Valparaiso Care & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor nutritional intake for meals for a resident with history of weight loss for 1 of 1 resident reviewed for nutrition. (Resident 5) Finding includes:During an interview on 12/11/25 at 12:42 p.m., Resident 5's family member indicated he had weight loss recently and had been having problems eating. Record review for Resident 5 was completed on 12/16/25 at 9:06 a.m. Diagnoses included, but were not limited to, dementia, hypertension, anxiety, tremors, and dysphagia (difficulty swallowing food or liquids). The resident was admitted to the facility on [DATE].The admission Minimum Data Set (MDS) assessment, dated 11/17/25, indicated the resident was severely cognitively impaired. The resident required a setup for eating and had a weight loss of 5% or more. A Care Plan, dated 11/13/25 and revised 12/10/25, indicated the resident was a nutritional risk and had a significant weight loss. An intervention included to monitor the food and fluid intake at…

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 a resident with a gastrostomy tube (g-tube, feeding tube) received care and services as ordered by a Physician related to treatment of the area around the insertion site for 1 of 1 resident reviewed for tube feeding. (Resident 79)Finding includes:On 12/12/25 at 9:44 a.m., Resident 79 was observed sitting up in bed. The resident indicated she had a gastrostomy tube used for tube feedings and it had been bleeding for the last two months. The gastrostomy tube was observed with a split gauze that was soiled with dark colored drainage from the insertion site. Resident 79's record was reviewed on 12/15/25 at 2:52 p.m. Diagnoses included, but were not limited to, gastrostomy and tracheostomy status. The Quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated the resident was cognitively intact. Tube feeding was not marked. A Physician's Order, dated 4/1/25, indicated cleanse the gastrostomy site with soap and water, pat dry, and apply gauze every shift. A Care Plan, dated 12/2/24, indicated 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 record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to medication administration for 1 of 1 resident reviewed for dialysis. (Resident 8)Finding includes:Record review for Resident 8 was completed on 12/17/25 at 2:04 p.m. Diagnoses included, but were not limited to, hypertension, end stage renal disease, and obstructive uropathy. The admission MDS assessment, dated 11/11/25, indicated the resident was cognitively intact. The resident received antidepressant, diuretic, and antiplatelet medications. The resident received dialysis services.The December 2025 Physician's Order Summary indicated orders for the following medications:-furosemide (to treat fluid retention) 40 mg (milligrams) every day-losartan (manages high blood pressure) 50 mg every day-dialysis at dialysis center on Monday, Wednesday, and Friday at 11:00 a.m.The 2025 November and December Medication Administration Records indicated the medications were not administered on the following dates and times due to dialysis. The medications…

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 infection control measures were implemented related to an indwelling urinary catheter bag on the floor for 1 of 2 residents reviewed for urinary catheters (Resident 62), glove use during tracheostomy care for 1 of 1 resident reviewed for tracheostomy care (Resident 2) and lack of orders and care plans for enhanced barrier precautions (EBP) for 1 of 3 residents reviewed for transmission based precautions. (Resident 141)Findings include:1.On 12/11/25 at 3:15 p.m. and 12/12/25 at 9:15 a.m., Resident 62 was observed lying in his bed. His indwelling urinary catheter bag was lying on the floor. On 12/12/25 at 9:28 a.m., LPN 1 was standing at the resident's bedside doing nail care. The catheter bag was lying on the floor next to her. When asked if it should be on the floor, the nurse then picked it up and hung it on the side of the bed. The resident's record was reviewed on 12/12/25 at 3:06 p.m. Diagnoses included, but was not limited to, metabolic encephalopathy, neuromuscular dysfunction of the bladder 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 observation, record review, and interview, the facility failed to ensure medications were stored properly, with appropriate labeling and not expired, for 2 of 4 medication carts observed. (East Cart and Cottage Cart) Findings include: 1. On [DATE] at 1:28 p.m., the following was observed on the East Cart with LPN 1: - A Basaglar KwikPen (insulin) was dated with an open date on [DATE]. - A Rezvoglar KwikPen (insulin) was dated with an open date on [DATE]. - A Toujeo SoloStar (insulin) pen was opened with no open date written on the pen. - A Basaglar KwikPen was opened with no open date written on the pen. During an interview on [DATE] at 1:35 p.m., the East Unit Manager indicated the open insulins should have been dated and disposed of 30 days after opening. 2. On [DATE] at 1:41 p.m., the following was observed on the Cottage Cart with QMA 1: - An insulin lispro vial was dated with open date on [DATE]. - A Lantus (insulin) pen was opened with no open date written on the pen. - An insulin lispro pen 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 observation and interview, the facility failed to provide privacy related to a shared bathroom for 1 of 1 resident reviewed for privacy. (Resident 57) Finding includes: During an interview on 8/6/24 at 9:23 a.m., Resident 57 indicated she felt she lacked privacy in the bathroom because she had to share the bathroom with the two men residing in the room next door. She no longer utilized the toilet due to her continence status, but felt she should be able to go in the bathroom to wash her hands or face without a man opening the door or worrying a man could be coming in the bathroom while she was in there. On 8/6/24 at 9:44 a.m., Resident 57's bathroom was observed. The shared bathroom was located in between her room (room [ROOM NUMBER]) and the room next door (room [ROOM NUMBER]). There were doors on each side of the bathroom leading to the resident rooms. There were 2 male residents currently residing in room [ROOM NUMBER]. The record for Resident 57 was reviewed on 8/8/24 at 4:19 p.m. Diagnoses…

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 care plans were reviewed and revised to include changes related to resident infections and dialysis access points for 2 of 29 resident care plans reviewed. (Residents 69 and 57) Findings include: 1. On 8/6/24 at 9:17 a.m., Resident 69 was observed in his room. The resident indicated he had a surgical wound to the top of his right foot. He had been under precautions at one time for having an infection. He no longer had the infection and was not on precautions any longer. There were no signs posted for any TBP (Transmission Based Precautions) or any PPE (Personal Protective Equipment) bins located inside or outside of the room. Record review for Resident 69 was completed on 8/9/24 at 9:50 a.m. Diagnoses included, but were not limited to, heart failure, hypertension, diabetes mellitus and a history of MRSA (Methicillin-resistant Staphylococcus aureus - bacterial infection). The Significant Change Minimum Data Set (MDS) assessment, dated 7/5/24, indicated the resident was cognitively intact. The resident…

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 a resident with edema was monitored or treated for 1 of 1 resident reviewed for edema (Resident 18), medications were given as scheduled and accuchecks were documented for 2 of 5 residents reviewed for unnecessary medications. (Residents 91 and 120) Findings include: 1. On 8/6/24 at 1:41 p.m., Resident 18 was observed seated in her room in a wheelchair. Her legs were elevated with the footrests and she indicated they were swollen. On 8/7/24 at 1:19 p.m. the resident was seated in her room in a wheelchair, her call light was on. She indicated she wanted someone to put the footrests on her wheelchair so she could elevate her legs because they were swollen. On 8/9/24 at 1:12 p.m., the resident was seated in her room in a wheelchair. She indicated her legs had been swollen for about a month and she had told the nurses about it, but did not know what they were doing about it. The resident's record was reviewed on 8/7/24 at 2:40 p.m. Diagnoses included, but were not limited to, diabetes mellitus, heart…

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 care for a PICC (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) line in accordance with professional standards of practice, related to flushing the PICC line for 1 of 5 residents observed during medication pass. (Resident 3) Finding includes: During medication pass, the Infection Preventionist (IP) was observed preparing an intravenous medication for Resident 3 on 8/8/24 at 2:13 p.m. The IP prepared meropenem (an antibiotic) reconstituted solution 1 gram per 100 cc of normal saline. She washed her hands and donned clean gloves. She bent the connection between the 100 cc normal saline bag and the vial of meropenem, squeezed the normal saline into the vial, and then shook the vial to dissolve the meropenem powder medication. She held the vial above the bag and squeezed air from the bag into the vial to force the liquid back into the bag. She spiked the normal saline bag with new tubing and primed the tubing. She connected the tubing thru the pump…

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 a resident received the necessary care and treatment related to incorrect oxygen flow rate and a humidity bottle not changed for 1 of 4 residents reviewed for respiratory care. (Resident 70) Finding includes: On 8/5/24 at 1:29 p.m., Resident 70 was observed in a wheelchair. He had a nasal cannula in place and attached to a portable oxygen tank on the back of the wheelchair. The flow rate was set at 4 liters per minute (lpm). On 8/6/24 at 9:08 a.m., the resident was observed lying in bed with a nasal cannula in place attached to the portable oxygen tank. The tank was set to a flow rate of 4 lpm. The oxygen concentrator was also on and set at 4 lpm. The water bottle on the concentrator was dated 7/29/24. The resident's record was reviewed on 8/7/24 at 1:22 p.m. Diagnoses included, but were not limited to, Parkinson's disease and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set assessment, dated 7/31/24, indicated the resident had moderate cognitive impairment and required…

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

Based on observation, record review, and interview, the facility failed to provide the necessary care and services for residents who received hemodialysis, related to not monitoring the dialysis access site, for 1 of 1 resident reviewed for dialysis. (Resident 57) Finding includes: During an interview on 8/6/24 at 9:23 a.m., Resident 57 indicated she went to dialysis on Mondays, Wednesdays and Fridays. She had a right upper arm graft for her current dialysis access. She also had an old right arm fistula, but it was not working any longer. The record for Resident 57 was reviewed on 8/8/24 at 4:19 p.m. Diagnoses included, but were not limited to, end stage renal disease, type 2 diabetes mellitus, and hypertension. The Significant Change Minimum Data Set assessment, dated 6/21/24, indicated the resident was cognitively intact and received hemodialysis. A care plan, updated 7/17/24, indicated the resident received hemodialysis. Interventions included, .assess dialysis access site every shift for excessive bleeding, drainage, swelling, redness, warmth, bruit/thrill. Document findings .…

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 a resident with a peripherally inserted central catheter (PICC) was placed in enhanced barrier precautions (EBP) for high contact resident care activities, and for improper glove use for 1 of 5 residents reviewed during medication administration. Finding includes: During medication pass, the Infection Preventionist (IP) was observed preparing an intravenous medication for Resident 3 on 8/8/24 at 2:13 p.m. Upon entrance to Resident 3's room, there was no signage noted in or around the doorway for EBP and no personal protective equipment bins. The IP prepared meropenem reconstituted solution (an antibiotic) 1 gram per 100 cc of normal saline. She washed her hands and donned clean gloves. She bent the connection between the 100 cc normal saline bag and the vial of meropenem, squeezed the normal saline into the vial, and then shook the vial to dissolve the meropenem powder medication. She held the vial above the bag and squeezed air from the bag into the vial to force the liquid back into the bag. She…

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 allegations of abuse were reported to the Indiana Department of Health (IDOH) immediately or within the 2 hour time period for 2 of 6 residents reviewed for abuse. (Residents F and G) The facility also failed to ensure an allegation submitted was not misleading with the facts reported by the resident. (Resident F). Findings include: 1. During an interview on 10/23/23 at 9:56 a.m., Resident F indicated a staff member had thrown water in her face. She had reported the incident to the Nurse. Resident F's record was reviewed on 10/24/23 at 2:53 p.m. The diagnoses included, but were not limited to, chronic respiratory failure and dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 9/20/23, indicated a moderately impaired cognitive status and she required oxygen, suctioning, and a tracheostomy. A Progress Note, dated 10/14/23 at 1 p.m. and written by the Memory Care Social Service Director, indicated the resident's daughter had provided details about an incident that had occurred. A reported incident to IDOH…

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 Care Plan was developed for a resident who received an antidepressant medication for 1 of 24 residents reviewed for Care Plan development. (Resident 64) Finding includes: Resident 64's record was reviewed on 7/11/23 at 1:46 p.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia and Diabetes Mellitus. The resident was ventilator dependent. The admission Minimum Data Set (MDS) assessment, dated 5/29/23, indicated the resident took antidepressant medication 7 of 7 days during the assessment period. The current Physician's Orders indicated the resident took Trazodone (an antidepressant), 50 milligrams, every 12 hours. The record lacked a Care Plan for antidepressant medications. Interview with the MDS nurse on 7/12/23 at 2:18 p.m., indicated there should be a Care Plan in place for the antidepressant and there was not. She would implement it at that time. 3.1-35(a)

Based on observation, record review, and interview, the facility failed to ensure pressure offloading boots were in place as ordered for 1 of 4 residents reviewed for pressure ulcers. (Resident 90) Finding includes: On 7/10/23 at 10:19 a.m., Resident 90 was observed lying in bed watching television. There were no pressure offloading boots in place to his feet. On 7/12/23 at 10:35 a.m., Resident 90 was observed lying in bed with his eyes closed. No pressure offloading boots were in place to his feet. The boots were on the empty bed on the other side of the room. Two CNAs entered the room to assist the resident with getting out of bed. On 7/12/23 at 11:23 a.m. Resident 90 was observed seated in his Broda chair in the Main Dining Room. The pressure offloading boots were not in place to his feet. Resident 90's record was reviewed on 7/11/23 at 2:33 p.m. Diagnoses included, but were not limited to, dementia, congestive heart failure, and anemia. The Significant Change MDS (Minimum Data Set) assessment, dated 6/27/23, indicated the resident was not cognitively intact, was at risk for…

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 a resident was supervised and orders were obtained for an electronic cigarette for 1 of 1 residents reviewed for smoking. (Resident 44) Finding includes: On 7/11/23 at 10:20 a.m. Resident 44 was observed in bed with an electronic cigarette at his bedside. On 7/11/23 at 1:40 p.m. Resident 44 was observed sitting up in his bed smoking his e-cigarette. Interview with the resident at this time indicated that he bought his own refills for his electronic cigarettes and his family would bring them to him. The record for Resident 44 was reviewed on 7/12/23 at 1:17 p.m. Diagnoses included, but were not limited to, muscular dystrophy, chronic obstructive pulmonary disease (restrictive airway), and depression. The Quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact. Staff assistance was needed for mobility, transfers and toileting with supervision for eating. A Care Plan, updated on 6/30/23, indicated the resident has a history of of attempting to smoke 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.

Based on observation, record review and interview, the facility failed to care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line and changing the PICC site dressings for 1 of 1 resident reviewed for intravenous care. (Resident 90) Finding includes: On 7/10/23 at 10:19 a.m., Resident 90 was observed lying in bed watching television. There was a PICC line in place to his right upper arm. It was covered with a wrap and the date on the site dressing was unable to be seen. Resident 90's record was reviewed on 7/11/23 at 2:33 p.m. Diagnoses included, but were not limited to, dementia, congestive heart failure, and anemia. The Significant Change MDS (Minimum Data Set) assessment, dated 6/27/23, indicated the resident was not cognitively intact and had received IV (intravenous) medications. A Physician's Order, dated 6/22/23, indicated new PICC line to the right arm. A Physician's Order, dated 6/20/23 and discontinued 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.

Based on record review and interview, the facility failed to ensure residents with pain were assessed and monitored related to lack of non-pharmacological pain interventions, pain was not assessed for severity or location, and parameters were not in place for use of pain medication for 2 of 2 residents reviewed for pain. (Residents 64 and 28) Findings include: 1. Resident 64's record was reviewed on 7/11/23 at 1:46 p.m. Diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, sacrum pressure ulcers, neuropathy and Diabetes Mellitus. The resident was ventilator dependent. The admission Minimum Data Set (MDS) assessment, dated 5/29/23, indicated the resident had received an opioid medication 5 of 7 days during the assessment period. The resident's cognitive status was unable to be assessed and he was dependent on two staff for bed mobility and transfers. A current Physician's Order indicated to give Norco (an opioid pain medication), 5 milligrams(mg)/325 mg, every 4 hours as needed for pain. A current Physician's Order indicated to give Tylenol, 650 mg,…

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 each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to ensuring a pain medication was available and given as ordered by the Physician for 1 of 5 residents reviewed for unnecessary medications. (Resident 86) Finding includes: Resident 86's record was reviewed on 7/14/23 at 9:46 a.m. Diagnoses included, but were not limited to, spinal stenosis (narrowing of the spine), hypertension (high blood pressure), heart failure, diabetes, depression, low back pain, gout, difficulty walking, and muscle weakness. The Annual Minimum Data Set (MDS) assessment, dated 5/31/23, indicated the resident was cognitively intact. A Physician's Progress Note, dated 7/6/23 at 5:08 p.m., indicated the resident's chief complaint was neck pain. Assessment indicated he had failed 1 spinal injection and was to go back for another treatment shortly. Assessment plan for neck pain included, biofreeze as needed and scheduled…

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 a medication error rate of less than 5% for 1 of 7 residents observed during medication pass. Two errors were observed during 27 opportunities for errors during medication administration. This resulted in a medication error rate of 7.41%. (Resident 91) Finding includes: On 7/14/23 at 8:04 a.m., QMA 1 was observed preparing medications for Resident 91. She prepared 6 pills and 1 liquid medication and administered them to the resident. The resident's medications were reconciled on 7/14/23 at 8:25 a.m. The July 2023 Medication Administration Record indicated the resident was to receive potassium, 20 milliequivilants daily and Restasis eye drops, 1 drop in each eye, twice daily. Both medications had been signed out as given during the observed medication pass with QMA 1, however they had not been observed as given. Interview with the QMA, on 7/14/23 at 10:55 a.m., indicated she had missed the potassium. She indicated she gave the eye drops later that morning, but she was unable to locate the eye drops 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.