Flannery Oaks Guest House

Based on record review and interviews, the facility failed to complete quarterly assessments for 2 (#1, #3) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment. Findings: Review of the facility's policy titled, MDS Policy and Procedure with an effective date of 06/25/2015 revealed the following, in part: Policy Statement: All Minimal Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Resident #1 On 01/02/2025, a review of Resident #1's MDS assessment revealed a Quarterly MDS with an ARD (Assessment Reference Date) of 12/18/2024. Further review revealed the MDS assessment was not completed by 01/01/2025. Resident #3 On 01/02/2025, a review of Resident #3's MDS assessment revealed a Quarterly MDS with an ARD of 12/11/2024. Further review revealed the MDS assessment was not completed by 12/25/2024. An interview was conducted on 01/02/2025 at 11:50 a.m. with S4MDS. He confirmed all Quarterly Assessments should be completed within 14 days of the ARD. He confirmed Resident #1's MDS should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by S5CNA. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy dated 03/05/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part: Purpose: Each resident has the right to be free from abuse .No one shall abuse a resident .This policy applies to facility staff Policy: 3. Physical Abuse includes hitting, slapping . A review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. The resident had diagnoses, which included Vascular Dementia, Depression, and Anxiety Disorder. A review of Resident #2's Quarterly Minimum Data Set (MDS)…

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 interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure: 1.Staff accurately marked a resident was evaluated for PASRR on 2 (#62, #66) of 4 (#8, #36, #62, #66) resident's reviewed for PASRR; and 2.Staff accurately reflected the discharge status for 1 (#91) of 5 (#38, #84, #88, #91, #92) residents reviewed for discharge; and 3.Staff accurately reflected a resident had pressure ulcers for 1 of 1 (#43) resident reviewed for pressure ulcers. 1. Resident #62 Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder and Borderline Personality Disorder. Review of Resident #62's clinical record revealed a Level II PASRR with approval dates of 04/03/2024 through 04/02/2024. Review of Resident #62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 revealed question A1500, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 1 (#36) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR. Findings: Review of Resident #36's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Psychosis not due to a substance or known physiological condition (Onset Date: 08/25/2017). Review of Resident #36's most recent Level I PASRR Screening and Determination form revealed her previous assessment was performed on 08/18/2017. Review was attempted of Resident #36's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 08/25/2017 with no documentation available for review. Review of Resident #36's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2024, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews, the facility failed to ensure a record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for 1 (#8) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR. Findings: Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Schizophrenia (Onset Date: 07/27/2006). Review of Resident #8's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Further review revealed, in part, the following: Section I: I6000: Schizophrenia - Checked. Review was attempted of Resident #8's Pre-admission PASRR Level 1 Screening and Determination Review Form with no documentation available for review. An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #8 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet the needs of 2 (#23, #86) residents out of a 25 total sampled residents. The facility failed to: 1. Report Resident #23's urinalysis results to the consulting provider as ordered; and 2. Ensure care plan was comprehensive and individualized for Resident #86 whom exhibited frequent refusals and behaviors. Findings: 1. Review of the facility's policy titled, Notifying Clinicians - Laboratory/Diagnostic Testing Policy & Procedure revealed the following: Procedure: I. Laboratory Services (483.50) d. The facility must promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results . per the ordering physician's orders. Process: III. Once the laboratory . test is completed the results will be reported to the order physician, physician assistant, or nurse practitioner in a timely manner. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a therapeutic diet for 2 (#9 and #78) of 3 (#9, #70 and #78) residents reviewed for nutritional status. Findings: Resident #9 Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Dementia; Alzheimer's; Delusional Disorders; Aphasia; and Dysphagia. Review of Resident #9's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, which indicated resident had severe cognitive impairment. Further review revealed, in part, Resident #9 received a therapeutic diet. Review of Resident #9's current Physician Orders revealed, in part, the following: 02/01/2024: Pudding with Lunch and Dinner; 02/26/2024: Protein Juice with all Meals; and 10/03/2023: Ice Cream with…

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 interviews and record reviews the facility failed to identify a resident's past history of trauma, and/or triggers which may cause re-traumatization for 1of 1(#86) resident reviewed for Post-Traumatic Stress Disorder (PTSD). Findings: Review of Resident #86's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included the following: Bacteremia, Benign Prostate Hyperplasia, Lack of Coordination, and PTSD. Review of Resident #86's most recent Care Plan revealed, Resident #86 was not care planned for PTSD. Review of Resident #86's Social assessment dated [DATE] revealed the Trauma Informed Care screening questions were answered no. Review of Resident #86's physician progress notes dated 03/19/2024 to current revealed Resident #86's history of present illness included a PTSD diagnosis. Review of Resident #86's Psychiatric Notes dated 03/15/2024 revealed, in part, other comorbidities PTSD. On 05/14/2024 at 10:56 a.m., an interview was conducted with S20CNA. She stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 2 (#63, #78) of 3 (#63, #80, and #78) residents reviewed receiving hospice services. Findings: Resident #63 Review of Resident #63's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder, Delusional Disorders, Major Depressive Disorder, and Restlessness and Agitation. Review of Resident #63's May 2024 Physician's Orders revealed an order written on 03/13/2024 for Ativan 1 mg tablet, one tablet by mouth every 4 hours as needed (PRN) for anxiety/agitation. Further review revealed the PRN medication had no stop date. Review of Resident #62's May 2024 Medication Administration Record (MAR) revealed an Ativan 1 mg tablet by mouth every for hours as needed for anxiety/agitation was started on 03/13/2024. Further review revealed the PRN medication had no stop date. Resident #78 Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure medical records were accurately documented for 1 (#24) of 5 (#23, #24, #47, #62, #80) resident's reviewed for unnecessary medications. Findings: Review of Resident #24's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders (onset 04/14/2023), and Major Depressive Disorder. Review of Resident #24's May 2024 Physician's orders revealed an order started on 10/01/2023 for Risperdal 0.5 mg tablet, one tablet by mouth every evening. Diagnosis Major Depressive Disorder. Review of Resident #24's May 2024 MAR revealed an order started on 10/01/2023 for Risperdal 0.5 mg tablet, one tablet by mouth every evening. Diagnoses Major Depressive Disorder Review of Resident #24's Pharmaceutical Consultant Report, Antipsychotic Diagnosis Request, dated 05/02/2023 revealed the physician documented the diagnosis of Delusional Disorder as the reason the resident was receiving Risperdal. An interview…

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 reviews and interviews, the facility failed to develop procedures to ensure 2 (#51 and #62) of 5 (#9, #51, #62, #70 and #90) resident's records had documentation indicating resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. Findings: Review of the facility's policy, titled Pneumococcal Vaccination of Resident Policy and Procedure, reviewed 05/14/2024, dated 08/01/2022, revealed, in part: Purpose: It is the policy of this facility that each resident or their responsible party will be asked on admission if they have previously had the pneumococcal vaccinations and their age at the time of vaccination. The records that accompany the resident also will be used to determine immunization status. Procedure: 2. Facility will document pneumonia vaccine administration on Form Immunization Record and Form Vaccination [NAME] Roster. Review of Resident #51's clinical record from 10/01/2023 to 05/13/2024 revealed no documentation of pneumococcal immunization status. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure an alleged violation of physical abuse was reported within 2 hours to the State Survey Agency after an allegation was made for 1 (#295) of 3 (#5, #294, and #295) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse - Prevention and Prohibition Policy and Procedure revealed the following: Purpose: Each resident has the right to be free from abuse . This policy applies to covered individuals (the owner, operator, employees, managers, vendors, agency staff, agents, or contractors) . present in our facility. Policy: To provide a safe, abuse-free environment for all residents. If you suspect physical abuse of a resident contact the Administrator immediately. I. Types of Abuse: 3. Physical Abuse may including hitting, slapping, pinching, biting, shoving, and kicking. II. Procedures 7. Reporting/Response The facility employee or covered individual who becomes aware of abuse shall immediately report the matter to 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 interviews and record review, the facility failed to ensure services were provided by the facility to meet quality of professional standards. The facility failed to obtain physician's orders when the facility received medications from the pharmacy for 1 (#23) of 5 (#23, #51, #26, #294, and #47) residents reviewed for medication administration. Findings: Review of Resident #23's Clinical Record revealed a facility admit date of 10/01/2023 with diagnoses which included Stage 3 Chronic Kidney Disease, Urinary Tract Infection, Unspecified Injury of Unspecified Kidney, Acute Kidney Failure, Disorder of Urinary System, Overactive Bladder, and Personal History of Urinary Tract Infections. Review of the yearly MDS with ARD of 04/17/2024 revealed Resident #23 had a BIMS of 15, which indicated she was cognitively intact. Review of the most recent Care Plan revealed the following: Onset: 04/01/2024 Problem: I am at risk for infection returning Intervention: Administer my medications as ordered Onset: 11/28/2023 Problem: I have overactive bladder Intervention: Administer my 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide care and services in accordance with orders written for dining for 1 (#78) of 2 (#9 and #78) residents reviewed for requiring feeding assistance. Findings: Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was admitted to a local hospice agency on 02/08/2024 with a diagnosis of Muscle Wasting and Atrophy. Review of Resident #78's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, indicating resident was severely cognitively impaired. Further review revealed he required supervision or touching assist with eating. Review of Resident #78's Hospice Plan of Care, dated 02/08/2024, revealed, in part, the following: Physician's Orders: Patient must be fed all meals. Problem: Nutrition/Hydration diminished due to disease progression. Goal: For 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.

Based on observation, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (MR1) of 2 (MR1 and MR2) medication storage rooms observed. The facility failed to ensure a urine specimen was labeled with resident's first and last name, include a second identifier, and include the date and time of specimen collection. Findings: Review of the lab provider's policy, titled Urine Specimens, reviewed 05/14/2024, dated 01/2024, revealed, in part: Urinalysis and Culture and Susceptibility-Submit a urinalysis preservative tube and culture and susceptibility preservative tube. Label both tubes with the patient's first and last name and a second identifier. Include the date and time of specimen collection on each specimen container. On 05/14/2024 at 8:27 a.m., an observation was made of MR1 with S3IP. In the refrigerator labeled Specimens, a clear bag with two tubes filled with yellow fluid was discovered. Both tubes did not have a resident's name, date and time…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #86) residents observed with an indwelling catheter. Findings: A review of Resident #86's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses included the following: Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, and Cystitis. A review of Resident #86's MDS, with an ARD of 04/22/2024, indicated the resident had a BIMS of 7, which indicated he had severe cognitive impairment. Further review revealed he had an indwelling urinary catheter. On 05/13/2024 at 8:40 a.m., an observation was made of Resident #86 ambulating in his room, the indwelling catheter bag was hooked to the trash can. On 05/13/2024 at 11:20 a.m., an observation was made of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure services were provided to meet quality professional standards. The facility failed to ensure: 1. 1 (#21) of 3 (#21, #59, and #91) residents reviewed for falls were assessed with neurological checks following an unwitnessed fall; and 2. 1 (#103) of 2 (#103 and #363) residents reviewed for catheters were monitored for urinary retention after a urinary catheter was discontinued. Findings: Review of the facility's policy titled Falls revealed the following, in part: Purpose To evaluate extent of injury. To prevent complications. Procedure 9. If the fall was un-witnessed or involved a potential head injury, initiate neurological assessment checks. 13. Document all appropriate information in medical record. 1. Review of Resident #21's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included; Metabolic Encephalopathy, Muscle Wasting and Atrophy, Other Lack of Coordination, and Unspecified Abnormalities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#80) of 4 (#2, #80, #413, and #414) residents reviewed for pressure ulcers. The facility failed to ensure Resident #80 did not acquire a pressure ulcer while using a heel offloading device. Review of Resident #80's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Essential Hypertension, Type 2 Diabetes Mellitus, and Unspecified Protein-Calorie Malnutrition. Further review revealed she had diagnoses of Pressure Induced Deep Tissue Damage of Other Site, Unspecified Soft Tissue Disorder Related to Use/Pressure, Left Lower Leg and Unspecified Soft Tissue Disorder Related to Use/Pressure, Right Lower Leg with an onset date of 04/14/2023. Review of Resident #80's MDS with an ARD of 03/06/2023 revealed she had a BIMS of 14, which indicated she was cognitively intact. Further review…

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 and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure: 1. The can opener was properly cleaned and free of a sticky black substance; 2. The juice machine was properly cleaned and free of a brownish red substance; 3. The juice machine filter was properly cleaned and free of a brown and black substance; and 4. The juice machine connecters and tubing were properly cleaned and free of a black substance. Findings: An initial tour of the kitchen was conducted on 04/24/2023 at 8:40 a.m., with S16DS. The following observations were made: On 04/24/2023 at 8:45 a.m., the can opener was observed attached to a stainless steel food preparation counter with a large amount of a sticky black substance on the blade. S16DS confirmed the observation and stated the can opener should be cleaned daily and it had not been. On 04/24/2023 at 9:10 a.m., the juice machine was observed on a counter in the kitchen. The juice machine filter was observed with a large amount of 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.