Concordia Lutheran Health And Human Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical records, observations, and staff interviews, it was determined that the facility failed to properly monitor resident's personal refrigerators to ensure that food is properly stored and maintained for two of two residents (Residents R5 and R143), and failed to ensure enhanced barrier precautions (EBP) were implemented for two of three residents (Resident R10 and R40). Findings include: Review of facility policy Enhanced Barrier Precautions dated 1/3/25, indicated the facility will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions may be implemented for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. During an observation on 8/4/25, at 10:50 a.m. Resident R5 had a small personal refrigerator in their room. The temperature log had data recorded for 8/1/25, but no…

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 facility policy, clinical record review and staff interview, it was determined that the facility failed to complete Influenza vaccination consent and administer the Influenza vaccination in a timely manner for one of five residents (Resident R3).Findings include: Review of facility policy Infection Prevention and Control Program dated 4/28/25, indicated all residents and employees will be offered the influenza vaccine. Between October 1st and March 31st each year, the influenza vaccine shall be offered. The resident or employee will be provided information and education regarding the benefits and potential side effects. Education shall be documented in the residents or employee's medical record. Review of the admission record indicated that Resident R3 was admitted to the facility on [DATE]. Review of R3's Minimum Data Set (MDS-periodic assessment of care needs) dated 1/7/25, included diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and atrial fibrillation (disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen. Findings include: Review of the facility policy Date Marking for Food Safety dated 1/16/24, indicated the facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. During an observation of the main designated kitchen on 8/25/24 at 10:00 a.m, at the following was observed: - 1 bag of life cereal- no label or date - 2 boxes of pineapple juice- no dates - 1 bag of elbow pasta-no date - 2 boxes of [NAME] Buddy-no date - 1 box of Oatmeal Cream Pie- no date - 1 box of Fudge Rounds-no date Walk in Freezer-(1) bag of meat- no label or date Walk in cooler-(3)crates of drinks, stored on the floor During an observation of the main designated kitchen on 8/25/24, at 10:15…

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, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for three of six residents (Residents R24, R77, and R281). Findings include: Review of the facility policy Resident Self-Administration of Medication dated 1/16/24, indicated it is the policy of the facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The care plan must reflect resident self-administration. Review of the admission record indicated Resident R77 was admitted to the facility on [DATE]. Review of Resident R77's Minimum Data Set (MDS- a periodic assessment of care needs) dated 7/18/24, indicated the diagnoses of renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), atrial fibrillation (irregular heart rhythm), and high blood…

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 review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that appropriate treatment and services were provided for five of seven residents with a urinary catheter (a hollow, flexible tube that collects urine from the bladder and leads to a drainage bag) (Resident R38, R63, R78, R93 and R99). Findings include: Review of facility policy Indwelling Catheter Use and Removal dated 1/16/24, indicated if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards and practice of resident care policies and procedures that include but are not limited to: . Keeping the catheter anchored to prevent excessive tension on the catheter. . Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. Review of Resident R38's clinical record indicate re-admission to facility on…

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

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of seven residents to accurately reflect the current status of the resident (Resident R54 and R86). Findings include: A review of the facility policy Care Plan Revision Upon Status Change dated 1/16/24, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Review of Residents R54's clinical record indicates an admission date of 6/15/23. Review of Resident R54's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/28/24, indicated diagnosis of hypertension (high blood pressure), coronary artery disease (common type of heart disease) and diabetes (high sugar in the blood). Review of Resident R54's physician orders dated 7/17/23, indicate tubigrips bilateral lower extremities on in the a.m. off in the p.m. Review of Resident R54's Treatment administered record for August 2024 indicate tubigrips applied as ordered. Review of Resident R54's care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility procedure review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care of a medical device for one of four residents (Resident R283). Findings include: Review of the facility procedure Closed Suction Drain with Bulb: Management dated 1/16/24, indicated to assess the closed suction drain and tube for proper functioning. Ensure patency, airtight connections, and presence of any leaks or kinks in the drainage system. Secure the drain to the patient's clothing with a safety pin. Ensure the suction device is below the level of the wound and does not pull at the insertion site. Review of the clinical record indicated Resident R283 admitted to the facility on [DATE], with the diagnoses of rib fractures, atrial fibrillation (irregular heart rhythm), heart failure (heart doesn ' t pump blood as well as it should), s/p cholecystitis with possible perforation (gallbladder…

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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and obtain physician orders regarding the dressing displacement for one of three residents (Resident R100). Findings include: Review of the facility policy Negative Pressure Wound Therapy (NPWT-wound vac- used to draw out fluid and infection from a wound to help it heal) dated 1/16/24, indicated to avoid leaving the NPWT device off for more than two hours. If this occurs, remove the old dressing and initiate an NPWT dressing or apply an alternative absorptive dressing as prescribed by the practitioner. Review of the clinical record indicated Resident R100 admitted to the facility on [DATE], with the diagnosis of sepsis (extreme response to an infection), depression, and pressure ulcer of the sacral region (a triangular bone that connects the spine with the hip and pelvic cavity. 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain sanitary conditions of respiratory equipment for two of eight residents reviewed (Residents R38 and R281), and failed to care plan use and management of respiratory equipment for two of three residents (Resident R5 and R6). Findings include: Review of facility policy Oxygen Concentrator dated 1/16/24, indicated that oxygen is administered under orders of the attending physician, except in the case of an emergency. Review of Resident R5's clinical record indicated admission to the facility on 3/14/24, with the diagnoses of heart failure (heart doesn't pump blood as well as it should), Parkinson's Disease (disorder of the nervous system that results in tremors), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Review of Resident R5's physician orders dated 5/11/24, indicated: -Change CPAP/BIPAP (a continuous positive airway…

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

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician and failed to notify the physician of missed medications for one of four residents (Residents R335). Findings include: Review of the facility policy Unavailable Medications dated 1/16/24 indicated the facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed (PRN), and emergency medications. A supply of commonly used medications is maintained in house for timely initiation of medications. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable, notify physician of inability to obtain medication upon notification or awareness that the medication is unavailable. Obtain alternative treatment orders and/or specific order for monitoring resident while medication is on hold. Review of the clinical record indicated Resident R335 was a new admission to the facility on…

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to properly store medical supplies and biologicals in one of four medication rooms (Blankenbuehler medication room). Findings include: A review of the facility policy Medication Storage in the Facility last reviewed 1/16/24, indicates medications are to be stored safely, securely, and properly. A review of the facility policy Date Marking for Food Safety last reviewed 1/16/24, indicates the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. During an observation on 8/26/24, at 11:08 a.m. of the Blankenbuehler Medication Room the following was observed under the sink: . One container of Micro-kill bleach wipes . One gallon of distilled water During an observation on 8/26/24, at 11:08 a.m. of the Blankenbuehler Medication Room, the following was observed in the resident pantry refrigerator: . One opened bag of cheddar cheese cubes, not marked with date/time opened. . Two box of AA batteries .…

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 facility policy, Centers for Disease Control (CDC) documents, clinical record review, observation, and staff interview, it was determined that the facility failed to follow enhanced barrier precautions for one of two residents with an enteral feeding (Resident R96), and failed to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R93). Findings include: Review of the facility policy Enhanced Barrier Precautions (EBP) dated 1/16/24, indicated EBP - conditions to address with precautions includes wounds, indwelling medical devices (central lines, dialysis catheters feeding tubes, and tracheostomy/ventilator tubes), even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO). Gowns and gloves are to be worn during high contact activities such as device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Review of the CDC's Frequently asked Questions about Enhanced…

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 job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents requiring adequate supervision to prevent elopement. Findings include: Review of CFR 483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Based on the findings in this report that identified that the facility failed to maintain necessary supervision to prevent elopement which resulted in one resident being found at the bottom of ten stairs in a wheelchair after elopement and placed seven other residents in an Immediate Jeopardy. Facility failed to provide fundamental principal that applies to treatment and care provided to facility residents. The facility failed to ensure that residents receive treatment and care in accordance with…

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

Based on facility policy, observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the dish room which created the potential for cross contamination. (Main Kitchen) Findings include: Review of facility policy Sanitation Inspection dated 1/6/23, indicated all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. During an observation of dish room on 10/18/23, at 1:15 p.m. it was revealed area above clean side of dish machine area had a build up of a black substance, dirt and grime in the main kitchen. During an interview on 10/18/23, at 1:30 p.m. the Corporate Food Service Employee E7 confirmed the brown substance in dish room and it has not been confirming the potential for cross contamination and food borne illness. 28 Pa Code: 201.14(a) Responsibility of licensee.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of two residents reviewed (Residents R134 and R136). Findings include: Review of Resident R134's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 9/25/23, indicated the resident was admitted to the facility on [DATE]. It was indicated the resident was discharged on 9/25/23, to the hospital. Review of Resident R134's progress note dated 9/25/23, indicated the resident was discharged to a personal care home. Review of Resident R136's MDS dated [DATE], indicated the resident was admitted to the facility on [DATE]. It was indicated the resident was discharged on 8/7/23, to the community. Review of Resident R136's progress note dated 8/7/23, indicated the resident sent to the emergency room. It was stated it was unclear if he will be discharged home from there our back to the facility. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, resident observations, clinical record review and staff interviews, it was determined that the facility failed to develop a plan of care to include a focus and interventions to for a resident's tube feed in order to maintain a resident's highest practicable physical well-being as required for one of six residents reviewed. (Resident R114) Findings include: Review of Resident R114's Minimum Data Set (MDS-periodic assessment of care needs) dated 9/26/23 indicated Resident R144 was admitted to the facility on [DATE] with diagnosis of malnutrition, dysphagia (difficulty swallowing), and high blood pressure. Review of Resident R114's physician order dated 9/15/23, indicated to check tube placement prior to medication, feedings, and flushes and document the amount of formula and water provided every eight hours. Review of Resident R114's physician order dated 10/5/23, indicated to administer Osmolite 1.2 (a type of tube feeding supplement) via jejunostomy tube (J-tube is a soft,…

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 review of facility policy, clinical records and staff interview, it was determined that the facility failed to follow a order as prescribed by the physician for one of four residents (Resident R66). Findings include: A review of the facility policy, Consulting Physician/Practitioner Orders dated 10/17/22, last reviewed 1/6/23, indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order, document the verification order by entering the order and the time, date, and signature in the electronic health record, and follow facility procedures for verbal or telephone orders including, nothing the order, submitting to pharmacy, and transcribing medication or treatment admiration record. A review of the clinical record indicated Resident R66 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infraction, muscle weakness and dysphagia. A 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 review of facility policy and the clinical record and interview with staff, it was determined that the facility failed to provide care and treatment as ordered for two of four residents with foley catheters reviewed (Resident R66, R106). Findings include: A review of the facility policy, Consulting Physician/Practitioner Orders dated 10/17/22, last reviewed 1/6/23, indicated for consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will call the attending physician to verify the order, document the verification order by entering the order and the time, date, and signature in the electronic health record, and follow facility procedures for verbal or telephone orders including, nothing the order, submitting to pharmacy, and transcribing medication or treatment admiration record. A review of the facility policy, Indwelling Catheter Use and Removal dated 10/17/22, last reviewed 1/6/23, indicated it is the policy of the facility to ensure that indwelling…

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 personnel files and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of five Employees reviewed (Nurse Aide, Employee E5). Findings Include: Review of Nurse Aide (NA), Employee E5 personnel file indicated he was hired on 5/15/23, as a non-certified nursing assistant. Review of NA, Employee E5's personnel file indicated he completed the Nurse Aide Training program on 6/8/23. A further review indicated NA, Employee E5 failed the Nurse Aide Written exam on 10/5/23. Review of the facility Deployment Sheets dated 10/7/23, indicated NA, Employee E5 worked 2:00 p.m. until 10:30 p.m. Review of the facility Deployment Sheets dated 10/10/23, indicated NA, Employee E5 worked 10:00 p.m. until 6:30 a.m. Review of the facility Deployment Sheets dated 10/11/23, indicated NA, Employee E5 worked 10:00 p.m. until 2:00 a.m. During an interview on 10/20/23, at 9:01 a.m., the Nursing Home Administrator (NHA) stated NA, Employee E5 had until 10/6/23, 120 days from…

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

Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for two out of five personnel files (Nurse Aide Employee E2 and E3). Findings include: Review of Nurse aide, Employee E2's personnel record indicated she was hired on 1/1/16. Review of Nurse aide, Employee E2's personnel record indicated an annual performance evaluation for the year 2022, was completed on 5/2/22. A further review of Nurse aide, Employee E2's personnel record indicated the facility failed to complete a performance evaluation within 12 months. Nurse aide, Employee E2 performance evaluation for the year 2023, was completed on 9/1/23. Review of Nurse aide Employee E3 personnel record indicated she was hired on 10/24/94. Review of Nurse aide, Employee E3's personnel record indicated an annual performance evaluation for the year 2022, was completed on 6/5/22. A further review of Nurse aide, Employee E3's personnel record indicated the facility failed to complete a performance evaluation within 12 months. Review of…

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

Based on review of facility policy, personnel files and staff interview it was determined that the facility failed to ensure the minimum 12 hours of nurse aide training per year and annual training on dementia management for one out of five nurse aide personnel files were completed (Nurse aide, Employee E4). Findings include: The facility Nurse Aide job description last reviewed 1/6/23, indicated that the nurse aide provides each assigned resident with routine individualized nursing care in accordance with state and federal regulations, and accreditation standards. Review of Nurse Aide, Employee E4's personnel record indicated he was hired on 8/15/11. Review of Nurse Aide, Employee E4's personnel record did not include an annual in-service training on dementia and abuse prevention training. A further reviewed of Nurse Aide, Employee E4's personnel record failed to include a minimum of 12 hours of nurse aide training per year as required under §483.95(g)(1). During an interview on 10/20/23, at 11:51 a.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to…

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