St Joe Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Resident #18, #34, #44, and #53) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy titled, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24…

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 document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #41 and #131) out of 28 sampled residents and two residents (Resident #40 and #138) outside the sample. The facility's census was 139. The facility did not provide a policy regarding MDS accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section J1400 should be coded yes if the resident is receiving hospice services; - Section N0300 should state the number of days during the 7-day look-back period that any type of injection was received; - Section N0350A should state the number of days during the 7-day look-back period that insulin injections were received. 1. Review of Resident #40's medical record showed: - An admission date of 05/01/24; - Diagnoses of type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar…

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 implement a care plan with specific interventions to meet individual needs for four residents (Resident #31, #41, #55 and #111) out of 28 sampled residents. The facility's census was 139. Review of the facility's Comprehensive Person-Centered Care Plan Policy, last revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being; - When possible, interventions address the underlying sources of the problems, not just symptoms or triggers; - Assessment of residents are on-going…

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 update and revise care plans with specific interventions to meet individual needs for five residents (Resident #1, #6, #18, #34, and #126) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for two residents (Resident #24 and #55) out of three sampled residents. The facility's census was 139. The facility did not provide a facility regarding shower frequency. 1. Review of Resident #24's medical record showed: - An admission date of 11/29/23; - Diagnoses of arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), spinal stenosis (spaces inside the bones of the spine get too small), chronic obstructive pulmonary disease (COPD, disease that makes breathing difficult), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), heart failure (the heart does not pump blood as well as it should), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health…

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 an order for oxygen administration and failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #41) out of two sampled residents. The facility's census was 139. Review of the facility's policy titled, CPAP (continuous positive airway pressure)/BIPAP Support, revised March 2015, showed in preparation for BIPAP, review the physician's order to determine the oxygen concentration and flow, and the PEEP (positive end-expiratory pressure, settings) pressure for the machine. Review of Resident #41's medical record showed: - admission date of 09/12/24; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and…

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

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 35 opportunities with three errors made, for an error rate of 8.57%, which affected three residents (Residents #32, #102 and #133) out of seven sampled residents. The facility's census was 139. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration; - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. Review of the NovoLog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) instructions, revised February 2015, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing;…

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 maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care for one resident (Resident #31) out of 28 sampled residents. The facility's census was 139. Review of the facility's Handwashing/Hand Hygiene Policy, dated 2001, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors; - Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids or contaminated surfaces, after touching a resident or 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, interview, and record review, the facility failed to maintain infection control practices during perineal care for one resident (Resident #1) out of one sampled resident. The facility's census was 137. Review of the facility's Perineal Care Policy, dated February 2018, showed: - Purpose of procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation and to observe the skin condition; - Place equipment on bedside stand and arrange to be easily reached; - Wash hands thoroughly, dry and put on gloves; - Wet washcloth and apply skin cleanser; - Wash perineal area from front to back; - Turn resident to side and wash rectal area thoroughly, wiping from the base of labia towards and extending over the buttocks; - Rinse and dry thoroughly; - Discard disposable items, remove gloves and wash hands; - Reposition bed covers and make resident comfortable; - Wash and dry hands thoroughly. Review of the facility's Enhanced Barrier Precaution Policy, dated August 2022, showed: - Enhanced Barrier Precautions (EBP) are used as 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.

Based on interview and record review, facility staff failed to report an allegation of resident-to-resident abuse to the state licensing agency officials as required for two residents (Resident #1 and #2) out of four sampled residents. Resident #2 pushed Resident #1 which caused him/her to fall and sustain a head injury that required two staples to the left forehead and a skin tear to his/her left elbow. The facility census was 141. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last updated 09/22, showed: - Verbal or written notification of an incident or suspicion of abuse or neglect to the immediate supervisor, charge nurse, the Director of Nurses (DON), the Social Service Designee (SSD) or the Administrator; - Verbal or written notification of an incident or suspicion of abuse or neglect to the facility's Ombudsman; - Call Missouri Department of Health and Senior Services Hotline; - If you knowingly do not report instances of abuse, you may be subject to disciplinary and legal action. Review of Resident #1'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails for 12 residents (Resident #6, #23, #25, #26, #27, #47, #52, #60, #68, #88, #90, and #91) of 28 sampled residents. The facility census was 141. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed seven different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for 12 residents (Residents #6, #23, #25, #26, #27, #47, #52, #60, #68, #88, #90, and #91) out of 28 sampled residents. The facility's census was 141. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 141. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Clean, sanitary and orderly environment; - Pleasant, neutral scents. Observation on 01/10/24 at 11:17 A.M., of the 200 Hall shower room showed broken tiles with rough edges surrounding the floor drain threshold for the shower entrance. Observation on 01/11/24 at 11:55 A.M., of room [ROOM NUMBER]'s bathroom sink showed water dripping from the drain into a plastic wash basin sitting on the floor. The wash basin contained dark colored liquid and more than ten dead gnats. Gnats flew around the bathroom and landed on the sink 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 interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer to the hospital for three residents (Residents #23, #35 and #52) out of 28 sampled residents. The facility census was 141. The facility did not provide a policy regarding a facility-initiated transfer. 1. Review of Resident #23's medical record showed: - Resident transferred to the hospital for medical evaluation on 11/28/23, and readmitted to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 2. Review of Resident #35's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/16/23, and readmitted to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 3. Review of Resident #52's medical…

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 inform the resident and/or resident representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #23, #35 and #52) out of 28 sampled residents. The facility's census was 141. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - Purpose is to notify all residents and/or resident's representative of the bed hold policy for the facility; - If the resident or representative wants to hold the bed, a signed authorization must be obtained with each discharge, these forms are located in the business office; - Upon discharge, the nursing supervisor will re-inform the resident and/or responsible party of the bed hold policy. The designee will follow up the next business day to assure resident and/or responsible party understands the requirements of the bed hold policy; - If the resident or representative does not choose to hold the bed, the bed will be released, and any personal belongings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to document an accurate Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, for two residents (Resident #23 and #60) out of 28 sampled residents. The facility's census was 141. Review of the facility's policy titled, Electronic Transmission of the MDS, revised November 2019, showed the MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. 1. Review of Resident #23's medical record showed: - admission date of 03/24/23; - Diagnoses of chronic kidney disease, stage 4 (gradual loss of kidney function over time), type II diabetes mellitus (chronic condition that affects the way the body processes blood sugar), anxiety disorder (disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), hyperkalemia (elevated level of potassium in the blood), and essential hypertension (abnormally high blood pressure); -…

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 implement a care plan with specific interventions to meet individual needs for three residents (Resident #25, #26, and #52) out of 28 sampled residents. The facility census was 141. Review of the facility's policy titled, Comprehensive Care Plan, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident. 1. Review of Resident #25's medical record showed: - An admission date of 08/25/23; - Diagnoses of dementia (progressive or persistent loss of intellectual functioning), pain in the left hip, history of falling, visual hallucinations (seeing something that is not there), atrial fibrillation (an abnormal heart beat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (disorder characterized by feelings of worry or fear that are strong enough to interfere 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.

Based on interview and record review, the facility failed to follow physician's wound care orders for four residents (Resident #26, #58, #95, and #116) out four sampled residents with wounds. The facility census was 141. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #26's medical record showed: - admission date of 11/15/23; - Diagnoses of chronic non-pressure ulcer (non-healing wound not caused by pressure) of left and right lower leg, stage two pressure ulcer (shallow open injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, and unstageable (unable to see the wound bed) pressure ulcer of the sacrum (triangular bone at the base of the spinal column). Review of the resident's wound care documentation showed: - An order to cleanse the right medial (middle) foot and ankle, right lateral (on the side) lower extremity with normal saline (salt and water solution that can be used for cleansing wounds) or dermal wound cleanser (first-aid antiseptic that helps reduce the risk of infection),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive a minimum of two showers per week and preferences were not acknowledged for eight residents (Resident #1, #6, #19, #23, #51, #52, #68 and #123) out of 28 sampled residents. The facility census was 141. Review of the facility's policy titled, Shower, revised 02/03/22, showed: - All residents will be offered and given a shower on their scheduled shower days unless the resident refuses or a staffing emergency; - If a full shower is unable to be given, a bed bath will be offered and a full shower given as soon as possible; - If an alert resident declines a bed bath and only wants a shower, the shower will be completed within 48 hours. 1. Review of Resident #1's medical record showed: - admission date of 05/26/2022; - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment…

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 staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three observed medication carts. This had the potential to affect all residents. The facility census was 141. Review of the facility's policy titled, Controlled Substances, dated April 2019, showed: - The facility will follow all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances; - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together; - Policies and procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. Review of the 100/200/300…

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 ensure vials of Insulin Glargine (medication to control high blood sugar with diabetes) and Tubersol (a solution used during a tuberculosis test) were dated when opened. This had the potential to affect all residents. The facility's census was 141. Review of the facility's policy titled, Storage of Medications, revised November 2020, showed: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the manufacturer's recommendations for Tubersol, revised September 2015, showed the medication to be discarded 30 days after opened. Review of the manufacturer's recommendations for Insulin Glargine, revised December 2020, showed the medication to be discarded after 28 days, even if there is insulin left in the pen or vial.…

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.