Sunshine Health & Rehab

Based on record review and interview, the facility failed to ensure services provided met professional standards of practice related to nursing assessments for 1 of 5 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk for injury and adverse outcomes. Findings included . Per the Washington State Board of Nursing Frequently Asked Questions (https://nursing.wa.gov/practicing-nurses/frequently-asked-questions#NA-FAQ) assessments requiring the use of the nursing process must be completed by an individual with a nursing license (licensed practical nurse or registered nurse). Per the facility's policy titled, Resident Fall Prevention Protocol, revised August 2024, showed nursing staff were to complete fall risk assessments following a fall, and were to assess the level of injury present. Review of the March 2025 progress notes for Resident 1 showed on 03/29/2025 the resident had a fall in their bathroom and had been assisted up into their wheelchair before the nurse assessed them for injury. Per the note, the resident had pain and swelling 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 interview and record review the facility failed to not request or require residents to waive their rights to retain personal property including items of value to admit to the facility for 4 of 4 sampled residents (Resident 23, 76, 184, and 185), reviewed for resident rights. This failure placed all residents at risk of inability to exercise their resident rights, unmet needs, and diminished quality of life. Findings included . Review of the facility policy titled, Resident Rights revised February 2018, showed residents had the right to keep and use their personal belongings and property as long as it did not interfere with the rights, health, or safety of others. The facility was to protect resident property from theft. The policy further showed residents had the right to manage their own money, choose a trusted person to do so, or may deposit funds into a personal resident account (trust fund) with the facility. The facility must allow residents access to their bank accounts, cash, and other financial…

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 review policies and/or procedures yearly as required, perform hand hygiene when indicated, and store soiled laundry in a manner to prevent the spread of infection. In addition, the facility failed to implement, follow, and discontinue transmission-based precautions when indicated for 2 of 3 sampled residents (Resident 23 and 135), reviewed for infection control. This failure placed all residents, staff, and visitors at risk of development of a multi-drug-resistant organisms (MDRO), communicable diseases, and diminished quality of life Findings included . POLICIES Review of the facility policy titled, Vaccination of Residents, showed the policy was revised November 2012. No documentation was found to show the policy had been reviewed yearly as required. Review of the facility policy titled, Influenza Vaccine, showed the policy was revised November 2012. No documentation was found to show the policy had been reviewed yearly as required.…

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

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist met the qualifications for experience, education, training and/or certification for the role to assume responsibility of the facility's Infection Prevention and Control Program for 1 of 1 sampled staff (Staff C), reviewed for infection preventionist qualifications. This failure placed all residents, staff, and visitors at risk of contracting communicable diseases, unmet infection control issues, and lack of oversite of the facility staff's infection control practices. Findings included . In an interview on 10/21/2024 at 9:03 AM, Staff A, Administrator, stated Staff C was the facility's infection preventionist. Documentation of Staff C's completion of specialized infection prevention and control training was requested at that time. No documentation was provided. Review of the 10/21/2024 staff list showed Staff C was identified as the facility's only infection prevention and control staff. In an interview on 10/24/2024 at 4:06 PM, Staff B, Director of Nursing, stated Staff C 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 7 of 7 sampled residents (Residents 6, 7, 8, 25, 48, 50, and 53), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 revised October 2023, showed the RAI consisted of three basic components: the MDS, the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yields information about…

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 consistently provide bathing for 2 of 4 sampled residents (Resident 28 and 234), reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor personal hygiene, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Activities of Daily Living reviewed October 2024, showed the facility would ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable. The policy further showed care, and services would be provided to include bathing, dressing, grooming, and oral care. A resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. <Resident 28> According to the comprehensive assessment, dated 10/05/2024, Resident 28 admitted to the facility on [DATE] with diagnoses including heart failure, malnutrition and anxiety disorder. The assessment…

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 routinely implement a system with sufficient detail to enable an accurate reconciliation of all controlled drugs, including the facilities emergency medication supply in 1 of 1 sampled medication rooms (Victorian Rose) reviewed for medication storage. This failure placed the facility at increased risk for potential controlled substance drug diversion and detracted from the facility's ability to promptly identify drug diversion. Findings included . Review of the facility policy titled, Medication Storage in the Facility reviewed January 2020, showed medication storage conditions were monitored on a monthly basis by the consultant pharmacist or the pharmacy designee. Controlled substances that required refrigeration were to be stored within a locked box, attached to the inside of the refrigerator. The policy further showed controlled substances were subject to special handling, storage, disposal and record keeping. Medications subject to abuse or diversion were to be stored in permanently affixed, double 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the undated facility policy titled, Record of Food Temperatures showed the dietary department would check food temperatures on all items prepared by the dietary department, hot foods should be held at 135 degrees Fahrenheit (F), and potentially hazardous cold food kept at or below 41 degrees F. The policy instructed staff to measure and record food temperature on a temperature log every meal. Hot food temperature should be checked when placed on the steam table. Food that did not meet food code standard temperature were not to be served. Cold menu items were to be placed in an ice bath pan for holding until served. The policy instructed staff to clean, sanitize and calibrate 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 interview and record review the facility failed to routinely provide education on benefits and potential side effects of vaccinations, offer pneumococcal (bacteria that could cause respiratory infections) and influenza (flu, contagious viral respiratory illness) vaccinations when indicated, and document in the resident's medical record accordingly for 3 of 5 sampled residents (Resident 4, 52 and 78), reviewed for immunizations. These failures placed residents at risk of being unable to make informed decisions regarding immunizations, acquiring communicable diseases, and diminished quality of life. Findings included . Review of the facility policy titled, Vaccination of Residents revised November 2012, showed all residents would be offered vaccinations to aid in the prevention of infectious diseases. Residents and/or their representatives would be provided information and education regarding benefits and potential side effects of vaccinations. The policy further showed education provided would 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 interview and record review, the facility failed to provide documented evidence of the required annual 12-hours of in-service training, which included dementia training for 5 of 5 nursing assistants (I, L, M, O, V ), reviewed for nursing assistant continuing education and abuse prevention for 2 of 5 staff (I, V), as required. This deficient practice placed the residents at risk of being cared for by inadequately trained staff, and unmet care needs. Findings included . According to the Facility Assessment Tool, dated 07/23/2024, the facility required in-service nurse assistants (NA) trainings must be at least 12 hours per year, and include dementia management and resident abuse prevention training. Sunshine Health Facilities, Inc. Employee Handbook, 2024, page 32, documented Many of the in-services offered to staff are required by state law. Participation in in-services are reflected in your performance evaluations and required as part of your employment. During an interview on 10/28/2024 at 2:37 PM, Staff B, Director of Nursing, stated that the staff trainings for NA'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, interview, and record review the facility failed to ensure the resident was evaluated and assessed by the interdisciplinary team (IDT), a physician order was obtained, and care planned for safe self-administration of medications, as required for 1 of 4 sampled residents, (Resident 23), reviewed for resident rights. This failure placed residents at risk of medication errors, adverse side effects, and diminished quality of life. Findings included . Review of the facility policy titled, Preparation and General Guidelines for Self-Administration of Medications effective January 2020, showed residents who desired to self-administer medications were permitted to do so after the IDT determined it was safe for the resident and other residents of the facility and there was a provider's order to self-administer. An assessment would be completed of the resident's cognitive, physical and visual ability. The IDT would verify the resident's ability to self-administer medication by conducting a skills…

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 a medication error rate of less than five percent. Specifically, two medication errors were identified during 26 medication administration opportunities. This resulted in an error rate of 7.69 %. This failure placed residents at risk of receiving subtherapeutic effects of their medications, possible adverse side effects, and diminished quality of life. Findings included . According to progress notes dated 10/21/2024, Resident 141 was admitted to the facility that day with diagnoses that included Gastroesophageal Reflux Disease (GERD, a gastrointestinal disorder causing a backup of stomach contents back into the esophagus) and Irritable Bowel Syndrome (IBS, a bowel disorder characterized by abdominal pain, discomfort and bloating). The resident was alert and made their needs known. On 10/24/2024 at 8:38 AM, observed as Staff N, Registered Nurse, prepared and gave Resident 141 their medications. The resident was sitting up with a finished breakfast tray in front of them. Metoclopramide 5mg (an…

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.

F801 Based on interview and record review the facility failed to employ a dietician that had the licensure and/or certification to practice as a Registered Dietician in Washington State, as required for 1 of 1 staff (Staff U), reviewed for Registered Dietician qualifications. This failure placed all residents at risk for unmet nutritional needs and diminished quality of life. Findings included . Review of the facility's undated policy titled, Professional Licenses showed all professional licenses were tracked using an online human resources management system. The policy further showed if a license lapsed, the employee would be removed from the schedule and not allowed to work until resolved. Review of the Academy of Nutrition of Dietetics Scope of Practice for Registered Dietician Nutritionist revised 2024, showed RDNs operated within applicable federal and state laws and regulations and accreditation organization standards. When the practitioner and patient/client were located in different states, the practitioner must be licensed in the state where the patient/client is located…

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 implement antibiotic protocols to ensure antibiotics were appropriately prescribed for 1 of 6 sampled residents (Resident 4), reviewed for antibiotic stewardship. This failure placed residents at risk of development of [NAME]-drug-resistant organisms (MDRO), adverse side effects, and diminished quality of life. Findings included . Review of the facility policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes revised July 2016, showed antibiotic usage and outcome data would be collected, documented on the antibiotic surveillance tracking form, information used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. The policy showed all clinical infections treated with antibiotics would undergo review by the infection preventionist or designee within 48 hours of antibiotic start to determine if continued therapy was justified. The policy…

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 an individualized care plan for 1 of 3 residents (1) reviewed who had unique environmental fall risk concerns. Specifically, Resident 1 was at risk for tripping over their lengthy oxygen tubing, and this was not identified and included in their fall prevention care plan. This failure placed Resident 1 and other residents at risk for avoidable falls, injury and decreased quality of life. Findings included . The facility Resident Fall Prevention Protocol reviewed/revised 01/2024 documented the facility used a systems approach to preventing falls that included hazard identification and risk, analysis of hazards and risks, planning and implementation of individualized interventions to reduce fall risk, evaluation and monitoring for effectiveness, and updating the plan of care as necessary. An admission assessment dated [DATE] documented Resident 1 had diagnoses including right tibia fracture (shin bone) and chronic obstructive…

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 orders for oxygen were implemented during a transportation to the facility for admission for 1 of 3 residents (1) reviewed. Specifically, Resident 1 did not wear oxygen when transported from the hospital to the facility. Shortly after arrival, the resident had low blood pressure and developed chest pain and was returned to the emergency department for evaluation. This failure put the resident at risk for decompensation and unintended deterioration of their health. Findings included . The 05/08/2024 admission assessment documented Resident 1 had diagnoses including COPD (chronic obstructive pulmonary disease, long-standing inflammation of the lungs that can cause difficulty breathing) and atrial fibrillation (irregular heartbeat). Resident 1 was cognitively intact and wore oxygen. During an interview on 06/05/2024 at 2:55 PM, Resident 1's family representative stated Resident 1 had fallen at home and had broken their right knee 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 interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), admitted with impaired skin integrity, and at increased risk for continued skin breakdown, was consistently monitored to prevent development of pressure areas and worsening of identified areas. This failure caused a diminished quality of life for Resident 1 when they developed a pressure ulcer on their coccyx (tailbone area) and worsening of identified at risk areas on both heels. Findings included . Record review showed that Resident 1 was admitted to the facility on [DATE] with diagnoses of infection in the bone of their left ankle and foot, kidney disease and heart failure. Resident 1's admission assessment dated [DATE], showed the resident required assistance to reposition in bed, was at risk for pressure ulcer development, did not have a pressure ulcer and did not refuse care. A hospital Discharge summary dated [DATE] stated Resident 1 was at high risk for skin breakdown and had an infection of their…

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 4 dietary staff members (Staff K, L, M, and N) wore facial hair coverings while in the kitchen, as required. In addition, the facility failed to monitor the temperature and contents of 2 refrigerators that contained resident food. Failure to monitor refrigerator temperatures and contents for expired or spoiled food, and staff not wearing beard coverings in the kitchen placed all residents at risk for food-borne illness and contamination. Findings included . According to the Policy and Procedure Manual, 2019, titled Food safety and Sanitation, employees in the nutrition services department were required to wear beard nets, when facial hair was visible. According to the Policy and Procedure Manual, 2019, titled Food Brought in from Outside Sources and Personal Food Storage, foods brought in should be labeled with the resident's name and date the food was brought into the facility. In addition, the document showed that all refrigerators should have internal thermometers, and that designated 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 implement infection surveillance (an ongoing, systematic collection, analysis, and interpretation of data relating to infections to reduce spread of infections), for 6 of 7 sampled residents (Residents 20, 28, 238, 236, 3 and 21), who were reviewed for physician orders related to infections. These failures placed the residents and staff at risk for development of contagious disease. Findings included . On 06/07/2023 at 11:02 AM during an interview with Staff H, Licensed Practical Nurse (LPN), Infection Preventionist (IP), it was stated that they received and reviewed a list of residents taking antibiotics (medicines that fight infections caused by bacteria in humans) from the pharmacy each month. When reviewing the infection surveillance form with Staff H, they explained that they used McGreer's criteria (a data collection tool used to retrospectively [look back] to count true infections, and the appropriateness of antibiotic usage), as a method 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 identify an allegation as potential misappropriation of resident property, report the allegation to the State Survey Agency, and complete a thorough investigation as required for 1 of 1 sampled residents (Resident 1), reviewed for personal property. This failure placed residents at risk for potential misappropriation of personal property and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. According to the 05/15/2023 admission assessment, Resident 1 required extensive staff assistance to perform most activities of daily living, and was able to make their needs known. During an initial interview on 06/04/2023 at 3:41 PM, Resident 1 stated that they reported to staff they were missing clothing items and money from the drawer in their room. In a follow-up interview on 06/07/2023 at 10:00 AM, Resident 1 further stated that on 05/31/2023, they reported to Staff C, Certified Occupational Therapy Assistant…

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 act upon the pharmacist recommendation reports for 3 consecutive months, for 1 of 5 sampled residents (Resident 10), reviewed for unnecessary medications. This failure placed the resident at risk of adverse medication effects and a diminished quality of life. Findings included . According to a 01/24/2023 admission assessment, Resident 10 had diagnoses which included schizophrenia (a serious mental disorder that impairs the person's ability to perceive reality), dementia, and anxiety. The pharmacist monthly medication review report to nursing for February 2023 showed that the resident was on antidepressant medications (to treat depression), a medication for neuropathy (nerve pain) and an antiplatelet medication (to decrease the risk of blood clots.) The report further showed a request by the pharmacist for supporting diagnoses to be added to the resident's record, as the resident did not have diagnoses of depression, neuropathy, or an increased risk of blood clots. A second pharmacy medication review for February 2023…

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.