Harmar Place Nursing and Rehabilitation

Based on observations, record review, staff interview, and resident interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing and prevent new ulcers from developing. This affected one resident (#66) of three residents reviewed for pressure ulcers. The facility census was 75. Findings include: Review of the medical record for Resident #66 revealed an admission date of 06/16/24 and diagnoses including acute kidney failure, hypertension, and stage four pressure ulcer. A Minimum Data Set assessment completed 12/28/24 documented a brief interview for mental status (BIMS) score of 11 (moderately impaired cognition). The resident was dependent upon staff for lower body dressing, required substantial/maximal assistance from staff with bed to chair transfers, and required partial/moderate assistance from staff with rolling in bed. The resident was unable to walk. The resident was noted to have a Stage 4 pressure ulcer present upon admission (Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss:…

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, resident interviews, staff interviews, and review of written staff statements from facility investigation, the facility failed to timely address pain. This affected three residents (#36, #78, #185) of three residents reviewed pain. The facility census was 75. Findings include: 1. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, and atherosclerotic heart disease. Review of physician orders revealed Resident #36 had an order in place dated 09/24/23 for Tylenol oral tablet 325 milligrams (mg) give two tablets by mouth every four hours as needed for pain not to exceed 3000 mg per day. Review of a care plan dated 06/10/24 revealed Resident #36 had pain related to an old left arm fracture which left her with limited range of motion and chronic pain. Her goal was to verbalize satisfaction with her pain control regimen through the review date of 02/24/25. Interventions included assessing for cause of pain,…

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, staff interview, and resident interview, the facility failed to ensure a resident received the appropriate treatment and services for depression. This affected one resident (#78) of two residents reviewed for behavioral care in a sample of 24. The facility census was 75. Findings include: Review of the medical record for Resident #78 revealed an admission date of 01/31/25 and diagnoses including depression, bipolar disorder, post traumatic stress disorder (PTSD), and anxiety disorder. A physician progress note on 01/31/25 stated the resident was admitted after a recent craniotomy for meningioma ( a tumor of the membranes surrounding the brain). The resident had physician's orders for an antidepressant medication daily (started 02/01/25) and an antianxiety medication three times daily (started 01/31/25). A Minimum Data Set assessment completed 02/04/25 documented a brief interview for mental status score of 15 (intact cognition). It also documented a mood score of 20 (20-27 indicates severe depression). Interview with Physical Therapy Assistant #315 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 record review and staff interview, the facility failed to ensure pharmacy recommendations were responded to timely by the physician and/ or the physician provided a rationale as to why the pharmacy recommendations were not acted upon. This affected two residents (#5 and #36) of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, dementia, and depression. Review of Resident #5's monthly medication regimen reviews documented under the progress notes of the electronic medical record (EMR) revealed the resident's medications had been reviewed for any irregularities monthly in the past 12 months. The medication regimen review completed on 08/22/24 noted an irregularity with the resident's prescribed medications and a recommendation was made to the physician for review. Review of Resident #5's consultation report dated 08/22/24 revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure antihypertensive medications used in the treatment for hypertension were held as needed in accordance with the physician's orders. This affected one resident (#5) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #5's medical record revealed she was originally admitted to the facility on [DATE] with a readmission date of 10/31/22. Her diagnoses included essential hypertension, chronic atrial fibrillation, and congestive heart failure. Review of Resident #5's physician's orders revealed the resident had an order to receive Metoprolol Tartrate 50 milligrams (mg) by mouth twice a day for high blood pressure. The order included parameters to hold the medication if the resident's systolic blood pressure (SBP) was less than 100 millimeters of mercury (mmHg). Review of Resident #5's medication administration record (MAR) for January 2025 revealed the nurses were documenting the resident's blood pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident did not receive an anxiolytic medication on an as needed (prn) basis longer than 14 days, without the physician providing the necessary documentation required for an extended use. This affected one resident (#28) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #28's medical record revealed the resident was admitted to the facility on [DATE]. She was readmitted to the facility on [DATE]. Her diagnoses included anxiety disorder. Review of a consultation report for Resident #28 dated 07/17/24 revealed the consulting pharmacist noted an irregularity in the resident's medications when reviewing the resident's medications as part of a monthly medication regimen review. The pharmacist identified the resident had an order for Xanax 0.25 milligrams (mg) with directions to give one tablet by mouth every eight hours as needed for anxiety. The pharmacist asked the physician to please discontinue…

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

Based on observations, record review, staff interview, and resident interview, the facility failed to ensure medical records were accurately documented for a resident with a pressure ulcer. This affected one resident (#66) of three residents reviewed for pressure ulcers. The facility census was 75. Findings include: Review of the medical record for Resident #66 revealed an admission date of 06/16/24 and diagnoses including acute kidney failure, hypertension, and stage four pressure ulcer. A Minimum Data Set assessment completed 12/28/24 documented a brief interview for mental status (BIMS) score of 11 (moderately impaired cognition). The resident was dependent upon staff for lower body dressing, required substantial/maximal assistance from staff with bed to chair transfers, and required partial/moderate assistance from staff with rolling in bed. The resident was unable to walk. The resident was noted to have a Stage 4 pressure ulcer present upon admission. (Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly…

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, policy review and interview, the facility failed to initiate fall interventions and complete fall interventions as recommended. This affected three of three residents (Resident #69, #139 and #141) reviewed for falls. The facility census was 77. Findings include: 1. Medical record review revealed Resident #139 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, obstructive uropathy and hypertension. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #139 was severely impaired for daily decision-making, had signs/symptoms of fluctuating inattention and disorganized thinking and required the use of a walker for ambulation. a. Review of the Fall Incident Report dated 01/06/24 revealed Resident #139 was lying on the floor with non-skid footwear in place and his walker beside him. A skin tear was noted to elbow, an abrasion to his left shoulder and he was assisted back to bed. The resident stated he got dizzy…

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, policy review and interview, the facility failed to provide adequate accommodations to prevent possible resident exposure to a known pet allergy. This had the potential to affect one (Resident #69) of one resident identified as having a pet allergy. The facility census was 77. Findings include: Medical record review revealed Resident #69 was admitted on [DATE] with diagnoses including epilepsy, macular degeneration, weakness, dizziness and anxiety. The resident record indicated an allergy to cats. Review of the quarterly MDS assessment dated [DATE] revealed Resident #69 was cognitively intact for daily decision-making. On 03/12/24 at 6:10 A.M., interview with Licensed Practical Nurse (LPN) #13 stated the facility has cats and they get on everything. LPN #13 did not know if there were any residents allergic to cats. On 03/12/24 at 6:12 A.M., observation revealed a facility cat was walking in the television/dining area on the 100 Hall. On 03/12/24 at 6:25 A.M.,…

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 interview, the facility failed to ensure comprehensive assessments were accurate for immunizations. This affected two (Resident #69 and #101) of five residents reviewed for immunizations. The facility census was 77. Findings include: 1. Medical record review revealed Resident #69 was admitted on [DATE] with diagnoses including epilepsy, cardiomegaly and cerebral infarction. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #69 was offered and refused the influenza vaccine. Review of the medical record revealed no evidence Resident #69 was offered the influenza vaccine or had received education regarding the risks or benefits of the vaccine. On 03/13/24 at 8:01 A.M., interview with the Director of Nursing (DON) verified Resident #69 was not offered or received an influenza vaccination in 2023. On 03/27/24 at 10:31 A.M., the DON verified via electronic mail that the quarterly MDS assessment dated [DATE] was inaccurate for refusal of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure as needed (PRN) antipsychotic medications were not administered as a fall intervention. This affected one (Resident #141) of three residents reviewed for accidents. The facility census was 77. Findings include: Medical record review revealed Resident #141 was admitted on [DATE] with diagnoses including urinary tract infection, unspecified dementia, anxiety and a high fall risk. Review of the admission Physician Orders dated 03/03/24 revealed Resident #141 received Seroquel (antipsychotic) 12.5 milligrams (mg) daily. Review of the Incident Report dated 03/10/24 revealed staff had toileted Resident #141 and put her to bed at 8:15 P.M. and at 8:30 P.M. the resident was heard yelling. Resident #141 was on the floor in her room and was crawling on her hands and knees in the hallway yelling at another resident to help her up. The immediate action was to assist her to the wheelchair and administer a one-time 25mg dose of Seroquel.…

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

Based on observation and interview, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect all 77 residents who ate food from the kitchen. Findings include: On 03/12/24 between 10:00 A.M. and 10:23 A.M. , observation of the kitchen revealed the following: 1. The dry storage area had a small window with a window sill that was covered with approximately 30 to 40 small black/brown insects. The insects were dead and two dead bugs were observed on top of a can of condensed milk that was being stored on a shelf underneath the window. 2. The dish room had four black/brown insects with wings that were dead under the storage area and dish table. 3. The opposite end of the dish room contained three carts containing clean coffee pots, 20 clear plastic drinking glasses, various pots and pans and two sets of goggles, three nosey cups and nine water pitchers. A stand up fan was positioned against the back wall and was blowing on the carts with the clean dishes. The fan screen was observed to have dust tendrils adhered to the fan screen and were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the facility failed to administer immunizations as required. This affected two (Resident #69 and #101) of five residents reviewed for immunizations. The facility census was 77. Findings include: 1. Medical record review revealed Resident #69 was admitted on [DATE] with diagnoses including epilepsy, cardiomegaly and cerebral infarction. Review of the Physician Order Summary dated 05/23/22 revealed Resident #69 may have the annual influenza vaccine per facility policy. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #69 was offered and refused the influenza vaccine. Review of the medical record revealed no evidence Resident #69 was offered the influenza vaccine or had received education regarding the risks or benefits of the vaccine. On 03/13/24 at 8:01 A.M., interview with the Director of Nursing (DON) verified Resident #69 was not offered or received an influenza vaccination in 2023. The DON stated 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 medical record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident had the right to choose schedules and make choices about showering/ bathing. This affected one of three residents reviewed for choices (#4). The facility census was 75. Findings include: Review of the medical record for Resident #4 revealed an admission date of 06/17/23 and a diagnosis of fracture of right femur (prior to admission). Review of a Minimum Data Set (MDS) assessment completed 06/23/23 revealed a Brief Interview for Mental Status score of 13, indicating intact cognition. The MDS further indicated the resident required extensive assistance from one staff for transfers, walking, locomotion, personal hygiene, and bathing. Review of the plan of care dated 06/18/23 revealed Resident #4 had an activities of daily living self care performance deficit related to recent right femur fracture. It stated the resident preferred a shower and required extensive assistance from staff 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 closed medical record review, interview, and policy review the facility failed to ensure transfer information was documented in the resident's medical record. This affected one resident (#75) of one reviewed for hospitalization. Findings included: Closed medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of large intestine, abdominal aortic aneurysm, dysphagia, stage two pressure ulcer, cachexia cancer, kidney failure, respiratory failure, congestive heart disease, atrial fibrillation, and sleep apnea. Review of progress notes dated 05/12/23 revealed the Nurse Practitioner was visiting and noticed a large amount of blood from the rectum. New orders were received to send the resident to the emergency room. Report was called to the emergency room and the resident's son was notified. Further review Resident #75's medical record revealed no documented evidence the required transfer information was provided to the hospital. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, interview, and policy review the facility failed to ensure residents and/or resident representatives were provided with transfer notice as required for a facility initiated transfer. This affected one resident (#75) of one reviewed for hospitalization. Findings included: Closed medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of large intestine, abdominal aortic aneurysm, dysphagia, stage two pressure ulcer, cachexia cancer, kidney failure, respiratory failure, congestive heart disease, atrial fibrillation, and sleep apnea. Review of progress notes dated 05/12/23 revealed the Nurse Practitioner was visiting and noticed a large amount of blood from the rectum. New orders were received to send the resident to the emergency room. Report was called to the emergency room and the resident's son was notified. Further review of Resident #75's medical record revealed no documented evidence the 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 record review, review of the facility's shower schedules, observation, resident interview, staff interview and policy review, the facility failed to ensure residents who were dependent on staff for personal care received the assistance they needed with washing their hair and trimming their fingernails. This affected two residents (#4 and #129) of two residents reviewed for activities of daily living. Findings include: 1. A review of Resident #129's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, chronic neck/ back pain, and neuropathy. A review of Resident #129's care plans revealed he had an activities of daily living (ADL's) self care performance deficit that was initiated on 07/20/23. The care plan interventions indicated he was to have a bed bath, until cleared to shower, two to three times a week in the afternoon. He required a one to two person assist with bathing. A review of Resident #129's Kardex (care information used by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure residents received audiology/optometry services timely when needed. This affected two residents (#12 and #50) of two residents reviewed for vision/ hearing. Findings include: 1. Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and vision impairment. A review of Resident #50's ancillary service consent form dated 05/25/23 revealed the resident consented to receive optometry services from the facility's contracted optometrist while residing in the facility. A review of Resident #50's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed resident's vision was adequate with the use of corrective lenses. A review of Resident #50's active care plans revealed the resident had impaired vision function related to not having her eyes dilated for quite some time and her prescription had changed. A review of 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 medical record review, staff interview, and policy review, the facility failed to ensure a resident with significant weight loss received timely interventions as recommended by the dietetic technician. This affected one of five residents reviewed for nutrition (#31). The facility census was 75. Findings include: Review of the medical record for Resident #31 revealed an admission date of 12/14/22 and diagnoses including dementia, dysphagia (difficulty swallowing), Parkinson's disease, and diabetes. The resident weighed 90.4 pounds upon admission on [DATE]. A Minimum Data Set assessment completed 04/28/23 documented a Brief Interview for Mental Status score of 9, indicating moderately impaired cognition. It stated the resident was 62 inches tall, weighed 92 pounds, had no weight loss, and required extensive assistance from staff with eating. The resident had a plan of care in place, revised 07/13/23, which stated the resident had a nutritional problem or potential nutritional problem related to advanced…

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, interview, and policy review the facility failed to ensure residents received timely dental services. This affected one resident (#50) of two reviewed for dental. Findings included: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and vision impairment. A review of Resident #50's census revealed the resident primary insurance was Medicare until 06/16/23 she was switched to Medicaid. A review of Resident #50's ancillary service consent form dated 05/25/23 revealed the resident consented to receive dental services from the facility's contracted dentist while residing in the facility. A review of Resident #50's five-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was edentulous. The resident was not assessed to have broken or loosely fitting full or partial dentures. A review of Resident #50's active care plans revealed the resident had upper and lower dentures. A review of 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.

Based on medical record review, staff interview, and policy review, the facility failed to implement the antibiotic stewardship policy and procedure for antibiotic use. This affected two of five residents reviewed for unnecessary medications (#18 and #30). The facility census was 75. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 10/14/20 and a diagnosis of dementia. A Minimum Data Set assessment completed 05/24/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Review of nurses progress notes on 04/12/23 at 3:15 P.M. revealed Resident #18 returned to the facility in stable condition. New medication orders received following procedure and hospital to call facility to schedule follow up appointment within the next few days (procedure not specified in nurses notes). Record review revealed a physician's order on 04/12/23 for an antibiotic (Keflex) 250 milligrams twice daily for post op prophylaxis. There was no stop date for the antibiotic. Review of a fax cover sheet addressed 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 review of immunization records, policy review, and staff interview, the facility failed to ensure a resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations for a resident who refused both. This affected one of one residents who refused the influenza and pneumococcal immunizations in a sample of five (#18). The facility census was 75. Findings include: Review of the medical record for Resident #18 revealed an admission date of 10/14/20. A Minimum Data Set assessment completed 05/24/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Review of the immunization records for Resident #18 revealed both the influenza and pneumococcal immunizations had been refused (no dates). Record review revealed the resident/responsible party had been offered the influenza vaccine with education on 10/28/20 with it being declined at that time. There was no evidence the flu vaccine was offered with education annually. There was no evidence 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.

Based on review of immunization records, personnel records, staff interview, and policy review, the facility failed to ensure residents and staff were provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine and failed to have policies/procedures in place regarding COVID-19 vaccines for residents. This affected one of five sampled residents (#18) and one of one staff reviewed. The facility census was 75. Findings include: 1. Five residents were reviewed for COVID-19 vaccines. Four had received the initial doses and had received a recent annual booster. Resident #18, however, had refused the COVID-19 vaccines. Review of the medical record for Resident #18 revealed an admission date of 10/14/20. A Minimum Data Set assessment completed 05/24/23 documented a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Review of the immunization records for Resident #18 revealed the COVID-19 vaccine had been refused by the resident on 12/23/20 and 04/20/22. There was no evidence education had been provided 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 and staff interview the facility failed to ensure residents were treated with dignity by providing residents with knives at mealtime. This affected 14 of 14 residents (Residents #1, #3, #6, #21, #22, #23, #25, #26, #29, #36, #38, #42, #48, and #74) who resided on The Haven (a dementia care unit). Findings include: Observation of The Haven's meal service on 07/26/21 at 11:50 A.M. revealed resident's meal trays were delivered. Observation of Residents #1, #3, #6, #21, #22, #23, #25, #26, #29, #36, #38, #42, #48, and #74's meal trays revealed no knives on the resident trays. Observation of The Haven's meal service on 07/28/21 at 8:29 A.M. revealed resident's meal trays were delivered and there were no knives on the trays. At the time of the observation, interview with State Tested Nursing Assistant (STNA) #143, STNA #202, and Registered Nurse (RN) #165 verified the lack of knives and these staff obtained knives from a cabinet drawer to butter resident's bread. Observation of The Haven on 07/28/21 at 12:07 P.M. revealed STNA #202 stated to Resident #22 let me get 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 staff interview and medical record review, the facility failed to ensure resident plans of care addressed resident's needs in the areas of activities, skin non-pressure, dementia care, eating, and device usage. This affected six of 18 sampled residents (Resident #4, #22, #44, #46, #67, and #274) whose care plans were reviewed. The census was 74. Findings include: 1. Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22's annual minimum date set (MDS) assessment dated [DATE] revealed the following. Resident 322's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to provide meaningful activities to all residents. This affected four (Residents #18, #22, #44, and #67) of six residents reviewed for activities. The census was 74. Findings Include: 1. Observations from 07/26/21 at 11:00 A.M. to 08/02/21 at 3:30 P.M. revealed no group activities or activities outside of his room were offered to Resident #18. He remained in his bed the vast majority of the time. Record review revealed Resident #18 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, hypertensive retinopathy, dermatochalasis, chronic gastritis with bleeding, diverticulitis, iron deficiency anemia, metabolic encephalopathy, atrial fibrillation, osteoarthritis, hypothyroidism, dementia,unspecified psychosis, atherosclerotic heart disease, hypertension, and hyperlipidemia. His Brief Interview for Mental Status (BIMS) score was five, which indicated he had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the pharmacy failed to ensure controlled drug records were maintained and periodically reconciled for accuracy. This affected one (Resident #52) of two residents reviewed for controlled substances. The census was 74. Findings include: Medical record review revealed Resident #52 was admitted on [DATE] with diagnoses including complex regional pain syndrome I, osteoarthritis, and a history of COVID-19. Review of the electronic Medication Administration Record (eMAR) dated July 2021 revealed Resident #52 was administered Ultram 50 milligrams (mg) three times a day and Lyrica 75 mg twice a day for pain. The medications were documented as administered on 07/11/21. Review of the Individual Certificate of Disposition for Control Drugs dated 07/05/21 through 07/13/21 revealed Ultram was administered at 8:00 A.M. and 12:06 P.M A single dose of Ultram 50 mg was documented as wasted/refused on 07/11/21 with no time documented. There was no account of the…

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

Based on observations and staff interview, the facility failed to maintain a living environment free from needing repair. This affected seven (Residents #5, #7 #19, #22, #47, #48, and #67) of 74 residents in the facility. Findings Include: 1. Observations on 07/27/21 between 10:30 A.M. and 11:00 A.M. revealed the following issues in Resident #5, Resident #7, Resident #19, and Resident #47 rooms: chunks of dry wall missing from the wall behind Resident #5 and Resident #47 door (cased by the door handle), and large black marks and chunks of dry wall missing from the back wall of Resident #7 and Resident #19 room. Interview with Maintenance Staff #108 on 08/02/21 at 4:50 P.M. confirmed the chunks of drywall missing in all four resident's rooms. He stated the facility uses an electronic maintenance system to report and confirm work completed. He confirmed all staff have access to it, and items that need to be fixed in the rooms could/should be reported by the direct care staff; the maintenance staff are not in each resident's room each day. Depending on the item that needs to get fixed…

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 residents had comprehensive assessments in the areas of activities, potential restraint use, and residing on a dementia unit. This affected two of 18 residents (Resident #22 and #67) reviewed for comprehensive assessments. Findings include: 1. Review of Resident # 67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four…

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 resident interview, staff interview, medical record review, and observation the facility failed to maintain a resident's ability to eat. This affected one of five sampled residents (Resident #46) reviewed for nutrition. Findings include: Review of Resident #46's medical record revealed she was admitted on [DATE] with diagnoses that included: atrial fibrillation, hypo-osmolality and hyponatremia, gastro-esophageal reflux disease, malignant neoplasm of breast, acquired absence of right breast, and moderate protein calorie malnutrition. Review of Resident #46's admission Minimum Data Set (MDS) dated [DATE] revealed her speech was clear, she made herself understood, she understands others, her cognition was moderately impaired, and she had mild depression. Resident #46 had no indicators of psychosis, no behaviors, and did not reject care. Resident #46 was independent with set up help to eat. Resident #46 had no difficulty chewing, her partials (dentures) fit, she had significant unplanned weight gain that…

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, staff interview, and medical record review the facility failed to ensure a resident receiving medications with blood thinning properties had a means in place to prevent bruising. This affected one of six residents (Resident #22) reviewed for unnecessary medication. Findings include: Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22's annual minimum date set (MDS) dated [DATE] revealed the following. Resident # 22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period that…

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 proper supervision was provided to a resident that was a high fall risk. This affected one (Resident #28) of two residents reviewed for accidents. The census was 74. Findings Include: Record review revealed Resident #28 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia and hemiparesis, neuromuscular dysfunction of the bladder, atrial fibrillation, dysarthria, dysphagia, chronic kidney disease (stage III), morbid obesity, major depressive disorder, type II diabetes, chronic obstructive pulmonary disease. Her Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact. The assessment was completed on 05/25/21. Review of Resident #28's medical records revealed on 06/23/21, staff heard her yelling from her bathroom. When they responded, they found Resident #28 face down on the ground. She stated she was leaning forward to wipe and fell off the toilet; causing 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 observations, medical record review, resident interview, staff interview, and facility policy review, the facility failed to implement nutritional recommendations/interventions for residents who lost a significant amount of weight. Also, the facility failed to monitor significant weight loss and then did not provide meals as indicated on the menu to a resident. This affected three of five residents reviewed for nutrition (Residents #18, #46, #274). The census was 74. Findings Include: 1. Record review revealed Resident #18 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, hypertensive retinopathy, dermatochalasis, chronic gastritis with bleeding, diverticulitis, iron deficiency anemia, metabolic encephalopathy, atrial fibrillation, osteoarthritis, hypothyroidism, dementia,unspecified psychosis, atherosclerotic heart disease, hypertension, and hyperlipidemia. His Brief Interview for Mental Status (BIMS) score was five, which indicated he had a severe cognitive impairment.…

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, staff interview, medical record review, activity calendar review, and memory brochure the facility failed to ensure residents who were diagnosed with dementia received memory care to support the resident's well-being. This affected two of three sampled residents (Resident #22 and #67) reviewed for dementia care. Findings include: 1. Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22 annual minimum data set (MDS) dated [DATE] revealed the following. Resident # 22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one…

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 identified drug irregularity was addressed by the physician that included the rational for rejecting the recommendation. This affected one of six sampled residents (Resident #67) reviewed for unnecessary medications. Findings include: Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care. dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's admission Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 had delusions, other behaviors that occurred one to three days during the assessment period that did not impact her or other residents care, and she wandered four to six…

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 provide adequate justification for the use of anti-psychotic medications. This affected two (Residents #10 and #67) of six residents reviewed for unnecessary medications. The census was 74. Findings Include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE]. His diagnoses were Alzheimer's disease, melanoma in right ear, anxiety disorder, dementia with behavioral disturbances, vascular dementia with behavioral disturbances, major depressive disorder, and hemiplegia and hemiparesis. His Brief Interview for Mental Status (BIMS) score was four, which indicated he had a severe cognitive impairment. The assessment was completed on 04/20/21. Review of Resident #10 medical records revealed he was prescribed Zyprexa (since 12/05/17), with dosages changing over time and the justification changing as well. From 04/12/18 to 03/09/21, he was prescribed and administered Zyprexa five milligrams (mg) for vascular dementia 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, medical record review, medication administration guidance review, policy review, and interview, the facility failed to ensure a medication error rate was not 5% or greater. There were 32 opportunities for error with three actual errors resulting in a 9.38 % medication error rate. This affected three (Resident #15, #30 and #59) of five residents observed during medication administration. The census was 74. Findings include: 1. Medical record review revealed Resident #15 was admitted on [DATE] with diagnoses including malignant neoplasm of the brain and major depressive disorder. Review of the electronic Physician Orders dated July 2021 revealed to administer Potassium Chloride (KCL) 20 miliequivalents (mEq) extended-release twice a day for hypokalemia (low potassium level). On 07/27/21 at 3:29 P.M., observation revealed Licensed Practical Nurse (LPN) #119 placed a KCL extended-release 20 mEq in 15 ml of water in a medication cup, dissolved the tablet which formed into a slurry and mixed it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure documentation in a resident's record was accurate. This affected one of 18 sampled residents (Resident #22). Findings include: Review of Resident #22's medical record revealed she was admitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia without behaviors, hypertensive chronic kidney disease, hyperlipidemia, type two diabetes, stage four kidney disease, obesity, peripheral vascular disease, hypomagnesemia, polyosteoarthritis, and major depressive disorder single episode. Review of Resident #22 annual minimum data set (MDS) dated [DATE] revealed the following. Resident #22's speech was clear, she was usually understood, and she usually understands others, her cognition was severely impaired. Resident #22 had minimal depression, had delusions, other behaviors one to three days during the assessment period that did not impact the resident or other residents, she did not reject care, and she wandered. 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 staff interview, hospice contract review, and medical record review the facility failed to maintain hospice communication in the resident's medical record. This affected one of one sampled resident's (Resident #67) reviewed for hospice. Findings include: Review of Resident #67's medical record revealed she was admitted [DATE] with diagnoses that included: senile degeneration of brain, palliative care, dementia without behaviors, essential hypertension, insomnia, malignant neoplasm of breast, anxiety, and over active bladder. Review of Resident #67's quarterly Minimum Data Set (MDS) dated [DATE] revealed the following. Resident #67's speech was clear, she made herself understood, she understands others, her cognition was severely impaired, and she had minimal depression. Resident #67 was on hospice. Review of Resident #67's medical record revealed there were no hospice notes available for review. Interview of the Director of Nursing on 08/02/2021 at 1:30 P.M. revealed the hospice notes were not available…

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, policy review and interview, the facility failed to follow acceptable infection control practices during a dressing change. This affected one (Resident #47) of one resident observed for a dressing change. The facility census was 74. Findings include: Medical record review revealed Resident #47 was admitted on [DATE] and readmitted on [DATE] with diagnoses including a Stage II pressure ulcer to the right heel and osteomyelitis. Review of the electronic Physician Orders dated 07/26/21 revealed daily treatments to the right heel included the following: cleanse right heel with soap and water then saline wound wash, pat dry, apply the ordered dressing, cover with gauze then wrap with kerlix. On 07/29/21 between 2:20 P.M. and 2:41 P.M., observation of Licensed Practical Nurse (LPN) #123 complete Resident #47's right heel dressing change revealed the following: LPN #123 gathered supplies, washed her hands, applied gloves, and placed a clean towel on the bed under 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.