Central Queens Rehab & Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #168 Based on observations, interviews and record review conducted during the recertification and complaint survey from 7/19/23 to 7/24/23, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. This was evident for one (Resident #168) of six residents reviewed for Activities of Daily Living. Specifically, Resident #168 was was not asked about bathing preferences when their shower schedule was created, and they were informed about their shower schedule. The findings are: The facility's policy and procedure titled Activities of Daily Living Supporting dated 1/23 documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and person, and oral hygiene. Resident #168 was admitted to the facility on [DATE] with diagnoses of bilateral above knee amputation and muscle weakness. The Minimum Data Set 3.0 (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interviews during the Recertification and abbreviated survey conducted from 7/19/23 to 7/26/25, the facility did not ensure that residents' privacy and confidentiality were maintained. This was evident for 1 of 1 resident reviewed for Privacy out of a total sample of 35 residents (Resident # 15). Specifically, Resident #15's privacy curtain was missing and left the resident exposed to everybody entering the room. The findings are: The facility policy and procedure on resident's right last reviewed on January 2023 document that employees shall treat all residents with kindness, respect and dignity. The policy and procedure further documented that Federal and State laws guarantee certain basic rights to all residents in the facility. These rights include the resident's right to privacy and confidentiality. On 7/19/2023 at 10:11 AM, Resident #15 was observed in bed talking to his roommate. No privacy curtain noted. On 7/19/2023 at 2:21 PM, Resident #15 was observed in bed talking to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during a Recertification survey from 07/19/2023 to 07/26/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 1 (2nd Floor) of 5 Units. Specifically, resident rooms were observed with mismatched paint and dry wall patches, clutter including multiple cardboard boxes and food containers, rusty and cracked light fixtures, ripped fall mats, ripped leather on a resident's recliner, and ripped and dirty privacy curtains. The findings are: The policy titled Care of Equipment revised 01/31/2023 documented curtains observed to be soiled or in disrepair should be reported to the Maintenance department for immediate removal and resolution. All equipment in disrepair should be communicated to the Maintenance department in a timely manner. On 7/19/2023 between 9:47 AM and 3:33 PM, the following was observed on the 2nd Floor: -room [ROOM NUMBER] had fall mats on the floor by resident beds with ripped…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure Minimum Data Set (MDS) 3.0 assessment was completed within 14 days of admission. This was evident for Resident #157 reviewed for Resident Assessment out of 38 total sampled residents. Specifically, Resident #157's admission MDS was not completed within 14 days of their admission to the facility. The findings are: The facility policy titled Submission and Correction of the MDS Assessments dated 1/19/2023 documented the MDS completion date for admission assessments must be no later than 13 days after the entry date. Resident # 157 was admitted to the facility on [DATE] with diagnoses of sepsis and metabolic Encephalopathy. The admission MDS assessment for Resident #157 had an assessment reference date of 1/31/2023 and a completion date of 3/5/2023, more than 14 days after admission. On 07/25/23 at 11:37 AM, the MDS Coordinator (MDSC) was interviewed and stated they 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview conducted during the Recertification survey from 07/19/2023 to 07/26/2023, the facility did not ensure the resident and their representatives were provided with a written summary of the baseline care plan (BCP). This was evident for 2 (Resident #43 and #387) of 38 total sampled residents. Specifically, 1) Resident #43's representative was to provide with a copy of the BCP and, 2) Resident #387 was not provided with a copy of their BCP. The findings are: The facility policy titled Care Plans - Baseline dated 01/2023 documented the resident and their representative will be provided a summary of the baseline care plan. 1) Resident #43 had diagnoses of cerebral infarction and schizoaffective disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #43 had severely impaired cognition , did not participate in the assessment, and the resident's family or significant other participated in the assessment and goal setting. On 07/25/2023 at 4:10 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 observations, interviews, and record review conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure an effective discharge planning process was developed and implemented. This was evident for 1 (Resident #82) of 3 residents reviewed for Discharge out of 38 total sampled residents. Specifically, documents needed for discharge planning were not submitted to another facility per Resident #82's request. The findings are: The policy titled Discharging the Resident dated 1/2023 documented the facility will facilitate a safe discharge for the residents. Resident #82 had diagnoses of peripheral venous insufficiency and opioid dependence. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #82 was cognitively intact, participated in the assessment, expected to be discharged to the community, and discharge planning was in progress. During the interview on 7/19/23 at 11:57 AM, Resident #82 stated they requested a transfer to another facility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 07/19/2023 to 07/26/2023, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for Resident #95 reviewed for Activities out of 38 total sampled residents. Specifically, Resident #95 was not provided with television (TV) stations in their preferred language. The findings are: The facility policy titled Activity Evaluation dated 1/2023 documented the activity evaluation is conducted to help develop an activity plan that reflects the choices and interests of the residents. Preferences are included in the evaluation. The facility policy titled TV Channel dated 3/20/2018 documented the facility offered regular TV channels (2-21), two Spanish channels, and one movie channel (6). Resident # 95 had diagnoses of cerebral infarction and unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview conducted during the recertification and abbreviated survey, the facility did not ensure a Physician order on oxygen tubing was followed to prevent the transmission of infectious disease. This was evident for 1 (Resident #14) of 2 residents reviewed for Respiratory Care out of a total sample of 35 residents. Specifically, Resident #14's oxygen tubing was not changed in accordance with Physician Order (PO). The findings are: Resident #14 was admitted with diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #14 was cognitively intact and required the extensive assistance of 2 people for bed mobility. On 7/19/2023 at 10:36 AM, 7/20/2023 at 11:39 AM, and 7/21/2023 at 10:43 AM, Resident #14 was observed in bed receiving continuous oxygen via nasal canula. Oxygen tubing dated 7/11/2023 connected Resident #14's nasal canula to the oxygen concentrator. The PO dated 6/5/2023…

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 interviews conducted during a recertification survey from 7/19/2024 to 7/24/2024, the facility did not ensure that all drugs and biologicals were labeled in accordance with professional standards. This was evident for 2 (2nd and 3rd Floor) of 3 medication rooms. Specifically, 1) two boxes of expired flu vaccines were observed in the 3rd Floor medication room, and 2) one box of expired covid vaccines was observed in the 2nd Floor medication room. The findings are: The facility policy titled Medication Storage dated January 2023 documented discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1) On 07/25/2023 at 02:37 PM, the 3rd Floor medication room refrigerator was observed with two boxes of influenza Afluria quadrivalent vaccines 2022-2023 formula (20 prefilled syringes 0.5 ml/dose) with expiration date of 06/30/2023. On 07/25/2023 at 02:50 PM, Licensed Practical Nurse (LPN) #1 was interviewed and stated all nurses are responsible for checking medication expiration dates. The night…

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 interviews conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure garbage and refuse was disposed of properly. This was evident during kitchen observation. Specifically, the garbage compactor door was observed ajar, and multiple flies were observed flying on top of garbage inside the compactor. The findings are: The facility policy titled Kitchen Garbage and Refuse Disposal dated 1/2023 documented food related garbage and refuse are disposed of in accordance with current state laws. During an observation of the kitchen on 7/24/23 at 10:44 AM, Dietary Worker (DW) #1 was brought the garbage to the garbage disposal area located outside near the facility staff parking lot. The garbage compactor was ajar and multiple flies were observed flying on top of the garbage piled inside the compactor. On 7/24/23 at 10:51 AM, DW #1 was interviewed and stated the compactor door should have been kept closed to keep flies and pest away from the garbage. DW #1 did not know why the compactor door was left open. 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 record review and staff interviews conducted during the Recertification and Abbreviated survey the facility did not ensure a surety bond was purchased to provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 100 of 134 residents who maintained personal funds accounts at the facility. The finding is: On 05/20/2021 the facility submitted a document titled Midway Nursing Home Disbursement Worksheet dated 05/19/2021 which showed a total balance of resident's funds in the amount of $327,083,00. The facility presented a surety bond dated 12/20/2020 to 12/20/2021 in the amount of $140,000. The facility did not ensure that the surety bond was sufficient to cover all personal funds of residents deposited with the facility. On 05/20/2021 at 10:10 AM, an interview was conducted with the Facility Administrator (FA). The FA stated that the surety…

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 staff interviews conducted during a Recertification and Abbreviated survey, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, 1). a care plan was not created for a resident with a diagnosis of Human Immunodeficiency Virus, and 2). A care plan was not implemented for a resident on fluid restrictions. This was evident for 1 of 3 residents reviewed for Nutrition and 1 of 2 residents reviewed for Respiratory Care and of out of a sample of 27 residents (Resident #7 and Resident #34). The findings are: The facility policy titled Comprehensive Care Plan Development and Meetings dated November 28, 2016 documented that it is the policy of Midway Nursing Home that each resident admitted to the facility will have a Comprehensive Care Plan (CCP) completed in accordance 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 observations, record reviews and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, 1). Physician's order were not implemented for a resident receiving oral chemotherapy anti-hypertensive medications with special order requirements and monitoring and 2). fluid restriction for a resident with edema was not implemented. This was evident for 1 of 3 residents reviewed for Activities of Daily Living and 1 of 2 residents reviewed for Respiratory Care out of a sample of 27 residents. (Resident # 114 and Resident #34). The findings are: 1. Resident # 114 was admitted to the facility with diagnoses that included Hypertension and Cancer of the breast. (a). Physician's order dated 2/5/2020 and renewed on 4/29/2021 documented Ibrance 125 milligram (mg) 1 tablet (tab) daily (OD)…

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 conducted during a Recertification and Abbreviated survey, the facility did not ensure that the Minimum Data Set (MDS) accurately reflected the resident's status. Specifically, diagnosis of Human Immunodeficiency Virus (HIV) was not captured on the MDS. This was evident for 1 of 2 residents reviewed for Respiratory Care and of 1 of 3 residents reviewed for Nutrition out of a sample of 27 residents (Resident #20 and Resident #7). The findings are: The facility policy and procedure titled Comprehensive Assessment, MDS and Care Planning with an effective date of 09/01/2011 documented that information obtained from the comprehensive assessment enables the staff to plan care that focuses on the resident's ability to achieve higher or highest practicable mode of functioning that includes but is not limited to the following medically defined condition and Past Medical History. 1) Resident #20 was admitted to the facility with diagoses that included Asthma, Respiratory Failure,…

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 interviews and record reviews during the Recertification and Abbreviated survey, the facility did not ensure each resident or resident representative was given the opportunity to participate in the review and revision of the care plan. Specifically, a resident was not invited to participate in their care plan meeting. This was evident for 1 of 1 resident reviewed for Care Plan out of a sample of 27 residents. (Resident #71). The findings are: The facility policy dated 11/28/2016 documented the CCP (Comprehensive Care Plan) will be reviewed and revised periodically by the interdisciplinary team. The resident and/or their representative will view and sign the comprehensive person centered care plan. The policy also documented that the resident would be invited to their CCP and renminded the day of the meeting. Documentation will be performed in the resident's clinical record by the team member reminding the resident. admission MDS dated [DATE] documented diagnoses that included Coronary Artery Disease,…

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 staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure that the facility review the resident's total program of care, including medications, and treatments, at each visit. Specifically, there was no documented evidence of medical follow-up for a resident admitted with a diagnosis of Human Immunodeficiency Virus (HIV). This was evidenced for 1 of 3 residents reviewed for Nutrition out of a sample of 27 residents (Resident # 7). The finding is: The facility policy dated March 1, 2021 titled Physician Services documented that it is the policy of Midway Nursing Home to provide Physician Services in accordance with State and Federal Regulations. The policy also documented that the physician will review the resident's total program of care, including medications and treatments, at each visit. Resident #7 was admitted to the facility with diagnoses that included Hypertension, Diabetes Mellitus, and Human Immunodeficiency Virus…

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 staff interview conducted during the Recertification and Abbreviated survey, the facility did not ensure timely identification and removal from current medication supply of medications for disposition. Specifically, an opened bottle of medication was observed in the medication cart past the expiration date. This was evident on 1 of 5 units reviewed for Medication Storage (Unit 3). The facility policy and procedure titled Expired Medication dated 3/20/2015 documented all medication carts, cabinets and refrigerators will be routinely checked by nursing personnel. All expired medications will be removed and discarded. The procedure included on a weekly basis, 11-7 nurse will check all above-mentioned areas for any expired medications. Same will be discarded. The central supply clerk will also check inventory in supply room as well as cabinets on units for any expired medications. Same will be discarded. The form titled Nursing dept Audit Tool dated 5/15/2021 documented yes that discontinued or expired medications are removed from 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 staff interview during the Recertification and Abbreviated survey, the facility did not ensure medication and biologicals drugs were stored and labeled in accordance with currently accepted professional principles. Specifically, 1). the facility did not ensure the multidose medications were properly labeled with opening date and resident name on the bottle and vial, and 2). insulin pens were not stored in a manner to prevent cross-contamination. This was evident on 1 of 5 units reviewed during the Medication Storage and Labeling Task. The findings are: On 5/20/2021 at 12:28 pm, the medication cart on the 6th Floor was observed. 8 bottles of Artificial Tears were observed stored in boxes. 6 of the bottles had no resident names or dates eyedrops were opened labeled on the bottles. In addition, 1 Admelog insulin pen and 2 Lantus Solostar insulin pens were observed placed loosely in the tray of the medication cart and were not stored separately from each other. An interview was conducted immediately with Licensed Nurse Practical (LPN) #5. LPN #5 stated insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview conducted during a Recertification and Abbreviated survey, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. Specifically, during a lunch meal a resident was not provided with an insulated mug with lid that was ordered. This was observed during the Dining Observation Task for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 27 residents (Resident #45). The finding is: The facility policy titled Adaptive Feeding Service Program dated February 2019 documented that it is the policy of Midway Nursing Home that residents will be evaluated as needed and will receive necessary adaptive devices for meals to ensure completion of meals and to enhance their quality of life and to reach their highest level of independence. Resident # 45 was admitted with diagnoses that included Coronary Artery Disease, Cerebrovascular Accident and Depression. The Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated survey, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented. Specifically, the physician frequently documented an incorrect gender and age of residents in the clinical records. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 27 residents. (Residents #5 and 74). The findings are: Resident #74 was admitted to the facility with diagnoses which included Anxiety Disorder and Depression. On 05/18/21 at 10:45 AM, the resident was observed in the room, alert and awake. The resident was well groomed and looked age appropriate. On 05/18/21, a review of resident's face sheet was conducted. The resident's face sheet documented that the resident year of birth as 1953 ([AGE] years of age) and resident's gender as female. On 05/18/21, a review of medical record revealed…

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