Westminster Village Health & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was allowed to return to the facility after an emergency room (ER) visit due to behaviors once the hospital determined the resident did not meet the criteria for hospital admission for 1 of 3 residents reviewed for quality of care (Resident B). Findings include: During an interview, on 3/20/25 at 11:19 a.m., Hospital Employee 8 indicated Resident B presented to the ER, on 2/20/25, and the facility reported the resident had aggressive behaviors. The resident did not have behaviors in the ER, and there was no medical reason to admit him to the hospital, so they attempted to send him back to the facility. The Administrator refused to allow him to return to the facility and indicated they would not accept him back until he had a psychiatric evaluation. The resident had recently had a medication change at the facility, and the hospital provider thought the behaviors might have been due to the change. Hospital Employee 8 notified 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 ensure a resident-centered behavior management care plan was developed and interventions were identified and attempted during behavioral episodes prior to the resident being transferred to the emergency room (ER) for behaviors for 1 of 3 residents reviewed for quality of care (Resident B). Findings include: During an interview, on 3/20/25 at 11:19 a.m., Hospital Employee 8 indicated Resident B presented to the ER, on 2/20/25, and the facility reported the resident had aggressive behaviors. The resident did not have behaviors in the ER, and there was no medical reason to admit him to the hospital, so they attempted to send him back to the facility. The Administrator refused to allow him to return to the facility and indicated they would not accept him back until he had a psychiatric evaluation. The resident had recently had a medication change, and the hospital provider thought the behaviors might have been due to the change. The Hospital Employee…

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 prepare and serve food in a sanitary manner on 3 of 3 kitchen observations. Findings include: On 3/20/24 at 9:43 a.m., during initial dietary observation. Observed the following. a. Employee 5 had a beard cover not covering all of his mustache b. Food on the steam table was uncovered c. Debris on the floor throughout food prep area d. Dark debris on the outside and inside of the food warmer. Dried dark debris on the inside and bottom of the convection oven e. Review of dishwasher temperature log indicated the documentation from 1/1/24 to 3/20/24 lacked entries of wash temperatures. The Dietary Director was unable to provide a dishwasher temperature log for 2/15/24 to 2/29/24. On 3/20/24 at 11:58 a.m., During routine dining observation in the 1st floor dining room, observed, Employee 6, wash his hands and turned the water off with his bare hand. On 3/20/24 at 12:10 p.m., observed Employee 3 wash her hands and turn off water with bare hands. On 3/20/24 at 12:14 p.m., observed Employee 6 serving food without gloves on while…

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 obtain a supporting diagnosis for an indwelling Foley Catheter (a thin, flexible catheter used especially to drain urine from the bladder) for 1 of 3 residents reviewed for catheters (Resident 52). Findings include: On 3/21/24 at 9:10 a.m., during observation and interview with Resident 52, the resident indicated the indwelling Foley catheter was placed when she was in the hospital, but she could not recall why she had a catheter and indicated she had not had a catheter prior to going to the hospital. On 3/27/24 at 2:00 p.m., the Director of Nursing (DON) indicated the facility did not obtain a supporting diagnosis when the resident returned from the hospital because they were waiting on the follow-up appointment with urology to obtain the diagnosis. She indicated the physician would not give them the diagnosis and referred them to urology. On 3/25/24 at 11:27 a.m., Resident 52's record was reviewed. Diagnosis included but were not limited to, displaced fracture of the lower end of right femur (a break in 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 record review and interview, the facility failed to address a significant weight discrepancy for 1 of 2 residents reviewed for nutrition (Resident 1). Finding includes: Resident 1's record was reviewed on 3/22/24 at 10:29 a.m. The profile indicated the resident's diagnoses included, but were not limited to, unspecified diastolic (congestive) heart failure (occurs if the left ventricle muscle becomes still or thickened), cerebral infarction affecting right dominant side (a left-brain stroke happens when blood supply to left side of brain is stopped. The left side of brain is in charge of the right side of the body), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). An annual minimum data set assessment (MDS- part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 3/7/24, indicated the resident had impairment on one side. The assessment lacked…

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 record review and interview, the facility failed to ensure a post dialysis assessment was completed on 1 of 1 resident reviewed for dialysis (Resident 23). Finding includes: Resident 23's record was reviewed on 3/25/24 at 1:26 p.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), and hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). A quarterly Minimum Data Set (MDS) assessment (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 1/11/24, indicated the resident was cognitively intact and was marked as being on dialysis. A physician order, dated 2/17/23, resident to receive dialysis on Monday, Wednesday, and Friday, leaving at 6…

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 record review and interview, the facility failed to ensure verbal physician's orders were counter signed per pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications (Resident 37 and 11). Findings include: 1. On 3/22/24 at 8:55 a.m., record reviewed for resident 37. Record indicated diagnosis included but were not limited to, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), vascular dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), focal epilepsy (a disorder of the brain characterized by repeated seizures), hypertension (high blood pressure), hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into your bloodstream. This makes your metabolism slow down. Also called underactive thyroid). Physician Orders included but were not limited to, Cyanocobalamin Tablet 1000 mcg (micrograms) by mouth one time a day related to vitamin B…

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 record review and interview, the facility failed to ensure verbal physician's orders, for psychotropic medications (medications or other substances that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had been signed by the physician for 2 of 5 residents reviewed for unnecessary medications (Resident 47 and 16). Findings include: 1. Resident 47's record was reviewed on 3/21/24 at 2:07 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and borderline personality disorder (a mental health condition in which a person has long-term patterns of unstable or explosive emotions). A quarterly minimum data set assessment (MDS-part of the federally…

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

Based on observations, interviews, and record reviews, the facility failed to ensure medications were stored and labeled properly and the facility failed to ensure expired medications were disposed for 2 of 3 medication carts reviewed for medication storage (Residents 47 and 14). Findings include: 1. On 3/25/24 at 9:01 a.m., the 200 hall second medication cart contained an undated and opened Lispro (medication used to lower blood sugar) insulin pen. The insulin pen contained a label that indicated it was for Resident 47. The cart also contained a Lantus (insulin medication) insulin pen that had an open date of 2/22/24. The insulin pen contained a label that indicated it was for Resident 47. During an interview, on 3/25/24 at 9:04 a.m., Licensed Practical Nurse (LPN) 7 indicated insulin pens should have an open date placed on them when they are used, and insulin medication was good for 28 days once it was opened. The insulin pen that was dated for 2/22/24 should have been discarded. Resident 47's record was reviewed on 3/25/24 at 10:48 a.m. The profile indicated the resident's…

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

Based on observation and interview, the facility failed to maintain a separation between clean linen, from the soiled linen area for 1 of 1 observation of the laundry area. Finding include: On 3/26/24 at 9:36 a.m., during observation of the soiled laundry area, several barrels containing linens were uncovered, which had been placed against the wall in front of the washing machines. The washing machines were in use with soiled laundry at the time of the observation. On 3/26/24 at 9:45 a.m., during interview with Employee 12, the employee indicated the linens and clothing within the laundry barrels had been washed and were clean. She indicated she was waiting to put them into the dryer. The employee indicated she was aware the lids had not been placed on the barrel to protect the clean linen and acknowledged the barrels containing the washed clean linen, were within the soiled laundry area. On 3/26/2024 at 10:08 a.m., the Administrator provided a document, titled, Laundry and Bedding, Soiled, dated September 2022, and indicated it was the policy currently being used by the facility.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were provided showers as preferred for 1 of 24 residents reviewed for choices (Resident 100). Finding includes: During an interview, on 1/5/23 at 2:01 p.m., Resident 100's wife indicated, her husband had not had a shower since Sunday, 1/1/23. The resident took showers daily and sometimes two showers a day, morning and evening, prior to his admission into the facility, when he was at home. Resident 100's record was reviewed on 1/13/23 at 10:31 a.m. The resident was admitted to the facility, on 12/30/22, with diagnoses included, but not limited to, heart failure, acute and chronic respiratory failure (difficulty breathing), chronic obstructive pulmonary disease (COPD-chronic condition involving constriction of the airways and difficulty or discomfort in breathing). An admission Minimum Data Set (MDS) assessment, dated 1/5/23, indicated the resident had a moderate cognitive impairment, it was very important for the resident to choose…

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 record review and interview, the facility failed to ensure documented evidence of notification to the receiving hospital prior to the transfer of a resident for evaluation and treatment for 1 of 4 residents reviewed for hospitalization (Residents 9). Finding includes: Resident 9's record was reviewed on 1/13/23 at 2:32 p.m. An annual Minimum Data Set (MDS) assessment, dated 12/2/22, indicated the resident had a severe cognitive impairment. Diagnoses on the resident's profile included, but was not limited to, chronic obstructive pulmonary disease (COPD-a chronic condition involving constriction of the airways and difficulty or discomfort in breathing) and respiratory failure. Census information indicated Resident 9 had been discharged to the hospital on [DATE] and returned to the facility on [DATE]. A progress note, dated 11/22/22 at 5:45 a.m., indicated Resident 9 kept calling out for her mom. The nurse had witnessed the resident attempting to transfer self out of the bed and stated that she wanted 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 record review and interview, the facility failed to ensure transfer/discharge documents were developed and provided for hospital transfers for 2 of 4 residents reviewed for hospitalization (Resident 48 and 9), and notification of the transfer/discharge was provided to the Ombudsman for 1 of 4 residents reviewed for hospitalization (Resident 9). Findings include: 1. Resident 48's closed record was reviewed on 1/17/23 at 9:28 a.m. The profile indicated the resident had been admitted to the facility for diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (COPD-a chronic condition involving constriction of the airways and difficulty or discomfort in breathing), heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's need for blood), and was positive for COVID-19. A discharge, return not anticipated Minimum Data Set (MDS) assessment, dated 12/28/22, indicated the resident had an unplanned discharge to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a bed hold policy was provided to a resident with a hospitalization for 1 of 4 residents reviewed for hospitalizations (Resident 9). Finding includes: Resident 9's record was reviewed on 1/13/23 at 2:32 p.m. An annual Minimum Data Set (MDS) assessment, dated 12/2/22, indicated the resident had a severe cognitive impairment. Diagnoses on the resident's profile included, but was not limited to, chronic obstructive pulmonary disease (COPD-chronic condition involving constriction of the airways and difficulty or discomfort in breathing) and respiratory failure (difficulty breathing). Census information indicated Resident 9 had been discharged to the hospital on [DATE] and returned to the facility on [DATE] and the resident had been discharged to the hospital on [DATE] and returned to the facility on [DATE]. A progress note, dated 11/15/22 at 11:38 a.m., indicated staff had reported to the physician Resident 9 had right and left upper lung lobe…

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, record review, and interview, the facility failed to ensure nail care was provided to a dependent resident for 1 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Resident 2). Finding includes: On 1/4/23 at 12:25 p.m., Resident 2 was observed, with long, untrimmed fingernails with dark debris underneath the fingernails on bilateral (both) hands, while lying in bed, feeding himself lunch from a bedside table. On 1/5/23 at 11:50 a.m., Resident 2 was observed with long, untrimmed fingernails with dark debris underneath the fingernails on both hands, while lying in bed watching television. On 1/6/23 at 3:11 p.m., Resident 2 was observed in his room lying in bed with long, untrimmed fingernails with dark debris underneath the fingernails on both of his hands. Resident 2's clinical record was reviewed on 1/10/23 at 1:15 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 11/9/22, indicated the resident had a moderate cognitive impairment, required extensive assistance of two person for bed…

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 assess and treat a Resident's two pressure ulcers present upon admission into the facility for 1 of 1 resident reviewed for pressure ulcers (Resident 100). Finding includes: During an interview, on 1/5/21 at 10:02 a.m., Resident 100 indicated he had been admitted to the facility from another facility, on 12/30/22, with two pressure ulcers on his bottom. The other facility had changed the dressings. Resident 100's record was reviewed on 1/13/23 at 10:31 a.m. The resident was admitted to the facility, on 12/30/22, with diagnoses included, but not limited to, heart failure, acute and chronic respiratory failure (difficulty breathing), chronic obstructive pulmonary disease (COPD-chronic condition involving constriction of the airways and difficulty or discomfort in breathing). A Clinical admission Assessment, dated 12/30/22 at 4:32 p.m., indicated the resident did not have any pressure ulcers upon admission to the facility. A physician order, dated 12/30/22, indicated pressure reducing chair cushion and pressure reducing…

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 record review and interview, the facility failed to ensure a Resident, who had experienced significant weight loss, received a physician and registered dietician ordered health shake supplement for 1 of 1 resident reviewed for weight loss (Resident 9). Finding includes: Resident 9's record was reviewed on 1/13/23 at 2:32 p.m. A quarterly Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident had a severe cognitive impairment; impaired hearing; required extensive assistance of one staff for eating, bed mobility, transfers, locomotion, dressing, person hygiene, toilet use, and bathing; weight loss, and had two hospitalizations. Diagnoses on the resident's profile included, but was not limited to, Non-Alzheimer's dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), chronic obstructive pulmonary disease (COPD-chronic condition involving constriction of the airways and difficulty or discomfort in breathing), respiratory…

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 record review and interview, the facility failed to ensure physician's orders were followed related to monitoring a resident's daily weight and the assessment of his fistula as ordered for 1 of 1 resident reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), (Resident 29). Findings include: Resident 29's record was reviewed on 1/10/23 at 9:53 a.m. The profile indicated the resident's diagnoses included, but were not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). An annual Minimum Data Set (MDS) assessment, dated 5/11/22, indicated the resident required dialysis services. A care plan, dated 5/19/22 and revised on 11/18/22, indicated the resident received hemodialysis (a treatment to filter wastes and water from your blood) through a fistula (a connection that's made between an artery and a vein for dialysis access) in…

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

Based on record review and interview, the facility failed to ensure documentation of the administration of medications for 1 of 5 residents reviewed for unnecessary medications (Resident 18). Findings include: Resident 18's record was reviewed on 1/6/23 at 3:03 p.m. The profile indicated the resident diagnoses included, but were not limited to, hyperlipidemia (known as high cholesterol, when there are too many lipids [fats] in the blood), gastro-esophageal reflux disease (GERD-when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]), and restless leg syndrome (causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them). Review of the resident's December 2022 and January 2023 medication administration records (MARs) indicated the following: a. A physician's order, dated 3/29/22, indicated atorvastatin calcium tablet (a medication used to lower cholesterol) 40 milligrams (mg), by mouth at bedtime. The December 2022 MAR lacked documentation of the medication having been administered on the evening shifts…

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 record review and interview, the facility failed to ensure documented physician rationale for a declination of a gradual dose reduction (GDR) of a psychotropic medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) and documentation of the administration of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident 18). Findings include: Resident 18's record was reviewed on 1/6/23 at 3:03 p.m. The profile indicated the resident's diagnoses included, but were not limited to, delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and abnormal weight loss. An admission Minimum Data Set (MDS) assessment, dated 3/1/22, indicated the resident had a mood severity score (also known as PHQ-9. A questionnaire to assist in determination of depression severity) and received medications which…

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.