Belen Meadows Healthcare and Rehabilitation Center

Based on record review and interview, the facility failed to keep accurate and complete resident records for 2 (R #97 and #123) of 2 (R #97 and #123) residents. This deficient practice could likely cause confusion about the resident's care the resident based on the documentation presented in the resident's electronic medical record. The findings are: R #97 A. Record review of R #97's face sheet revealed an admission date of 04/19/24 with the following diagnoses:- Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),-Osteoarthritis (condition caused by wear and tear of the joints causing loss of range of motion and pain with movement),-Chronic pain,-Left femur (long bone that connects the hip to the knee) fracture. B. Record review of R #97's After-Hour Encounter note (a note written by the provider not during regular business hours) revealed the following:- Dated 06/10/25 at 9:00 am, R #97 had a fall sometime between 06/10/25 at 9:00 pm and 06/11/25 at 1:00 am. - Dated 06/11/25 at 1:00 am, R #97 had a fall…

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 staff interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis of major depressive disorder for 1 (R #9) of 1 (R #9) resident. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.The findings are: A. Record review of the facility's Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients policy, revised 02/16/24, revealed the Social Worker or designated staff will assure all patients with mental disorders and intellectual disability received appropriate pre-admission screenings according to Federal and State regulations. The policy stated if a PASARR was not completed or was incorrect, then Social Services would coordinate with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to send a resident out to the hospital in a timely manner after the resident had a fall with pain and possible injury for 1 (R #97) of 1 (R #97) resident. This deficient practice could likely cause the resident to be in pain longer than necessary. The findings are: A. Record review of R #97's face sheet revealed she was admitted on [DATE] with the following diagnoses.-Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),-Osteoarthritis (condition caused by wear and tear of the joints causing loss of range of motion and pain with movement),-Chronic pain,-Left femur (long bone that connects the hip to the knee) fracture. B. Record review of R #97's After-Hour Encounter note (a note written by the provider not during regular business hours) revealed the following:- Dated 06/10/25 at 9:00 am, R #97 had a fall sometime between 06/10/25 at 9:00 pm and 06/11/25 at 1:00 am. - Dated 06/11/25…

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

Based on observations, interviews, and record reviews, the facility failed to ensure a residents specialized air mattress was properly inflated for 1 (R #12) of 1 (R #12) resident. If the facility fails to ensure the residents' air mattress was properly inflated, then the resident could be at risk of entrapment or of development or worsening of a resident's pressure ulcers.The findings are:A. Record review of R #12's admission Record, dated 09/16/25, revealed an admission date of 05/02/22 with the following diagnoses:-Reduced mobility (decreased ability to move the body independently).-Legally blind.-Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin).-Morbid obesity (severely overweight). B. Record review of R #12's Provider Orders, dated 07/22/25, revealed the following:-Specialty mattress. (a mattress designed to prevent or treat pressure injuries (bedsores) by reducing or redistributing pressure on the skin) -Alternating air mattress (a therapeutic or specialty mattress that contains air cells which automatically inflate and deflate in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly maintain respiratory care equipment for 1 (R #6) of 1 (R #6) residents when staff failed to date R #6's oxygen humidifier (to moisturize dry oxygen). If staff fail to date oxygen humidifiers, then residents could be at risk of serious infections. The findings are:A. Record review of the facility's Oxygen Policy, last revised on 08/07/23, showed the following:- If oxygen humidifier was used, staff should label with date.- Staff should replace disposable oxygen setup (equipment used for oxygen administration) every seven days. B. Record review of R #6's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnosis of congestive heart failure (CHF; impaired heart function) and anemia (low red blood cell count). C. Record review of R #6's Provider Orders showed the following:- Dated 07/28/25, an active order to administer oxygen at two liter/minute through a nasal cannula to keep oxygen above 90 percent (%),…

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 Cross reference to F759. Based on record review, observation, and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to dispose of medication after it was completed for 1 (R #55) of 1 (R #55) resident. If staff fail to dispose of completed medications, then residents could be at increased risk of medication errors, receive unnecessary treatments, and medication could be diverted. The findings are:A. Record review of the facility's Disposal of Medications Policy, dated January 2024, showed the following:- If a prescriber discontinued a medication, the medication container was removed from the medication cart as soon as practicable according to State and Federal regulations in a timely manner.- Medications awaiting disposal or return were stored in a locked secure area designated for that purpose and separated from active orders until destroyed or picked up by the pharmacy staff.- Medications awaiting…

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 reviews and interviews, the facility failed to ensure residents obtained routine dental care for 1 (R #6) of 1 (R #6) resident reviewed for dental services, when the facility failed to provide documentation to show R #6 received routine dental services at least annually. If staff fail to arrange for residents' dental services, then it could lead to untreated tooth decay (damage to tooth surface), gum disease, and other oral health issues like bad breath, tooth sensitivity, and tooth loss. The findings are:A. Record review of the facility's Dental Services policy, dated 11/28/17 and last revised on 09/15/25, showed the following:- The facility provided or obtained, from an outside resource, routine and emergency dental services, to meet the needs of each resident.- Routine dental services meant an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental x-rays as needed, dental cleaning, and fillings (a treatment to repair a damaged tooth).- When necessary or…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's wheelchair was maintained in safe operating condition for 1 (R #62) of 1 (R #62) resident. If staff do not maintain resident equipment, then residents are at risk of injury. The findings are: A. Record review of R #62's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/03/25, identified diagnoses of repeated falls, generalized muscle weakness, and need for assistance with personal care. B. Record review of R # 62's comprehensive care plan, revised on 09/12/25, showed interventions for assistance with activities of daily living (ADL; personal care tasks such as bathing, dressing, eating, toileting, and mobility), transfers, locomotion, and mobility due to limited mobility. C. On 09/16/25 at 12:29 a.m., during an observation and interview, R # 62 sat in his wheelchair in the common area. The back bar across the wheelchair was not attached and hung on the left side. R # 62 stated his wheelchair was broken for an extended period of time.…

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

Based on interview, the facility failed to inform residents and resident representatives in writing of a room change, including the reason for the change, when residents changed rooms due to a flooding event. for 8 (R #1-8) of 8 (R #1-8) residents that were moved. This deficient practice is likely to result in frustration and confusion for residents. The findings are: A. On 01/07/25 at 10:20 am during an interview with Nurse Manager (NM) #1, she stated the Managers were called into the facility because of the flooding on the 200 wing on 01/06/25. She stated the Managers were asked to assist in moving residents. She stated she assisted moving residents R #5 and R #3. She stated she did not call the residents' families or the resident representatives to inform them of the move or of the flooding issue. NM #1 states she was not aware if any staff called the families or resident representatives of R #1-8 to inform them of the move and flooding. B. Record Review of R #6's medical record revealed staff documented the following: - Dated 1/7/2025 at 11:15 am, due to water/ plumping issue,…

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, observation and interviews, the facility failed to ensure staff documented the medication refrigerator temperatures in the medication storage room. This deficient practice is likely to result in all residents living in the facility, as identified on the census list provided by the Executive Director (ED) on 06/24/24, receiving medication that has lost their potency or effectiveness due to not being stored at the proper temperature. The findings are: A. Record review of the medication storage room temperature log book for the medication #1 refrigerator, the medication #2 refrigerator, and the specimen refrigerator revealed staff did not document temperature recordings for the following dates: 1. 06/21/24 pm. 2. 06/22/24 am and pm. 3. 06/23/24 am and pm. B. On 06/24/24 at 10:28 am during observation of the medication storage room, the medication #1 refrigerator, the medication #2 refrigerator, and the specimen refrigerator contained insulin and other medications that required refrigeration. C. On 06/28/24 at 12:23 pm, during an interview with the Director 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 record review, observation, and interview, the facility failed to ensure that residents received food according to their meal ticket for 3 (R #30, R #62, and R #64) of 4 (R #28, R #30, R #62, and R #64) residents reviewed for dietary services. This deficient practice could likely result in residents not receiving enough food or food that was expected according to the menu. the findings are: R #62: A. On 06/24/24 at 10:26 am, during an interview with R #62, he reported I don't get enough food. I am supposed to get double portions. B. Record review of R #62's dietary meal ticket (an individualized description from the kitchen of what staff should serve a resident), dated 06/28/24, revealed the following: - Regular/liberalized diet. - Double portions of all items. - King Ranch Chicken casserole - two squares, dinner roll - two each, margarine - two each, sliced peaches - 1 cup, vanilla ice cream- 1/2 cup, assorted beverage - 12 ounces, house supplement - two each. C. On 06/28/24 at 12:30 pm, during an observation of R #62's meal tray, the meal tray did not match R #62's meal…

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 an environment in good condition when staff failed to repair a broken door knob for 1 (R # 52) of 4 (R #'s 10, 52, 100 and 168) reviewed for homelike environment. If the facility fails to maintain the building, then residents could feel uncomfortable in their environment. The findings are: A. On 06/27/24 at 12:51 PM during a random observation and interview with R #52, R #52's bathroom door did not have a doorknob and could not be opened. R #52 stated the doorknob was broken for several weeks, and he was not able to access his restroom. He stated he told the CNAs, and they were aware the doorknob was broken. B. Record review of R #52's Minimum Data Set, dated [DATE] revealed that R #52 was continent and was able to toilet himself. C. On 06/28/24 at 10:21 am, an observation of R #52's room revealed the bathroom door did not have a doorknob. D. Record review of facility work order request #2920, dated 06/17/24, revealed a work order was submitted…

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 the comprehensive care plan was accurate for 1 (R #37) of 1 (R #37) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are: A. Record review of R #37's care plan, dated 06/04/24, revealed the following focus areas: - R #37 may not smoke per smoking evaluation, initiated 02/26/23, - R #37 may smoke with supervision per smoking evaluation, initiated 05/05/23. B. On 06/28/24 at 11:03 am during an interview with the Director of Nursing (DON), she stated R #37 did not smoke nor did she have a history of smoking. She added the resident's care plan should not have either smoking statement listed.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was accurately revised for 1 (R #37) of 1 (R #37) residents reviewed for care plans. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are: A. Record review of R #37's care plan, dated 06/04/24, revealed R #37 had an active urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra) and was at risk for sepsis, initiated 02/10/24. B. Record review of R #37's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/22/24, revealed the resident did not have a UTI in the past 30 days. C. On 06/28/24 at 11:03 am during an interview with the Director of Nursing (DON), she stated R #37 had a UTI in February 2024 and has not had once since. She added that the care plan should reflect that R #37 was at risk for developing UTIs, not that R #37 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to meet professional standards of quality by failing to obtain wound care orders for 1 (R #12) of 3 (R #12, 15, and 16) residents reviewed for pressure sores. If the facility does not get wound care orders, it could create confusion on what wound care should be provided, or the residents may not get wound care. The findings are: A. Record review of the admission history and physical (H and P) for R #12, completed on 12/14/23 indicated the following under skin: -Wound on L (left) heel and big toe of R (right) foot; -Stage 2 pressure wound (sore has broken through the top layer of the skin and part of the layer below wound is open and shallow and could have clear or yellow fluid) on sacrococcygeal (sacrum or tail bone). B. Record review of the face sheet for R #12 revealed the resident was admitted to the facility on [DATE] with a left heel wound and a wound on his right big toe. No documentation of a wound on his tail bone. C. Record review of the…

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

Based on interview and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) documentation included a summary of the investigation and findings or conclusions regarding the resident's concerns, and no resolution that consisted of education for staff, for 2 (R #2 and R #5) of 3 (R #2, R #5, and R #6) residents reviewed for grievances. The deficient practice could likely result in residents feeling unimportant and/or unsatisfied with the results of the grievance process. The findings are: A. Record review of the facility's grievance book revealed: 1. A grievance filed by R #5, dated 07/11/23, revealed the record did not contain a summary of the investigation and findings results. The resolution was to consist of staff being educated on resident approach on 07/11/23. 2. A grievance filed by R #2, dated 08/02/23, revealed the record did not contain a summary of the investigation and the findings results. 3. A grievance filed by R #2, dated 08/23/23, revealed the record did not contain a summary of the investigation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a thorough investigation regarding an injury of unknown origin for 1 (R #6) of 3 (R#2, R #5, and R #6) residents viewed during a compliant investigation. If the facility is not going to conduct investigations, they may be unable to ensure that residents are free from neglect and could likely result in residents being at risk for further injury. The findings are: A. Record review of facility policy, Abuse Prohibition, revised 10/24/22, revealed, Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. The investigation will be thoroughly documented with in risk management portal. Ensure that documentation of witnessed interviews is included. B. Record review of the facility's nursing progress note, dated for 07/16/23, revealed the resident's family member reported something was different about the resident's nose. C. Record review of the risk management documentation, dated 07/16/23, for R #6, revealed 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 document a resident assessment when they received a report of a health status irregularity and to document observations of an identified health status irregularity. These deficient practices was found to affect 2 (R #2 and R #6) of 5 (R #1, R #2, R #3, R #4, and R#6) residents reviewed for nursing assessments after a change in condition occurred. This deficient practice could likely result in: 1. Residents not being properly assessed and treated for new concerns and; 2. Staff not having information they need to provide, competent, comprehensive care, and services if vital information is missing from the assessments. The findings are R #2 A. Record review of a facility grievance, dated 07/18/23, R #2 stated, at approximately 1:00 am on 07/15/23, he started feeling numbness on his right side and told the nurse he wanted to go to the hospital. He stated the nurse told him that she needed to make a phone call. R #2 stated when the nurse hung up the phone,…

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 N. On 03/13/23 at 10:45 am, the following observations were made for the 100 hall: Observation made of 4 call lights on: room [ROOM NUMBER] for R #69 stated she had just turned her call light on. room [ROOM NUMBER] for R #59, she stated that her light had been on a long time. She stated that she needed to be changed. room [ROOM NUMBER] for R #28, her light was observed to be continuously on for 45 minutes. room [ROOM NUMBER] for R #46, his light was observed to be on for thirty minutes, when asked R #46 stated his light had been on longer than thrifty minutes and he needed his urinal dumped. O. On 03/14/23 at 12:05 pm, during an interview with Volunteer Ombudsman, he stated that he does hear complaints from the residents about call lights not being answered, but those complaints have gotten better. He stated that previously he had heard of residents waiting up to 45 minutes for a call light to be answered. He stated that they are staffed with more CNA's than he had seen so he knows they have been working on it.…

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.

This is a repeat citation. Based on record review, observation, and interview, the facility failed to maintain menu options by not following the menu and not placing all menu items on a resident's meal tray. This deficient practice has the potential to affect all 103 residents identified on the census list provided by the Administrator on 03/06/23 and could likely result in reduced food intake, weight loss, and a decline in a resident's psychosocial health (the health of someone's emotions, behaviors, and social abilities) due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. The findings are: A Record review of the lunch menu for 03/07/23 revealed the items to be served for lunch were a sloppy joe on roll, seasoned potatoes, mixed veggies, potato wedges, and pineapple crisp with whipped topping. B. On 03/07/23 at 11:27 am, during a observation of the lunch meals on the dining room tables, the pineapple crisp desserts were observed to be missing the whipped cream topping. C. On 03/09/23 at 10:13 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.

Based on record review, observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator/freezer and dry storage room were dated and labeled. 2. Ensuring that packages of dry food items were closed after opening. 3. Ensuring that dented cans were removed from the to use shelf. 4. Ensuring food in bulk, dry storage bins were dated and labeled. 6. Daily monitoring/logging of food temperatures at meal times. 7. Daily monitoring/logging of water temperature and chemical sanitizer strength on the three- compartment sink log. 8. Ensuring that the plastic display/housing of a digital thermometer does not touch the food item being measured. 9. Covering all food items on a resident's meal tray being transported through the facility for in-room dining. These deficient practices could lead to foodborne illnesses that could affect all 103 residents identified on the alphabetical census list, provided by the Administrator on 03/13/23, who eat food prepared in the kitchen. The findings are: A. On 03/06/23 at 9:13…

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 that residents were aware of and/or understood the risks and benefits of medication they were receiving for 3 (R's #25, 37 and 78) of 3 (R's #25, 37, and 78) residents by not informing residents of why a medication was being prescribed and administered and what diagnoses/condition it was treating. This deficient practice could likely result in residents feeling anxious and potentially receiving unnecessary treatment/medication. The findings are: Findings for R #25 A. Record review of Face Sheet dated 01/07/23 for R #25 revealed an initial admission date of 10/28/22 and included the following diagnoses: Depressive Episodes (a period of at least two weeks during which a person feels sadness or loss of interest), Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) with Anxiety (feeling of uneasiness and worry), and Anxiety Disorder. B. Record review of Physicians Orders dated 10/31/22 for R #25 revealed, Cymbalta (medication used to treat depression…

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 that staff maintain the right for residents to preserve personal items for 2 (R #53 and 247) of 2 (R#'s 53 and 247) residents reviewed for personal items. This deficient practice is likely to cause the resident to feel that their personal possessions are not treated with respect. The findings are: R #247 A. On 03/07/23 at 1:12 pm, during an interview with R #247, it was reported that he had verbally reported missing clothing items (unknown staff members). R #247 stated that magically the laundry will bring you clothes that you know are not yours. Its like its their attempt to replace your stolen items with other items. He stated that he is missing pant's. He said when they didn't replace them, laundry came with other pants and they didn't find my pants but laundry wanted me to have them so they gave them to me. They didn't fit. R #247 could not recall how long ago he reported the pants missing or who he had reported it to. R #53 B. On 03/08/23 at 10:38 am, during an interview with R #53, he reported missing clothing…

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 to ensure the MOST forms were complete for 8 (R #s 25, 53, 57, 58, 62, 63, 88, and 247) of 12 (R #s 25, 53, 57, 58, 62, 63, 69, 73, 79, 88, 197 and 247) resident's records reviewed for Advanced Directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) the Medical Orders For Scope of Treatment (MOST) form were: 1. Signed by a physician for R #25, 57, 58, 88, and 247 2. Signed by a resident/Power of Attorney (POA) for R #63 3. Present in R #53 and 62 's records. This deficient practice is likely to affect resident's fulfillment of their end of life medical choices and could result in unnecessary suffering for the resident. The findings are: Findings for R #88 A. Record review of R #88's face sheet revealed admission date 08/10/22. B. Record review of R #88's the MOST form dated 12/19/22 revealed R #88 MOST Form was not signed by a physician as required. C. On 03/07/23 at 2:14 pm, during an interview with…

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

Based on record review and interview, the facility failed to file a grievance for 2 residents (R #53 and #247) out of 2 (R #53 and #247) residents reviewed for personal property. This deficient practice could likely cause residents frustration at not getting their clothing back from the laundry or seeing other residents wear their clothing and that their grievance wasn't taken seriously. The findings are: R #247 A. On 03/07/23 at 1:12 pm, during an interview with R #247, it was reported that he had verbally reported missing clothing items (unknown staff members). R #247 stated that magically the laundry will bring you clothes that you know are not yours. Its like its their attempt to replace your stolen items with other items. He stated that he is missing pant's. He said when they didn't replace them, laundry came with other pants and they didn't find my pants but laundry wanted me to have them so they gave them to me. They didn't fit. R #247 could not recall how long ago he reported the pants missing or he had reported it to. R #53 B. On 03/08/23 at 10:38 am, during an interview…

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, observation, and interview, the facility failed to create an accurate Baseline Care Plan within 48 hours of admission for 3 (R #s 25, 62, and 91) of 8 (R #'s 25, 37, 40, 57, 62, 63, 85, and 91) 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 needed care and/or residents not being able to attain or maintain their highest practicable level of well-being. The finding are: Findings for Resident #25: A. Record review of Face Sheet dated 01/07/23 for R #25 revealed an initial admission date of 10/28/22 and included the following diagnoses: Encounter for Surgical Aftercare Following Surgery on the Digestive System, Squamous Cell Carcinoma of Skin (type of skin cancer), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with Diabetic Polyneuropathy (nerve damage caused by diabetes), Anal Fissure (a small tear…

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 develop and implement (put into place) a comprehensive person-centered care plan for 2 (R #s 20, and 40) of 7 (R #s 20, 25, 40, 57, 62, 63, and 247) residents reviewed for care plans. This deficient practice could likely result in staff's failure to understand and implement the needs and treatments of the residents. The findings are: Resident #40 A. Record review of Face Sheet dated 10/25/19 for R #40 revealed this as an initial admission date. B. Record review of Minimum Data Set (MDS) (MDS - tool used to assess the health and needs of nursing home residents) dated 11/01/19 for R #40 revealed, Section L - Oral/Dental Status: No natural teeth or tooth fragment(s) (edentulous - lacking teeth) . Section V- Care Area Assessment (CAA) Summary: Dental Care triggered for Care Plan . Location and Date of CAA Documentation: Care Plan in Place. [there is no care plan] C. Record review of Minimum Data Set, dated [DATE] for R #40 revealed, Section L - Oral/Dental…

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.

Findings for R #37 N. On 03/07/23 at 12:33 pm during an interview, R #37 stated, I have had to wait up to three hours for someone to answer my call light and change me after I had a bowel movement. I also waited one time from 5:00 pm until 4:00 am to be changed, I sat in a urine soaked depends for almost 12 hours. They are not cleaning me completely, I've had to call my husband to come and clean me down there because they don't clean me completely. I got a UTI (urinary tract infection - infection of any part of the urinary system) from waiting so long to be changed. O. Record review of Care Plan dated 03/01/23 for R #37 revealed, Focus: [name of R #37] is incontinent of urine with potential for improved control or management of urinary elimination. Goal: Resident will demonstrate improved urinary elimination control as evidenced by experiencing less than ___ episodes of urinary incontinence perday. Interventions: 1) Administer supplement as ordered. 2) Encourage resident to consume all fluids during meals. Offer/encourage fluids of choice. 3) Facilitate easy access to bathroom with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to offer vision services for 3 (R #55, R #66, and R #299) of 4 (R#'s 55, 66, 298, and R #299) residents reviewed for vision needs. This deficient practice could likely result in an increased frustration and decreased enjoyment for the resident in daily life. The findings are: Findings for R #66: A. Record review of R #66's EHR (Electronic Health Record) revealed that R #66 was admitted on [DATE] with the following pertinent diagnosis: expressive language disorder (a lifelong condition that impacts the ability to use language to express your own ideas when speaking). B. On 03/08/23 at 10:49 am, during an observation, it was noted that R #66 was wearing his glasses on his face and the right temple of his frame was no longer attached to his glasses. C. On 03/08/23 at 10:49 am, during an interview with R #66, he confirmed that he would like new glasses. Findings for R #299: D. Record review of R #299's EHR revealed that R #299 was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to arrange foot care services for 2 (R #3 and R #61) of 2 (R #3 and R #61) residents reviewed for toenail overgrowth. This deficient practice could likely result in residents feeling uncomfortable due to: 1. Appearance and/or feel of toenail overgrowth; and 2. Accidental scratching. Findings for R #3: A. Record review of #3's face sheet revealed that she was admitted to the facility on [DATE] with the pertinent diagnosis of type 2 diabetes mellitus without complications (a chronic disease that affects the way the body processes blood sugar). B. On 03/07/23 at 2:20 pm, during an observation of R #3, it was noted that her toenails had grown past her toes. C. Record review of physician orders, dated 02/08/21, revealed Podiatry, Dental and Ophthalmology Obtain as needed Consult and treatment for patient health and comfort. D. On 03/13/23 at 11:37 am, during an interview with the Social Services Assistant (SSA), she confirmed that R #3 had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that 3 (R #'s 3, 6, and 66) out 4 (R #'s 3, 6, 53, and 66) residents were seen within 60 days. This deficient practice could likely result in residents not receiving the required medical assessment in a timely manner. The findings are: Findings for R #3: A. Record review of R #3's EHR (Electronic Health Record) revealed that R #3 was admitted to the facility on [DATE]. Further review revealed that the last time she was seen by a physician was 01/03/23. Findings for R #66: B. Record review of R #66's EHR revealed that R #66 was admitted to the facility on [DATE]. Further review revealed that the last time he was seen by a physician was 01/10/23. Findings for R #6: C. Record review of R #6's EHR revealed that R #6 was admitted to the facility on [DATE]. Further review revealed that the last time she was seen by a physician was 01/03/23. D. On 03/13/23 at 12:11 pm, during an interview with Medical records clerk, when asked if she has a role 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 and interview the facility failed to properly store medications in the medication carts for all the residents on the 200-unit hallway (residents were identified by the Matrix provided by the administrator on 03/06/23) when they failed to store loose medications. This deficient practice could result in residents obtaining medications not prescribed for them and resulting in adverse (unwanted, harmful, or abnormal result) side effects. The findings are: A. On 03/07/23 at 2:24 PM, during an observation of the medication cart on 200 Hall, revealed 1 white medication tablet was on the bottom of the cart. B. On 03/07/23 at 2:28 PM, during an interview CMA (Certified Medication Aide) #1, confirmed the white medication tablet was loose on the bottom of the cart. CMA #1 stated they usually check the carts at the beginning of their shift. C. On 03/07/23 at 3:34 PM, during an interview, the DON (Director of Nursing) confirmed that any loose medications should be discarded, and that CMA's and nurses are supposed to check their carts at the beginning of each shift.

This is a repeat citation. Based on observation, record review, and interview, the facility failed to ensure the food was appealing and attractive for 5 (R #9, #19, #54, #70 and #94) of 5 (R #9, #19, #54, #70 and #94) residents sampled for food. This deficient practice could likely result in a decline in the psychosocial health (the health of someone's emotions, behaviors, and social abilities) of the residents due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment and could likely result in resident weight loss, if resident refuses to eat what is served. The findings are: A. On 03/06/23 at 11:29 am, during a dining room observation, it was observed that the main entrée for the lunch meal was a burrito made with whole pinto beans with shredded cheese in a white flour tortilla which was folded over (single fold) in half, not rolled. There was a small side salad of diced tomatoes and chopped iceberg lettuce. The presentation was observed to be unappealing as there were no other items on the plate. The color of both 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, record review, and interview, the facility failed to accurately document resident information related to Activities of Daily Living (bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) for 4 (R #'s 46, 53, 84, and 148) of 5 (R#'s 3, 46, 53, 84, and 148) residents reviewed for documentation. This deficient practice could likely result in residents not receiving showers as preferred and/or staff being unaware of resident needs due to a lack of documentation. The findings are: Findings for R #53: A. On 03/07/23 at 1:16 pm, during an interview with R #53, he explained that he has not had a shower in weeks. B. Record review of R #53's shower sheets located in the shower sheet binder revealed that the most recent shower sheet that was available was dated 12/28/22. He did not have any recent shower sheets in the binder. C. Record review of tasks located in R #53's EHR (Electronic Health Record) revealed that for the last 30 days, there was one entry relating to if he showered and what type of assistance was…

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, record review, and interviews, the facility failed to ensure staff followed proper infection control for Transmission-Based Precautions (TBP) of 2 (R #28 and R #84) of 2 (R #28 and R #84) residents reviewed for isolation precautions to prevent the spread of C. difficile infection (CDI- a germ that causes diarrhea and an inflammation of the colon) for all residents identified on the resident census list provided by the Center Executive Director on. This failure increased the risk of transmission of CDI to other residents, and staff by: 1. Staff failing to perform hand hygiene between each resident encounter. 2. Staff failing to ensure they were donning (putting on personal protective equipment {PPE}when entering the room, and doffing (took off PPE) when leaving the room. 3. Staff failing to correctly perform hand hygiene when exiting a room with contact precautions. These deficient practices are likely to result in the spread of infections and illnesses. The findings are: A. Record Review of facility policy titled 18.0 Contact precautions revision date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to track and monitor the vaccination status for 3 (R#'s 25, 31, and 60) of 5 (R#'s 25, 31, 37, 60, and 298) residents reviewed for Pneumococcal (lung infections are caused by bacteria with illness range from mild to severe) and/or Influenza (infectious viral disease usually affecting the upper respiratory system, sinus, throat and large airways in lungs) vaccines. This deficient practice could likely result in increased Pneumococcal and Influenza related infections amongst residents. The findings are: A. Record review of the facility policy, titled IC 601 Pneumococcal Vaccination revised 11/15/22 revealed, in adherence with current recommendations of the Advisory Committee on Immunization practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC) .Upon admission, obtain the pneumococcal vaccination history on all residents. Document the resident either received the pneumococcal vaccinations on the resident's MAR (Medication…

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 ensure sanitary conditions for 1 (R #36) of 1 (R #36) resident reviewed for physical environment by housekeeping not cleaning the residents floor properly leaving smeared juice and food on the floor. If the facility fails to maintain resident rooms in a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. On 03/06/23 at 2:48 pm, during an observation of R #36's room it was noted that R #36's floor was dirty with food and was sticky from spilled juice. B. On 03/06/23 at 2:49 pm, during an interview with R #36, stated, When housekeeping was finished mopping my floor this morning (03/06/23) they did not clean the floor properly. The floor was left sticky to walk on and food was still on the floor after being cleaned. C. On 03/06/23 at 2:54 pm, during an interview with Certified Nursing Assistant (CNA) #1 confirmed that the R #36's floor was dirty with food and sticky with juice.

Based on observation, record review and interview, the facility failed to meet professional standards of quality for 1 (R #78) of 6 (R #9, R #12, R #30, R #51, R #69, and R #78) residents observed for medication administration. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects. The findings are: A. On 03/07/23 at 09:29 AM, during an observation of medication pass for R #78, CMA (Certified Medication Aide) #2 administered Metoprolol Tartrate (medication used to treat high blood pressure) 25 mg (milligrams). CMA #2 documented R #78's blood pressure (force of blood on the walls of the blood vessels that carry oxygenated blood away from the heart to the tissues) as 116/66 and heart rate 64 (number indicating the times a heart beats per minute). B. Record review of R #78's orders revealed: Order date 04/04/22 Metoprolol Tartrate Tablet 25 MG. Give 25 mg by mouth one time a day for HTN (Abbreviation for hypertension/high blood pressure) Hold if HR (heart rate) < (less than) 65 bpm (beats per minute) AND/OR SBP…

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 resident safety for 1 (R #247) of 1 (R #247) resident reviewed for bed positioning. This deficient practice could likely result in the resident experiencing a fall and discomfort. The findings are: A. Record review of R #247's face sheet revealed that he was admitted to the facility on [DATE] with a pertinent diagnosis of: hemiplegia [paralysis on one side of the body] and hemiparesis [muscle weakness or partial paralysis on one side of the body] following cerebral infarction affecting left non-dominant side (paralysis on one side of the body as a result of a stroke), acquired absence (amputation) of right leg below knee, contracture in left knee (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), muscle weakness, and lack of coordination. B. On 03/08/23 at 10:34 am, during an observation of R #247, it was observed that his bed was left in a high…

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, observation, and interview, the facility failed to ensure that 1 (R #25) of 1 (R #25) resident reviewed for behavioral health concerns was receiving necessary behavioral health care to meet the resident's need. This deficient practice could likely cause the resident not to receive the mental health care and treatment that she may need to ensure her the highest practicable physical, mental, and psychosocial well-being. The findings are: Resident #25 A. On 03/08/23 at 1:44 pm during a random observation and attempted interview, R #25 appeared out of it, she was constantly confused and was unable to appropriately answer questions. R #25 was in and out of sleep during interview. B. Record review of Face Sheet dated 01/07/23 for R #25 revealed an initial admission date of 10/28/22 and included the following diagnoses: Depressive Episodes (a period of time, at least two weeks, when a person feels depressed or loses interest in things they generally enjoy), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere…

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 keep residents free from unnecessary psychotropic medications (a medication that works by adjusting the number of major chemicals in the brain) for 1 (R #87) of 1 (R #87) resident sampled for unnecessary medications, when they: 1. Continued to administer Trazodone (used to treat depression, it is a type of medication called a serotonin modulator that works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance), a psychotropic medication to a resident with a documented refusal and declined consent to psychotropic medication treatment, and 2. Failed to monitor medication effectiveness by not notifying the physician of the resident's repeated refusals of psychotropic medication. These deficient practices could likely result in residents receiving unwanted psychotropic medications, residents being administered medications they do not need, residents experiencing potential adverse side effects, and…

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