Sandstone Estates Rehab Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for allegations of abuse were completed for two of two sampled residents (#11 and #13) and that the residents were protected from further abuse during an investigation. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken. -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive. The resident's admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Review of the facility's Visitor Sign In log revealed that a male and a female visitor had signed into the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical review, staff interviews, and facility policy, the facility failed to ensure that physician orders were followed according to professional standards for two out of five residents (#24 and #29). The deficient practice could result in residents not receiving care that meets professional standards. Findings include: -Resident (#24) was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with hyperglycemia. The care plan for Diabetes Mellitus dated September 24, 2024, included an intervention to administer medications as ordered and to refer to current orders and/or medication administration record. The care plan also included to monitor for potential side effects and to report changes or abnormalities to the medical provider as applicable. The minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Review of the clinical record revealed a physician's order dated September 25,…

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, staff interviews, review of records, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two residents (#43 and #21). The medication error rate was 7.41%. The deficient practice could result in further medication errors. Findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included chronic obstruction pulmonary disease, type 2 diabetes mellitus, insomnia and hypertension. During a medication administration observation conducted on [DATE] at approximately 8:24 am with a Registered Nurse (RN/staff #700), the RN was observed to administer. - one Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025 and one Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) with expiration date October, 2025, were given to resident #43. However, review of the physician's order revealed that Jardiance (Empagliflozin) 10mg tablet, was discontinued on [DATE]. 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 clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident (#420) was free from misappropriation of resident medications. The deficient practice could result in further incidents of misappropriation. -Findings Include: Resident #420 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, major depressive disorder, post-traumatic stress disorder, and heart failure. A physician order dated January 26, 2023, for Oxycodone HCl Oral Tablet 20 mg to give 1 tablet by mouth every 3 hours as needed for pain. The order was placed by a licensed practical nurse (LPN/Staff #220) and discontinued the same day by the same LPN. An additional order dated February 02, 2023 revealed Morphine Sulfate Oral Tablet 15 MG to give 1 tablet by mouth every 3 hours as needed by pain. The order was placed by the LPN (Staff #220) and was also discontinued that same day by the same LPN. Review of the personnel file for the LPN…

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, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#12) was provided shower and dressing in timely manner. This deficient practice could result in residents not being provided hygiene care and services. Findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic kidney diseases, anxiety, and depression. Review of the care plan dated November 30, 2023 revealed the resident had activities of daily living (ADL) performance deficit related to general weakness. Review of the admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident required two or more-person assistance with shower/bathing self. Review of the resident bathing schedule showed that resident was schedule for bathing every Tuesday and Friday. Review of progress…

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, staff interviews, facility documentation, policies and procedure, the facility failed to ensure expired medications were appropriately disposed of and not available for resident use. The deficient practice could result in residents receiving expired medications. Findings include: During a medication administration observation conducted on October 22, 2024 at approximately 9:30 am with a licensed practical nurse (LPN/staff #710), the LPN were observed putting Amiodarone HCl Oral Tablet 200 MG in a small paper cup for administration. The medication was observed to be expired on on September 30, 2024. When asked regarding expired medication, she stated that she haven't looked at the expiration date and was observed taking out expired medication from cup and putting in biohazard bin. She then put medication strip bubble of Amiodarone HCl Oral Tablet with expired on September 30, 2024 back into North 1 cart drawer. An Interview was conducted on October 22, 2024 at 12:41pm with a licensed practical nurse (LPN/staff # 710), that was observed during the medication,…

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 clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#24) of five sampled residents was not administered an unnecessary medication. The deficient practice could result in further incidents of residents receiving unnecessary medications. Findings include: Resident (#24) was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with hyperglycemia. The care plan for Diabetes Mellitus dated on September 24, 2024 included the intervention to administer medications as ordered and to refer to current orders and/or medication administration record. The care plan also included to monitor for potential side effects and to report changes or abnormalities to medical provider as applicable. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. A review of the current order summary revealed an order for Lantus solution…

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, record review, and staff interviews, the facility failed to ensure that one resident (#43) was free from significant medication errors. The deficient practice could result in residents receiving unnecessary medications. Findings include: Resident #43 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstruction pulmonary disease, type 2 diabetes mellitus, insomnia and hypertension. A care plan initiated on February 7, 2024 revealed the resident has potential for fluctuating blood glucose levels related to diabetes. Interventions included to give medication as ordered by the physician and monitor for signs and symptoms of hypoglycemia and hyperglycemia. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident had cognitive skills for daily decision making as 0 indicating independence in decisions regarding tasks of daily life. During a medication administration observation conducted on October 22, 2024 at approximately 8:24 am 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.

Based on resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and at a temperature that is safe for consumption.The deficient practice has the potential for residents to acquire food-born illness. Review of the lunch menu for October 22, 2024 revealed the following: -Chili Cheese Dog -Sweet Potato Fries -Herb [NAME] Beans -Banana Pudding An observation was conducted on October 22, 2024 at 12:50 PM of a test tray. The test tray temperatures were taken by staff as follows: -Chili Cheese Dog-123 F -Sweet Potato Fries-121 F -Banana Pudding 63 F The test tray sampled by surveyors who reported that the chili cheese dog cooked but served cold. Two of the seven surveyors noted that the sweet potato fries were cold but crunchy. Additionally, three out of seven surveyors indicated that the banana pudding was not chilled. An interview conducted on October 21, 2024 at 9:06 a.m. with Resident # 32, with a BIMS Score of 11, stated that on October 20, 2024, he had to push his call light three times for because his…

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, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration. The deficient practice could result in contaminated medications being administered to residents. Findings: During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 7:56 a.m., for resident #426, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on north 2 cart. - metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for Diabetes management - Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth one time a day for Supplement During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 8:08 a.m., for resident #49, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on north 2 cart. - Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 3 tablet by…

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 clinical record review, staff interviews, the RAI (Resident Assessment Instrument) Manual and policy review, the facility failed to ensure a significant change MDS (Minimum Data Set) assessment was completed for one resident (#4) within the required timeframe. The sample size was 23. The deficient practice could result in the resident not receiving continuity of care. Findings include: Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia. A physician's order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday. On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident's weight at 231.0 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most…

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 clinical record review, staff interview, facility documentation and review of policies and procedures, the facility failed to ensure that a care plan for treatment and care of pressure ulcer was developed for one resident (#77). Findings include: -Resident #77 was admitted on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, pneumonia, respiratory failure, and unspecified with hypoxia. Review of the facility assessment, Weekly Skin Observation, dated December 23, 2022 at 7:36 p.m., included a right antecubital bruise, and generalized bruising on both legs from previous injuries/falls. A facility assessment, Wound Rounds, dated December 27, 2022 included a wound on the coccyx. Per the assessment, the type is pressure ulcer, and the clinical stage is unstageable. The assessment included a tissue type of bright beefy read, 50%, and loosely adherent slough of 50%. Review of the facility assessment, Weekly Skin Observation, dated January 6, 2023 at 08:21 a.m., included an open…

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 clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#20) received treatment and services in accordance with professional standards of practice. The deficient practice could result in residents not receiving the treatment and care based on their assessed needs. Regarding Resident #20 Findings include: -Resident #20 was admitted on [DATE] with diagnoses that included chronic hypoxia, type 2 diabetes, morbid obesity, and spinal stenosis. Review of weekly skin observation dated December 17, 2022 at 2:29 p.m., included the following: -Redness underneath axilla area -Redness in the groins -Redness in the folds of stomach area -Redness on coccyx Further record review revealed no additional weekly skin observation. A skin/wound note written on December 19, 2022 at 1:53 p.m., by the LPN/wound nurse (staff #33) included a clarification to admission skin assessment. Per the note, the resident has redness under both armpits. Review of a physician…

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 clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to prevent a pressure ulcer from developing in accordance with professional standards by failing to provide consistent preventative treatment for one resident (#77). Findings include: Resident #77 was admitted on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, pneumonia, and respiratory failure, unspecified with hypoxia. Review the facility assessment, Weekly Skin Observation, dated December 23, 2022 at 7:36 p.m., included the following: -A right antecubital bruise -A generalized bruising on both legs A care plan initiated on December 23, 2023, included a skin breakdown due to stage 1 pressure ulcer present on admission. The following interventions were included: -Keep skin clean and dry. -Avoid friction and sheering. -Encourage nutrition. Review of skin/wound nursing note dated December 27, 2022 at 4:28 p.m., stated a clarification to admission skin assessment, 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, resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#238) environment was free from accidents/hazards, and that one resident (#74) received adequate supervision to prevent medication accidents. The sample size was 23. The deficient practice could lead to residents sustaining accident-related injuries. Findings include: -Regarding Resident #238: Resident #238 admitted to the facility on [DATE] with diagnoses including chronic systolic (congestive) heart failure, orthostatic hypotension and history of falling. A nurses progress note dated 09/09/22 at 9:31 a.m. included that the writer heard a loud bang from the nurses station. The note included that the writer went to assess the situation and found the resident sitting in his bed with the headboard on his bed as well as glass from the picture that had fallen on him. Per the note, the glass was cleaned off the resident and he was assisted to the chair and further assessed…

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 the clinical record review, staff interviews and policy reviews, the facility failed to ensure one resident ' s (#4) weight was obtained as ordered and/or that he maintained acceptable parameters of nutritional status. The sample size was 23. The deficient practice could result in residents with unplanned weight loss. Findings include: Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia. A physician ' s order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday. On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident ' s weight at 231.0 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living. A risk for compromised…

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

Based on review of facility documentation, staff interviews, review of the Payroll Based Journal (PBJ) and policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 82. The deficient practice has the potential to affect resident care. Findings include: Review of the PBJ revealed on dates in the second quarter 2022, the facility failed to ensure an RN was on duty for 8 consecutive hours for dates including: March 19, 20, 26 and 27, 2022. Review of the punch detail for nursing staff for the month of March 2022 provided no evidence that an RN was on duty for those dates. On 01/26/23 at 1:49 p.m. an interview was conducted with the staffing coordinator (staff #16). She stated that there is an RN on duty 8 hours per day, 7 days per week. She stated that they have to have an RN on duty. She stated that she could not recall whether or not there were times when an RN was not on duty in the building. An interview was conducted on 01/26/23 at 2:40 p.m. with the Director of Nursing (DON/staff #8). She stated…

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, staff interviews, review of the policy and procedures, the facility failed to discard expired medications and failed to ensure expired medications were not available for administration. Findings include: A medication pass observation was conducted on January 24, 2023 at 8:09 a.m. with a licensed practical nurse (LPN/staff #45) in the loop unit. During the observation, staff #45 placed one tablet of zinc sulfate 50 milligrams in the medication cup to be administered to a resident. However, upon inspection of the zinc sulfate, it revealed an expiration date of June 2022. An immediate interview with staff #45 was conducted in which she inspected the bottle of the zinc sulfate. After inspecting the medication bottle, she stated the medication had expired on June 2022. She stated she usually look at the expiration of the medications but not today. She stated she would have administered the expired medication to the resident if it was not caught during the observation. She stated she would dispose the medications and she would get a new bottle from the storage.…

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 clinical record review, staff interviews and facility policy review, the facility failed to ensure that one resident (#4) had care plan revisions to meet their needs. The sample size was 23. The deficient practice could result in a lack of care provided to meet the resident's needs. Findings include: -Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia. A physician ' s order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday. On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident's weight at 231.0 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living. A risk for compromised nutritional status care plan initiated…

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 closed clinical record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident's (#4) clinical record was accurately documented in accordance with accepted professional standards of practices. The deficient practice could result in the resident's clinical record not being accurate and complete. Findings include: Resident #4 was admitted [DATE] with pertinent diagnosis that include stage 4 sacrum pressure ulcer, type 2 diabetes, malnutrition, chronic obstructive pulmonary disease, and heart failure. The record review of the MDS (Minimum Data Set), revealed an MDS dated [DATE] noted a BIMS (Brief Interview for Mental Status) of 15, indicating that the resident has no cognitive impairment. Review of the care plan dated December 19, 2022 the resident is at risk for impaired skin integrity related to a current wound and poor nutrition. Noted interventions include 'Evaluate skin', 'monitor for redness, especially over bony prominences', and 'provide 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.