San Antonio Wellness & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for two of six residents (Resident #1 and Resident #2) reviewed for medical records accuracy. 1. The facility failed to ensure Resident #1's orders for facility admission and for secure unit admission were reflected in the active orders. 2. The facility failed to ensure Resident #2's orders for facility admission and for secure unit admission were reflected in the active orders. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.Findings included: 1. Record review of Resident #1's admission Record, dated 09/10/2025, revealed a [AGE] year-old female admitted on [DATE]. Resident #1 was listed as her own responsible party with [family member] listed as financial Power of Attorney and Emergency Contact #1. Record 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 interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 6 residents (Residents #12, and #18) reviewed for freedom from abuse and misappropriation.1. The facility failed to report the incident of misappropriation on 5.2.25 for Resident # 12 missing a gold diamond necklace. 2. The facility failed to report the incident of alleged abuse on 05/01/2025 for Resident #18.These failures could put the residents at risk of abuse, allegations of abuse not being…

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 interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 8 residents (Resident #18) reviewed for abuse and neglect. The facility did not investigate an incident in which Resident #18 made a grievance that a staff member was rough with her and did not stop perineal care when requested. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included:Record review of Resident #18's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old resident with an initial admission date of 12/16/2023 and diagnoses including Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Depression, and morbid obesity. Record review of Resident #18's Comprehensive Person-Centered Care Plan, dated printed 07/01/2025, reflected Resident #18, consistently denies…

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 interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #15) reviewed for care plan revisions.The facility failed to ensure Resident #15's care plan was comprehensive and updated to reflect Resident #15 had an incident of resident-to-resident aggression. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #15's face sheet dated 07/02/2025 revealed an [AGE] year-old admitted to the facility on [DATE] with diagnoses that included unspecified dementia (group of thinking and social symptoms that interferes with daily functioning), anxiety disorder, and personal history of covid-19. Record review of Resident #15's most recent admission MDS assessment dated…

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

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 3 patios reviewed for entrapment and lack of supervision. 1. The secured enclosed patio by the 100-300 hall dining room was accessed by a door that would allow residents, staff, and the public to exit to the secured enclosed patio but would lock behind anyone and would prevent access back into the dining room. 2. The secured enclosed patio by the 400-600 hall dining room was accessed by a door that would allow residents, staff, and the public to exit to the secured enclosed patio but would lock behind anyone and would prevent access back into the dining room. This failure could place residents, staff, and the public at risk for entrapment. The findings included: During an observation of the facility during initial rounds on 11/05/2024 from 09:00 to 06:00 PM revealed 3 secured patios. One enclosed secured patio was located by the 100-300 hall dining…

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, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 11/07/2024 at 12:08 p.m. revealed the DA carried a bag of hamburger buns from the pantry, placed them on the counter, after she placed the bag down, pulled back plastic wrap from a sandwich on a plate reached up, grabbed a knife by the blade from the magnetic knife holder on the wall, cut the sandwich in half and then placed the plastic wrap back over the sandwich. The DA did not stop to remove gloves and wash her hands or change gloves. Observation on 11/07/2024 at 12:12 p.m. revealed the DA while wearing gloves she went into the pantry, brought back a loaf of bread, opened the bread removed the bread from the bag placed it on 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 observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 Residents (Resident #48) reviewed for dignity. CNA F walked into Resident #48's room without knocking and while Surveyor and Resident #48 were having a discussion about his medical concerns. This deficient practice could affect any resident and contribute to residents feeling like their feelings, privacy or dignity does not matter. The findings were: Record review of Resident #48's face sheet, dated 11/8/24, revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus with Diabetic Neuropathy and Major Depressive Disorder, recurrent, moderate, Record Review of Resident #48's annual MDS, dated [DATE] revealed his BIMS was 14 reflecting minimal cognitive impairment, he did not have…

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, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 8 residents (Resident #4) reviewed for grievances. The facility failed to create a greience for Resident #4 who made a grievance to LVN D, LVN C, CNA A, and The BOM alleging she did not receive medications on Sunday 10/27/2024. This failure could place residents at risk for not having their grievances heard and or resolved. The findings included: A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was an [AGE] year-old female admitte d on 09/19/2022 for long term…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #16) reviewed for mechanical soft diet needs. 1. The facility failed to follow the physicians' orders and the Speech Language Pathologist's (SLP) recommendations for Resident #16's mechanical soft diet and served Resident #16 potato chips on 11/05/2024 for lunch. 2. The facility failed to follow the physicians' orders and the Speech Language Pathologist's (SLP) recommendations for Resident #16's mechanical soft diet and served Resident #16 potato chips on 11/05/2024 for dinner. This failure could place residents at risk for harm by aspiration of food into the lungs due to swallowing difficulties. The findings included: A record review of Resident #16's admission record dated 11/05/2024, revealed an admission date of 09/04/2024 with diagnoses which included dysphagia oropharyngeal phase…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 resident (Resident #1) reviewed for infection control, in that: The facility failed to ensure LVN A changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided incontinent care to Resident #1. This deficient practice could place residents at risk for infection due to improper care practices. The findings included: Record review of Resident #1's face sheet dated 10/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cognitive communication deficit, profound intellectual disabilities, and benign prostatic hyperplasia without lower urinary tract symptoms. Record 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 observation, interview and record review the facility failed to ensure they assisted residents in obtaining routine dental care for 1 of 5 Resident (Resident #2) whose records were review for dental services. Nursing staff failed to refer Resident #2 for dental services since her admission; for 6 months. This deficient practice could affect residents in need of dental services and result in the development of infections and a decline in physical condition The findings were: Review of Resident #2's face sheet, dated 1/16/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Cognitive Communication Deficit. Review of Resident #2's annual MDS assessment, dated 12/22/23, revealed her BIMS score was severely cognitively impaired and she was dependent for oral care. Review of Resident #2's Care Plan, revised on 12/20/23 revealed she had a communication problem and one of the interventions was to anticipate needs. Further review revealed Resident #2 had a self-care ADL…

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 interview and record review the facility failed to ensure in response to allegations of abuse, were reported immediately, but not later than 2 hours after the allegation was made, when the events that caused the allegation involved abuse for 1 of 5 Residents (Resident #1) whose records were reviewed for abuse. CNA A reported to nursing staff that CNA B slapped Resident #1 on the right upper thigh. Nursing staff failed to follow the chain of command and report it to the ADM right away which delayed the ADM in reporting the allegation of abuse to the State Survey Agency within 2 hours. This deficient practice could affect any resident and contribute to further resident abuse. The findings were: Review of Resident #1's face sheet, dated 1/16/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Personal History of (healed) traumatic fracture. Review of Resident #1's quarterly MDS assessment, dated 12/12/23 with a BIMS score of 2 reflective of severe cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good oral hygiene for 1 of 5 Residents (Resident #2) whose records were reviewed for adl care. Nursing staff failed to clean Resident #2's lips and brush her teeth after breakfast. This deficient practice could affect dependent residents and contribute to poor oral hygiene, tooth decay, infections and decline in physical condition The findings were: Review of Resident #2's face sheet, dated 1/16/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia and Cognitive Communication Deficit. Review of Resident #2's annual MDS assessment, dated 12/22/23, revealed her BIMS score was severely cognitively impaired and she was dependent for oral care. Review of Resident #2's Care Plan, revised on 12/20/23 revealed she had a communication problem and one of the interventions was to anticipate needs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 4 resident (Residents #3 and #20) reviewed for incontinent care, in that: 1. While providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin. 2. While providing incontinent care for Resident #20, CNA G used a back to front motion to clean Resident #'s buttocks. CNA G did not clean Resident #20's anal area. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1. Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia (decline in cognitive abilities), Anxiety (A group 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 observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skillss and techniques to provide nursing and related services for 2 of 4 residents (Residents #3 and #20) by 2 of 4 certified staff (CNA G and CNA H) reviewed for competent staff, in that: 1. While providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin. 2. While providing incontinent care for Resident #20, CNA G used a back to front motion to clean Resident #'s buttocks. CNA G did not clean Resident #20's anal area. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection. The findings included: 1. Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #3) reviewed for infection control, in that: While providing incontinent care for Resident #3, CNA H touched the fall matt on the floor with her bare hands and did not wash her hands before putting her gloves on and starting providing care. CNA H did not change gloves and sanitize or wash her hands before touching Resident #3's clean brief. These failures could place residents at-risk for infection due to improper care practices. The findings include: Record review of Resident #3's face sheet, dated 01/16/2024, revealed an admission date of 05/04/2021, and a readmission date of 12/03/2023, with diagnoses which included: Hemiplegia (Paralysis of one side of the body),Dementia (decline in cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 4 of 12 residents (Resident #4, #5, #10, and #11) reviewed for pharmacy services in that: 1. The facility did not ensure LVN C did not administer Resident #4's medicated eye drops Brimonidine Tartrate-Timolol [a medication used to treat high fluid pressure in the eye] and Dorzolamide HCl-Timolol [a medication used to treat high fluid pressure in the eye] 5 minutes apart, as per physician's orders. 2. The facility did not ensure LVN C did not administer Resident #5's complete morning dose of furosemide [a medication used to reduce extra fluid in the body caused by conditions such as heart failure, liver disease, and kidney disease]. 3. The facility did not ensure Resident #10 and Resident #11 received their 8:00 a.m. medications within 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, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 12 residents (Resident #5) reviewed for storage of drugs, in that: While preparing Resident #5's morning medications, LVN C left 1 of Resident #5's furosemide pill unattended and unsecured on top of her medication cart. This deficient practice could place residents at risk of medication misuse and diversion. The findings were: Record review of Resident #5's face sheet, dated 12/1/23, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of cellulitis [inflammation of the skin] of left lower limb, unspecified protein-calorie malnutrition, muscle weakness (generalized), heart failure, unspecified, and peripheral vascular disease [a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #1) of 3 residents reviewed for accurate medical records in that: LVN A initialed off on Resident #1's MAR indicating she had provided the medication when she had not provided the medication. This deficient practice could result in misinformation about professional care provided. The findings included: Record review of Resident #1's electronic face sheet dated 01/09/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bimalleolar fracture of right lower leg (type of ankle fracture), hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet the body's needs), and cardiomyopathy (disease of heart that causes the heart muscle to lose ability to pump blood). Record review of Resident #1's care plan dated 01/09/2024 reflected Focus .Pain and Discomfort .Interventions .Pain medication as ordered. Record…

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

Based on observations and interviews, the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable and for 3 (200 Hall, 300 Hall and 600 Hall) of 6 medication carts in that: 1. The facility failed to ensure expired medications were not found on the 200 Hall and 300 Hall medication carts. 2. The facility failed to ensure the nurse and medication aide medication carts for 600 Hall were not left unattended and unlocked. These deficient practices affect residents who receive medications and could result in less potent or adverse effects and drug diversion. The findings included: 1. Observation on 10/06/2023 at 11:17 a.m. of medications in Hall 300 medication cart revealed a bottle of Retaire PM lubricant eye ointment for dry eyes with an expiration date of 02/2023. Interview on 10/06/2023 at 11:20 a.m. with MA E, revealed a new resident came in and he brought his own…

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, the facility failed to ensure that the menu was followed for 1 of 1 meal observed in that: 1. The facility failed to ensure all residents received [NAME] Peas with Sauteed Onions with their lunch meal on 10/03/2023. 2. The facility failed to ensure [NAME] Peas with Sauteed Onions was prepared by the recipe. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life. The findings were: Record review of the facility's Day 10 menu for Tuesday 10/03/23 lunch meal revealed Meatloaf with Tomato Sauce, Scalloped Potatoes, [NAME] Peas with Sauteed Onions, Bread Slice/Margarine, Chocolate Pudding, Beverage of Choice, Water were to be served. Record review on 10/03/2023 at 12:32 p.m. revealed a daily menu board in the dining room that listed Meatloaf with Tomato Sauce, Scalloped Potatoes, [NAME] Peas with Sauteed Onions, Bread Slice/Margarine, Chocolate Pudding, Beverage of Choice, Water for the lunch meal. The menu revealed no indication that [NAME] Peas without Sauteed Onions were to be…

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, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food nutrition services, in that: 1. The facility failed to ensure [NAME] Y's hairnet was covering his mustache while preparing for lunch. 2. The facility failed to ensure that staff didn't wear facial jewelry while preparing foods. 3. The facility failed to maintain the cleanliness of the ice machine found within the kitchen. These failures could place residents at risk for food contamination and foodborne illnesses. The findings included: 1. Observation on 10/03/23 at 11:03 a.m. revealed [NAME] Y standing by the stove preparing lunch without his mustache covered by a hairnet. During an interview and observation on 10/03/23 beginning at 11:14 a.m., Director of Nursing Services (DNS) told [NAME] Y to cover his mustache and DNS revealed that [NAME] Y's hairnet that covered his mustache and beard sometimes fell down his face, exposing his mustache, because the hair net is…

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

Based on interview and record review, the facility failed to provide effective communications mandatory training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure effective communication training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings were completed. The HR…

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

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel…

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 interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send…

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

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be completed and the DON would ensure trainings 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.

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings included: Review of Facility Staff Roster, undated, revealed: MA L - date of hire - 10/03/2022 CNA M - date of hire - 08/16/2018 CNA N - date of hire - 09/23/2022 CNA Q - date of hire - 08/16/2022 CNA R - date of hire - 07/26/2019 CNA B - date of hire - 12/13/2019 ADON W - date of hire - 07/10/2020 ADON X - date of hire - 05/15/2019 During a record review and interview with the HR Personnel on 10/06/2023 at 8:15 p.m., the HR Personnel revealed each month the corporate office would send down which trainings staff were to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to promote resident self-determination through support of family choice for 1 of 8 residents (Resident #56) reviewed for resident rights. The facility did not follow Resident #56's and the family's request to not have resident be tube fed. This failure could place residents at risk for feelings of depression, lack self-determination and decreased quality of life. The findings included: Record review of Resident #56's electronic face sheet dated 10/05/23 revealed Resident #56 was initially admitted on [DATE] and was re-admitted [DATE]. His diagnoses included unspecified dementia, expressive language disorder, aphasia(loss of ability to understand or express speech), dysphagia(impairment in the production of speech), and unspecified protein-calorie malnutrition. Record review of Resident #56's quarterly MDS assessment, dated 09/21/23, revealed that BIMS should not be conducted and staff assessment for mental status was that resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to accurately reflect the resident's status on the quarterly MDS for one (Resident #25) of 8 residents reviewed for MDS assessments in that: The facility failed to properly code Resident #25's quarterly MDS assessment a 3 for always incontinent instead of 9 for not rated since he had an indwelling urinary catheter. This deficient practice could result in missed or inaccurate care. The findings included: Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage), and neuromuscular dysfunction of bladder (nerves and muscles do not work together well and may result in the bladder not filling or emptying correctly). Record 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 interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #95) out of 16 residents reviewed for care plans in that: The facility failed to ensure Resident #95 had a baseline care plan created within 48 hours when she was readmitted to the facility from the hospital. This deficient practice affects residents who are readmitted or new admissions and could result in decreased quality of care. The findings included: Record review of Resident #95's electronic face sheet dated 10/06/2023 reflected she was initially admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. Her diagnoses included: cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain), vascular dementia (problems with reasoning, planning, judgment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #56) reviewed for care plans, in that: The facility failed to implement Resident #56's comprehensive person-centered care plan to address ADL self-care of eating. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record 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 interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 2 (Resident #74 and #101) out of 16 residents reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #74's comprehensive care plan Interventions/Tasks were revised to reflect interventions taken after falls have occurred. 2. The facility failed to ensure Resident #101's comprehensive care plan was revised within the required timeframe. These failures could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care. The findings included: 1. Record review of Resident #74's electronic face sheet dated 10/06/23 reflected he was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included muscle wasting and atrophy, difficulty in walking, unspecified lack of coordination, other mechanical complication of surgically created age-related osteoporosis (a medical condition 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 observations, interviews and record reviews, the facility failed to ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #25) of 4 residents reviewed for pressure sore prevention and management in that: The facility failed to ensure Resident #25's heel protectors were on his feet during the 3 days of observations. This deficient practice affects residents at risk for skin breakdown and could result in pressure sores. The findings included: Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion and lacerations), hemiplegia (one sided paralysis), aphasia (loss of ability to understand or express speech, caused by brain damage),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 ( Resident #25) out of 3 residents reviewed for indwelling urinary catheters in that: The facility failed to ensure Resident #25 had a leg strap to secure his indwelling urinary catheter tubing. The facility failed to ensure C NA B did not lift Resident #25's urinary catheter bag and tubing with urine in it above the resident's bladder when he assisted with incontinent care for the resident. This deficient practice affects residents with indwelling urinary catheters and could result in urinary tract infections and trauma to the stoma site. The findings included: Record review of Resident #25's electronic face sheet dated 10/04/2023 reflected he was initially admitted to the facility on [DATE]. His diagnoses included: unspecified focal traumatic brain injury (localized damage and includes contusion 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 observations, interviews, and record reviews, the facility failed to ensure nurse aides can demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for 2 residents (#25 and #92) of 2 residents observed for incontinent care and catheter care in that: 1. The facility faled to ensure C NA A did not wipe Resident #25's catheter tubing toward the site and not away to prevent contamination and C NA B raised the urinary drainage bag above the resident's bladder twice when turning him side to side. 2. The facility failed to ensure CNA B did not raide Resident #25's urinary drainage bag above the resident's bladder twice when turning him side to side. 3. The facility failed to ensure C NA A wiped Resident #92 thouroughly cleaned the Resident's perineal area and then turned the resident over and cleaned her anal area from back to front once when she performed incontinent care. These deficient practices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to keep information that is resident-identifiable from the public for one Hallway (600) of 6 hallways observed and failed to maintain medical records in accordance with professional standards and practices for 1 resident (#25) out of 8 resident records reviewed in that: 1. The facility failed to prevent RN G from having identifiable resident information on top of her medication cart unattended. 2. The facility failed to ensure Resident #25's heel protectors were not initialed on his nursing MAR and that were never applied to his feet. These deficient practices could affect all residents whose records are maintained by the facility and could place them at risk for violation of privacy and errors in care and treatment. The findings included: 1. Observation on 10/05/2023 at 5:12 p.m. of the 600 Hall medication cart, sitting in the hallway outside of the nurse's station, unattended, revealed a printed list of resident's names by room number,…

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, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 ( Residents #228 and #244) of 7 residents observed for infection control in that: 1. The facility failed to ensure MA I did not pull plastic drinking cups from the side of her cart by sticking her finger in one pulling it apart from the others. MA I stacked up her medication cups with medications in them and carried them with her fingers around the rims when she brought them in to Resident #228. 2. The facility failed to ensure RN G did not contaminated the medication cup by placing her finger in the medication cup with medications prior to giving them to Resident #244. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting pathogens that could lead to infection. The findings included: 1. In an observation during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #1) reviewed for infection control in that: During Resident #1's incontinent care, CNA A did not perform hand hygiene between glove changes. This deficient practice could affect residents who require incontinent care and place them at risk for infection. The findings were: Record review of Resident #1's face sheet, dated 9/20/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of other sequelae [a condition following a previous disease or injury] of cerebral infarction [a disruption in the brain's blood flow], unspecified protein-calorie malnutrition, unspecified dementia [a general term for impaired ability to remember, think, or make decisions], unspecified severity,…

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 the facility failed to post nurse staffing information to include the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides per shift and the resident census on a daily basis for one of two days (08/21/2023) reviewed for nurse staffing information. The facility did not post the required current nurse staffing information on 08/21/2023. This failure could place residents at risk of not having access to information regarding staffing data and the facility census. Findings include: Observation on 08/21/2023 at 03:37 p.m., revealed a document labeled Daily Associates Posting dated 08/18/2023, was posted on a wall next to the facility receptionist's desk and above the electronic sign-in machine. During an interview on 08/21/2023 at 06:58 p.m., the ADMIN stated the posted nurse staffing document was dated 08/18/2023. The ADMIN revealed she was unaware if the nurse staffing information was posted in another location at the facility.…

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, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys on for 1 medication cart (500-hall Medication Cart) of 6 medication carts (500-hall Medication Cart) reviewed for medication storage. The facility failed to ensure the medication cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings include: Observation on 08/21/2023 at 05:25 p.m. revealed an unlocked medication cart on 500-hall, with the lock not pushed in and no facility staff standing next to the cart. Multiple medication drawers were unsecured which contained multi-patient bottles which included over the counter bottles and prescription pill packs. The drawer with controlled substances was found to be accessible but controlled substances were in a separate internal, locked…

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.