Arc At Trotwood LLC

Based on medical record review, staff and resident interviews, and policy review, the facility failed to administer medications as per physician orders. This affected one (#112) out of three residents reviewed for medication administration. The facility census was 102. Findings include: Review of the medical record for Resident #112 revealed an admission date of 12/09/24 with medical diagnoses of chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and chronic respiratory failure. Review of the medical record for Resident #112 revealed an annual Minimum Data Set (MDS) assessment, dated 12/11/25, indicated Resident #112 was cognitively intact and was independent with eating, bed mobility, toileting hygiene, and set-up assistance with showers and transfers. Review of the medical record for Resident #112 revealed a physician order dated 12/09/24 for metformin 500 milligram (mg) one tablet by mouth two times per day, orders dated 12/10/24 for ferrous sulfate 325 mg one tablet by mouth daily, loratadine 10 mg one tablet by mouth daily, Theragran-M one tablet by mouth…

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 medical record review, staff interviews, and policy review, the facility failed to administer insulin as ordered and to ensure blood pressure medications were administered per the ordered parameters resulting in significant medication errors. This affected one (#64) out of three residents reviewed for medications. The facility census was 102. Findings include: Review of the medical record for Resident #64 revealed an admission date of 10/18/25 with medical diagnoses of acute and chronic respiratory failure, dysphagia, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and end stage renal disease (ESRD). Review of the medical record for Resident #64 revealed an admission Minimum Data Set (MDS) assessment, dated 10/31/25, which indicated Resident #64 was cognitively intact and required substantial/maximum assistance with toilet hygiene and bathing, was dependent upon staff for transfers, and required supervision with bed mobility. Review of the medical record for Resident #64 revealed a physician order dated 10/20/25 for midodrine 10 mg one tablet via…

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, medical record and facility policy review, the facility failed to securely store medications. This affected one resident (#57) of five reviewed for medication administration. The facility census was 89.Findings include:Review of the medical record for Resident #57 revealed an admission date of 01/22/25 with diagnoses including but not limited to dysphagia following cerebral infarction, type two diabetes, hemiplegia and hemiparesis affected the non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required set up assistance for eating. Resident #57 was totally dependent on staff for toileting, transfers and bed mobility.Review of the physician orders for Resident #57 revealed an order stating resident required assistance from staff to complete self-care and mobility due to hemiplegia dated 06/17/25 and an order for Fluticasone Propionate Nasal Suspension 50 micrograms two spray in both…

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, medical record and facility policy review, the facility failed to ensure the medical record was accurate. The facility documented medication as administered by facility staff when it was self-administered by the resident without nursing supervision. This affected one resident (#57) of five reviewed for medication administration. The facility census was 89.Findings Include:Review of the medical record for Resident #57 revealed an admission date of 01/22/25 with diagnoses including but not limited to dysphagia following cerebral infarction, type two diabetes, hemiplegia and hemiparesis affected the non-dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required set up assistance for eating. Resident #57 was totally dependent on staff for toileting, transfers and bed mobility.Review of the physician orders for Resident #57 revealed an order stating resident required assistance from staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in a way to avoid cross contamination. This affected one resident (#86) of five residents observed during medication administration. The Facility census was 89. Findings Include: Medical record review for Resident #86 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease, epilepsy, and nontraumatic intracerebral hemorrhage. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #86 dated 08/12/25 revealed intact cognition. Resident #86 required set up assistance to moderate assistance for activities of daily living. Review of the physician orders for Resident #86 for the month of August 2025 revealed resident had an order for Aspirin enteric coated delayed release 81 milligram (mg) tablet, give one tablet one time a day dated 12/15/24. Observation of medication pass on…

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

Based on interview and record review, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the Medicaid resource limit and that the residents may lose eligibility for Medicaid. This affected six (#10, #43, #5, #29, #27 and #11) out of seven residents reviewed for personal funds. The facility census was 97. Findings include: On 05/21/25 at 12:11 PM, during review of the list of resident funds documentation provided by the facility during the survey it was noted that Resident #10, #43, #5, #29, #27 and #11 were all Medicaid recipients and all had balances over $2,000 dollars in their funds accounts. Interview with Business Office Manager (BOM) #4 confirmed Resident #10, #43, #5, #29, #27 and #11 were Medicaid recipients and their balances were over the maximum amount allowed by Medicaid. BOM #4 was asked to provide spend down notification letters that were sent to the residents. BOM #4 stated that there were no spend down notification letters sent to the residents. BOM #4 stated that letters were on her desk but have not been…

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

Based on interview, record review, facility policy review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 92 days of the prior MDS assessment for 1 (Resident #49) of 9 residents reviewed for the resident assessment task. In addition, the facility failed to ensure quarterly MDS assessments were signed as complete within 14 days of the Assessment Reference Date (ARD) for 3 (Residents #4, #34, and #46) of 9 residents reviewed for the resident assessment task. Findings included: A facility policy titled, MDS Completion and Submission Timeframes, revised 10/2023, revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The policy specified, 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The CMS Long-Term Care Facility RAI 3.0…

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

Based on interview, record review, facility document review, and facility policy review, the facility failed to resolve a concern in a timely manner for 1 (Resident #66) of 2 residents reviewed for grievances. In addition, the facility failed to document concerns, ensure resolution, and provide feedback for 1 (Resident #57) of 2 residents reviewed for grievances. Findings included: A facility policy titled, Grievances, effective 03/2024, revealed, Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. The Grievances policy specified, Grievances may be filed orally (meaning spoken), in writing, or anonymously. The policy revealed, Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). 1. An admission Record revealed the facility admitted Resident #66 on 03/07/2025. According to the admission Record,…

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

Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded related to the use of a non-invasive mechanical ventilator for 1 (Resident #57) of 2 residents reviewed for respiratory services. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy revealed, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. An admission Record indicated the facility admitted Resident #57 on 07/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of heart failure, chronic obstructive pulmonary disease (COPD), sleep apnea, lobar pneumonia, and dependence on supplemental oxygen. A quarterly Minimum Data Set (MDS), with an 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.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected all diagnosed mental disorders and prescribed psychotropic medications for 2 (Resident #16 and Resident #92) of 4 residents reviewed for PASARR requirements. Findings included: A facility policy titled, Preadmission Screening and Annual [sic] Resident Review (PASARR), effective 03/2024, indicated, It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD) [serious mental illness/serious mental disorder], intellectual disability (ID) or related condition. 1. An admission Record revealed the facility originally admitted Resident #16 on 02/21/2025 and most recently admitted the resident on 04/19/2025. According to the…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff documented the administration of medications in accordance with acceptable standards of practice. Specifically, staff documented the administration of medication prior to actually administering the medication for 1 (Resident #57) of 4 residents observed during medication administration. Findings included: A facility policy titled, Medication Administration Policy, revised 01/2015, revealed the section titled, I. Level of Responsibility, included, - Licensed nurse (RN [registered nurse], LPN [licensed practical nurse]) may; a) prepare, b) administer, and c) record the administration of medications. An admission Record indicated the facility admitted Resident #57 on 07/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy, heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2025, 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.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff checked for incontinence every two hours and provided incontinence care when indicated for 1 (Resident #57) 1 sampled resident reviewed for urinary tract infections. Specifically, during the dayshift on 05/15/2025, Resident #57 was not checked for incontinence or provided incontinence care until 10:40 AM. Findings included: A facility policy titled, Incontinence Care, dated 10/2024, indicated, Purpose: To prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or approximately every two hours and provided perineal and genital care after each episode. An admission Record indicated the facility admitted Resident #57 on 07/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of type two diabetes mellitus, urinary tract infection, overactive bladder, and dementia. A quarterly Minimum Data Set…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide residents with food at an appetizing temperature for 1 (Resident #5) of 20 sampled residents. Findings included: A facility policy titled, Food Temp [Temperature] Point of Service Guidelines, updated 11/2024, revealed, Food will be served at an appropriate and palatable temperature for hot food items equal to or greater than 115-120 degrees Fahrenheit per stated guidelines F483.60: Proper 'safe and appetizing temperature' means both appetizing to the resident and minimizing the risks for scalding and burns. An admission Record revealed the facility admitted Resident #5 on 06/04/2024. According to the admission Record, the resident had a medical history that included a diagnosis of end stage renal failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/07/20255, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed Resident #5 required setup or clean…

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

Based on interview, record review, and facility policy review, the facility failed to ensure residents' medical records were accurate and complete for 2 (Resident #57 and Resident #204) of 22 sampled residents. Findings included: A facility policy titled, Medical Record Policy, revised 06/2022, revealed, It is the policy of this facility that an organized, accurate and complete written record will be maintained for each resident in accordance with applicable State and Federal guidelines and laws. The Standards section of the policy revealed, 1. The Director of Nursing/designee with the support of the Medical Records Technician shall assure that medical records are maintained in accordance with the facility/s [sic] policies and procedures, and applicable federal and state regulations. Further review revealed, 6. The resident record shall contain at least the following information: k. Record of Medications and Treatments. Medication and treatment records, including records of oxygen administration, alcoholic beverages, skin treatments, catheter/ostomy care, etc. [et cetera, and so…

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

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in a way to avoid transmission of communicable diseases and infections. Specifically, facility staff touched resident medications with their bare hands when administering medication, which affected 2 (Resident #20 and Resident #57) of 4 residents observed during medication administration. Findings included: A facility policy titled, Infection Control Program, revised 11/2017, revealed, 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and healthcare workers. A facility policy titled, Medication Administration Policy, revised 01/2015, revealed it did not include a procedure of medication administration of oral medications. 1. An admission Record indicated the facility admitted Resident #20 on 04/14/2025. According to the admission Record, the resident had a medical history that included diagnoses of a history 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 medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to develop a comprehensive person-centered care plan for a resident who developed pressure ulcers while residing in the facility. This affected one (#30) out of the three residents reviewed for pressure ulcer care and services. The facility census was 68. Findings include: Review of the medical record for the Resident #30 revealed an admission date of 08/31/24 with medical diagnoses of metabolic encephalopathy, diabetes mellitus, history of cerebral infarction, dysphagia, hypertension, and hypothyroidism. Review of the medical record revealed a discharge date of 10/16/24. Review of the medical record for Resident #30 revealed an admission Minimum Data Set (MDS) assessment, dated 09/09/24, which indicated Resident #30 had moderate cognitive impairment. The MDS indicated Resident #30 required supervision/touching assistance with eating and was dependent upon staff for toilet hygiene and transfers and required substantial/maximum assistance for bathing 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 medical record review, observations and staff interview, the facility failed to follow infection control procedures while performing wound care. This affected one (#11) out of three residents reviewed for infection control. The facility census was 68. Findings include: Review of the medical record for Resident #11 revealed an admission date of 06/04/24 with medical diagnoses of end stage renal disease, diabetes mellitus, obesity, right sided hemiparesis, and atherosclerotic heart disease. Review of the medical record for Resident #11 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #11 had moderate cognitive impairment and required substantial/maximum staff assistance for toilet hygiene, bathing, and bed mobility and was dependent upon staff for transfers. Review of the medical record for Resident #11 revealed a skin assessment, dated 10/15/24, which indicated Resident #11 had a deep tissue injury (DTI) to left heel which measured 2 centimeters (cm) by 2 cm with 100%…

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, staff and resident interviews, review of self-reported incidents (SRIs) and policy review, the facility failed to thoroughly investigate an allegation of misappropriation. This affected one (#51) resident of the three residents reviewed for misappropriation. The facility census was 79. Findings include: Review of the medical record for Resident #51 revealed an admission date of 03/14/24. Diagnoses included chronic obstructive pulmonary disease (COPD), dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 was cognitively intact. Review of the facility's SRI dated 07/26/24 at 2:23 P.M., revealed Resident #52's relative stole a check from Resident #51 and cashed it. Resident #51 reported Resident #52 had a niece that wrote a check out to Resident #52's account. Resident #51 was assisted to the bank to file a fraud claim and called the police to file a report. Resident #52''s niece 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.

Based on observation, medical record review, staff and resident interviews, and policy review, the facility failed to ensure a resident's urine collection bag was covered with a privacy bag. This affected one (#13) of one resident observed with an indwelling catheter and an urine collection bag. The facility identified three (#13, #14, and #15) residents with indwelling catheters. The facility census was 78. Findings include: Review of the medical record for Resident #13 revealed an admission date of 02/07/20, with medical diagnoses of dementia, conversion disorder with seizures, neuromuscular dysfunction of bladder, and hypertension. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment, dated 07/15/24, which indicated Resident #13 had severe cognitive impairment, was dependent upon staff for toilet hygiene, and had an indwelling catheter in place. Review of Resident #13's physician orders revealed a physician order dated 07/09/24, for skilled nursing to exchange 16 French suprapubic tube monthly and to flush suprapubic catheter 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, resident and staff interviews, and review of a medical record, the facility failed to maintain flooring in resident rooms in a safe and homelike manner. This affected one (#17) of seven residents reviewed for environment. The facility census was 68 Findings include: Review of the medical record for Resident #17 revealed an admission date of 01/05/24 with diagnoses of acute encephalopathy, pressure ulcer of both feet, stage three (full-thickness skin loss), and sepsis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, required set-up assistance for eating, supervision assistance for oral hygiene, toileting hygiene, and wheelchair mobility, and required partial assistance for bathing, dressing, personal hygiene, bed mobility, and transfers. Observation on 06/25/24 at 11:00 A.M. of Resident #17's bedroom noted two areas of missing flooring by the foot of the bed measuring approximately three inches long by six inches wide by 0.5 inches…

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, staff interview, and review of the facility policy the facility failed to maintain mechanical equipment in a safe operating condition. This had the potential to affect all residents residing in the facility. The facility census was 76. Findings include: Observation of the laundry room on 05/28/24 at 8:47 A.M. with the Maintenance Supervisor (MS) # 300 revealed the facility had three dryers in use for resident laundry. All three dryers had a thick layer of lint on the vents. Interview on 05/28/24 at 8:47 A.M. with MS #300 confirmed the lint on all three dryer vents was very thick and it appeared they had not been cleaned for several loads or possibly even several days of use. MS #300 confirmed the vents should be cleared of lint after each load of laundry. MS #300 confirmed the facility should have a lint cleaning log in the laundry with signatures of staff to verify cleaning of the vents after each load, but the facility did not have a record of the dryer vent cleaning. Interview on 05/28/24 at 8:49 A.M. with Laundry Worker (LW) #302 confirmed he had completed…

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, staff interview, review of the facility policy, and review of Material Safety Data Sheets (MSDS), the facility failed to store, prepare, and distribute food in a sanitary manner. This had the potential to affect 75 residents residing at the facility. The facility identified one (Resident #50) who did not receive food from the facility kitchen. The facility census was 76. Findings include: Initial tour of the facility kitchen on 05/28/24 at 8:57 A.M. with Dietary Director (DD) #301 revealed there was a large hole in the floor with a missing floor tile at the end of the tray line counter. There was rust and metal flaking off the end of the tray line counter that was used for food preparation. The tray line counter also had food debris and splatter running down the side. The trash cans located in the kitchen had food splatter running down the sides and did not have lids on them. There was black dirt, black smudge, and food debris all along the walls and under the appliances. There were grease stains on the front of the oven. There was a large container of oven 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to timely a assess and treat resident injuries following falls. This affected one (Resident #67) resident of three residents reviewed for falls. The facility census was 76 residents. Findings include: Review of the medical record for Resident #67 revealed an admission date of 10/25/23 with diagnoses including pulmonary hypertension and chronic kidney disease. Review of the care plan for Resident #67 dated 11/01/23 revealed the resident was at risk for falls related to new surroundings, impaired safety awareness, and history of falls. Interventions included the following: anticipate and meet the resident's needs, ensure call light was within reach, keep personal items within reach, monitor for behavior changes, monitor for side effects from medications. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #67 dated 04/13/24 revealed the resident had intact cognition, was dependent…

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 medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to adequately assess and treat resident pain following a fall. This affected one (Resident #67) of three residents reviewed for falls. The facility census was 76. Findings include: Review of the medical record for Resident #67 revealed an admission date of 10/25/23 with diagnoses including pulmonary hypertension and chronic kidney disease. Review of the care plan for Resident #67 dated 11/01/23 revealed the resident had the potential for pain/alteration in comfort related to osteoarthritis, weakness, and history of falls. Interventions included the following: monitor need for scheduled analgesics, evaluate the effectiveness of pain intervention, review for compliance, alleviating of symptoms, dosing schedules and residents satisfaction with results, impact of functional ability and impact on cognition, monitor/document for probable cause of each pain episode, remove/limit…

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, staff interview, and review of the facility policy, the facility failed to provide adequate incontinence care in a sanitary manner. This affected one (Resident #13) of three residents reviewed for incontinence care. The facility census was 76. Findings include: Review of the medical record for Resident #13 revealed an admission date of 07/02/23 with diagnoses including cerebral palsy, heart failure, schizoaffective disorder, and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #13 dated 04/17/24 the resident had intact cognition was dependent on staff with toileting and was always incontinent of bowel and bladder. Review of the physician's order for Resident #13 revealed an order dated 05/03/24 for staff to apply zinc oxide topical ointment to the peri-area and buttocks after each incontinent episode. Observation of incontinence care on 05/28/24 at 1:09 P.M. for Resident #13 per State Tested Nursing Assistants (STNAs) #10 and #11 revealed the resident's incontinence brief was heavily saturated…

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 medical record reviews, staff interviews, and policy review, the facility failed to assess a resident's fall risk upon admission to the facility. This affected two (#5 and #84) out of three residents reviewed for falls. The facility census was 81. Findings included: 1. Review of the medical record for Resident #5 revealed an admission date of 09/26/23 with medical diagnoses of cerebral infarction, Parkinsonism, schizoaffective disorder, and hemiparesis. Review of the medical record for Resident #5 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/15/24, which indicated Resident #5 was cognitively intact and required supervision for eating, maximum staff assistance for toilet hygiene, transfers, and bed mobility and was dependent upon staff for bathing. The MDS indicated Resident #5 had two or more falls without injury since the last assessment. Review of the medical record for Resident #5 revealed a Nursing admission Assessment, dated 09/27/24, which stated the unable to determine 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.

Based on record review, observations and staff interviews, the facility failed to provide a safe and homelike environment. This affected one (#27) resident out of the three residents reviewed for environment. The facility census was 81. Findings included: Review of the medical record for Resident #27 revealed an admission date of 12/21/23 with medical diagnoses of congestive heart failure, bipolar disease, dementia, and hypertension. Review of the medical record for Resident #27 revealed an admission Minimum Data Set (MDS) assessment, dated 12/28/23, which indicated Resident #27 was cognitively intact and required maximum staff assistance with toilet hygiene, moderate staff assistance with transfers, and supervision with eating and bed mobility. Observation on 03/21/24 at 10:50 A.M. of Resident #27 revealed the resident lying in bed. Resident #27's room was noted to have five floor tiles broken with sections of each tile missing, a soap dispenser hanging off the wall near the sink, and wires exposed from the bottom of the heating register which was located near Resident #27's bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff and physician interviews, the facility failed to ensure non-pressure ulcer skin conditions were appropriately assessed and monitored. Additionally, the facility failed to ensure treatments were implemented for non-pressure ulcer skin conditions. This affected one (#9) out of three residents reviewed for wounds. The facility census was 86. Findings include : Review of medical record for Resident #9 revealed admission date of 12/05/23. Diagnoses include pneumonia, Chronic Obstructive Pulmonary Disease and anemia. The resident was discharged on 12/24/23. The discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was independent for eating and bed mobility and refused transfers. Record review of the 12/05/23 admission wound assessment for Resident #9 revealed an arterial ulcer to the right second toe measuring 1.3 centimeters (cm) by (x) 1.4 cm x 0.1 cm. A second wound was documented as excoriation to the right chest measuring 2.7 cm x 3.0 cm. A third wound 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and review of medication information from Medscape, the facility failed to ensure insulin was administered as physician ordered resulting in significant medication errors. This affected two (#16 and #40) out of three residents reviewed for medication administration. The facility census was 86. Findings include: 1. Review of medical record for Resident #40 revealed admission date of 09/21/23. The resident was admitted with diagnoses including asthma, depression, and stage four kidney disease. The resident remains in the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of eight indicating impaired cognition. He required set up assistance for eating, moderated assistance for bed mobility and was dependent on transfers. Record review of the physician orders revealed an order to give six units of Humalog (short acting insulin) subcutaneously before meals and at bedtime every day with a start…

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 medical record review, observations, staff and resident interviews and policy review, the facility failed to ensure residents were given routine showers/bathes for three (#86, #88, and #114) residents out of four residents reviewed for showers/bathes. Additionally, the facility failed to ensure fingernail care was completed for one (#86) resident out of the four reviewed for fingernail care. The facility census was 77. Findings included: 1. Review of the medical record for Resident #86 revealed an admission date of 12/20/16 with medical diagnoses of chronic obstructive pulmonary disease (COPD), hypertension (HTN), and stroke with hemiparesis. Review of the medical record for Resident #86 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #86 had moderate cognitive impairment and required partial to moderate staff assistance with toileting, transfers, bathing and substantial to maximum staff assistance for personal hygiene. Review of the medical record for Resident #86…

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 medical record review and staff and resident interviews, the facility failed to ensure medications were administered as ordered. This affected two (#94 and #114) out of the four residents reviewed for medication administration. The facility census was 77. Findings included: 1. Review of the medical record for Resident #94 revealed an admission date of 09/12/23 with medical diagnoses of lumbago with sciatica, left and right sides, diabetes mellitus (DM), congestive heart failure, hypothyroidism, chronic obstructive pulmonary disease (COPD), and morbid obesity. Review of the medical record for Resident #94 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #94 was cognitively intact and required supervision with bathing, dressing, and bed mobility. The MDS indicated Resident #94 received insulin injections, a diuretic, an opioid, and an antibiotic during the reference period. Review of the medical record for Resident #94 revealed physician orders dated 09/15/23 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a police report, review of concern reports, staff interview, resident interview, review of self-reported incidents (SRIs), and policy review, the facility failed to report resident allegations of abuse and misappropriation to the State Survey Agency. This affected two (#21 and #71) of the six residents reviewed for abuse. The facility census was 68. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/05/16 with medical diagnoses of neoplasm of the nasopharynx, chronic kidney disease stage III, and hypothyroidism. The medical record revealed Resident #71 was discharged on 07/09/23. Review of the medical record for Resident #71 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #71 was cognitively intact, required extensive staff assistance for bed mobility, transfers, and toileting, and was dependent for eating. Review of a facility form titled, Report of Concern, dated 07/13/23, completed by…

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 medical record review, staff interview, resident interview, review of concern forms, review of a police report, and policy review, the facility failed to thoroughly investigate allegations of abuse and misappropriation. This affected two (#21 and #71) of the six residents reviewed for abuse. The facility census was 68. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/05/16 with medical diagnoses of neoplasm of the nasopharynx, chronic kidney disease stage III, and hypothyroidism. The medical record revealed Resident #71 was discharged on 07/09/23. Review of the medical record for Resident #71 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #71 was cognitively intact, required extensive staff assistance for bed mobility, transfers, and toileting, and was dependent for eating. Review of a facility form titled, Report of Concern, dated 07/13/23, completed by LSW #100 revealed Resident #71's spouse reported concerns that 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 medical record review and staff interview, the facility failed to complete quarterly care conferences to ensure the resident and resident representative was involved in care planning decisions. This affected three (#38, #50, and #71) of six residents reviewed for participation in their plan of care. The census was 68. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/05/16 with medical diagnoses of neoplasm of the nasopharynx, chronic kidney disease stage III, and hypothyroidism. The medical record revealed Resident #71 was discharged on 07/09/23. Review of the medical record for Resident #71 revealed a Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 06/06/23, which indicated Resident #71 was cognitively intact, required extensive staff assistance for bed mobility, transfers, and toileting, and was dependent for eating. The medical record revealed the facility completed quarterly MDS assessments with ARDs on 12/05/22 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.

Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored in a safe and effective manner. This affected one (#41) of the four residents observed for medication administration. The facility census was 68. Finding include: Review of the medical record for Resident #41 revealed an admission date of 06/09/23 with medical diagnoses of right sided hemiparesis, hypertension, hypothyroidism, anxiety, and chronic obstructive pulmonary disease. Review of the medical record for Resident #41 revealed a Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 07/13/23, which indicated Resident #41 was cognitively intact and dependent for bed mobility, transfers, toileting, and bathing. Review of the medical record for Resident #41 revealed no documentation to support a self-administration medication assessment was completed by the facility. Observation on 08/23/23 at 9:14 A.M. revealed Resident #41 sitting up in her bed with a medication pill cup sitting in her lap with four unidentified medications in the pill cup.…

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 review of facility time punches and staff interview, the facility failed to ensure Registered Nurse (RN) coverage was provided for at least eight hours a day, seven days a week. This had the potential to affect all 61 residents at the facility. The facility census was 61. Findings include: Review of the facility's RN documented hours from 06/04/22 through 07/20/22, provided by the Administrator, revealed four days in which the facility had a census of greater than sixty residents and did not have the required eight hours of Registered Nurse coverage. On 06/09/22, RN #390 worked 1.42 hours, RN #400 worked 0.67 hours, and no additional RN coverage was provided for 06/09/22. On 06/14/22, RN #400 worked 2.3 hours, and the Interim Director of Nursing, who was an RN, worked 4.0 hours over her scheduled time for a total of 6.3 hours of RN coverage on 06/14/22. On 06/16/22, RN #390 worked 0.62 hours and no additional hours for RN coverage was provided for 06/16/22. On 07/01/22, RN #390 worked 0.78 hours and no additional RN coverage was provided for 07/01/22. Interview with the RN…

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

Based on staff interview and personnel file review, the facility failed to complete annual performance evaluations for State Tested Nursing Assistants (STNA). This affected two (STNA #155 and #190) out of three STNA's reviewed who were employed at the facility for longer than one year. This had the potential to affect all 61 residents at the facility. The facility census was 61. Findings include: 1. Review of STNA #155's personnel file revealed a hire date of 03/01/21. Further review of the STNA's file revealed no evidence of an annual performance evaluation. 2. Review of STNA #190's personnel file revealed a hire date of 11/07/19. Further review of the STNA's file revealed no evidence of an annual performance evaluation. Interview with the Human Resources Manager (HR) #291 on 07/19/22 at 12:29 P.M. confirmed there was no evidence of an annual performance evaluation having been completed for STNA #155 and STNA #190.

Based on review of a staff roster and staff interview, the facility failed to ensure a full-time Licensed Social Worker was employed on a full-time basis. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Findings include: Review of the facility's staff roster revealed there was no Licensed Social Worker (LSW) listed as a current employee. Interview on 07/21/22 at 9:05 A.M. with the Director of Nursing (DON) revealed he believed the facility had been without a LSW since January 2022. Interview on 07/21/22 at 2:30 P.M. with the Administrator revealed there had been an LSW employed from 03/31/21 to 01/17/22. The Administrator reported an LSW was hired to fill the vacant position on 04/25/22 but resigned on 05/06/22.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the medical record for Resident #68 revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. He was re-admitted to the facility on [DATE]. Diagnoses included vascular dementia with behavioral disturbance, type two diabetes mellitus without complications, and cerebral infarction. Review of the significant change MDS assessment, dated 05/10/22, revealed Resident #68 had severely impaired cognition. Review of the nursing progress note dated 05/21/22 revealed Resident #68 was sent to the hospital for further evaluation following a fall. Review of the facility form titled Notice of Resident Transfer or Discharge, dated 05/23/22, revealed Resident #68 was discharged to the hospital on [DATE]. There was no evidence the facility provided the notification to the Office of the State Long-Term Care Ombudsman. Interview on 07/21/22 at 2:30 P.M. with the Administrator confirmed there was no evidence of notification to the Office of the State Long-Term Care Ombudsman. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #24 revealed an admission date of [DATE]. His diagnoses included acute kidney failure, insomnia, cerebrovascular disease, depression, and diabetes mellitus two. Review of the MDS assessment for Resident #24, dated [DATE], revealed he was cognitively intact. Further review of the MDS assessment revealed he required assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #24's physician orders revealed an order for Trazodone (antidepressant medication) 100 milligram (mg), take one tablet by mouth everyday at bedtime and Sertraline HCL (antidepressant medication) 25 mg tablet give one and a half tablets daily at bedtime. Review of the Care Plans for Resident #24 revealed he had a care plan in place for depression with an onset date of [DATE]. Further review of the Care Plan for depression revealed a goal of showing at least one physical sign that stress is being alleviated by no episodes of uneasiness through 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 2. Review of Resident #64's medical record revealed an admission date of 10/19/21. admission diagnoses included chronic respiratory failure, diabetes, heart failure, major depressive disorder, bipolar disorder, and unspecified protein calorie malnutrition. Review of Resident #64's MDS assessment dated [DATE] revealed Resident #64 was cognitively intact. The MDS revealed the resident required dependent two-person assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the medical record for Resident #64 revealed no evidence of a care conference having been held with Resident #64. Interview with Resident #64 on 07/18/22 at 1:44 P.M. revealed he had not been invited to nor had he attended any care conference. Resident #64 denied any staff discussion related to his goals or preferences in regard to his care at the facility. Interview on 07/21/22 at 9:05 A.M. with the Director of Nursing revealed the facility had no documentation of a care conference for Resident #64. Based 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 medical record review, observation, resident interview, and staff interview, the facility failed to timely identify a pressure ulcer. This affected one (Resident #32) out of two residents reviewed for pressure ulcers. The facility census was 61. Findings include: Review of the medical record for Resident #32 revealed Resident #32 was discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Her diagnosis included history of Coronavirus disease 2019, metabolic encephalopathy, anemia, and non-rheumatic mitral valve prolapse. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #32, dated 04/27/22, revealed she had impaired cognition. Further review of the MDS assessment revealed Resident #32 was totally dependent on staff for dressing, bed mobility, toilet use, and personal hygiene. Review of the the Treatment Administration Record (TAR) for Resident #32 dated July 2022 revealed an order dated 07/13/22 to apply house barrier cream after each…

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 medical record review, observation, and staff interview, the facility failed to ensure a resident did not have access to hazardous substances. This affected one (Resident #24) out of one resident reviewed for medication storage. The facility census was 61. Findings include: Review of the medical record for Resident #24 revealed an admission date of 06/29/22. His diagnosis included acute kidney failure, cerebrovascular disease, depression, and diabetes mellitus two. Review of the Minimum Data Set (MDS) assessment for Resident #24, dated 07/19/22, revealed he was cognitively intact. Further review of the MDS assessment revealed Resident #24 required assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #24 was independent with eating. Review of the Care Plans for Resident #24 revealed he had a care plan in place for depression with an onset date of 04/23/22. Further review of the care plan for depression affirmed a goal dated 07/26/22 to show at least one physical sign that stress is being alleviated by no episodes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure catheter care was completed as ordered. This affected one (Resident #27) out of two residents reviewed for catheter care. The facility census was 61. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate, obstructive and reflux uropathy, and chronic kidney disease stage three. Review of the five-day Minimum Data Set assessment, dated 05/19/22, revealed Resident #27 had intact cognition. Resident #27 was assessed to require extensive assistance for bed mobility, dressing, toileting, and personal hygiene, and was totally dependent on staff for eating. Review of the plan of care dated 02/23/22 revealed Resident #27 was at risk for infection and trauma to the urinary tract due to indwelling catheter related to diagnoses of obstructive uropathy and prostate cancer. Interventions included…

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 medical record review, staff interview, and policy review, the facility failed to ensure resident meal intakes and weights were routinely monitored. This affected two (Resident #27 and #43) out of two residents reviewed for nutrition. The facility census was 61. Findings include: 1. Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. He was re-admitted to the facility on [DATE] and was discharged back to the hospital on [DATE]. Resident #27 was then re-admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate, obstructive and reflux uropathy, obesity, and chronic kidney disease stage three. Review of the five-day Minimum Data Set (MDS) assessment, dated 05/19/22, revealed Resident #27 had intact cognition. Resident #27 was totally dependent on staff for eating. Review of Resident #27's Plan of Care dated 02/07/22 revealed the resident was at risk for a nutritional decline…

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 medical record review, observation, staff interview, and facility policy review, the facility failed to ensure residents had the appropriate emergency tracheostomy supplies at bedside and had oxygen tubing changed timely. This affected two (Resident #3 and #42) out of three residents reviewed for respiratory care. The facility census was 61. Findings include: 1. Review of Resident #3's medical record dated 09/13/17 revealed an admission date of 09/13/17. admission diagnoses included dysphagia, malignant neoplasm of nasopharynx, and acute embolism and thrombus of the lower extremities. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Further review of the MDS revealed Resident #3 required extensive two-person assistance for toileting, and required supervision with one-person physical assistance for bed mobility, dressing, and personal hygiene. The MDS further identified the resident had a tracheostomy. Review of Resident #3's plan of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to appropriately monitor and assess resident dialysis access sites. This affected two (Resident #15 and #43) out of two residents reviewed for dialysis. The facility census was 61. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 12/14/21. admission diagnoses included end stage renal disease, diabetes, chronic kidney disease, and heart failure. Review of Resident #15's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. The MDS revealed the resident required extensive two-person assistance for bed mobility and toileting. The resident required extensive one-person assistance for dressing, and personal hygiene. The resident required limited one-person assistance for transfers. Review of Resident #15's plan of care dated 07/18/22 revealed the resident received dialysis three times a week related to end-stage renal disease. Interventions…

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 medical record review, staff interview, and facility policy review, the facility failed to timely implement a pharmacy recommendation which was approved by the physician. This affected one (Resident #64) out of six residents reviewed for unnecessary medications. The facility census was 61. Findings include: Review of Resident #64's medical record revealed an admission date of 10/19/21. admission diagnoses included chronic respiratory failure, diabetes, heart failure, and unspecified protein calorie malnutrition. Review of Resident #64's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #64's undated plan of care revealed the resident was at risk for ineffective breathing related to congestive heart failure and chronic obstructive pulmonary disease. Interventions included to administer medications as ordered. The plan of care revealed the resident was at risk for decline in mood and side effects due to the use of antidepressants. Review of Resident #64's…

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 medical record review, the facility failed to ensure a medications were stored appropriately. This affected one (Resident #24) out of one resident reviewed for medication storage. The facility census was 61. Findings include: Review of the medical record for Resident #24 revealed an admission date of 06/29/22. His diagnoses included acute kidney failure, cerebrovascular disease, depression, and diabetes mellitus two. Review of the Minimum Data Set (MDS) assessment for Resident #24, dated 07/19/22, revealed he was cognitively intact. Further review of the MDS assessment revealed Resident #24 required assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #24 was independent with eating. Further review of the nursing progress notes for Resident #24, dated 07/18/22 at 11:25 A.M. revealed a bottle of Milk [NAME] (dietary supplement) and diclofenac gel (non-steroidal anti-inflammatory drug) as well as artificial tears (eyedrops…

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 medical record review, staff interview, and policy review, the facility failed to ensure residents were provided dental services in a timely manner. This affected one (Resident #50) out of one resident reviewed for dental services. The facility census was 61. Findings include: Review of the medical record for Resident #50 revealed an admission date of 01/04/22. Diagnoses included Parkinson's disease, unspecified dementia without behavioral disturbance, glaucoma, and alcohol abuse. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/16/22, revealed the resident had severely impaired cognition. The resident was assessed to require supervision for eating. Review of the nursing progress note dated 03/30/22 revealed Resident #50 had a cracked tooth. The note indicated the resident was added to the list to see the dentist. Review of the medical record for Resident #50 revealed no evidence the resident saw the dentist after being placed on the list on 03/30/22. Interview on 07/21/22 at 3:14 P.M. with the Administrator revealed Resident #50 was on the list to see…

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 medical record review and staff interview, the facility failed to accurately document the administration of tube feeding. This affected one (Resident #27) out of one resident reviewed for tube feeding. The facility census was 61. Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] and was discharged to the hospital on [DATE]. He was re-admitted to the facility on [DATE] and was discharged back to the hospital on [DATE]. Resident #27 was then re-admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate, obesity, and chronic kidney disease stage three. Review of the five-day Minimum Data Set (MDS) assessment, dated 05/19/22, revealed Resident #27 had intact cognition. This resident was assessed to require extensive assistance for bed mobility, dressing, toileting, and personal hygiene, and was totally dependent on staff for eating. Review of the plan of care dated 06/17/22 revealed the resident required…

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 medical record review, observation, and staff interview, the facility failed to practice proper hand hygiene during a wound dressing change. This affected one (Resident #27) out of one resident observed for wound dressing changes. The facility census was 61 Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of prostate, obstructive and reflux uropathy, and chronic kidney disease stage three. Review of the five-day Minimum Data Set (MDS) assessment, dated 05/19/22, revealed Resident #27 had intact cognition. The resident was assessed to require extensive assistance for bed mobility, dressing, toileting, and personal hygiene. Review of the physician order for Resident #27 dated 07/17/22, revealed an order to cleanse right calf with normal saline, pat dry. Apply betadine moistened gauze, cover with dressing, and change two times a day. Observation on 07/21/22 at 3:06 P.M. of wound care for…

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

Based on observation, staff interview, and review of facility policy, the facility failed to properly store resident medication. This had the potential to affect 46 resident's (#9, #16, #18, #20, #21, #22, #23, #27, #30, #32, #35, #36, #37, #38, #40, #46, #47, #52, #54, #56, #57, #60, #61, #66, #69, #70, #72, #74, #76, #77, #80, #81, #84, #92, #96, #97, #101, #103, #104, #105, #106, #110, #111, #422, #423, and #424) the facility identified as cognitively impaired and independently mobile and that could access the unsecured medications. The facility census was 113. Findings include: Observation conducted on 06/26/19 at 6:14 A.M. revealed medication sitting on the top of the counter at the nurses station at the entrance of the facility. Review of the medication revealed medications including Metformin (diabetic medication) 60 tablets, Trazodone (antidepressant and sedative) 15 tablets 50 mg each, Vimpat (anti-seizure/controlled substance) 28 tablets 200 mg each, Norco (narcotic pain medication) 30 tablets 5-325 mg each, and one bottle of Fluticasone (nasal spray) 50 micrograms.…

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, medical record review, and staff and resident interview, the facility failed to accommodate a residents needs by ensuring the call lights were made readily available to residents who were capable of using them. This affected one (#110) of 32 residents observed for access to call lights. The facility census was 113. Findings include: Review of Resident #110's medical record revealed the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Diagnoses include presence of automatic cardiac defibrillator, coronary angioplasty status, old myocardial infarction, acute embolism and deep vein thrombosis, history of pulmonary embolism ventricle tachycardia, unspecified atrial flutter, and unspecified dementia without behavioral disturbance. The facility completed a minimum data set assessment (MDS 3.0) of the resident's cognitive and physical functional status dated 05/01/19. The assessment identified the resident a having moderate cognitive impairment, and requiring…

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 medical record review, staff and resident interviews, and review of facility policy, the facility failed to timely respond to resident concerns with missing personal property. This affected two (#24 and #93) of three reviewed for personal property during the investigation stage of the annual survey. The facility census was 113. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including polyarthritis, rheumatoid arthritis, muscle weakness, reduced mobility, need for assistance with personal care, systemic lupus, cardiac arrhythmia, major depressive disorder, type two diabetes, convulsions, anxiety disorder, and hypertension. Review of Social Services Progress Note dated 06/14/19 and again on 06/24/19 revealed Resident #24 had been reassessed and was upgraded to alert and oriented with a new BIMS score of 15, which revealed the resident was cognitively intact. Interview conducted on 06/24/19 at 2:47 P.M. Resident #24 stated she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, the facility failed to provide written notification of transfer when a resident was transferred out of the facility to the hospital. This affected one (#93) out of two residents reviewed for Hospitalizations during the survey. The facility census was 113. Findings include: Review of the medical record revealed Resident #93 was admitted to the facility on [DATE] with diagnoses including abscess of groin, muscle weakness, type two diabetes, anemia, need for assistance with personal care, end stage renal disease, heart disease, peripheral vascular disease, chronic ulcer of right foot, and altered mental status. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired with disorganized think and inattention behaviors continuously present. Review of Section E-Behavior revealed the resident had verbal behavioral symptoms directed toward others and rejection of care noted one to three…

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 medical record review and staff interview, the facility failed to ensure an Minimum Data Set (MDS) assessments was coded accurately. This affected one (#115) of three residents closed records reviewed for MDS assessment accuracy. The census was 113. Findings include: Review of Resident #115's closed record on 06/27/19 at 2:00 P.M. showed the resident was discharged on 04/29/19. Review of the MDS 3.0 assessment dated [DATE] showed the resident's discharge was an unplanned discharge with return not anticipated to an acute hospital. Review of Nurse's Note dated 04/29/19 revealed discharge instructions were reviewed. The resident was provided with a five day supply of medications and 14 Oxycontin 10 mg tablets to take home. The resident verbalized understanding and was waiting for a friend to pick her up. Review of Social Services Note dated 04/30/19 showed the resident discharged to home on [DATE] with home health care services. Interview with MDS Nurse #467 on 06/27/19 at 2:32 P.M. verified the MDS…

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, medical record review, staff and resident interview and policy review, the facility failed to develop and implement comprehensive plans of care related for contracture care and management. This affected two (#15 and #59) of two reviewed for Positioning/Mobility. The facility census was 113. Findings include: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses including hemiplegia following cerebrovascular disease, chronic pain, major depressive disorder, contracture left knee, contracture of unspecified joint, and subluxation of left shoulder joint. The facility completed a quarterly minimum data set assessment (MDS 3.0) of Resident #15's cognitive and physical functional status dated 05/15/19. The 05/15/19 assessment identified the resident as having good memory and recall, and required the physical assistance of one staff person to complete bed mobility, dressing toileting, and personal hygiene. The resident did not transfer or walk during the assessment period. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, and policy review, the facility failed to ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming related to nail care. This affected two (#59 and #24) of five residents reviewed for Activities of Daily Living. The facility census was 113. Findings include: 1. Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infarction, hemiplegia following cerebral infarction, dysphagia, diabetes mellitus type 2, hypertension, and major depressive disorder. The facility completed a minimum data set assessment (MDS 3.0) of the resident's cognitive and physical functional status dated 06/17/19. The 06/17/19 assessment identified the resident as having short and long term memory problems, severely impaired cognitive skills, and requiring the physical assistance of two staff for bed mobility,…

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, medical record review, and staff and resident interview, the facility failed to ensure that each resident with limited range of motion received appropriate treatment, services, and devices to improve range of motion or prevent further decline. This affected one (#15) of two residents reviewed for Positioning/Mobility. The facility census was 113. Findings include: Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia following cerebrovascular disease, chronic pain, major depressive disorder, contracture left knee, contracture of unspecified joint, and subluxation of left shoulder joint. The facility completed a quarterly minimum data set assessment (MDS 3.0) of Resident #15's cognitive and physical functional status dated 05/15/19. The 05/15/19 assessment identified the resident as having good memory and recall, and required the physical assistance of one staff person to complete bed mobility, dressing…

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, medical record review, and staff and resident interview, the facility failed to maintain the resident call system in good working order. This affected one (#37) of 32 residents observed for access to call lights. The facility census was 113. Findings include: Review of Resident #37's medical record revealed the resident was admitted to the facility 04/27/18. Diagnoses include contractures of the left and right knee, Alzheimer's disease, major depressive disorder, peripheral vascular disease, need for assistance with personal care, left below the knee amputation, and repeated falls. The facility completed a minimum data set assessment (MDS 3.0) of the facility's cognitive and physical functional status dates 04/30/19. The 04/30/19 assessment identified the resident as having good memory and recall and requiring the physical assistance of one staff person for bed mobility and transfer. On 06/24/19 at 3:48 P.M. Resident #37 was observed and interviewed regarding call light function and use. He reported he was able to and did use his call light to alert staff when…

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.