CareOne at New Milford

Based on interviews and review of other facility documentation, the facility failed to ensure that the physician must review the resident's total program of care and date progress notes at each visit. This deficient practice was identified for 1 of 35 residents, (Resident #63), reviewed for physician services. This deficient practice was evidenced by the following: On 2/24/25 at 10:59 AM, the surveyor observed Resident #63 was seated in a wheelchair in front of their room, repeatedly stated, why, I am here, come here. The surveyor reviewed Resident #63's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other forms of scoliosis (is a medical condition characterized by a sideways curvature of the spine), thoracolumbar region, other specified persistent mood disorders, unspecified psychosis not due to a…

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

COMPLAINT #NJ175735 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to provide or obtain routine medications in order to meet the needs of each resident for 3 of 35 residents reviewed (Residents #5, #32, and #352). This deficient practice was evidenced by the following: 1. On 2/26/25 at 7:57 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) prepared and administered medications (meds) of Resident #5 (from the 2nd floor unit). LPN#1 informed the surveyor that there was no available Florastor (used as a probiotic, or friendly bacteria, to prevent the growth of harmful bacteria in the stomach and intestines) 250 mg (milligrams) in the medicine (med) cart. LPN#1 stated that she would check later in the back up machine for Florastor. LPN#1 did two residents for med pass observation. The surveyor did not observed LPN#1 went to get the Florastor or notified the physician of unavailable med. The surveyor reviewed the medical records for Resident #5. A review of the admission Record (AR, 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 observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medications (meds). This deficient practice was identified for 2 of 6 residents reviewed for psychoactive meds used (Residents #32 and #63), and was evidenced by the following: 1. On 2/24/25 at 11:06 AM, the surveyor observed Resident # 32 seated in a wheelchair (w/c) in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide #1 (RA#1), who informed the surveyor that the resident will be going down for lunch. The surveyor reviewed the medical records for Resident #32. A review of the admission Record (AR, an admission summary) reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement)…

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 review of pertinent documents, it was determined that the facility failed to properly store medications securely and appropriately according to facility's policy and standard of clinical practice. The deficient practice was identified in 1 of 4 medication carts inspected on 3 of 3 units. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. On 3/3/25 at 12:04 PM, the surveyor entered the 1st floor nursing unit. The surveyor observed a medication storage cart (medcart) that was unlocked as evidenced by the locking button…

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 other pertinent documents, it was determined that the facility failed to maintain a complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 1 of the 35 residents reviewed (Residents #107). This deficient practice was evidenced by the following: During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, the surveyor observed Resident #107 lying on bed. On that same date and time, the resident informed the surveyor that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. The resident further stated that they had incidents of falls in the facility, and unsure when and where in the facility the fall incidents happened. The resident's bed was not in a low position. The surveyor reviewed the medical records of Resident #107 and revealed: A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses that included but not limited to other sequelae of cerebral…

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.

REPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 of 3 staff (Licensed Practical Nurse) and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately…

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 review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 1 of five 5 Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: On 3/3/25 at 9:13 AM, the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs showed the following: CNA #1 had a date of hire (doh) of 1/25/18. According to the Transcript, CNA #1 did not have QAPI training. CNA #2 had a doh of 11/20/07. According to the Transcript, CNA #2 did not have QAPI training. On 3/3/25 at 12:16 PM, the surveyor interviewed the Facility Educator (FE) regarding CNA education and mandatory topics. The FE stated that she tracked their education based on their anniversary date. She added that if a mandatory topic was done…

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 Complaint #: NJ00162219 Based on record review staff interviews, and facility policy review, the facility failed to ensure an injury of unknown origin was reported to appropriate entities in a timely manner for one of eleven residents (Resident (R) 1) reviewed for abuse of 21 sample residents. R1 experienced an injury to her finger and the incident was not reported to the local Ombudsman, the family, or the State Agency. Findings include: Review of R1's admission Record, dated 01/26/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes and Alzheimer's Disease. Review of R1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/05/22 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R1 had severe cognitive impairment. The assessment indicated the resident exhibited…

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 C#: NJ00169205, NJ00162219 Based on record review, staff interviews, and facility policy review, the facility failed to ensure a thorough investigation was conducted related to injuries of unknown origin for two of eleven residents (Residents (R) 1 and R4) reviewed for abuse of 21 sample residents. R1 experienced an injury to her finger and R4 had a broken clavicle; these incidents were not investigated by the facility. Findings include: 1. Review of R1's admission Record, dated 01/26/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes and Alzheimer's Disease. Review of R1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/05/22 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R1 had severe cognitive impairment. The assessment indicated the resident exhibited…

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

Based on observation, interview, and record review, it was determined that the facility failed to: a) follow a physician's order with regards to the use of an assistive device for one of three residents, Resident #5 reviewed for the limited range of motion (ROM); b) utilized the Braden Scale for Predicting Pressure Sore Risk (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ) for two of four residents, Residents #15 and #83 reviewed for pressure ulcers; c) follow a physician's recommendation and discontinuing a wound treatment for a healed wound in a timely manner for one of four residents (Resident#136) reviewed for wounds. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems,…

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 review of facility documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received performance review for four of five CNA files reviewed. The deficient practice was evidenced by the following: On 01/12/23 at 12:50 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the education, competencies and performance reviews for five CNA's. On 01/13/23, the facility provided the education and competencies for four of the five CNA's. The facility indicated that one of the five CNAs had resigned. The facility did not provide performance reviews for the five CNAs. On 01/17/23 at 01:45 PM, the surveyor, in the presence of the survey team and the Director of Nursing (DON), asked the LNHA to provide the performance reviews for the four CNAs. The facility did not provide performance reviews for the five CNAs. On 01/18/23 at 9:00 AM, the surveyor, in the presence of the survey team, asked the DON and LNHA for the performance reviews for the five CNAs. The DON stated that she would have…

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 review of the facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a) expired narcotic medications were removed from active inventory b) dispensed and received medication from the pharmacy were reconciled for accuracy which resulted in the wrong dosage stocked in the active inventory c) expired biological from 6/22 were removed from active inventory This deficient practice was identified for one of one of the electronic emergency (backup) machine [name redacted] observed and was evidenced as follows: 1. On 01/17/23 at 9:59 AM, the surveyor received the [name redacted] Inventory report from the Director of Nursing (DON). On 01/17/23 at 10:14 AM, during an interview with the surveyor, the Registered Nurse/Unit Manager (RN/UM) stated that as a supervisor, she was responsible for the reconciliation of the narcotic medications stored in the backup machine (cycle counts) with another supervisor. The Supervisors alternate days as assigned. The UM/RN…

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 interview and review of the facility provided documents, it was determined that the facility failed to ensure that the care planning (care conference meeting) was scheduled and that the resident's representative (RR) was provided sufficient notice in advance of the meeting according to the facility practice and policy for one of three quarters care conference reviewed for Resident#83. This deficient practice was evidenced by the following: On 01/11/23 at 8:58 AM, the RR informed the survey team that he/she visits Resident #83 almost every day. The RR had a concern that care planning meetings stopped since August 2022 and no invitation was provided to the RR. On 01/11/23 at 11:04 AM, the surveyor observed Resident #83 seated in a wheelchair, clean and well-dressed. The surveyor reviewed the medical record of Resident #83. The resident's admission Record (or face sheet; admission summary) reflected that the resident was admitted to the facility with diagnoses that included Unspecified Dementia with other behavioral disturbance, major depressive disorder, peripheral…

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 review of pertinent documents, the facility failed to ensure that the method for filing a grievance was consistent with the facility's practice and policy. This deficient practice was identified for three of four grievance incidents of Resident #83. The evidence was as follows: On 01/05/23 at 10:42 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated that he started working at the facility three months ago. The DON stated that she started working on 12/15/22, the same time when both the previous DON and Infection Preventionist Nurse left the facility. On 01/11/23 at 8:58 AM, the resident representative (RR) informed the survey team that he/she visits Resident #83 almost every day. The RR stated that he/she complained to the previous administrator about the resident's arms discoloration and was told that it was taken care of and that the resident had fragile skin. The RR further stated that he/she had an issue with the Certified Nursing Aide (CNA)…

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 review of medical records, it was determined that the facility failed to develop a person-centered comprehensive care plan to address the actual skin impairments for one of four residents (Resident #15) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 01/05/23 at 10:42 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the DON stated that she started working on 12/15/22, the same time when both the previous DON and Infection Preventionist Nurse (IPN) left the facility. The DON further stated that the IPN was also the Wound Nurse (WN). On 01/05/23 at 12:20 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. On 01/05/23 at 12:28 PM, the surveyor observed the resident seated with left foot dressing. The surveyor reviewed Resident #15's medical record. The admission Record (or face sheet; an admission summary)…

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, review of the medical record, and review of other facility documentation, it was determined that the facility failed to a) initiate a baseline care plan which included at risk for falls within 48 hours of admission and thoroughly and completely investigate a fall to include the addition of interventions to prevent a fall for one of four residents reviewed for falls, Resident #321; and b) failed to follow and maintain fall prevention interventions as written on the resident's plan of care for one of four residents reviewed for falls, Resident #132. The deficient practice was evidenced by the following: 1. On 01/05/23 at 12:05 PM, the surveyor observed Resident #321 in a reclined chair in the day room of the third floor unit. The resident's right side of the upper face was bruised. On 01/09/23 at 9:45 AM, the surveyor reviewed Resident #321's electronic medical record. The admission Record (AR; or face sheet; an admission summary) indicated that the resident had diagnoses which…

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

Based on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure that the Registered Nurse (RN) had the specific competencies and skill sets necessary to care for residents' needs. This deficient practice was evidenced by the following: On 01/05/23 at 12:20 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. On 01/05/23 at 12:28 PM, the surveyor observed the resident seated with left foot dressing. The surveyor reviewed Resident #15's medical records. The admission Record (AR; or face sheet which included the admission summary) showed that the resident was admitted to the facility with diagnoses that included Diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin), chronic kidney disease (a gradual loss of kidney function over time), and peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside heart and brain to narrow,…

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 review of pertinent documents, it was determined that the facility failed to maintain the kitchen in a sanitary manner as evidenced by the following: On 01/06/23 at 11:31 AM, the surveyor toured the kitchen on the second day with Food Service Director (FSD). The surveyor observed the food prep area with open food and kitchen staff preparing the lunch meal trays. Above the prep area were two kitchen tiles in between two air vents with an accumulation of black debris. At that time, the FSD stated that the black debris was an accumulation of dust. The surveyor asked the FSD regarding the cleaning schedule of air vents and above kitchen tiles. The FSD informed the surveyor that the air vents and above tiles should be cleaned once a month by the night shift kitchen staff and that there was a log for cleaning. In addition, the surveyor asked the FSD to show the cleaning log and when was the last time it was cleaned. On that same date and time, the FSD was not able to provide documentation and log that the air vents and tiles were cleaned. The FSD…

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 review of the facility documents, it was determined that the facility failed to: a) perform hand hygiene appropriately for two of eight staff and, b) properly dispose of PPE (personal protective equipment) for one of two staff observed in TBP (transmission based precautions) room in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. In addition, when cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for 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 observation, interview, and record review it was determined that the facility failed to complete a wound treatment in accordance with the physician's order. This was identified for 1 of 1 residents (Residents #135) reviewed for wounnd treatments. The deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as…

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 review of facility documents, it was determined that the facility failed to obtain a physician's order for the use of Oxygen and failed to maintain safe cleaning and storage of BiPAP (a Bi-level positive pressure airway ventilation machine to improve oxygenation) equipment according to professional standards of practice. This deficient practice was observed for 2 of 3 residents (Resident #21 and #177) reviewed for oxygen use and was evidenced by the following: 1. On 1/19/21 at 11 AM, the surveyor observed Resident #21 in bed awake and alert to person, place and date. The resident was receiving Oxygen 2 liters per minute (LPM) via a nasal cannula. The surveyor observed the tubing was dated 1/18/21. During the interview, the surveyor observed a BiPAP machine on top of the resident's dresser. The surveyor asked the resident about the use of the BiPAP machine. The resident stated that the 3-11 shift nurse places the face mask and connects the tubing to the machine each night to help her breathe easy as he/she sleeps and the 11-7 shift…

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.