Betty Ann Nursing Center

Based on record review and interview, the facility failed to ensure a comprehensive care plan was developed for one (#29) of 23 sampled residents who were reviewed for comprehensive care plans. The administrator identified 47 residents who resided at the facility. Findings: Resident #29 had diagnoses which included cerebral vascular accident, osteoarthritis, and hemiplegia/hemiparesis. A Care Plan, initiated 08/02/24, documented focus for DNR status and indwelling catheter. No other concerns were documented on the comprehensive care plan. An admission assessment for Resident #29, dated 08/15/24, documented ten areas of concern for care planning as follows: cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, behavioral symptoms, falls, nutritional status, dehydration fluid maintenance, dental care, pressure ulcer, and psychotropic drug use. Only one of the concerns were included in the comprehensive care plan. On 10/03/24 at 8:47 a.m., the DON stated a comprehensive care plan should have been developed and did not know the…

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

Based on observation, record review and interview, the facility failed to ensure the care plan was revised and updated for one (#14) of 12 sampled residents whose care plans were reviewed. The administrator identified 47 residents who resided at the facility. Findings: Resident #14 had diagnoses which included pressure ulcer of left heel and diabetes type II. The care plan for Resident #14 documented a wound to the left heel was initiated 02/21/24 and resolved 04/24/24. The care plan did not document any further updates for pressure ulcers or deep tissue injuries. A Physician's Order, dated 09/06/24, documented to cleanse the wound with wound cleanser, pat dry then apply Santyl External Ointment 250 UNIT/GM (Collagenase) to the right heel topically one time a day for wound care, and cover with silicone border dressing daily until resolved. A quarterly assessment, dated 09/24/24, documented Resident #14 had no deep tissue injuries or pressure wounds. On 10/02/24 at 9:53 a.m., wound care was observed for Resident #14. The left heel wound was observed to be a closed wound, dark in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure interventions were in place to prevent reduction in range of motion/mobility for one (#29) of one sampled residents who were reviewed for range of motion/mobility. The DON identified seven residents who had limited range of motion. Findings: Resident #29 had diagnoses which included hemiplegia and hemiparesis following a cerebral infarction. The admission assessment, dated 08/02/24, documented no impairments to the upper or lower body. A Progress Note, dated 08/03/24 at 2:00 a.m., documented Resident #29 admitted to the facility on [DATE] with noted left hand weakness and without grasp due to a cerebral vascular accident. On 10/02/24 at 8:30 a.m., CNA #1 stated Resident #29 did not allow them to do anything with their hand. They stated they had not seen anything in their room for the left hand. On 10/02/24 at 8:35 a.m., LPN #1 stated Resident #29 was new to them. They stated the resident had no limitation in range of motion and 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 record review and interview, the facility failed to ensure supplements were offered/documented for one (#29) of one sampled residents who was reviewed for nutrition. The dietary manager identified 14 residents who was ordered supplements in the facility. Findings: Resident #29 had diagnoses which included moderate protein calorie malnutrition. The Dietician's Recommendation for Primary Care Providers form, dated 08/17/24, documented the resident was 26% below ideal body weight, had a diagnosis of protein calorie malnutrition, and recommended a supplement twice daily between meals. The physician agreed with the dietician recommendation. The electronic clinical record, dated 08/02/24, documented the resident's weight was 145 pounds. A Physician's Order, dated 08/20/24, documented the resident was ordered a dietary supplement between meals. A Physician's Order, dated 08/23/24, documented the resident was ordered Ensure three times per day. The electronic clinical record, dated 09/05/24, documented the resident's weight was 135.2 pounds, which indicated a 6.76 % weight loss in…

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

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for one (#36) of five sampled residents who were reviewed for unnecessary medications. The DON identified 47 residents who resided in the facility. Findings: Resident #36 had diagnoses which included dementia, mood disorder, and unspecified psychosis. The Physician's Order, dated 04/23/24, documented to obtain a lipid panel and PSA for annual labs. The Progress Note, dated 04/26/24, documented the resident had refused lab for three days. Review of the clinical record revealed the resident had complied with obtaining labs twice in June 2024 and three times in July 2024. The labs obtained did not include a PSA for annual labs per the physician's order. On 10/01/24 at 9:35 a.m., the ADON stated the lipid panel was completed in June 2024, but they would need to look for the lab results for the PSA. The ADON stated the resident would initially refuse labs, but after they talked to the resident and explained the lab to them they were compliant and agreeable to obtaining labs…

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

Based on observation, record review, and interview, the facility failed to ensure hot foods were served at palatable temperatures for one (#29) of one sampled resident who was reviewed for food. The DON identified 47 residents who received nourishment from the kitchen. Findings: The undated Food Temperatures policy, read in part, .Temperatures should be taken periodically to ensure hot foods stay above 140 [degrees] F and cold foods stay below 40 [degrees] F during the portioning, transporting and serving process until received by the resident . On 09/30/24 at 10:35 a.m., Resident #29 stated hot foods were served cold all the time. The resident stated they ate their meals in their room. On 10/02/24 at 11:51 a.m., the hall trays were observed to be prepared and ready for service on a metal cart with a plastic zippered cover. A test tray was placed on the hall cart. The noon meal consisted of penne pasta with chicken and alfredo sauce, green beans, bread, and spiced apples. On 10/02/24 at 12:04 p.m., CNA #2 was observed to obtain the hall cart from the dining room and begin delivering…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure code status orders were accurately documented for two (#23 and #51) of three residents sampled for advance directives. The Resident Census and Conditions of Residents form, dated [DATE], documented 51 residents resided in the facility. Findings: 1. Res #23 had diagnoses which included schizophrenia, bipolar disorder, and hypertension. A facility Advance Directive policy, dated [DATE], documented in part .Information about whether or not the resident has executed an advance directive shall be displayed prominent in the medical record .The director of nursing or designee will notify the attending physician of advance directives so that the appropriate orders can be documented in the resident's medical record and plan of care . A facility Do Not Resuscitate Order policy, dated [DATE], documented in part, .Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's orders sheet maintained in 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 record review and interview, the facility failed to notify the physician of vital signs out of parameter per physician orders for two (#41 and #46) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents form, dated 07/24/23, documented 51 residents resided in the facility. Findings: 1. Res #41 had diagnoses which included hypertension. A physician order, dated 06/29/23, documented to administer amlodipine 5 mg two times per day for hypertension. The order documented to hold the medication for systolic blood pressure less then 100 or diastolic blood pressure less than 60 and notify the primary care physician. A physician order, dated 06/29/23, documented to administer losartan 50 mg two times per day for hypertension. The order documented to hold the medication for systolic blood pressure less then 100 or diastolic blood pressure less than 60 and notify the primary care physician. The July 2023 MAR documented the amlodipine and losartan were held eight out of 50 opportunities for blood pressure parameters. A record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the physical environment of the facility was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility. Findings: On 07/24/23 at 10:36 a.m., upon entrance to the facility the wood laminate floor was observed to be missing and buckled. On 07/25/23 at 9:11 a.m., a tour of the front shower room was conducted. The following observations were made: a. the base board was missing on the wall adjacent to the hand sink. There was an accumulation of black residue on the wall, b. material was peeling off of the hand sink cabinet and the cabinet was warped, and c. there was an accumulation of black residue on the floor around the hand sink cabinet. On 07/25/23 at 9:16 a.m., a tour of the shower room on the back hall was conducted. The following observations were made: a. material was peeling off of the floor, b. base board tiles were missing, and c. there…

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

Based on record review and interview, the facility failed to update care plans for changes in treatment for two (#23 and #27) of 13 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form, dated 07/24/23, documented 51 residents resided in the facility. Findings: 1. Res #23 had diagnoses which included hypertension and localized edema. A physician order, dated 04/18/23, documented to discontinue Lasix (a diuretic). A care plan, revised 05/11/23, documented the resident was at risk for alteration in cardiac function related to hypertension and use of diuretics. The care plan documented to administer medications for localized edema and to monitor for side effects of Lasix. On 07/25/23 at 12:37 p.m., the DON stated she had not noticed the diuretic was discontinued on the care plan review. 2. Res #27 had diagnoses which included Alzheimer's disease, C-diff, and gastrointestinal hemorrhage. A physician order, dated 07/18/23, documented to administer Vancomycin 125 mg by mouth every six hours for C-diff (contagious infection of the large…

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

Based on observation, record review, and interview, the facility failed to: a. change a resident's catheter as ordered by the physician, b. obtain an order to change a resident's catheter, catheter bag, and tubing, and c. provide catheter care every shift for one (#39) of one sampled resident reviewed for catheters. The Resident Census and Conditions of Residents report, dated 07/24/23, documented five residents who had internal or external catheters. Findings: The Catheter Care, Urinary policy, revised 09/2014, read in parts, .The following information should be recorded in the resident's medical record .The date and time that catheter care was given .The name and title of the individual(s) giving the catheter care . Res #39 had diagnoses which included urinary retention. A physician order, dated 04/11/23, documented to change Foley catheter 16 Fr/10 cc bulb one time a day every 30 days. A care plan, dated 04/11/23, documented the resident had an urinary catheter. It documented to provide catheter care every shift per policy. There was no documentation catheter care was provided…

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.

3. The Catheter Care, Urinary policy, revised 09/2014, read in parts, .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . Res #39 had diagnoses which included urinary retention. A physician order, dated 04/11/23, documented to change Foley catheter 16 Fr/10 cc bulb one time a day every 30 days. On 07/24/23 at 12:16 p.m., Res #39 was observed in their wheelchair in the dining room. Their catheter bag below their wheelchair and was resting on the floor. On 07/24/23 at 12:47 p.m., Res #39 was observed propelling themselves in their wheelchair down the hall from the dining room to their room. Their catheter bag below their wheelchair was dragging the floor. On 07/25/23 at 9:19 a.m., Res #39 was in their bed. Their catheter bag was observed resting on the floor on the side of their bed. On 07/25/23 at 9:25 a.m., CNA #1 was asked how residents' catheter bags were to be stored. They stated they should be stored off of the floor. They were asked if Res #39's catheter was off of the floor. CNA #1 looked at the resident's catheter and stated they forgot…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure transfers were performed safely for one (#46) of three residents sampled for accidents. Findings 1. Res #46 had diagnoses which included cerebral palsy and physical debility. A quarterly MDS, dated [DATE], documented the resident was totally dependent on two staff for transfers. On 07/24/23 at 11:53 a.m., Res #46 was observed during a transfer from their bed to their wheelchair. The resident was observed being transferred via a full body lift. The staff were observed lifting the resident from the bed and moving the lift to rest above the resident's wheelchair. CNA #2 was observed tilting the empty wheelchair onto its back wheels and moving it under the lift. CNA #1 was observed lowering the resident into the wheelchair with the front wheels held off of the ground. CNA #2 lowered the wheelchair as the resident's weight shifted the front wheels to the ground. On 07/24/23 at 12:03 p.m., CNA #2 was asked about the procedure 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, record review, and interview, the facility failed to ensure medications were administered according to physician orders for one (#16) of four residents sampled for medication pass. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility. Findings: Res #16 had diagnoses which included dementia, stroke, benign brain tumor, and communication disorder. A physician order, dated 06/05/20, documented to administer tamsulosin 0.4 mg tablet daily for benign prostatic hyperplasia. A physician order, dated 06/05/20, documented to administer magnesium oxide 400 mg tablet twice daily for replacement. A physician order, dated 06/06/20, documented to administer clopidogrel 75 mg tablet daily for stroke. A physician order, dated 06/06/20, documented to administer finasteride 5 mg tablet daily for benign prostatic hyperplasia. A physician order, dated 06/06/20, documented to administer folic acid 1 mg tablet daily for anemia. A physician order, dated 06/06/20, documented to administer multivitamin tab daily 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, record review, and interview, the facility failed to ensure medication error rate below five percent. A total of 41 opportunities were observed with 16 errors. Total medication error rate was 39.02%. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility. Findings: Res #16 had diagnoses which included dementia, stroke, benign brain tumor, and communication disorder. A physician order, dated 06/05/2020, documented to administer tamsulosin 0.4 mg tablet daily for benign prostatic hyperplasia. A physician order, dated 06/05/2020, documented to administer magnesium oxide 400 mg tablet twice daily for replacement. A physician order, dated 06/06/2020, documented to administer clopidogrel 75 mg tablet daily for stroke. A physician order, dated 06/06/2020, documented to administer finasteride 5 mg tablet daily for benign prostatic hyperplasia. A physician order, dated 06/06/2020, documented to administer folic acid 1 mg tablet daily for anemia. A physician order, dated 06/06/2020, documented to administer…

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

Based on record review and interview, the facility failed to obtain labs as ordered by the physician for one (#39) of five sampled residents reviewed for lab services. The Resident Census and Conditions of Residents report, dated 07/24/23, documented 51 residents resided in the facility. Findings: Res #39 had diagnoses which included mood disorder. A physician order, dated 04/25/23, documented VPA level every two weeks, then monthly for therapeutic medication monitoring. There was no documentation the VPA level was obtained every two weeks. On 07/25/23 at 1:53 p.m., the DON was asked to locate documentation where the VPA level was collected every two weeks after the physician ordered the labs. On 07/25/23 at 4:58 p.m., the ADON stated they did not find documentation the labs were collected.

Based on interview and record review, it was determined the facility failed to ensure the surety bond was at an amount to cover the total amount of monies in the trust account for 53 of 53 residents who were identified as having a personal funds account with the facility. Findings: The daily balance for resident funds was reviewed for 11/2019, 12/2019, and 01/2020. The highest balance documented was $58,100. The bank statements documented the facility trust account was more than the surety bond every day from 11/15/19 to present. On 01/14/20 at 12:07 p.m., the business office manager (BOM) was asked for documentation of a surety bond. The BOM provided a copy of a surety bond dated 05/04/16 with no documented expiration date. The attached surety rider documented the bond was decreased to $30,000. The BOM asked how much money was in the account at this time. She stated $38,000. She was asked if it should cover the entire amount in the account. She stated yes. She was asked if the $30,000 covered the monies in the trust account. She stated no. She stated she checked the balance amounts…

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

Based on observation, interview, and record review, it was determined the facility failed to maintain a clean ice machine. The facility identified 53 residents who obtained ice from the ice machine. Findings: On 01/08/20 at 3:45 p.m., the dietary manager was asked to open the top portion of the ice machine. She stated maintenance was responsible for cleaning the top. She was asked to have maintenance open the top. At 4:00 p.m., maintenance #1 opened the top of the ice machine. Upon inspection a white cloth was used to wipe the inside of the water reservoir. A slimy substance of black, yellow, and brown colors were observed on the water reservoir wall. He was shown the cloth. He stated that it was soiled and he would clean it. On 01/08/20 at 4:15 p.m., maintenance #1 was asked how he cleaned the machine. He stated he followed the manufacturer's recommendation. He stated the only thing he cleaned it with was water and a de-scaler. He was asked if he used the de-scaler that time. He provided no response. He began cleaning the ice machine again. The maintenance log for monthly ice…

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, it was determined the facility failed to provide care and services according to the resident's plan of care for one (#39) of ten residents sampled for care provision. The facility failed to notify a resident's physician of results of low finger stick blood sugars (FSBS). The facility identified 12 residents who had orders for FSBS. Findings: Resident #39 had a diagnosis of type two diabetes mellitus and vascular dementia. A physician's order, dated 11/20/19, documented the resident was to have his finger stick blood sugar obtained before meals and at bedtime. The order documented to notify the physician if the resident's FSBS was below 70. The resident's 12/2019 injection administration records documented the resident's FSBSs were below 70 three times that month. There was no documentation in the resident's clinical record the resident's physician was notified of the FSBS results. The resident's 01/2020 injection administration records documented the resident's FSBSs were below 70 four times that month. There was no documentation in 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, and record review, it was determined the facility failed to implement an infection control program to prevent potential infections for eight (#8, #27, #36, #48, #50, #53, #54, and #106) of 22 residents reviewed for infection control. The facility failed to: a. provide treatment of a pressure ulcer in a manner to prevent infection for resident (#36), b. failed to perform hand hygiene in a manner to prevent cross contamination during the medication pass for seven (#8, #27, #48, #50, #53, #54, and #106). The facility identified 53 residents resided in the facility. Findings: 1. Resident #36 had diagnoses which included pressure ulcer to the right inner ankle and idiopathic peripheral autonomic neuropathy. A physician's order, dated 01/05/20, documented, .Clean right inner ankle with SNS [sterile normal saline] and pat dry with gauze sponges. Using a sterile cotton tipped applicator apply thin layer of gentamicin ointment into wound bed, then using a sterile cotton tipped applicator apply nickel sized about [sic] of santyl into wound bed, cover 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 and interview, it was determined the facility failed to ensure call lights in resident rooms and bathrooms were functional for six (#2, #18, #25, #32, #42, and #51) of the 24 residents whose call lights were checked. This had the potential to affect all 53 residents who resided in the facility. Findings: On 01/08/20 at 10:44 a.m., the call light in room [ROOM NUMBER] for resident #32 was observed. The call light in the room was not in working order. The resident was asked about the call light. She stated it had stopped working the night before. She was asked what she would do if she needed help. She stated she could get up and she would yell for help. At 11:03 a.m., the call light in room [ROOM NUMBER] for resident #2 was observed. The call light in both the room and bathroom were not working. The resident was asked what she would do if she needed help. She stated she would yell for help. At 11:20 a.m., the call light in room [ROOM NUMBER] for resident #25 was observed. The call light in…

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