4/29/21 art 12:00 PM, Staff #10 revealed it is the expectation of the facility's staff to notify the pharmacy if a medication is missing, then have the medication delivered, and to notify the resident's physician of the missed medication doses. After, surveyor…

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

Based on medical record review and interview, it was determined the facility staff failed to obtain dental consultations for 1 of 3 residents (Resident #22) selected for review of dental care and 1 of 45 residents selected for review during the annual survey. The findings include: On 4/26/21 a review of Resident #22 medical record revealed that on 1/10/18 the resident's physician ordered dental consultations yearly, and as needed. Further record review revealed the resident was seen last seen by a dentist on 1/10/18. There is no evidence the resident was seen by a dentist or a dental hygienist in 2019 or 2020. An interview with Resident #22 on 4/26/21 at 1:00 PM confirmed the resident had not been seen by a dentist for a long time. (Of note, the resident did not verbalize any concern related to mouth pain or difficulty in chewing). In an interview with the Nursing Home Administrator and Director of Nursing on 4/30/21 at 2:00 PM they confirmed the surveyor's findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff it was determined that the facility failed to 1) Ensure that sanitary practices were followed and kitchen equipment was well maintained and 2) Ensure the nourishment refrigerator contained products that were not expired and safe for resident consumption. This was evident during the initial tour of the facility. This deficient practice has the potential to affect all residents. The findings include: 1. On [DATE] at 8:15 AM a tour of the facility's main kitchen was conducted with the Administrator in Training (Staff #24). The ice cream freezer in the Rabbi's office was observed with a half ripped temperature log for the previous month of March and no temperature log for the current month of April. The milk refrigerator outside the Rabbi's office was also observed without a temperature log at this time. Further inspection of the main kitchen revealed that the fire suppression system above the stove range was in disrepair and the nozzles were not properly…

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 staff interview, it was determined the facility staff failed to dispose of garbage and refuse properly. The findings include: On 4/23/2021 at 9:02 AM, 4/26/2021 at 8:43 AM, and 4/27/2021 at 10:57 AM the facility's dumpsters were observed with open side doors. All doors and lids on dumpsters should remain closed to maintain cleanliness and reduce the risk of pests. The findings were reviewed with the Administrator on 4/29/2021 at 11:00 AM.

Based on medical record review and staff interview, it was determined the facility failed to maintain the medical record in the most complete and accurate form for 1 of 48 residents in the final sample (Resident #66). The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. On 4/27/2021 at 11:31 AM, medical record review for Resident #66 revealed an order for Skin Assessment Weekly every day shift every Wed document using the following codes: 0 - No skin impairments 1 - Previous skin impairment present 2 - newly identified skin impairment starting 1/6/2021 with no end date. Review of Resident #66's Treatment Administration Records for January - April 2021 revealed that staff were marking yes and no rather than the numbered system ordered by the physician. This was evident for the entire month of January, 2/3/2021, 2/10/2021, and 2/17/2021, the entire month of March and 4/7/2021. Interview with the Director of Nursing 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.

Based on observation and staff interview it was determined that the facility failed to maintain kitchen and resident equipment in safe operating condition. This deficient practice has the potential to affect all residents. The findings include: On 4/22/2021 at 7:45 AM when entering the facility the ADA Operator, more commonly known as the Hadicap button, was not functional for the facility's front entrance. Interview with the Administrator and Administrator in Training on 4/26/2021 at 7:50 AM confirmed that the front door ADA Operator was not functioning and the Administrator stated they were having trouble getting it repaired due to the COVID-19 pandemic. The Administrator was unable to specify how long the ADA Operator for the door had not been functional. During a tour of the main kitchen with the Administrator in Training on 4/22/2021 at 8:15 AM the fire suppression system over the stove range was observed dislodged from the fume hood and hanging at an angle in disrepair. The angle at which the suppression system was hanging would discharge fire suppressant onto the back wall…

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 an interviews with a resident it was determined the facility failed to enhance and promote a resident's dignity when entering into their room to provide care. This was found to be evident for 1 out of 36 residents (Resident #6) during the survey. The findings include: An interview was conducted with Resident #6 on 10/18/18 at 10:35 AM and s/he was asked the question, do staff treat you with respect and dignity and the resident responded, no. Resident # 6 went on to say that staff does not knock prior to entering my room and that they do not acknowledge who they are. The resident also stated that there is a staff that works at the facility that is mean and nasty to residents. Resident #6 was asked to provide the surveyor with a name and s/he stated that s/he fears retaliation. An interview was conducted with the Administrator and the Director of Nursing on 10/22/18 at 10:10 AM and they were made aware of the resident's concerns. The Administrator stated that the facility will investigate all the concerns as well as educate staff.

Based on interview and review of pertinent documentation it was determined that the facility failed to allow a resident the autonomy to choose activities of his/her liking. This was evident in the review of 1 of 1 residents (Resident #83) reviewed for choices during the survey. The findings include: During an interview on 10/18/18 at 8:46 AM with Resident #83 s/he revealed that going to bingo was a big deal. S/he further stated that it is a concern that bingo is all s/he looks forward to and s/he cannot attend because they are scheduling rehab therapy at that time. Review on 10/22/18 at 2:16 PM of Resident #83's care plan with the facility Director of Nursing (DON) revealed that Bingo is included as one of the resident's identified preferred activities. A review of Resident #83's activity participation log on 10/22/18 at 2:34 PM with the Activity Director #3 revealed documented attendance in bingo only 1-2 times a month since August. According to the activity calendar bingo is offered minimally weekly. The concern that a resident's preference was not met and or documented as met or…

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

Based on observations and interviews with facility staff it was determined the facility failed to have a survey results sign posted identifying the location of the survey results. This was found to be evident during a resident council meeting with residents during the facility's annual survey. The findings include: The survey team conducted a council meeting on 10/19/18 at 11:33 AM with Resident's #11, #88, #24, #14, #39 and #9 in attendance. The residents were asked if they know about survey results and where they were located to review, and the residents stated that they were unaware of where the survey results could be found. The survey results were observed in the front lobby sitting on a table. There was no sign indicating where the survey results could be found. An interview was conducted with the Nursing Home Administrator (NHA) on 10/19/18 at 2:40 PM. The NHA was made aware that the survey book was located in the front lobby sitting on a table and that there was no sign posted identifying the location of the survey results, and that the book was not available on the unit and…

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

Based on medical record review, observation and interview it was determined that the facility failed to ensure that a resident was kept free from restraints as evidenced by the use of a tab alarm without a physician order, care plan or documented indication for the use of the alarm. This was found to be evident for 1 out of 2 residents (Resident #43) reviewed for restraints during the survey. The findings include: Review of Resident #43's medical record revealed the resident had resided at the facility for more than a year and whose diagnoses includes dementia, chronic back pain and high blood pressure. Review of the 8/30/18 Minimum Data Set assessment revealed that the resident had both short and long term memory problems and required extensive assistance of staff for transfers. This MDS assessment also revealed that the resident had no falls since admission. On 10/18/18 at 9:48 AM the resident was observed to be dressed and in the wheelchair. A position change alarm was observed on the wheelchair and was attached to the resident's clothing. A position change alarm is a device 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that facility staff failed to report a resident's injury of unknown origin to the Office of Healthcare Quality. This was evident for 1 of 36 residents (Resident #244) reviewed during survey investigation. The findings include: The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs. Injuries of unknown origin are to be reported to the Office of Healthcare Quality in a timely manner. Resident #244's medical record was reviewed on 10/24/18. The review revealed a Nurse's Note entered into the medical record on 9/12/18 that read: Resident is status post fall. Bump remains on resident's forehead. On 10/25/18 Resident #244's medical record was found to include a Skin assessment dated [DATE] that read: Hematoma to right side of head and discoloration. A hematoma is a large bruise. A review of facility…

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 document accurate Minimum Data Set (MDS) assessments for a Resident. This was evident for 1 of 34 residents (Resident #96) selected for review during the survey process. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff 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. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use, Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops…

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 facility staff it was determined that the facility failed to develop care plans addressing a resident's individualized needs related to 1) a resident's dental concerns and 2) a transfer plan of care for a physically dependent resident. This was found to be evident for of 2 of 36 residents (Resident #1 and #244) reviewed during the investigative portion of the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident and to modify the care plan based on the resident's status. 1) During interview with Resident #1 on 10/18/18 at 9:45 AM Surveyor noted the acquired absence of multiple upper and lower natural teeth. During the interview Resident #1 currently had no complaints regarding chewing or eating or mouth pain. However, did voice multiple other illnesses. Review of Resident #1's medical record on 10/18/18 at 10:30 AM revealed diagnoses including somatization…

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 interviews with facility staff it was determined the facility failed to revise a resident care plan to meet the specific care needs for a resident with history of falls. This was found to be evident for 1 out of 3 residents (Resident # 17) reviewed for falls during the facility's annual survey. The findings include: Review of the medical record for Resident #17 was done on 10/22/18 and it revealed that on 10/15/18 the resident had a fall that resulted in a cervical fracture. Review of the incident/accident report revealed that on 10/15/18 Resident #17 was found lying on his/her back on the floor by staff after the staff heard a loud crashing sound. According to report, fall precaution measures that were put in place included a chair alarm and fall mats. Review of the facility's fall investigation indicated that the precipitating factor was the resident wanted to walk to get his/her sister. The resident was in his/her wheelchair before trying to walk. The incident report indicated the resident's mental status as confused and impulsive. Review of 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 interview with staff it was determined that the facility failed to ensure a resident received twice weekly showers and skin assessments as ordered. This was found to be evident for 1 out of 36 residents (Resident #2) reviewed during the survey. The findings include: Review of Resident #2's medical record revealed the resident was cognitively intact as evidenced by a 10/4/18 Minimum Data Set (MDS) assessment with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. This 10/4/18 MDS assessment, as well as the 6/24/18 MDS, revealed that the resident was totally dependant on staff for bathing. On 10/23/18 the resident expressed a concern regarding not receiving showers when they are due. Review of the Geriatric Nursing Assistant (GNA) Activity of Daily Living documentation failed to reveal any documentation regarding whether a shower or a bed bath was provided. On 10/23/18 at 10:07 AM the Unit Nurse Manger #4 reported that the GNA's tell the nurse when a shower is given and that it is documented on the nurse's treatment record (TAR). 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 and review of pertinent facility records it was determined that the facility failed to provide activities for individuals based on their identified care plans and choices. This was evident for 3 of 3 residents (Resident #83, #12 and #49) reviewed for activities. The findings include: 1) During an interview on 10/18/18 at 8:46 AM with Resident #83 s/he revealed that going to bingo was a big deal. S/he further stated that it is a concern that bingo is all s/he looks forward to and s/he cannot attend because they are scheduling rehab therapy at that time. Review on 10/22/18 at 2:16 PM of Resident #83's care plan with the facility Director of Nursing (DON) revealed that Bingo is included as one of the resident's identified preferred activities. A review of Resident #83's activity participation log on 10/22/18 at 2:34 PM with the Activity Director #3, revealed documented attendance in bingo only 1-2 times a month since August. According to the activity calendar bingo is offered minimally weekly. The concern that a resident's preference was not met and or documented…

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 that facility staff failed to maintain a resident's bed in low position as outlined in the resident's plan of care. This was evident for 1 of 36 residents (Resident #244) reviewed during survey investigation. The findings include: Resident #244's care plan was reviewed on 10/25/18. The care plan is an individualized outline used to plan, assess and evaluate the effectiveness of the resident's care. Examination of Resident #244's care plan revealed that a care plan focus that addressed the resident's communicative and sensory impairments was initiated on 9/27/17. This care plan focus included an intervention, also initiated on 9/27/17, which read: Ensure/provide a safe environment. Adequate low glare light, Bed in lowest position and wheels locked. Beds are commonly maintained in a low position to minimize the risk of falls and the extent of fall related injuries. A review of facility documentation revealed that on 9/19/18 at approximately 2:45 AM Resident #244 was found on the floor of (his/her) room with a bump 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.

Based on medical record review and interview with facility staff it was determined that the facility failed to maintain a pain management regimen according to the resident's needs, rights and choices. This was evident for 1 of 1 resident reviewed for pain (Resident #194). The findings include: Medical record review of Resident #194 revealed recent diagnosis of stage IV bladder cancer with metastasis (the development of secondary malignant growths at a distance from a primary site of cancer) to the bones and lungs. Resident #194 was admitted on a pain regimen to include: Oxycodone 5 mg for severe pain, Tylenol for mild pain and Morphine 15 mg every 12 hours. On 10/11/18 Resident #194 was ordered by his/her attending physician an increased dose of Morphine to 30 mg every 12 hours. A corresponding physician note completed on 10/11/18 documented that the resident reported back pain worse with sitting and generalized weakness. Further the resident was eager to do rehab and goal was to ensure pain control, continue morphine and Oxycodone. On 10/16/18 the attending physician documented…

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 it was determined that the facility failed to keep a resident safe from a significant medication error as evidenced by the placement of a pain relief patch on the wrong area of the body. This was found to be evident for 1 out of the 4 residents (Resident #78) observed during medication pass administration observation completed during the survey. The findings include: Review of Resident #78's medical record revealed the resident was admitted to the facility in August 2018 with a diagnosis that included status post surgery for a left hip fracture. On 10/22/18 at 9:08 AM surveyor observed Certified Medicine Aid (CMA) #8 administer Resident #78's morning medications. This included the observation of an Aspercreme Lidocaine 4% Patch applied to the resident's ribs just below the left nipple line. The Asperecreme Lidocaine Patch is a topical anesthetic used to treat pain. After the observation was completed review of the medical record revealed an order for Aspercreme Lidocaine Patch 4% to be applied to the resident's left hip 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 review and staff interview it was determined that facility staff failed to maintain residents' medical records in a complete and readily accessible manner as evidenced by 1) failure to ensure primary care physician notes were available in the resident's chart for review by other health care providers; and 2) failure to ensure documentation of the resident's history of transfers and the level of assistance required with transfers. This was evident for 2 of 36 residents (Resident #43 and #244) reviewed during the survey. The findings include: 1) On 10/22/18 review of Resident #43's medical record revealed the resident has resided at the facility for more than a year and whose diagnoses includes dementia, chronic back pain and high blood pressure. Further review of the medical record failed to reveal any primary care physician notes since a note dated 11/6/17. On 10/22/18 at 3:37 PM surveyor reviewed the concern with the Unit Nurse Manager #4 that the most recent primary care physician note…

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.