Colonial Pines Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 3 of 3 (Residents #4, Resident #13, and Resident #22) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Resident #4, Resident #13 and Resident #22. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes. Findings included: Record review of face sheet dated 10/29/24 for Resident #4 indicated she admitted to the facility on [DATE] and was a [AGE] year-old female with diagnoses of cerebral infarction (disrupted blood flow to the brain), dementia unspecified (decline in cognitive abilities), dysphagia (difficulty swallowing). Record review of quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 2 dining rooms (400 hall Dining Room), 1 of 4 halls (400 hall) and 1 of 6 (Resident #33) residents reviewed for environment. The facility failed to ensure that the 400-hall dining room and floors and walls were clean and maintained in good repair on 10/27/24. The facility failed to ensure the 400 hall walls and floors were maintained in good repair on 10/27/24. The facility failed to ensure Resident #33's box fan was free of dust and debris on 10/27/24. These failures could affect residents and the staff by placing them at risk for diminished quality of life and injury due to lack of a sanitary and well-kept environment. Findings: 1.During an observation on 10/27/24 at 9:09 am revealed the dining room floors located on hall 400 were dirty with a sticky substance and dark colored grime. There was a dark, black, thick buildup around the edges of all the walls. The…

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

Based on interviews, and record reviews, the facility failed provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 out of 8 dietary staff. The facility did not ensure Dietary Aide H had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies. Findings included : During an observation of the kitchen on 10/27/24 at 9:30 a.m. revealed Dietary Aide H was working in the kitchen as a dietary aide. Review of the food handler's certificates of completion provided by the facility on 10/28/2024, revealed Dietary Aide H did not have a food handler's certificate. An attempted telephone interview on 10/28/2024 at 2:25 p.m. with Dietary Aide H was unsuccessful. During an interview on 10/29/2024 at 9:42 a.m., the Dietary Manager said she was responsible for ensuring staff completed their food handler certification training upon hire and every 2 years. The Dietary Manager said she was unsure why Dietary Aide H had not…

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 review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerator were not kept past their expiration dates. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the cooler/refrigerator on 10/27/2024 at 9:30am, the following items were observed: (2) 32-ounce containers of vanilla Greek yogurt with the expiration date on 10/22/24. During an interview on 10/29/24 at 9:05 a.m. [NAME] E said it was everyone's responsibility to check for expired foods in the fridge. He said they threw away expired foods. He said the Dietary Manager check ed for expired foods in the separate storage area. He said he had checked the refrigerator Thursday 10/24/24 for expired food and did not see the expired food. He said he did not have time to look at every…

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 maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. One of six gas stove burners (right back) did not light automatically, when the knob was turned, and all 6 burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings include: During an observation on 10/27/24 at 9:30 a.m., revealed the gas stove had six burners and one burner located in the right back had excess carbon buildup. The right back burner would not light automatically. During an interview on 10/27/24 09:30 a.m. [NAME] F said that the burner would not light last week. She said the Maintenance Director fixed the oven about 1-2 months ago and the burner had been working up until last week. During an interview on 10/29/24 at 8:25 a.m., the Maintenance Director said he had worked at the facility for 6-7 years. He said no one had…

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

Based on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for the 1 of 1 facility . The facility failed to ensure the staff were smoking in the designated smoking area and disposing of smoking materials properly on 10/27/24. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings: During an observation on 10/27/24 at 9:40 AM revealed cigarette butts were observed in a plastic cup on the ground outside the exit door located on 400 hall and there were four cigarette butts sitting on the outside keypad next to the door. During an interview on 10/27/24 at 9:42 AM LVN C said there were no residents that smoked on the 400 hall and the cigarette butts belonged to the staff. She said there was a smoking area out back and the area outside the exit door was not a designated area to smoke. She said if smoking occurred in undesignated areas there could be risk of fires. During an interview on 10/27/24 at 9:44 AM CNA D said she worked on 400…

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 each resident was treated with respect, dignity, and care for 1 of 2 Residents (Resident # 3) observed for care in that: The facility failed to ensure Resident #3's urinary drainage bag had a privacy cover on 10/22/2024. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect. Findings included: Record review of a Face Sheet for Resident #3 dated 10/22/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of intellectual disabilities (a condition that limits intelligence and disrupts the ability to live independently), anemia (low red blood cells that affect oxygen delivery to the body), and retention of urine (bladder not able to empty urine). Record review of a care plan for Resident #3 dated 9/18/2024 indicated he was at risk for problems with elimination related to retention of urine. He had a urinary…

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 incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 Resident's (Resident #3) reviewed for catheter and incontinence care. 1. The facility failed to ensure LVN A maintained the urine catheter drainage bag below Resident #3's bladder on 10/22/2024. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections. Findings included: Record review of a Face Sheet for Resident #3 dated 10/22/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of intellectual disabilities (a condition that limits intelligence and disrupts the ability to live independently), anemia (low red blood cells that affect oxygen delivery to the body), and retention of urine (bladder not able 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from verbal abuse for one of twelve residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent verbal abuse for Resident #1 witnessed by CNA A and CNA B to have been told to shut up and you are the one who shit on yourself by CNA C on 03/26/2024 at approximately 1:00 p.m. during incontinence care. The noncompliance was identified as PNC that began on 03/26/2024 and ended on 04/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse. Findings included: Review of a face sheet for Resident #1, dated 04/24/2024, revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: type 2 diabetes mellitus with hyperglycemia (high blood pressure), non-ketotic hyperglycinemia (metabolic accumulation of large amounts of glycine in blood, urine, 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 implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident to ensure residents were free from verbal abuse for one of twelve residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent verbal abuse for Resident #1 witnessed by CNA A and CNA B to have been told to shut up and you are the one who shit on yourself by CNA C on 03/26/2024 at approximately 1:00 p.m. during incontinence care. The noncompliance was identified as PNC that began on 03/26/2024 and ended on 04/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse. Findings included: Review of a face sheet for Resident #1, dated 04/24/2024, revealed he was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: type 2 diabetes mellitus with hyperglycemia (high blood pressure),…

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

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 in that: The facility failed to ensure opened items in the dry storage were labeled and dated correctly. The facility failed to ensure all food items were discarded by the expiration date. The facility failed to ensure there was soap at the handwashing sink. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: During an observation and interview on 9/5/23 beginning at 10:48 am it was observed that there was no soap at the handwashing sink. The DM said that she was not responsible for the soap, that it had been out about a day and that staff were washing hands in the dish sink using the hose that has hot water and soap mixed together. The ish sink observed with dirty dishes in it, there was a hose on the left side that had a button to push and hot water mixed with soap would come out of the hose while the button…

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 14 of 14 employees (Administrator, DON, ADON, DM, AD, LVN A, LVN B, LVN C, Rehab Director, CNA D, CNA E, MA F, CNA G, AND CNA H) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, ADON, DM, AD, LVN A, LVN B, LVN C, Rehab Director, CNA D, CNA E, MA F, CNA G, and CNA H. This failure could place staff and residents at risk for not being aware of facility programs, implementation and monitoring. Findings: Record review of personnel files indicated: the Administrator was hired 2/08/2023, the DON was hired 02/06/2023, the ADON was hired on 11/07/2022, DM was hired 6/02/2023, AD was hired 04/01/2010, LVN A was hired 9/14/2022, LVN B was hired on 5/30/2023, LVN C was hired 3/11/2019, Rehab Director was hired 12/01/2001, CNA D was hired 8/15/2019, CNA E was…

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

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 11 of 14 employees (Administrator, DON, ADON, DM, AD, LVN A, Rehab Director, CNA D, CNA E, CNA G, AND CNA H) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to the Administrator, DON, ADON, DM, AD, LVN A, Rehab Director, CNA D, CNA E, CNA G, AND CNA H. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. Findings: Record review of personnel file indicated: the Administrator was hired 2/08/2023, the DON was hired 02/06/2023, the ADON was hired on 11/07/2022, DM was hired 6/02/2023, AD was hired 04/01/2010, LVN A was hired 9/14/2022, Rehab Director was hired 12/01/2001, CNA D was hired 8/15/2019, CNA E was hired 5/30/2023, CNA G was 12/19/2022, AND CNA H was hired on 3/22/2022. Record review of training report indicated the Compliance and Ethics required training was not completed on hire for the Administrator, DON, ADON, DM, LVN A,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 16 residents (Resident #6) reviewed for resident rights. The facility failed to treat Resident #6 with respect and dignity when she had to ask staff where her food was three times while the other residents seated with her in the dining room were already eating. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety. Findings: Record review of facility face sheet dated 09/06/2023 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of cerebral infarction (stroke). Record review of quarterly MDS dated [DATE] revealed a BIMS of 12 indicating moderate cognitive impairment and required supervision and setup with eating. During an observation on 09/05/23 at 12:33 pm…

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 immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #43) reviewed for notification of changes in that: The facility did not notify Resident #43's physician (Physician M) for a significant change in weekly weight indicating a gain of 5-pound gain or greater as ordered (weight gain of 59.1 pounds.) This deficient practice could place residents at risk of not having their physician notified of changes resulting in a delay in continuity of care. The findings were: Record review of Resident #43's face sheet, dated 09/06/23, revealed Resident #43 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (chronic lung disease), coronary artery disease (blockage of the coronary arteries), anxiety (feeling anxious) and hypertension (high blood pressure). Further record review of this document revealed Resident #43…

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 comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #259) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #259 addressing oxygen use. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings: Record review of facility face sheet dated 9/06/2023 indicated Resident #259 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of atrial flutter (irregular heartbeat), and chronic obstructive pulmonary disease (COPD) (impaired lung function). Record review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #43) reviewed for care plans. The facility failed to ensure Resident #43's care plan was revised to reflected current orders for monitoring weekly weights and reporting greater than 5-pound weight gain. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of a face sheet for Resident #43 dated 6/20/23 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression, and hypertension. Record review of a quarterly MDS assessment dated [DATE] for Resident #43 indicated that he had a BIMS score of 15, indicating that he was cognitively intact. Record review of comprehensive care plan revision…

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 that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 1 of 8 residents (Resident #259) reviewed for respiratory care. The facility failed to ensure Resident #259 had an order for oxygen therapy and the correct liter flow was administered to the resident. This failure could place residents requiring O2 therapy at risk of hypoxia and not receiving prescribed care and services. Findings: Record review of facility face sheet dated 9/06/2023 indicated Resident #259 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of atrial flutter (irregular heartbeat), and chronic obstructive pulmonary disease (COPD) (impaired lung function). Record review of facility admission data report dated 08/20/2023 indicated Resident #259 was receiving continuous oxygen. Record review of admission…

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 provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 1 medication storage room reviewed for pharmacy services. The facility failed to properly date Tubersol Purified Protein Derivative (Mantoux Tuberculosis skin testing solution) in the medication storage refrigerator with an open date. The facility failed to remove 2 vials of Flucelvax from the medication storage room refrigerator that had expired on 06/30/2023. The facility failed to monitor and log the temperatures of the medication storage refrigerator twice daily as indicated by policy. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. Findings included: During an observation on 09/06/23 at 7:30 AM with LVN J the medication room refrigerator had 1 opened vial of Tubersol Purified Protein Derivative prescription date filled 6/23 with no open date and instructions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain infection control prevention and practices for medication administration of eye drops by 1 of 4 staff reviewed for infection control. (MA F) * The facility failed to ensure MA F washed her hands, gloved, and followed policy for administration of eye drops. This failure could place residents at risk of bacterial and viral infections or other diseases from pathogens contracted through contamination of mucosa. Findings included: Record Review of an order summary dated 09/06/23 for Resident #1 indicated she was [AGE] years old admitted [DATE] and with a BIMS score of 15 indicating he was cognitively intact. Resident had a current order for Artificial Tears 1 %-0.2 %-0.2 % eye drops for diagnosis of dry eyes- 1 drops instill in both eyes 2 times per day Wait 5 min between of additional eye drops. During an observation and interview on 09/06/23 at 08:30 AM MA F stated that she worked as a MA for many years. She gathered a tissue 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.