Avamere Rehabilitation Of Cascade Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, interview and record review, the facility failed to ensure care and services were provided in a manner that promoted residents' dignity related to urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) care for 2 of 2 sampled residents (Residents 11 & 39) reviewed for urinary catheter. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life. Findings included . 1) Resident 11 was admitted to the facility on [DATE]. The modification of admission Minimum Data Set (MDS) assessment, dated 06/27/2024, documented Resident 11 was moderately cognitively impaired and had an indwelling catheter. Resident 11's Alteration in Elimination Care Plan, dated 06/26/2024, documented .Keep drainage bag covered for dignity. Resident 11's Indwelling Catheter Care Plan, dated 07/26/2024, revised 08/07/2024, documented .drainage bag to remain covered . On 08/05/2024 at 3:59 PM, Resident 11 was observed sleeping…

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 residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 6 sampled residents (53) reviewed for right to participate in planning care. This failure placed residents at risk of a diminished quality of life when not allowed to be involved in their long-term care needs. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 06/18/2024, showed the resident was alert and oriented. The electronic health records (EHR) showed a care conference was conducted on 03/25/2024, and no other care conferences were documented. The EHR showed Resident 53 had a quarterly MDS assessment, dated 06/18/2024. On 08/08/2024 at 10:27 AM, Staff K, Social Services Coordinator, said care conferences were done at the residents' request, significant change or quarterly. At 10:49 AM, Staff M, Social Services Director, said she expected care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 1 of 6 sampled residents (53) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 06/18/2024, showed the resident was alert and oriented. Resident 53's electronic health record did not show an ADs or documentation that ADs were reviewed since March 2024, almost five months since the last review. Resident 53's care plan interventions, dated 03/19/2024, documented: Patient does not want to execute an Advance Directive at this time. On 08/08/2024 at 10:27 AM, Staff K, Social Services Coordinator, said Resident 53 did not want to generate an AD, but an AD should have been…

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 timely response and/or resolution to resident concerns about lost items was completed for 2 of 7 sampled residents (50 & 286) reviewed for grievances. This failure placed residents at risk for not having their concerns addressed, increased frustration and a decreased quality of life. Findings included . Record review of the facility's Lost Item Policy documented, if an item was missing, the resident or responsible party was expected to inform a staff member and/or fill out a Lost, Misplaced, Damaged Item form, which was then forwarded to Social Services. Social Services would initiate a search for the item and if the item was not recovered in the initial search (within three business days), Social Services staff would note the action taken on the Lost Item form and forward this form to the Administrator to determine further action needed. The administrator would notify the resident within five business days once a determination…

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 provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 2 of 6 sampled residents (36 & 31) reviewed for notices of bed holds. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 36 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment, dated 06/13/2024, showed the resident was severely cognitively impaired. The electronic health records (EHR) documented Resident 36 transferred to an acute hospital on [DATE]. No documentation was noted showing contact was made to the resident or resident's family regarding a Bed-Hold. On 08/07/2024 at 2:18 PM, Staff F, Admissions Coordinator, said when a resident was admitted to the hospital, admissions contacted the resident or the resident representative and covered the bed-hold agreement with them. Staff F said 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 a comprehensive person-centered care plan was developed and implemented for focused areas of care for 1 of 2 sampled residents (61) reviewed for care plans related to skin conditions. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 61 was admitted to the facility on [DATE]. The Modification of admission Minimum Data Set assessment, dated 06/30/2024, documented Resident 61 was alert and oriented and had an open lesion(s) on the foot. Record review of Resident 61's physician orders, dated 07/12/2024, documented: 1) Left lateral ankle abrasion: Cleanse with wound cleanser, skin prep periwound [tissue surrounding a wound], apply foam dressing. Change 3 times per week and as needed. every evening shift every other day for Wound care. 2) Right great toe abrasion: Cleanse with wound cleanser, skin prep periwound, apply hydrofera blue [an antibacterial wound…

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 ensure necessary care and services were provided for positioning in a wheelchair for 1 of 1 sampled resident (#21) reviewed for quality of care related to positioning. This failure placed residents at risk for unmet care needs, discomfort, a diminished quality of life and being unable to attain or maintain their highest practicable level of well-being. Findings included . Resident 21 was admitted to the facility on [DATE] with diagnoses including Inclusion Body Myositis (IBM). The quarterly Minimum Data Set assessment, dated 07/18/2024, showed Resident 21 was alert and oriented, had functional impairment on both sides, and required a motorized wheelchair for mobility once he is out of bed. The care plan, dated 12/16/2022, showed the resident has impaired physical mobility due to weakness requiring two person assist with a hoyer lift. The use of adaptive equipment to include power wheelchair for mobility. On 08/05/2024 at 11:28 AM,…

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 infection control and prevention practices were implemented for hand hygiene during a clean technique dressing change and during care of catheter bags for 2 of 8 sampled residents (Residents 51 & 11) reviewed for infection prevention and control. This failure placed residents at risk for wound infection, health complications and a diminished quality of life. Findings included . 1) Resident 51 was admitted on [DATE]. The 5-day admission Minimum Data Set (MDS) assessment, dated 11/29/2023, showed Resident 51 was alert and oriented, required one person assist with bed mobility, was assessed to be at risk of developing pressure ulcers, and had a healing Stage 2 pressure ulcer to the coccyx. The quarterly MDS, dated [DATE], indicated Resident 51 had one Stage 4 pressure ulcer to the right ischium (buttock and upper thigh). Resident 51's medical record showed the wound was first documented on 12/21/2023 measuring 2.67 cm (centimeter) x…

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 restorative nursing services to prevent potential avoidable reduction of range of motion (ROM) and mobility for 7 of 10 sampled residents (1, 2, 3, 4, 5, 6 & 7) reviewed for ROM/mobility services. This failure placed residents at risk for increased contractures and decreased quality of life. Findings included . 1) Resident 1 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting the left side. A contracture (a condition of shortening and hardening of muscles and tendons often leading to deformity and rigidity of joints), unspecified hand, was added to Resident 1's diagnosis on 01/30/2023. The Minimum Data Set, a comprehensive assessment tool, dated 02/21/2023, documented Resident 1 required extensive 1-2-person assistance with bed mobility, transfers, dressing, toilet use and hygiene. The resident restorative nursing program task list…

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, interviews, and record review, the facility failed to ensure cold food items, served to resident, were held at the proper cold holding temperature; and failed to maintain and document refrigerator temperatures for 3 of 3 unit refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness and a diminished quality of life. Findings included . <Cold Holding Temperatures> On 09/20/2023 at 11:40 AM, Staff D, Dietary Manager, was observed temping cold food item (cole slaw) using a facility thermometer. The cole slaw temped at 47.6 degrees Fahrenheit (F). When asked what the process for food that was not at cold holding temperatures, Staff D said the cole slaw should be at 41 degrees F or below. Staff D said they would return it to the refrigerator to get it to the correct temperature and put food on ice to help cool it down. Staff D obtained a shallow metal pan, placed ice in the metal pan and then placed approximately 12 cups of cole slaw on the ice and returned the rest of the food containers to the refrigerator. At 12:08 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, record review, and review of facility policy, the facility failed to ensure a care conference was held within 72 hours of admission and on a regular basis for 4 of 4 sampled residents (Residents (R) 40, R333, R55, and R71) reviewed for care conferences. This failure placed residents at risk of being uninformed regarding their care and services. Findings include . Review of the facility policy titled, Resident Participation-Assessment/Care Plans, dated February 2021, revealed, . The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan . Facility staff supports and encourages resident/representative participation in the care planning process by . ensuring that residents, representatives and families understand the care planning process holding care planning meetings at times of day when the resident, representative and family members can attend and are functioning at their best .…

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, record review, and facility policy review, the facility failed to ensure residents were provided notices of their resident rights, both orally and written, annually for five of five sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the resident council. This had the potential to affect all 81 residents in the facility. Findings included . Review of the facility's policy entitled, Resident Rights, revised 02/2021, revealed, . Employee shall treat all residents with kindness, respect. and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . Be informed about his or her rights and responsibilities . Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. During a Resident Council meeting on 09/20/23 at 1:29 PM, R49, R16, R28, R286, and R1, who the facility determined to be cognitively intact and regularly participated in the facility's monthly Resident Council meetings,…

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 observation, the facility failed to ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the resident council were provided information and contact information for the State Long-Term Care Ombudsman program. This had the potential to affect all 81 residents in the facility. Findings included . During a resident council meeting on 09/20/23 at 1:29 PM, R49, R16, R28, R286, and R1, who the facility determined to be cognitively intact and to regularly participated in the facility's monthly Resident Council Meetings, stated they were not aware of the Ombudsman's contact information and/or any location of such information in the building. The residents said they were not aware or could not recall knowing about or having contact with an Ombudsman. During an interview on 09/20/23 at 2:11 PM, Staff F, Activities Director, indicated she did not know about the Ombudsman program or such a person coming to visit the building. Staff F indicated there was information posted in her office about an Ombudsman. During an interview on 09/20/23…

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 and interview, the facility failed to ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the Resident Council meeting were familiar with their right to read the facility's survey results and knew where the results of the surveys were located. This had the potential to affect all 81 residents in the facility. Findings included . During a Resident Council meeting on 09/20/23 at 1:29 PM, R49, R16, R28, R286, and R1, who the facility determined to be cognitively intact and to regularly participate in the facility's monthly Resident Council meetings, stated they were not aware of their right to read the facility's survey results or where the survey book was located. During an interview on 09/20/23 at 2:11 PM, Staff F, Activities Director, said she did not know the state inspection survey results were supposed to be readily available to be read by residents or visitors. During an observation and interview on 09/20/23 at 2:59 PM with Staff A, Administrator, the survey results book was observed on a table at the entrance of 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 interview and record review, the facility failed to ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the Resident Council meeting were provided the opportunity to choose their preferred meal. This had the potential to affect all 81 residents in the facility. Findings included . Review of Week 3 Menu Week at a Glane Report for: Regular, dated 03/16/2023 and provided by the facility as the menu for the week, showed tomato or chicken noodle soup, chef salad, grilled cheese sandwich, or turkey sandwich were options to the regular menu. Foods always available were listed as egg salad sandwich, peanut butter and jelly sandwich, fruit and cottage cheese plate, cottage cheese cup, apple sauce cup, yogurt, graham crackers, chips, fruit cup, peanut butter and crackers, cheese and crackers, Jell-o cup, banana, and pudding. Review of Resident Council meeting minutes, dated 04/26/2023, 05/25/2023, 06/06/2023, 07/18/2023, and 08/23/2023 and provided by the facility, showed . resident asking for more food options for meals . fruit with cereals 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.

Based on interview, record review, and facility policy review, the facility failed ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the Resident Council meeting were aware of their right to ask for and receive snacks between meals and at bedtime. This had the potential to affect all 81 residents in the facility. Findings included . Review of the facility's policy entitled, Snacks (Between Meal and Bedtime), Servings dated 09/2010, revealed, . the purpose of this procedure is to provide the resident with adequate nutrition. Review the resident care plan and provide for any special needs for the resident. Check the tray before serving the snack to be sure that it is the correct diet ordered and that food consistency is appropriate to the residents' ability to chew and swallow . Review of Resident Council meeting minutes, dated 08/23/23 and provided by the facility, showed, . resident [sic] were asked about being offered snacks at bedtime and whenever you requested, and resident's answers were 'no' . During a Resident Council meeting on 09/20/23…

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, record review, and review of the facility's arbitration agreement, the facility failed to inform residents and/or their resident representative that signed arbitration agreements remained in effect for all care and services rendered at the facility even if such care and services were rendered following a discharge and readmission to the facility for 3 of 4 sampled residents and/or their resident representative (Resident (R) 24, R287, and R50) reviewed for arbitration agreements. Findings included . Review of a blank copy of the facility's Patient and Facility Arbitration Agreement. revised 04/2014 and provided by the facility, indicated, . The execution of this Arbitration Agreement is not a precondition to admission of the Patient to the Facility, and this Arbitration Agreement may be withdrawn by written notice to the Facility from the Patient within 30 days of signature. If not withdrawn within 30 days, this Arbitration Agreement shall remain in effect for all care and services rendered…

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 2) Review of R48's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses including fractures of the bones in his lower legs, end-stage renal disease, and was dependent on dialysis. Review of R48's admission Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 07/27/2023, showed R48 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated R48 was cognitively intact. Review of a Hospital DNR (Do Not Resuscitate) form, located in the Miscellaneous tab of the EMR, showed while in the hospital, R48 had a DNR order in place. There was no document located in the facility EMR, after R48 had been admitted , which indicated he had signed a POLST [Physician Order for Life-Sustaining Treatment] having the same wishes to have a DNR in place. During an interview on 09/20/2023 at 8:48 AM, Staff E stated, I believe the POLST did not come with 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 provide a written notice of transfer to the resident and/or the resident's representative describing the reason for transfer for 3 of 5 sampled residents (17, 26 & 25) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 17 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 08/27/2023, documented the resident was cognitively intact. Resident 17's Electronic Medical Record (EMR) documented an emergent transfer to an acute-care hospital on [DATE]. Resident 17 returned to the facility on [DATE]. The EMR did not show documentation of a written notice of transfer for Resident 17. 2) Resident 26 was admitted to the facility on [DATE]. The Medicare 5-day MDS, dated [DATE], documented the resident 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 ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 5 sampled residents (26) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . Resident 26 was admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set assessment, dated 07/17/2023, documented the resident was moderately cognitively impaired. Resident 26's EMR (Electronic Medical Record) documented an emergent transfer to an acute-care hospital on [DATE]. Resident 26 returned to the facility on [DATE]. The EMR did not show documentation of a bed hold for Resident 26. On 09/20/2023 at 10:04 AM, Staff M, Residential Care Manager and Registered Nurse (RN), said bed holds were completed by staff in the admissions department, not a task done by nurses.…

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.