Dennett Rehab Center

Based on observation, record review, and interview it was determined that the facility failed to ensure medications were secured and accounted for as evidenced by observation of a resident's medications which were left at the resident's bedside. Maintain and secure controlled medications in a separately locked, permanently affixed compartment. This was evident for 1 (Resident #2) during a random observation and 1 out of 3 refrigerators reviewed for medication storage during a surveyThe findings include:Controlled Medications are substances that have an accepted medical use, have potential for abuse, and may also lead to physical or psychological dependence. These medications fall under US Drug Enforcement Agency (DEA) Schedules II-V.1.) Resident #2 was re-admitted to the facility in February 2026 after a hospitalization for surgical repair of their fractured right hip. The resident's diagnoses included, but were not limited to, right neck of femur [hip] fracture and mild intellectual disability. On 3/15/26 at 8:04 PM an observation and interview with Resident #2 was conducted. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to ensure communication and collaboration on end of life care with the hospice agency. This was evident for 1 (Resident #78) of 1 residents reviewed for hospice and end of life care. The findings include:On 03/12/26 at 2:49 PM Resident #78's care plan indicated they were under Hospice of [NAME] County's care. Resident #78's care plan described they would have assistance with coping issues related to terminal illness and family would be provided emotional support to cope with the resident's decline and entry into Hospice. The care plan further indicated that the facility would update [NAME] County Hospice and the family of any changes, including significant changes, falls, and uncontrolled pain or discomfort.On 03/12/26 at 3:05 PM Resident #78's record was reviewed and revealed a progress note entered on 03/05/26 at 01:00 AM by Staff #4, a Licensed Practical Nurse (LPN), indicating: Resident #78 had been very agitated that evening.…

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 staff interviews, it was determined that the facility failed to ensure that licensed personnel used proper hand hygiene during medication administration to prevent and minimize the spread of infections. This was evident for two out of three licensed personnel (LPN #23 and LPN #25) observed during the medication administration task.Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve the use of Personal Protective Equipment (PPE) such as gown and glove use during high-contact resident care activities.The findings include:On 3/11/26 at 4:00 PM the surveyor observed Licensed Practical Nurse (LPN #23) exit room [ROOM NUMBER], approach the hall medication cart, retrieve medication, re-enter the room and exit the room without proper hand hygiene.On 3/11/26 at 4:04 PM the surveyor observed LPN #23 assist Resident #56 to the restroom and to bed. An EBP sign and PPE hung 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, interview, review of facility reported incidents and facility policy, it was determined that the facility failed to treat a vulnerable resident with respect and free from verbal abuse. This was evident during a complaint survey and a random observation of staff and resident interactions (Resident #39). The findings include: 1. During the tour and observation of resident care and staff activities on 3/3/25, Resident # 39 was observed at different times either rolling up and down the halls on all units in his/her wheelchair or scooting around on the floor on his/her buttocks. When the resident was observed on his/her buttocks previously staff had guided him/her back to his/her respective room where the resident stayed for a time before coming back out again scooting along the floor. This activity would occur repeatedly throughout the day. At approximately 1:06 PM Resident #39 was observed scooting up the hall from his/her room towards the nursing station. Staff GNA #5 at this time was heard saying here he comes again, he needs to be 1:1. At this time Resident #39…

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 the review of a facility reported incident #MD00214913, #MD00214911 and #MD00213420, medical record review, interview with facility staff and review of facility policies, it was determined that the facility failed to ensure that residents medications were secure, maintained and free from misappropriation. This was evident for 2 of 3 (#1 and #17) residents reviewed for medication misappropriation. This was identified a D of past non-compliance for facility reported incidents MD00214913 and MD00214911 for F602. The findings include: Review on 3/3/25 at 10:30 AM of the facility reported incidents #MD00214913 and #MD00214911 revealed concerns related to narcotic discrepancies and misappropriation. According to facility reported incident #MD00213420 occurring on 1/9/25, a family brought medications from home to the facility for Resident #302, which included Ativan (sedative). Unfortunately, about a week or so after they were discharged home, they alleged that the Ativan bottle they brought home no longer contained Ativan but metformin (diabetic medication). They called 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, interviews, record reviews, and policy reviews, the facility failed to follow infection control and prevention guidelines as follows: The facility staff did not don (put on) personal protective equipment (PPE) prior to entering a resident room and providing hands on care. This was evident during the random observation of staff to resident interactions and patient care. This failure had the potential to affect the spread of infections and involved Resident (39) The findings include: During the tour of the facility and observation of resident and staff practices, on 3/3/25 at approximately 12:45 PM, this surveyor observed LPN #3 in the room of Resident #39, with Resident #39 and GNA #4. Resident #39 was due for nutrition to be administrated via the gastrostomy tube (medical device that provides a direct route to the stomach for nutrition and medication). At this time s/he was very active and not responsive to the requests from LPN #3 to sit and let her administer the fluid bolus. GNA #4 was attempting to hold Resident #39's right arm and they both hollered for…

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

Based on review of complaints, interview, and documentation review, it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 9 of 21 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency. This deficient practice had the potential to affect all residents. The findings include: 1) Nine out of twenty-one complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not having sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of geriatric nursing assistants (GNAs) having up to 20-27 residents to take care of during any given shift. There were concerns that the residents were not receiving timely care, not receiving showers, and were not getting changed or toileted every 2 hours, only twice per shift. 2) Review of the Resident Census and Conditions CMS 672 form that was completed by the Nursing Home Administrator upon request from the surveyor 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 interview, and facility policy review, the facility failed to employ either a full-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to carry out the functions of the food and nutrition service department. This failure had the potential to affect all 75 residents who resided in the facility. Findings include: Review of the facility's policy titled, Professional Staffing, revised 10/22, indicated The Dining Services Department will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services, taking into consideration the resident assessments, individual plans of care and the number, acuity and diagnosis of the resident population. This includes a qualified dietitian or other clinically qualified nutrition professional, either full time or part time. If the qualified dietitian or other qualified nutrition professional is not employed full time, a director of food and nutrition services who meets the necessary qualifications will be employed .A 'qualified director of food and nutrition…

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

Based on observation, interview, record review, review of the facility's meal schedule, and facility policy review, the facility failed to have sufficient competent dietary staff to ensure food was prepared in a sanitary environment for one of one kitchen and food was served as scheduled for the main dining room, the Far East dining room, the East dining room and for two of two residents (Resident (R) 16 and R59) reviewed for timeliness of meals in accordance with professional standards for food safety. The lack of competent dietary staff had the potential to affect 74 residents of 75 residents who consumed meals that were prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Education and Training, revised 10/22, indicated All employees will be provided education and training upon hire and ongoing to ensure that they have the appropriate competencies, and skill sets to carry out the functions of the food and nutrition services, taking into consideration the needs of the resident population. Review of the facility's 2023-2024 Dining Services…

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

Based on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was labeled, dated, and/or covered, kitchen equipment and kitchen walls were clean, cookies on resident meal trays were covered when delivered from meal delivery carts to resident rooms, and pudding was served from the kitchen's tray line at an internal temperature of 41 degrees Fahrenheit (F.) or below. This had the potential to affect 74 of 75 residents who consumed food prepared in the facility's kitchen. Findings include: Review of the facility policy titled, Food Storage: Cold Foods, with a revision date of 02/23, indicated 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Equipment, with a revision date of 09/17, indicated Policy Statement All foodservice equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions…

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

Based on observation, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience by serving food on disposable plates to residents at meals for four of six hallways (100, 200, 600 and 700 Hallways) and failed to serve meals at the same time to residents who were seated at the same dining room table for one of two dining rooms (Far East dining room) for four of 41 sample residents (Resident (R) 31, R27, R28, and R47). This failure had the potential to affect all residents who were served meals prepared in the facility's one of one kitchen. Findings include: Review of the facility's policy titled, Dignity, revised 02/21, indicated Policy Statement Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feelings of self-worth and self-esteem .5. When assisting with care, residents are supported in exercising their rights. For example, residents are .e. provided with a dignified dining experience. 1. Observation on 11/18/24 from 6:00 PM to 6:44 PM of…

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

Based on observation, record review, interview, test tray review, and facility policy review, the facility failed to serve food that was palatable for two of six residents (Residents (R) 16, and R59) reviewed for food palatability of 41 sample residents. This had the potential to affect 74 of 75 residents who consumed food that was prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Food Quality and Palatability, with a revision date of 02/23, indicated Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet residents' needs .1. The Dining Service Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes .4. The Cook(s) prepare food in accordance with recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking…

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, the facility staff failed to honor the needs and preferences of a resident. This was evident for 2 (#205, #1) of 41 residents reviewed during an annual/complaint survey. The findings include: 1) Review of Resident #205's medical record on 11/19/24 revealed the Resident was admitted to the facility in October 2021 and the Resident resided in the same room his/her entire stay until April 2024. Interview with Resident #205's representative (RP) on 11/19/24 at 1:30 PM, the RP stated on 2/19/24 the facility notified him/her the facility was going to move the Resident's bed away from the wall due to the State making them. At that time the RP told the facility they did not want the bed moved. The RP stated the Resident had slept with bed against the wall at home and since the Resident was admitted to the facility the bed had been against the wall. The RP also stated the Resident's chair was arranged so the Resident could look out the window at the birds. The RP stated he/she arrived at the facility because he/she knew 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, facility documentation review, and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff. This was evident for 2 (#213, #202) of 16 facility reported incidents reviewed during an annual/complaint survey. The findings include: On 11/18/24 at 4:30 PM a review of Resident #213's medical record revealed the resident was admitted to the facility in March 2018 with diagnoses that included but were not limited to cerebral infarction (stroke) with hemiplegia and hemiparesis affecting the left non-dominate side, chronic obstructive pulmonary disease, and depression. Review of facility reported incident MD00180784 revealed on 1/2/22 at 5:35 PM LPN #10 and geriatric nursing assistant (GNA) #9 overheard GNA #29 coming out of Resident #213's room cussing verbally at Resident #213. Review of the investigative packet that was given to the surveyor revealed a written statement from GNA #9 that documented she was walking down the hall and heard GNA #29 and Resident #213 arguing and heard GNA #29 say to…

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

Based on review of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#213) of 16 facility reported incidents reviewed during an annual and complaint survey. The findings include: On 11/18/24 at 4:30 PM a review of facility reported incident MD00180784 was conducted and revealed on 1/2/22 at 5:35 PM LPN #9 and geriatric nursing assistant (GNA) #9 overheard GNA #29 coming out of Resident #213's room cussing verbally at Resident #213. Review of the investigative packet that was given to the surveyor revealed a failed fax confirmation sheet dated 1/3/22 at 9:56 AM. Also, the date at the top left of the Comprehensive and Extended Care Facilities Self-Report Form was dated 1/3/22 at 9:33 AM. There were no other fax or email confirmation sheets included in the investigation. The incident was not reported within 2 hours of the alleged verbal abuse and there was no documentation of when…

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

Based on review of a facility reported incident investigation and staff interview, it was determined the facility failed to thoroughly investigate an incident of alleged verbal abuse. This was evident for 1 (#213) of 16 facility reported incidents reviewed during an annual and complaint survey. The findings include: On 11/18/24 at 4:30 PM a review of facility reported incident MD00180784 was conducted and revealed on 1/2/22 at 5:35 PM LPN #10 and geriatric nursing assistant (GNA) #9 overheard GNA #29 coming out of Resident #213's room cussing verbally at Resident #213. Review of the investigative packet that was given to the surveyor revealed a written statement from GNA #9 and LPN #10. There were no other staff interviews and there were no resident interviews about the care they received from GNA #29 or if GNA #29 was ever verbally abusive to those residents. On 11/19/24 at 11:45 AM the Nursing Home Administrator (NHA) and the Regional Director of Clinical Operations stated there was no other documentation they could provide to the surveyor. Both confirmed that the investigation…

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, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User Manual Version 3.0, the facility failed to ensure one out of 41 sampled residents (Resident (R) 73) had an accurately coded Minimum Data Set (MDS) discharge assessment. Failure to code the MDS correctly led to an inaccurately coded discharge assessment. Findings include: Review of the CMS RAI User Manual Version 3.0, dated 10/01/24, revealed .Chapter 3 MDS Items [A] .A2105: Discharge Status .Item Rationale This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning .Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the two-digit code that corresponds to the resident's discharge status. Code 01, Home/Community: if 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 medical record review and interview, the facility staff failed to provide treatment and services in accordance with professional standards of practice (Resident #203). This was evident for 1 of 41 residents reviewed during an annual/complaint survey. The findings include: Review of Resident #203's medical record on [DATE] revealed the Resident was admitted to the facility on [DATE] at approximately 11:00 AM from the hospital with diagnosis to include chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Review of the Resident's admission physician orders revealed the Resident was ordered 4 different respiratory inhalers that were flagged as potential allergy and the LPN #5 messaged the Medical Director with the allergy concerns. Review of the facility investigation provided by the Administrator of the Resident's care revealed a message was sent to the Medical Director on [DATE] at 2:46 PM. Further review of Resident #203's medical record revealed a nurse's note on [DATE] at 9:35…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to implement a pressure injury intervention per the physician's orders and care plan for a stage two pressure ulcer and did not document treatment was provided for seven days for one of two residents (Resident (R) 3) reviewed for pressure ulcers out of 41 sampled residents. This failure had the potential to result in wound treatment and interventions not provided for the residents. Findings include: Review of the facility's undated policy titled, Wound Care, provided by the facility, revealed .Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022 and provided by the facility, 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, the facility staff failed to intervene in a timely manner for a resident with weight loss (Resident #205). This was evident for 1 of 3 residents reviewed for nutrition concerns during an annual survey. The findings include: Review of Resident #205's medical record on 11/19/24 revealed the Resident was admitted to the facility in October 2021 with diagnosis to include dementia. Dementia is a general term for a decline in mental abilities that affects a person's daily life. Review of Resident's weights documented in the electronic medical record revealed on 10/23/23 the Resident weighed 110 pounds. On 11/1/23 the Resident weighed 102 pounds. Further review of Resident #205's medical record revealed the Resident was not assessed by the former Dietitian until 11/13/23, 12 days after the noted weight loss. Review of a dietary note on 11/13/23 at 1:59 PM states: Significant Weight Change, Supplements: none, Recommendation: re-weigh. Further review of the Resident's weights revealed the Resident was not reweighed until 12/1/23 and at the time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen tubing and nasal cannula were stored in a clean and sanitary manner for one of one resident (Resident (R) 47) reviewed for respiratory care of 41 sample residents. This failure had the potential to lead to oxygen equipment not properly maintained. Findings include: Review of the facility's policy titled, Oxygen Administration, dated 10/2010 (sic), revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . General Guidelines: 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter .b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head . Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to administer pain medications to manage a resident's pain in a timely manner (Resident #203). This was evident for 1 of 41 residents reviewed during an annual/complaint survey. The findings include: Review of Resident #203's medical record on 11/19/24 revealed the Resident was admitted to the facility on [DATE] at approximately 11:00 AM from the hospital with diagnosis to include chronic pain. Further review of Resident #203's medical record revealed a physician order for Hydrocodone-Acetaminophen 10-325 mg 1 tablet every 4 hours as needed for pain. Hydrocodone and acetaminophen combination is used to relieve pain severe enough to require opioid treatment. Interview with Resident #203 on 11/19/24 at 9:04 AM stated he/she was upset when he/she couldn't get his/her pain medication after admission to the facility. During interview with LPN #5 on 11/19/24 at 9:13 AM, LPN #5 stated she was the nurse when the Resident was admitted and sent 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 observation, interviews, record reviews, and policy reviews, the facility failed to follow infection control and prevention guidelines as follows: 1. The facility staff did not don (put on) personal protective equipment (PPE) prior to entering two resident's rooms for two of two residents (Residents (R) 1 and R19), that were on droplet and contact precautions and had COVID. 2. The facility staff did not wash their hands and change gloves after removing the dressing and cleaning the pressure ulcers during a wound care observation for R26. 3. The facility staff did not review the Legionella policies annually. This failure had the potential to affect the spread of infections. Findings include: 1. Review of the facility-provided policy titled, Isolation - Categories of Transmission-Based precautions, revised September 2022, revealed Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection; or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to ensure one of twenty-two baseboard heater covers was in good repair on the 100 Hall of the East Wing for one of one resident (Resident (R) 17) of 41 sample residents. This failure had the potential to cause injury to the residents. Findings include: Review of the facility's policy titled, Homelike Environment, revised February 2021 and provided by the facility, revealed Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Review of R17's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R17 was admitted to the facility on [DATE]. Review of R17's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 10/04/24, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to immediately notify a resident's physician and representative when a resident was observed pocketing food. This was evident for 1 (Resident #4) of 6 residents reviewed during a complaint survey. The findings include: Oropharyngeal dysphagia is a term that describes swallowing problems occurring in the mouth and/or the throat. These swallowing problems most commonly result from impaired muscle function, sensory changes, or growths and obstructions in the mouth or throat. During an extended survey on 02/01/24, a review of Resident #4's medical record revealed a speech and language pathologist (SLP), staff member #26, progress note, dated 01/28/24 at 11:54 AM, indicating Resident #4 was observed by therapy staff member #16 pocketing food during mealtimes. SLP #26 documented Resident #4 was pocketing food and coughing with thin liquids. In an interview with SLP #26 on 02/01/24 at 12:37 PM, SLP #26 stated that she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to take steps to 1) address a change in a resident's ability to swallow, 2) follow the resident's care plan and assist resident with meals, and 3) document the resident's meal percentage consumed for each meal. This occurred when a resident was observed pocketing food. This was evident for 1 (Resident #4) of 6 residents reviewed during a complaint survey. The findings include: Oropharyngeal dysphagia is a term that describes swallowing problems occurring in the mouth and/or the throat. These swallowing problems most commonly result from impaired muscle function, sensory changes, or growths and obstructions in the mouth or throat. During an extended survey on 02/01/24, a review of Resident #4's medical record revealed a speech and language pathologist (SLP), staff member #26, progress note, dated 01/28/24 at 11:54 AM, indicating Resident #4 was observed by therapy staff member #16 pocketing food during mealtimes. SLP…

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 failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Residents #3 and #4) of 6 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) A review of Resident #2's medical record on 01/25/24 revealed 2 different Resident MOLST forms (Residents #2 and #3) had been scanned into Resident #2 electronic medical record. This could pose a problem if Resident #3's MOLST form was sent with Resident #2 to the hospital or doctor's appointment. 2) Review of Resident #4's medical record on 01/25/24 revealed a completed MOLST form, dated 01/04/24, that indicated Resident #4's physician completed section 6 and 7 by checking 2 different lines,…

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

Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 3 out of 3 personnel files reviewed. The findings include: A review was conducted of GNA personnel files on 7/11/19: 1) Review of Staff #5's employee personnel file documented a date of hire (DOH) of 12/15/93. A yearly performance review was not found in the personnel file. 2) Review of Staff #6's employee personnel file documented a DOH of 5/11/92. A yearly performance review was not found in the personnel file. 3) Review of Staff #7's employee personnel file documented a DOH of 11/15/07. A yearly performance review was not found in the personnel file. Staff #18 stated on 7/11/19 at 4:15 PM, I have only just started doing yearly competencies in January 2019. It is the CMS test that I am doing with the GNAs. The Director of Nursing (DON) stated on 7/11/19 at 4:17 PM, We have never yearly reviews for GNAs. We do the yearly education and dementia training but not yearly performance reviews.

Based on interview of facility staff, it was determined the facility staff failed to ensure a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation. The findings include: On initial tour of the facilities kitchen on 7/9/19 at 10:25 AM, revealed that the full time Food Service Manager (staff # 12) was not clinically qualified as per Federal and state regulations. The Food Service Manager indicated she was receiving education to become a Certified Dietary Manager. During the survey, it was determined that the facility had a part time dietitian. Interview of the dietitian (staff #20) on 7/12/19 at 12:28 PM revealed that she was generally at the facility at least one day of the week. The dietitian acknowledged that she was primarily clinical and did not have any supervisory oversight of the facilities kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on all nursing units. The findings include: Environmental observations were made during the survey from 7/9/19 to 7/16/19 of the following: Resident #6 had a 2 inch tear in the vinyl of the right wheelchair armrest with the underneath padding exposed. Resident #25 had torn vinyl on the left front wheelchair armrest and on the left outside armrest, with the underneath padding exposed. Resident #39 had torn vinyl on the top of the right wheelchair armrest, approximately 2 1/2 inches long, with the underneath padding exposed. The vinyl was torn on the wheelchair armrests of Resident #6, Resident #39 and Resident #25. In room [ROOM NUMBER], the plastic grate cover on the radiator was loose with missing pieces of the grate on the left side. In room…

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 the physician progress notes and/or history and physicals were not in the medical record after each visit. This was evident for 1 (#94) of 1 resident reviewed for edema, 1 (#93) of 4 residents reviewed for accidents, 1 (#48) 2 residents reviewed for nutrition, 1 (#24) of 1 resident reviewed for pain, and 1 (#3) of 5 residents reviewed for unnecessary medications. The findings include: 1) Review of the medical record for Resident #94 on 7/11/19 revealed that the physician's progress note, dated 4/2/19, was not placed in the medical record until 4/23/19, and the 1/8/19 progress note was not placed in the medical record until 2/5/19. 2) Review of the medical record for Resident #93 on 7/11/19 revealed that the physician's progress notes, dated 1/31/19, 2/28/19 and 3/13/19, were not placed in the medical record until 4/17/19. Staff #13 stated on 7/16/19 at 10:00 AM, as soon as I get the progress notes from the physician's office, I scan them into the medical record. Staff #13 stated, they are scanned in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to assure that residents are seen by a physician at least once every 30 days for the first 90 days, and at least once every 60 days thereafter. This was evident for 1 (#48) of 2 residents reviewed for nutrition and 1 (#8) of 3 residents reviewed for dementia care. The findings include. 1) Resident #48 was admitted to the facility on [DATE]. Review of the medical record on 7/11/19 revealed that the resident's attending physician examined the resident on 2/8/19. The next physician visit was documented on 4/2/19, a lapse of 52 days between the two visits during the resident's first 90 days of her/his admission to the facility. Besides the next documented physician visit of 5/6/19, there were no other physician and/or nurse practitioner notes found in the electronic or paper medical record. On 07/11/19 at 5:29 PM, the director of nursing confirmed that there was not any other physician documentation for this resident. 2)…

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

Based on review of facility documentation and interviews with the facility staff, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program. The findings include: Review of the Quality Assessment and Assurance (QAA) Program with the Quality Assurance Coordinator (staff #8) on 7/16/19 at 2:50 PM revealed that effective processes were not put in place regarding repeat deficiencies. The development of comprehensive care plans was cited on the last annual survey, dated 4/26/18. Free from accident hazards/supervision/devices was cited on the last survey dated 4/26/18. Physician visits-Review Care/Notes/order was a repeat citation from surveys dated 2/2017, and 4/26/18. The corrective actions that the facility implemented after the last annual survey failed to effectively correct these deficiencies and resulted in a continuation of the deficient practices.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to follow a resident's MOLST form related to medical tests. This was evident for 1 (#11) of 1 residents reviewed for hospice and end of life care. The findings include: On [DATE] at 2:21 PM, Resident #11's medical record was reviewed. Review of Resident #11's MOLST (Maryland Medical Order for Life Sustaining Treatment that documents a person's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatments), dated [DATE], revealed that Resident #1 elected No CPR, Option B, Palliative and Supportive care and, Option 5c, Do not perform any medical tests for diagnosis or treatment, indicating the resident did not want routine medical tests. However, further review of Resident #11's medical record revealed evidence the resident had multiple laboratory (lab) tests done. Review of Resident #11's lab results revealed: on [DATE], the resident had a CMP (comprehensive metabolic panel) and a thyroid…

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

Based on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 2 (#64, #94) of 4 residents reviewed for hospitalization following a fall. The findings include: Review of the medical record for Resident #94 on 7/10/19 documented that, on 1/19/19 at 7:30 AM, Resident #94 fell and was sent to the emergency room. Review of the medical record for Resident #64 on 7/15/19 documented that, on 5/18/19 at 6:30 PM, Resident #64 was unable to move right leg due to pain and was to be transferred to the emergency room for hip pain. There was no written documentation found in the medical record that Resident #94 and Resident #64 were oriented and prepared for the transfer in a manner that each resident could understand and there was no documentation of the resident's understanding of the transfer. Discussed with the Director of Nursing on 7/16/19 at 12:20 PM who confirmed the findings.

Based on resident representative and resident interview, observation, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#5) of residents reviewed for respiratory. 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. On 7/9/19 at 2:04 PM, Resident #5 was observed wearing nasal cannula (n/c) oxygen tubing which was connected to an oxygen (02) concentrator set at 2 liters/min (l/m). During an interview, Resident #5 stated that he/she wore the oxygen continuously. On 7/11/19 at 10:18 AM, Resident #5's medical record was reviewed. Review of Resident #5's physician orders revealed the resident had an order since 4/9/19 for oxygen to run continuously at 2 l/m for shortness of breath. Review of Resident #5's progress notes revealed on 2/15/19 at 1:55 PM, the nurse wrote that Resident #5 had a cough, thick sputum, shortness of breath (SOB) at…

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 staff interview, it was determined the facility failed to 1) develop a respiratory, resident centered care plan for a resident requiring continuous oxygen and 2) failed to label oxygen tubing when initiated. This was evident for 1 (#5) of 1 resident's reviewed for respiratory and 1 (#7) of 1 resident's reviewed for personal property. The findings include: 1) On 7/9/19 at 2:04 PM, Resident #5 was observed wearing nasal cannula (n/c) tubing connected to an oxygen concentrator set at 2 liters/minute (l/m). The oxygen tubing was not labeled with the date. At that time, the resident stated that he/she wore the oxygen continuously. Continued review of the medical record failed to reveal an order to change the tubing or to label the tubing. 0n 7/11/19 at 10:18 AM, review of Resident #5's medical record revealed a 4/9/19 physician order for oxygen to run continuously at 2 l/m for shortness of breath (SOB). Review of Resident #5's progress notes revealed Resident #5 had a history of bronchitis and shortness of breath. Review of the resident's…

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

Based on medical record review and staff interview, it was determined the physician failed to monitor changes related to a resident's weight during monthly visits. This was evident for 1 (#48) of 2 residents reviewed for nutrition. The findings include: Review of the medical record on 7/10/19 revealed that resident #48 had experienced excessive weight gain since admission to the facility in February 2019. Review of the registered dietitian's notes revealed ongoing documentation related to resident #48's weight gain. On 3/7/19, the dietitian documented that the resident had a weight gain of 7 pounds over the last month. Dietitian note of 4/11/10 indicated the resident had gained 18 pounds since admission. The dietitian's progress note of 4/27/19 revealed that the dietitian was notified of resident #48's significant weight gain. The 4/27/19 note indicated that the resident had gained 35 pounds since admission. The dietitian's note of 5/5/19 indicated the resident had lost 15 pounds over the last week related to fluid shifts and edema. The 5/5/19 note indicated that the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility documentation review, it was determined the facility staff failed to label medications when opened and discard medications when expired. This was evident for 1 of 4 medication carts observed. The findings include: Observation was made on [DATE] at 11:20 AM of the medication cart in the [NAME] unit medication room. Resident #78's opened bottle of Timolol eye drops, for glaucoma, had a date opened of [DATE]. According to the manufacturer's website the eye drops were only good for 30 days once opened. Resident #95's Breo Ellipta 200/25 inhaler was opened with no date opened documented anywhere on the inhaler. According to the manufacturer's website, the inhaler was only good for 6 weeks once opened. Resident #7's Levemir FlexPen (insulin) was opened with no date opened anywhere on the FlexPen. Resident #85's Lantus Flexpen had a date opened of [DATE], and should have been discarded on [DATE] as the Lantus was only good for 28 days once opened. Staff #10 was with…

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

Based on medical record review and staff interview, it was determined the facility staff failed to have laboratory reports filed in the resident's clinical record. This was evident for 1 (#11) of 1 resident's reviewed for hospice services and end of life care. The findings include: On 7/10/19 at 2:21 PM, Resident #11's medical record was reviewed. Review of Resident #11's laboratory (lab) results revealed a lab form dated 5/4/19 and labeled General Lab Report Final indicated that Resident #11 had a culture (test to identify bacteria from a sample of a blood, body fluid or other part of the body) done on 5/3/19 and to see a separate report for the results. The form did not identify where Resident #11's culture sample was from. On 5/3/19, in a progress note, the nurse documented that a physician's order had been given to get a culture Resident #11's right eye. Further review of the medical record failed to reveal the lab results of Resident #11's eye culture. On 7/11/19 at 8:13 AM, the Director of Nurses (DON) confirmed that a lab report of Resident #11's eye culture result was not in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint allegation (MD00139328), medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 (#11) of 1 resident reviewed for hospice and end of life care and 1 (#145) reviewed for a complaint allegation. The findings include: 1) On [DATE] at 2:21 PM, Resident #11's medical record was reviewed. Review of Resident #11's MOLST (Maryland Medical Order for Life Sustaining Treatment that documents a person's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatments), dated [DATE], revealed that Resident #1 elected No CPR, Option B, Palliative and Supportive care, indicating if cardiac and/or pulmonary arrest occurred, do not attempt resuscitation (No CPR) and allow death to occur naturally. Review of Resident #11's medical record revealed on [DATE], in a progress note, social services documented that Resident #11's MOLST is a full code, indicating that if cardiac and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by failing to label and store resident care equipment in a manner to prevent development and transmission of disease and infection. This was evident for 1 (room [ROOM NUMBER]) of 4 rooms in the 500 hall observed during the survey. The findings include: On 7/9/19 at 2:23 PM, a white, plastic specipan (a specimen collection unit for urine and stool samples), was observed on the top of the toilet tank of room [ROOM NUMBER]'s shared bathroom. The specipan, which had brown streaks inside it, was not covered to prevent the transmission of infection and was not labeled with a resident's name. On 7/11/19 at 12:30 PM, a second observation of room [ROOM NUMBER]'s shared bathroom revealed, on top of the toilet tank, there was a white, plastic specipan with brown streaks inside it, that was not covered to prevent the spread 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.