Artesia Healthcare & Rehabilitation Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #4) of 4 (R #1, R #2, R #4, and R #26) residents reviewed for care plans when staff failed to implement R #4's care plan for falls by utilizing the fall mat. This deficient practice could likely result in proper care not being provided to residents.The findings are: A. Record review of R #4's admission record revealed R #4 was admitted into the facility on [DATE].B. Record review of R #4's care plan, last revised on 03/31/25, revealed an intervention to offer fall mat as indicated.C. On 02/22/26 at 2:26 pm, a random observation of R #4's room, revealed R #4 was lying in bed and the fall mat was located underneath his bed.D. On 02/22/26 at 2:37 pm, during an interview with Registered Nurse (RN) #2 she confirmed R #4's fall mat was not placed correctly, and that it should be placed on the floor next to his bed.E. On 02/26/26 at 2:54 pm during an interview with the Director…

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

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #42) of 1 (R #42) resident reviewed when the staff failed to follow physician orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:Cross Reference 760A. Record review of R #42's physician's orders revealed an order dated 10/24/25 for Losartan (angiotensin(hormone) receptor blocker to treat high blood pressure) 25 milligrams (mg), give half tablet by mouth one time a day for hypertension. Notify MD (Medical Doctor) for hold orders if SBP (systolic (top number of blood pressure) blood pressure) less than 110 or DBP (diastolic (bottom number) blood pressure) less than 60 or pulse less than 60.B. On 02/25/26 at 8:54 am, during an observation of medication administration, Licensed Practical Nurse (LPN) #2 reported a blood pressure reading of 103/61. She then administered the medication outside the prescribed parameters. C. On 02/26/26 at 3:45 pm,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide quality of care when staff failed to implement and follow discharge orders for wound care for 1 (R #60) of 3 (R #1, R #4, and R #60) resident reviewed. These deficient practices could likely result in residents to not getting the treatment needed and/or potentially worsening conditions. The findings are:A. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE] with the following diagnoses:1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),3. Bacteremia (presence of bacteria and infectious organisms in the blood stream),4. Syphilis (a sexually transmitted infection [STI]), 5. Pseudomonas (bacteria that occurs in soil or waste),6. Resistant to multiple antibiotics (MDR; occurs when bacteria or fungi evolve to withstand multiple drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #60) of 2 (R #1 and R #60) residents reviewed for pain when the facility failed to:1. Administer medications as per physician's orders.2. Monitor pain.3. Implement a care plan and interventions for pain management.This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life. The findings are: A. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE] with the following diagnoses:1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),3. Bacteremia (presence of bacteria and infectious organisms in the blood stream),4. Syphilis (a sexually…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to obtain appropriate physician orders prior to installation of bed rails for 1 (R #60) of 2 (R #46 and R #60) residents reviewed for bedrails. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails. The findings are:A. Record review of R #60's admission record revealed R #60 was admitted into the facility on [DATE]. B. Record review of R #60's physician orders revealed no order for the use of bedrails.C. Record review of R #60's bedrail assessment dated [DATE] revealed R #60 does use bedrails to enhance mobility. D. On 02/23/26 at 8:38 am during a random observation of R #60's room revealed quarter size bedrails on the upper right and left sides of bed. E. On 02/23/26 at 8:42 pm during an interview with R #60, he confirmed he uses the bedrails for mobility and repositioning himself. F. On 02/26/26 at 2:54 pm, during an interview with the Director of Nursing (DON), she…

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

Based on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #42) of 1 (R #42) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication. The findings are:A. Record review of R #42's Physician's orders revealed an order dated 10/24/25 for Losartan (angiotensin(hormone) receptor blocker to treat high blood pressure) 25 milligrams (mg); Give 0.5 tablet by mouth one time a day for hypertension. Notify MD (Medical Doctor) for hold orders if SBP (systolic (top number of blood pressure) blood pressure) less than 110 or DBP (diastolic (bottom number) blood pressure) less than 60 or pulse less than 60.B. Record review of R #42's Medication Administration Record (MAR) for February 2026, revealed staff administered the following:-Losartan, 0.5 (or 1/2) of 25 mg, 02/02/26,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure hospice services met professional standards for 1 (R #4) of 1 (R #4) residents reviewed for hospice services by:1. Not having a qualifying diagnosis for R #4.2. Not having hospice plans of care for R #4.These deficient practices are likely to result in the resident not receiving the services that she needs. The findings are:A. Record review of R #4's admission record revealed R #4 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnosis:1. Alzheimer's disease (a progressive brain disorder that damages and destroys nerve cells leading to a decline in abilities and behavioral changes),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Epilepsy (a seizure disorder),4. Down Syndrome (a genetic condition),B. Record review of R #4's hospice admission order form (a form completed by a hospice nurse to identify diagnosis,…

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

Based on observations and interviews, the facility failed to utilize enhanced barrier precautions (an infection control intervention) when providing personal care to 1 (R #10) of 2 (R #10 and R #23) residents. Failure to utilize enhanced barrier precautions when performing personal care has the potential to spread organisms, diseases, and other health conditions among the residents. The findings are: A. On 02/22/26 at 10:02 am, during a random observation of R #10's room, the door to her room revealed a sign on the door that indicated R #10 was on enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when providing care for her.B. On 02/24/26 at 1:27 pm, during an observation and interview of R #10's tube feeding, Licensed Practical Nurse (LPN) #1 was observed accessing the feeding tube. LPN #1 wore gloves while accessing the tube but did not put on the required gown as per EBP signage on the door. LPN stated he is not…

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

Based on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are:A. Record review of the facility's list of reportable incidents revealed an incident for R #1 dated 11/13/25. B. Record review of the facility's five-day report revealed the following: 1. The investigation was completed2. There was no evidence that the results of the investigation was submitted to the state Survey Agency withing 5 working days of the incident. E. On 12/11/25 at 2:02 pm, during an interview with the Administrator (ADM) she confirmed it is the facility's responsibility to submit a five day follow up report with the results of the investigation to the state survey agency. She could not…

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

Based on observation, record review and interview, the facility failed to: 1. Complete the sign-off sheet and record the measurement of the dishwasher temperatures and sanitizing solutions daily. 2. Complete the sign-off sheet and record the food temperatures daily. 3. Ensure the sanitization logs were signed with the appropriate concentrations of sanitizer and water measured the proper dilution strength after dilution [cleaning solutions are measured in parts per million, (PPM). Greater than 50 PPM is required after diluting the concentrated sanitizing liquid] were completed daily.These failures could potentially affect all 54 residents in the facility who eat food prepared in the kitchen (residents were identified by the census provided by the Administrator on 09/23/25). If the facility fails to adhere to proper sanitization and food temperature monitoring, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are:DISHWASHERA. Record review of the facility's policy, Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to inform residents and the resident representative in writing of a room change prior to the resident changing rooms and include the reason for the room change for 1 (R #1) of 1 (R #1) resident reviewed for room change. This deficient practice is likely to result in frustration and confusion for the residents which could lead to mental anguish. The findings are:A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. Psychosis (a condition characterized by a loss of contact with reality, often involving symptoms like hallucinations, delusions, and disorganized thinking),2. Dementia (a broad term for a decline in mental ability severe enough to interfere with daily life),3. Need for Assistance with Personal Care.B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 05/27/25 revealed a Brief Interview 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 record review and interview, the facility administrator failed to report and thoroughly investigate an allegation of sexual assault. This deficient practice could affect all 46 residents residing in the facility according to the daily census provided by the Administrator (ADM) on 06/03/25. If the facility is not thoroughly reporting and investigating allegations of sexual assault, then residents are at a higher risk of being abused, neglected, or mistreated. The findings are: A. Record review of a grievance report dated 05/25/25 revealed staff reported an allegation of possible sexual assault on R #1 from R #2 to the Social Worker (SW). B. On 06/03/25 at 10:03 am during an interview, the SW confirmed she received a grievance from staff on 05/25/25 reporting an allegation of sexual assault on R #1. The SW stated she did report the allegation to the Administrator (ADM) on 05/25/25. C. Record review of the New Mexico Health Care Authority (HCA) complaints intake revealed HCA had not received a report from the facility regarding the allegation of possible resident sexual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report an an incident of abuse to the State Survey Agency for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are: A. Record review of R #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] section C revealed a Brief Interview for Mental Status (BIMS) score of zero (significant impairment). B. Record review of a grievance report dated 05/25/25 revealed staff reported an allegation of possible sexual assault on R #1 from R #2. C. Record review of the New Mexico Health Care Authority (HCA) complaints intake revealed HCA had not received a report from the facility regarding the allegation of possible resident sexual abuse for the grievance report dated 05/25/25. D. On 06/03/25 at 9:25 am during an interview, Housekeeper (HK) #1 confirmed she was told by another staff that R #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 record review and interview, the facility failed to complete a thorough investigation for allegations of abuse for 1 (R #1) of 1(R #1) resident reviewed for abuse. If the facility is not completing an accurate and thorough investigation for an allegation of abuse and submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of a grievance report dated 05/25/25 revealed: 1. Staff reported an allegation of possible sexual assault on R #1 from R #2. 2. R #2 denied the allegation and R #1 looked at the SW. 3. The administrator was informed of the allegation. 4. Follow/up Action taken stated Final outcome, no sign of abuse was detected. B. On 06/03/25 at 10:03 am during an interview, the Social Worker (SW) confirmed she received a grievance from staff on 05/25/25. The SW confirmed R #1 cannot communicate verbally and does not have the ability to defend herself if needed. SW stated R #2 denied the allegation and R #1…

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

Based on observation and interviews, the facility failed to provide a comfortable and homelike environment for 4 (R #9, R #28, R #34, and R #152) of 4 (R #9, R #28, R #34, and R #152) residents sampled for environment by not repairing or cleaning the following: 1. Peeling and chipped paint 2. Wall repairs not repainted to match rest of wall 3. Hand rails in 300 hall appeared worn and needed repair/refinishing. 4. The carpet in the 200 hall and 300 hall were stained, worn and faded. 5. The wall near the main entrance by fire alarm had been repaired with plaster but has no paint. 6. The ceiling tiles near nurses station have brown stains covering most of the tile. These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are: A. On 03/03/25 10:37 am a random observation of the facility environment revealed the following: 1. Peeling and chipped paint 2. Wall repairs not repainted to match rest of wall 3. Hand rails in 300 hall appeared worn and needed repair/refinishing. 4.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 3 (R #9, R #30, and R #45) of 4 (R #9, R #14, R #30, and R #45) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need. The findings are: Should S/S be D, 3 residents and each had on PASRR assessment R #9 A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE] with the following diagnoses: 1. Anxiety (feeling of worry, nervousness, or unease), 2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified, 3. Neuromuscular dysfunction of bladder, unspecified, 4. Repeated falls, 5. Need 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to prevent an accident for 1 (R #9) of 3 (R #6, R #9, and R #30) residents reviewed for falls when staff failed to complete a post-fall neurological evaluations (neurocheck; a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status). This deficient practice is likely to put residents at risk of unsafe situations. The findings are: A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE], with the following diagnoses: 1. Anxiety (feeling of worry, nervousness, or unease), 2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified, 3. Neuromuscular dysfunction of bladder, unspecified, 4. Repeated falls, 5. Need for assistance with personal care. B. Record review of R #9's quarterly Minimum Data Set (MDS; a federally mandated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident with a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) had an order that demonstrated that a catheter was necessary, what type of catheter was needed, and how to care for the catheter for 1 (R #9) of 2 (R #9 and R #30) residents reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents. The findings are: A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE], with the following diagnoses: 1. Anxiety (feeling of worry, nervousness, or unease), 2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified, 3. Neuromuscular dysfunction of bladder, unspecified, 4. Repeated falls, 5. Need for assistance with personal care. B. Record 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.

Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed three medication errors out of 29 opportunities for 1 (R #28) of 9 (R #2, R #4, R #12, R #17, R #20, R #22, R #25, R #28, R #152) residents reviewed during medication administration. This resulted in a medication error rate of 10.34%. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects. The findings are: A. On 03/05/25 at 9:40 am, during an observation of Licensed Practical Nurse (LPN) #1, obtained vital signs (measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) for R #28, blood pressure was 121/75 (121; systolic number: maximum pressure during contraction of heart, 75; diastolic number: minimum pressure at the end of hearth contraction) and a pulse (rhythmic throbbing of blood…

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

Based on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #28) of 1 (R #28) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication. The findings are: A. Record review of R #28's Physician's orders revealed the following: - Metoprolol (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) ER (extended release) Start date 12/10/24. Metoprolol succinate (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) ER (extended release), oral tablet, extended release 24-hour, 50 mg (milligram; dose of medication); Give 50 mg by mouth one time a day for hypertension (high blood pressure). Hold if pulse is below 60 and notify provider, hold if BP (blood pressure) is less than 140/90. -Amlodipine Besylate…

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 interview, the facility failed to assure medications were secured and inaccessible to unauthorized staff, visitors, and residents. This deficient practice has the potential to affect all 14 residents residing on the 200 hall as identified on the resident census provided by the Administrator on 05/14/25. Improperly stored medications could result in a resident, staff member, or visitor taking the medications not prescribed to them. The findings are: A. On 05/14/25 at 8:10 am a random observation of the 200 hall revealed a medication cart near room [ROOM NUMBER], had seven boxes of wound gel on top of the cart. Staff were not present in the area near the cart. B. On 05/14/25 at 8:14 am, during an interview with Director of Staff Development (DSD), she stated the wound gel should have been placed in the medication storage room and not left on top of the cart unattended.

Based on record review and interview, the facility failed to ensure their binding arbitration agreement (contract where parties agree to resolve disputes through a neutral third party instead of court) explicitly (in a clear and detailed manner, leaving no room for confusion or doubt) grants the resident and/or representative the right to rescind (to cancel) the agreement within 30 calendar days of signing the agreement for the 20 (R #3, R #5, R #7, R #8, R #10, R #11, R #13, R #15, R #17, R #18, R #19, R #20, R #23, R #24, R #25, R #28, R #30, R #32, R #35, and R #37) of 49 (R #1-R #49) This is not clear only 20 residents of the 49 residents binging arbitration agreement did not include a provision for the resident's and/or resident's representative ability to rescind the agreement within 30 calendar days and was not signed? Please provide evidence The census was 49, it's 49 total residents. Only 20 of those 49 residents agreed to sign the arbitration agreement. That's why I had it like this to start- Based on record review and interview, the facility failed to ensure their binding…

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 their binding arbitration agreement (a clause within a contract where parties agree to resolve disputes through arbitration (arbitration; formal out -of-court method of resolving disputes) and waive their right to a trial and agree to accept the arbitrator's decision as final) included a provision for convenient venue (a location in which to carry out arbitration proceedings which should be agreed upon and suitable for both parties) selection. Failure to include this provision in the agreement could likely result in residents who choose to seek arbitration experiencing frustration and difficulty deterring (discourage or prevent from acting on) them from exercising their rights for the 20 (R #3, R #5, R #7, R #8, R #10, R #11, R #13, R #15, R #17, R #18, R #19, R #20, R #23, R #24, R #25, R #28, R #30, R #32, R #35, and R #37) of 49 (R #1- R #49) residents that have signed the agreement as identified by the list the Administrator (ADM) provided on 03/5/25. The findings are: A. Record review of the facility's binging…

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

Based on observation and interviews, the facility failed to maintain proper infection prevention practices when staff did not clean the blood pressure cuff and vital sign equipment prior to and after taking vital signs for 3 (R #22, R #28, and R #152) of 3 (R #22, R #28, and R #152) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 03/05/25 at 9:42 am, during an observation of Nurse #1 revealed the following: 1. Nurse #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #22. 2. Nurse #1 then took vital signs on R #28 without cleaning the blood pressure cuff and vital sign equipment. 3. Nurse #1 then took vital signs on R #152 without cleaning the blood pressure cuff and vital sign equipment. B. On 03/05/25 at 10:18 am, during an interview with Nurse #1, he stated he should have cleaned off all vital sign equipment before taking R #22's vitals and in between each resident afterwards. C. On 03/05/25 at 10:45 am, during 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 and interview, the facility failed to ensure the hallway in the 200 hall was accessible for residents. This deficient practice is likely to affect all 14 residents residing on the 200 hall as identified on the resident census provided by the Administrator on 05/14/25. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 05/14/25 at 8:10 am a random observation of the 200 hall revealed the following: 1. A medication cart on the left side of the hallway near room [ROOM NUMBER]. 2. A housekeeping cart on the right side of the hallway near room [ROOM NUMBER], 3. A housekeeping cart on the left side of the hallway near room [ROOM NUMBER], 4. A mechanical lift on the right side of the hallway near rooms [ROOM NUMBERS]. B. On 05/14/25 at 8:30 am during an interview with Housekeeper (HK) #1, she confirmed there were objects on both sides of the hallway blocking 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 interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #45) of 2 (R #3 and R #45) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially life saving procedures. The findings are: A. Record review of R #45's face sheet revealed R #45 was admitted into the facility on [DATE]. B. Record review of R #45's physician orders dated [DATE], revealed R #45 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status. C. Record review of R #45's EHR revealed the record did not contain a valid advanced directive form. The New Mexico medical orders for scope of treatment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 2 (R #9 and R #30) of 5 (R #2, R #4, R #9, R #30, and R #44) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: R #9 A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE], with the following diagnoses: 1. Anxiety (feeling of worry, nervousness, or unease), 2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified, 3. Neuromuscular (dysfunction of bladder), unspecified, 4. Repeated falls, 5. Need for assistance with personal care. B. Record review of R #9's electronic health record (EHR) revealed a change of condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 2 (R #3 and R #45) of 3 (R #3, R #14 and R #45) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #3 A. Record review of R #3's face sheet revealed R #3 was admitted to the facility on [DATE], with the following diagnoses: 1. Pain in right hip, 2. History of falling, 3. Pain in right knee, 4. Muscle weakness (generalized), 5. Difficulty in walking, 6. Lack of coordination. B. On 03/04/25 at 10:06 am, during an observation of R #3's bed, revealed grab bars on each side of the bed C. Record review of R #3's care plan dated 12/18/24, revealed R #3 did not have a care plan for the use of grab bars. D. On 03/04/25 at 10:06 am, during an interview, R #3 stated she was aware she had grab bars on each side of the bed and used the garb bars to help…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #3 and R #4) of 5 (R #3, R #4, R #21, R #23, and R #36) residents reviewed for care plans. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #3 A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE]. B. Record review of R #3's care plan dated 12/18/24, revealed R #3 is at risk for abnormal bleeding or hemorrhage (the loss of blood from the circulatory system) due to anticoagulant (medication used to prevent and treat blood clots in blood vessels and the heart) use related to daily use of Plavix (a medicine used to prevent problems caused by blood clots). C. Record review of R #3's electronic health record (EHR), revealed a physician order for Plavix dated 12/18/24 and was discontinued 01/11/25. D. Record review of R #3's Medication Administration Record (MAR) for the month 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 and interview, the facility failed to provide a clean and safe environment. This deficient practice is likely to affect all 44 residents living in the facility as listed on the Resident Census provided by the Administrator on 04/24/24. Failure to maintain a safe and clean environment is likely to prevent residents from enjoying everyday outdoor activities. The findings are: A. On 04/24/24 at 1:06 pm, a random observation of the facility's courtyard area revealed - A black office chair on wheels on the sidewalk with bird feces on it. -The sidewalk, which served as the walking path for residents, was 75 percent covered with bird feces, pecans, and pecan shells and made the sidewalk impassable for residents. -The lid on the trash can could not be closed due to the trash can was full with empty cigarette boxes. -The grass was approximately 8 to 10 inches tall in some areas of the courtyard. - Items, such as used napkins, a coffee cup, cigarette box wrappers, and used tissues, were on the ground throughout the courtyard. - A garden hose stretched across the sidewalk,…

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 keep all 44 residents residing in the facility free from the potential for accidents or hazards by placing mothballs (a solid chemical in the form of a ball that is normally used to control moths, silverfish, and other pests that like wool and other natural fiber materials) in the courtyard area. This deficient practice could likely result in new or worsening health issues for the residents. The findings are: A. Record review of the facility's Material Safety Data Sheet (MSDS; a document that contains information on the potential hazards and procedures of working with a chemical) book revealed a naphthalene (the main chemical found in mothballs) sheet which listed short-term or long-term side effects could be caused if inhaled or absorbed through the skin. B. On 04/24/24 at 12:59 pm during an interview with R #2, he stated he saw mothballs in the courtyard area a few weeks back when he would go outside to smoke. R #2 said the mothballs had a strong odor. C. On 04/24/24 at 1:06 pm, during an interview with R #3, he stated…

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

Based on interview, the facility failed to treat residents with respect and dignity for 1 (R #1) of 1 (R #1) residents reviewed when staff did not discuss plans for removing the cats from the facility grounds prior to placing mothballs in the courtyard area. This deficient practice is likely to result in residents feeling that their feelings and preferences are unimportant. The findings are: A. On 04/24/24 at 1:50 pm during an interview, R #1 stated that she saw mothballs in the courtyard, and she picked some of them up to throw them away. R #1 further stated she was not informed of the facility's attempt to remove the cats prior to the mothballs being placed in the courtyard. R #1 started to cry and said, I was scared for my cats. She stated she did not understand why the facility would want to remove the cats, because she had an agreement with the facility allowing her to keep three cats. R #1 stated she met with the Ombudsman (a person who investigates, reports on, and helps settle complaints for residents in nursing homes) and the previous administrator, and they made an…

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

Based on interviews, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. This deficient practice had the potential to affect all 48 residents living in the facility as identified by the census provided by the Adminisstrator on 03/11/24. The findings are: A. During an interview with the Assistant Director of Nursing (ADON) on 03/14/24 at 3:42 pm, he confirmed the facility did not designate a registered nurse to serve as DON on a full-time basis. He stated there are three nurses that share the DON duties. The ADON stated, We meet together collaboratively and figure out what needs to be done. The ADON stated the staff normally call him or the Director of Staff Development when they need a DON. The ADON stated he told facility staff to call him, since his home is close to the facility and he can have a quick response time. B. During an interview on 03/14/24 at 4:04 pm, the MDS Director stated three nurses shared the duties of DON. The MDS Director stated the three nurses that share DON duties are herself, the ADON, and the…

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

Based on observation and interview, the facility failed to properly store medications and supplies for all 48 residents, as identified by the matrix provided by the Administrator on 03/11/24, when staff failed to ensure the expired supplies and medications were not stored in the supply room. The deficient practice could likely result in all residents receiving medication that are expired or the use of supplies that are expired. The findings are: A. On 03/11/24 at 1:30 pm, an observation of the Medication Supply room revealed: 1. Four and a half boxes of On Guard Blood Collection Set expired on 12/31/22. 2. Benadryl, 25 mg, unopened box expired on 01/24. B. On 03/11/24 at 2:00 pm during an interview with Registered Nurse (RN) #1 confirmed the lab kits and medication were expired. C. On 03/14/24 at 9:30 am and 1:45 pm during an interview, the Central Supply Clerk (CSC) confirmed the medication and supplies were expired. The CSC stated it was expected staff would remove expired medications or supplies from the storage unit. The CSC stated the medication and supply storage room were…

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

Based on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to: 1. Use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. 2. Have food at the proper temperature on the food steam table prior to serving. These deficient practices are likely to affect all 48 residents listed on the resident's census list provided by the Administrator on 03/11/24 and could likely lead to food borne illnesses in residents if safe food handling practices are not adhered to. The findings are: Findings for proper food handling techniques A. On 03/11/2024 at 5:14 pm during an observation of the dinner meal served in the dining room, receptionist #1 put her thumb in the bowl prior to serving the meal to the resident. B. On 03/11/24 at 5:21 pm during an observation of the dinner meal in the dining room, the Administrator handled a cup of cranberry juice by the rim of the cup while distributing the drink to the resident. C. On 03/14/24 at 3:40 pm during an interview with the Assist Director of Nursing…

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 interview, the facility failed to maintain a comfortable and homelike environment that was clean, in good condition, and free from ceiling and wall debris for 1 resident occupied room (room [ROOM NUMBER]) in the facility. Failure to maintain the resident room in a clean and comfortable manner is likely to prevent residents living in a comfortable, homelike environment. The findings are: A. On 03/13/24 at 2:45 pm during an observation in room [ROOM NUMBER], on the wall next to the closet had a scrape which measured 3 inches by 5 inches, a chipped area which measured 1 inch by 1 inch, and exposed drywall. Further observation revealed scuff marks along the wall close to the bathroom, and the ceiling tiles were worn and broken, which created a hole in the ceiling. B. On 03/14/24 at 2:00 pm during an interview with the Maintenance Director (MD), he stated he was in the process of patching and painting the walls, and replacing the ceiling tiles. The MD stated the walls and ceilings 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.

Based on observation, interview and record review, the facility failed to complete an accurate comprehensive assessment for 1 (R #28) of 1 (R #28) residents reviewed for assessments. This deficient practice is likely to result in residents not receiving an accurate assessment which could result in residents receiving less than optimal care and treatment. The findings are: A. On 03/11/24 at 2:33 PM, during an interview and observation with R #28, she stated she had glasses. R #28 picked up her glasses from her tray. B. Record review of R #28's medical appointments revealed R #28 had an optometrist (eye doctor) appointment on 08/23/23. Further record review revealed the resident had her vision checked and received a new prescription. C. On 03/13/24 at 11:46 am, during an interview with Social Worker (SW), she stated R #28 received the new glasses a few weeks after appointment on 08/23/23. D. Record review of R #28's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment, dated 01/27/24, revealed the resident did not use glasses. E. 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 interview and record review, the facility failed to revise the care plan for 2 (R #7 and R #28) of 2 (R #7 and R #28) residents reviewed for care plans. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the needs of the residents. The findings are: R #7 A. On 03/11/24 at 1:55 pm during an interview with R #7, she stated she had several urinary tract infections (UTIs) recently. B. Record review of the care plan for R #7, dated 03/13/24, revealed the following: - The care plan included information regarding the resident's UTIs through 08/04/23, but it did not include information on her last two diagnosed UTIs, dated 10/29/23 and 01/30/24. - R #7 took Macrobid, an antibiotic medication used to treat bladder infections. C. Record review of R #7's physician orders revealed the following: -A discontinued order, dated 08/16/23 for Macrobid Oral Capsule 100 milligrams (mg) (Nitrofurantoin Monohyd Macro). -A current order, dated 02/19/24, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to create an accurate Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 3 (R #6, R #38, and R #46) of 4 (R #6, R #35, R # 38, and R #46) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care resident's need. The findings are: R #6 A. Record review of R #6's face sheet revealed she was admitted into the facility on [DATE]. B. Record review of R #6's Care Plan, dated 12/04/23, revealed staff did not develop a baseline care plan which included the resident's advanced directives within 48 hours of admission. R # 38 C. Record review of R #38's face sheet revealed she was initially admitted into the facility on [DATE]. D. Record review of R #38's Care Plan, dated 07/24/23, revealed staff did not develop a baseline care plan…

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

Based on observation, record review, and interview the facility failed to ensure residents with wounds had the correct documentation and monitoring in accordance with the professional standards of practice for 1 (R #46) of 1 (R #46) residents reviewed for pressure injury (localized damage to the skin/tissue occurs due to pressure). This deficient practice is likely to result in residents having worsened conditions. The finds are: A. Record Review of R #46's skin/wound notes, revealed the following: - On 02/14/24, a wound stage 4 (These sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments) to the coccyx (tailbone) which measured 1.7 centimeters (cm) by 1.1 cm by 3.5 cm, with copious serious drainage (type of fluid that comes out of a wound with tissue damage) noted. The wound had undermining (occurs when significant erosion occurs underneath the outwardly visible wound edges resulting in more extensive damage beneath the skin surface) located at 8 to 3 o'clock (a clock face is used to explain where the undermining is located 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.