Oak Knoll Skilled Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for three residents (Residents #30, #46 and #24). In addition, the facility failed to follow accepted infection control and prevention to implement their water management program to prevent the spread of waterborne pathogens, such as legionella (a bacteria that causes legionnaire's disease which is a severe form of pneumonia or lung inflammation). This failure had the potential to affect all residents in 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, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for five of 18 sampled residents (Resident #62, #36, #26, #2 and #13). The census was 66. Review of the facility's Proper Use of Side Rails policy, revised October 2010, showed: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids to and prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -General Guidelines: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -Bed mobility; -Ability to change positions, transfer to and from bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents' needs were met by failing to ensure 10 residents who needed assistance with meal setup and eating were served and assisted for meals at the same time as the other residents in the dining room that did not require assistance. The ten residents sat and watched others at their table eat while they waited for food. Three of the ten residents were sampled residents (Resident #4, #2, and #3). Resident #4 was the last to be provided a meal and assistance with eating and waited over 30 minutes. The sample size was 4. The census was 70. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/23, showed: -Severe cognitive impairment; -Eating: Setup or clean-up assistance. Helper sets up or cleans up. Resident completes activity; -Upper body dressing: Supervision or touching assistance; -Lower body dressing: Supervision or touching assistance;…

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, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for four of 17 residents (Resident (R)13, R35, R36 and R137) in the sample. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment. Findings include: 1. Review of R13's Face Sheet from the electronic medical record (EMR) Resident tab showed an admission date of 11/09/11, readmission of 05/13/22, with medical diagnoses that included schizophrenia, major depressive disorder, mood (affective) disorder, neuropathy, asthma, cataracts, and atrial fibrillation. Review of R13's EMR MDS tab showed quarterly MDS assessment reference date (ARD) 02/15/22 and 05/18/22 with a status of Production Accepted. No quarterly MDS for August was found. In an interview on 11/10/22 at 1:10 PM, the MDS Coordinator (MDSC) confirmed there was a missing assessment, stating, No August quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three residents (Resident (R) 28) received quarterly personal fund statements. Specifically, R28 was cognitively impaired and R28's Resident Representative (RR) did not receive quarterly personal fund statements for January through September 2022. Findings include: Review of R28's undated Face Sheet located in the electronic medical record (EMR) under the resident tab revealed R28 was admitted [DATE] with diagnosis of dementia. Review of R28's annual Minimal Data Set (MDS), located in the EMR under the RAI tab, revealed R28 had a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired. During an interview on 11/08/22 at 4:04 PM, R28's RR stated the facility managed R28's personal funds account. R28's RR stated that he/she did not receive quarterly statements for R28's personal funds account. Review of R28's Personal Funds Ledger Card dated January through September…

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, record review, and facility policy review, the facility failed to notify the power of attorney (POA) or Hospice when a resident had a fall and was transferred to the hospital for one of one resident (Resident (R) 21) reviewed in a total sample of 17 residents. Findings include: Review of R21's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/03/22 found in the Electronic Medical Record (EMR) under the Resident assessment tab revealed that R21 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated resident was cognitively intact during the time of the accident. Review of R21's Progress note under the Progress notes tab showed that R21 was placed on hospice care on 09/21/22 by sister who was the POA. Review of the Advance Directive document confirmed the sister was the POA. Review of progress notes dated 10/03/22 found in the EMR under the Progress notes tab showed that no follow-up was made to the POA after R21 had fallen and hit her head. Review of the Progress note dated 10/03/22 at 04:39AM revealed, .due 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure three of three residents (Resident (R)32, R37, R38) or Resident Representative (RR) were issued a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) related to the end of Medicare A Skilled Services. This failure left the Residents and/or Resident Representatives uninformed of the possibility of continuing services and the expense that might be incurred. Findings include: 1. Review of R32's Face Sheet from the electronic medical record (EMR) Resident tab showed an admission date of 02/28/22, readmit date of 08/12/22 with medical diagnoses of congestive heart failure, hypertension, permanent atrial fibrillation, lymphedema, and cognitive communication deficit. Review of the Medicare A Notice of Medicare Provider Non-Coverage [NOMNC] document showed R38 started PT/OT/ST [physical/occupational/speech therapies] on 02/28/22 and was discontinued on 03/30/22. No SNFABN notice was provided to R32 or his/her Resident Representative. 2. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and admission packet review, the facility failed to ensure two of three residents (Resident (R)34, and R135) and/or their representatives reviewed for an emergent discharge to the hospital, out of a total sample of 17, were provided with a written notice of transfer that included all required information. The facility 's transfer notice forms did not include information on how to contact the Ombudsman or how to file an appeal, if desired. In addition, although transfer forms prepared by the facility may have been faxed to the hospital where the resident was being transferred, the facility failed to assure that both the resident and their representative received the forms. This failure has the potential to affect the resident and/or their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: 1. Review of R135's Face Sheet from the electronic medical record (EMR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy, the facility failed to ensure three of three (Resident (R) 135, 21, and R34) reviewed for hospitalization, the resident and/or their Resident Representative (RR) received a written bed hold notice upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital. Findings include: 1 Review of R135's Face Sheet from the electronic medical record (EMR) Resident tab showed a facility admission date of 05/24/13, a readmission date of 10/08/22 During an interview on 11/09/22 at 10:54 AM, R135 stated he/she had gone to the hospital last month after a fall because nobody could pick her up, so they called the ambulance. Review of R135's Progress Notes from the EMR Resident tab revealed: 10/06/22 7:43 AM Nursing Resident was observed laying on floor 2 [at] bedside, movements slowed, speech slowed, vs [vital signs] .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 record review, interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for processing for three of 17 residents (Resident (R)35, R36 and R137) in the sample. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment. Findings include: 1. Review of R35's Face Sheet from the electronic medical record (EMR) Resident tab showed an admission date of 12/31/19 with medical diagnoses that included schizophrenia, chronic obstructive pulmonary disease, chronic kidney disease, and hyperlipidemia. Review of R35's EMR MDS tab on 11/08/22 at 2:01 PM showed an annual MDS assessment reference date of 01/08/22 as an In Process status, with a quarterly MDS ARD 04/10/22 as accepted. During an interview on 11/10/22 at 1:17 PM, the MDS Coordinator (MDSC) stated the annual MDS should have been sent. 2. Review of R36's Face Sheet from the EMR Resident tab showed an admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one of 30 sampled residents (Resident (R) 33) was accurate. R33's MDS was not accurately coded to indicate the resident had experienced a significant weight loss. The failure to accurately code/assess the resident's condition has the potential to affect the care planning for the resident to receive all required services. Findings include: Review of R33's Face Sheet from the electronic medical record (EMR) Resident tab, Face Sheet subtab; showed an admission date of 02/14/22 and readmitted on [DATE]; with medical diagnoses that included hyperlipidemia, expressive language disorder, obstructive sleep apnea, depression, and urge incontinence. Review of R33's Resident tab, Vitals subtab, showed the following weights: 03/30/22 185.6 04/29/22 184.8 07/04/22 146.7 On 03/30/22, the resident weighed 185.6 lbs. On 07/04/22, the resident weighed 146.7…

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, record review and review of Pre-admission Screening and Resident Review (PASARR) website, the facility failed to ensure one of four residents (Resident (R)6) admitted with a mental health diagnosis had a Level I PASARR for possible referral for a Level II screening to enable receipt of potential services. This failure increases the risk of residents with a mental health diagnosis not receiving specialized services. Findings include: Review of R6's Face Sheet from the electronic medical record (EMR) Resident tab showed an admission date of 01/02/04 with medical diagnoses that included schizophrenia, psychosis, and major depressive disorder. Further review on 11/09/22 at 1:13 PM of R6's EMR, Resident tab, sub-tab Resident Documents did not show any PASARR screenings. During an interview on 11/11/22 at 3:30 PM, the Director of Nursing (DON) showed emails from 2019 where attempts were made to obtain a copy of any PASARR for R6 from 2019. The DON stated, I'm going to have to do a new one. It didn't dawn on me it hadn't been done, just that we didn't have it. I didn't…

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 policy review, the facility failed to ensure the care plan was updated for two of 17 residents (Resident (R) 33 and R135) reviewed. The failure to keep a care plan current could affect the appropriateness of care provided. Findings include: 1. Review of R33's Face Sheet from the electronic medical record (EMR) Resident tab, Face Sheet subtab; showed an admission date of 02/14/22 and readmitted on [DATE]; with medical diagnoses that included hyperlipidemia, expressive language disorder, obstructive sleep apnea, depression, and urge incontinence. During an interview on 11/09/22 at 12:47 PM R33's family member stated R33 has dentures, but staff may not put them in for her though. Review of R33's Progress Notes from the EMR Resident tab admission notes and nursing notes did not show any mention of dentures. Review of R33's Care Plan from the EMR MDS tab showed a problem start date of 03/01/22 that stated [R33's name] requires some ADLs [activities of daily living]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to investigate a fall incident for one of 17 residents (Resident (R) 135). The failure to identify a cause of the fall could result in a lack of effective interventions put into place and could result in additional falls and/or injuries. Findings include: Review of R135's Face Sheet from the electronic medical record (EMR) Resident tab showed a facility admission date of 05/24/13, a readmission date of 10/08/22, with medical diagnoses that included bipolar disorder, seizures, paranoid schizophrenia, major depressive disorder, hypertension, vitamin D deficiency, generalized osteoarthritis, nicotine dependence, bilateral post traumatic osteoarthritis of knee, spondylosis, low back pain, and other hypertrophic osteoarthritis of multiple sites. During an interview on 11/09/22 at 10:55 AM, R135 stated she had gone to the hospital last month after a fall because nobody could pick her up, so they called the ambulance. Review of R135's Progress Notes from the EMR…

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 record review and interview, the facility failed to monitor for behaviors and the effectiveness of the antidepressant medications for two of five residents (R) 19 and R30) reviewed for unnecessary medications. Findings include: 1. Review of the Face sheet under the resident tab showed that R19 had an admission date of 12/21/17. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/22 under the resident assessment tab in the Electronic Medical Record (EMR) showed that R 19 has an active diagnosis of depression. Review of the care plan in the EMR under the resident assessment tab showed that R19 had a care plan dated 12/21/21 for psychotropic drugs which indicateR19 is at risk for adverse consequences R/T [related to]receiving antidepressant medication (Amitriptyline) for treatment of depression and that approved approach was Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms. Review of the electronic Medication Administration Record (eMAR) showed that no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure antipsychotic medication was monitored for efficacy and side effects for one of five residents (Resident (R) 5) reviewed for unnecessary medications. R5 received Seroquel (an antipsychotic medication). The facility did not monitor R5 for possible side effects of the medication or response to the medication. Findings include: Review the Face Sheet, located in the electronic medical record (EMR) under the Resident tab revealed R5 was admitted [DATE] with diagnoses including dementia and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/22, located in the EMR under the RAI tab, revealed R5 had a BIMS score of 2 out of 15 which indicated the resident had severe cognitive impairment. Review of Physician Orders dated 10/03/22, located under the Resident tab in the EMR, indicated R5 received Seroquel (an antipsychotic medication) 25 milligram (mg) three times daily. Review of R5's care…

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 record review, the facility failed to ensure staff had access to, and were inserviced on, the facility's most recent abuse and neglect policies and procedures. In addition, the facility failed to ensure residents, family and/or guardians received copies of the facility's most recent abuse and neglect policies. The census was 67. Review of the facility's undated Resident Rights policy, given to all new residents in the resident handbook upon admission, showed: Definitions: -Abuse includes, but is not limited to, the willful infliction of physical, verbal, sexual, or mental anguish, or the willful deprivation by a caregiver or services necessary to maintain physical or mental health; -Neglect refers to the withholding of services from any person unable to provide for self the necessary services to maintain physical or mental health; -Exploitation refers to the act or process of taking advantage of any person by another person or caregiver for monetary, personal or other benefit for profit; -If you witness and incident; what do you do?: -Anyone who witnesses an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents receiving one on one activities received those activities consistently. The facility identified seven residents as receiving one on one activities and problems were found with all seven (Residents #1, #4, #5, #10, #22, #39 and #54). The census was 67. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/14/19, showed: -Rarely/never understood; -Activity preference: Blank. Review of the resident's one on one activity log, dated 8/2019, showed the resident received one on one activities six times. Review of the resident's quarterly assessment, dated 8/12/19 at 12:46 P.M., showed the resident is on the one on one list for 2 visits a week. Resident is quiet and when he/she does speak, words are confused and sentences do not make sense nor apply to the conversation trying to be held. Resident enjoys coffee and music. Resident will spend time in 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, interview and record review, the facility failed to put interventions in place after two sampled residents incurred injuries; one being an abrasion to the head and the other a bruise to the thigh (Residents #1 and #9). Staff also left a set of keys with pepper spray unattended on the cooler in the kitchen for two of two days of observation. The census was 67. Review of the facility's undated Incident Investigation Procedure, showed: -In the event of any incident the following procedures must be implemented immediately: -Assess the person; -Provide medical attention as needed; -Contact the physician, inform, and receive order(s); -Contact the family or responsible party; -When an incident occurs, Charge Nurse must complete the Phase I investigation process by completing the Data Collection and Incident Report; -Phase I: -Complete Data Collection form; -Interview alleged resident victim; -Interview witnesses; -Review resident victim medical record; -Review resident victim's normal interaction…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure alternatives were attempted prior to the installation of side/bed rails and failed to thoroughly assess residents for risks of entrapment. Two of the 25 residents sampled had side/bedrails, neither had orders for side/bed rails, but utilized them. Problems were found with both (Residents #1 and #9). The census was 67. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/19, showed: -Diagnosis of dementia; -Short/long term memory loss; -Required extensive staff assistance for bed mobility, dressing, toileting and personal hygiene; -Required total staff assistance for transfers; -Incontinent of bowel and bladder; -No falls; -No side/bedrail use. Review of the resident's care plan, updated 8/7/19, showed no documentation regarding side/bedrails. Review of the resident's progress notes, dated 9/7/2019 at 5:37 A.M., showed: -Certified nurse aide…

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.