Avenir At Maple Grove

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP) as required by facility policy when providing care and treatment to one resident (Resident #42), who had a wound, and also failed to ensure required signage was posted to indicate the use of EBP as required during high-contact personal care for two residents (Resident #42 and #33), in a review of three residents on EBP precautions. The facility failed to ensure staff performed proper hand hygiene when providing incontinence care to two residents (Resident #1 and #17), in a review of 19 sampled residents. The facility failed to implement their water management program to identify and reduce the risk of Legionella bacteria (cause of Legionnaire's disease - a severe form of pneumonia) growth and spread. The facility failed to track infections in the facility by organism and location. The facility census was 49. Review of the facility policy, Enhanced Barrier Precautions, revised…

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 maintain an infection prevention and control program (IPCP) that included a functional antibiotic stewardship program. In addition, the facility failed to ensure one additional resident (Resident #2), in a review of 19 sampled residents, had appropriate clinical indications for the use of an antibiotic The facility census was 49. Review of a Centers for Disease Control (CDC) undated document titled, The Core Elements of Antibiotic Stewardship for Nursing Homes showed the following: -Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority; -Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use; -All nursing homes should take steps to improve antibiotic prescribing practices and reduce inappropriate use; -Nursing homes monitor both antibiotic use practices and outcomes related to antibiotics in order to guide practice…

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 ensure one resident (Resident #8), in a review of 19 sampled residents, and one additional resident (Resident #28), the right to choose schedules (including waking times) and make choices about aspects of his/her life in the facility that were significant to the resident. The facility census was 49. Review of the facility policy, titled Resident Rights, revised 05/04/2022 showed the following: -The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: -a. The resident has the right to choose activities, schedules (including sleeping and waking times), assessments, and plan of care and other applicable provisions of this part; -b. The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident. 1. Review of Resident #8's Care Plan, revised 05/30/24, showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, according to the Resident Assessment Instrument (RAI) manual for two residents (Resident #17 and Resident #48), in a review of 19 sampled residents. The facility census was 49. Review of the RAI Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; -The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all…

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 staff provided care and treatment in accordance with professional standards of practice when staff failed to follow physician orders in providing continuous oxygen to one resident (Resident #49) to maintain the resident's oxygen needs, in a review of 19 sampled residents. The facility census was 49. 1. Review of Resident #1's Care Plan, revised 01/15/25, showed the following: -He/She had oxygen therapy related to chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe); -Monitor for signs/symptoms of respiratory distress and report to physician as needed; -He/She has COPD/asthma; -Give oxygen therapy as ordered by the physician; -Monitor for difficulty breathing on exertion. Remind the resident not to push beyond endurance. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/21/25, showed the following: -Moderately impaired cognition; -Primary…

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 consistently accommodate one resident's (Resident #31's) food preferences and failed to serve an appropriate food substitute/alternate. The facility census was 49. Review of the facility policy, Food Preparation Guidelines, dated 2023, showed the following: -Strategies to ensure residents satisfaction include honoring resident preferences, as possible, regarding food and drinks; -Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed; -Alternatives shall be appealing and of similar nutritive value to the food that is being substituted; -Alternatives shall be consistent with the usual and/or ordinary food items provided by the facility; -Staff should offer residents appropriate alternatives when they choose not to consume food/drink that is initially served or when a different food/drink choice is requested; -Resident preferences and allergies shall be obtained during the resident assessment process and added to the resident's dietary tray…

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.

Refer to Event ID UWJ112. Based on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 48. Review of the facility policy for Food Safety Requirements, dated 9/25/23, showed: -Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards: -Foods shall be prepared as directed until recommended temperatures of the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures as needed; -Staff shall monitor food temperatures while holding for delivery to ensure proper got and cold holding temperatures are maintained. Staff shall refer to the current FDA food code; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at 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, record review, and facility policy review, the facility failed to ensure residents and/or their responsible parties (RPs) were invited to participate in the care planning process for 2 (Resident #22 and Resident #29) of 2 residents sampled for care planning requirements. Staff interviews revealed the facility had not involved residents or their RPs in the care planning process since March of 2020. This affected all residents in the facility. Findings included: A review of the undated facility policy titled, Resident Participation - Care Conferences/Planning, revealed, Policy Statement The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Policy Interpretation and Implementation 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. The policy further indicated, 3. The resident/representative's right to…

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

Based on personnel record review, interviews, and facility document review, it was determined the facility failed to ensure 6 of 6 nurse aides (NAs) selected for review completed training to receive their certification within four months of their hire dates. Findings included: A review of an undated list of the facility's nurse aides (NAs) with hire dates, revealed the facility employed 11 NAs; six of the NAs were hired more than four months prior to the survey as indicated below: - NA #10, hire date of 02/28/2022 - NA #13, hire date of 12/10/2022 - NA #14, hire date of 04/18/2022 - NA #15, hire date of 12/05/2022 - NA #16, hire date of 08/10/2021 - NA #17, hire date of 01/18/2022 (tested in Illinois, but not in Missouri) A review of NA #10's personnel record revealed the record did not include any evidence indicating that NA #10 was certified or enrolled in a certified nurse aide (CNA) training program. A review of NA #13's personnel record revealed the record did not include any evidence indicating that NA #13 was certified or enrolled in a CNA training program. A review of NA…

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 provide food items at a safe and appetizing temperature. The facility census was 48. Review of the facility policy for Food Safety Requirements, dated 9/25/23, showed: -Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety; -When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards: -Foods shall be prepared as directed until recommended temperatures of the specific foods are reached. Staff shall refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures as needed; -Staff shall monitor food temperatures while holding for delivery to ensure proper got and cold holding temperatures are maintained. Staff shall refer to the current FDA food code; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out…

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, record review, and facility document and policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (Resident #4) of 3 residents reviewed for abuse prevention. Specially, the facility failed to prevent resident-to-resident abuse when they did not implement interventions immediately after the first indications of aggression. Findings included: Review of the facility policy titled, Abuse Prevention Program, with a revision date of December 2016, revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to the freedom from corporal punishment, involuntary seclusion, verbal, mental sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy indicated, As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone, including, but not necessarily limited to, facility staff, other residents,…

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 notify the ombudsman in writing when a resident was transferred or discharged from the facility for 1 (Resident #254) of 3 residents reviewed for transfer and discharge. Specifically, the ombudsman was not notified regarding an emergency transfer to an acute care facility which was considered a facility-initiated transfer. Findings included: A review of an admission Record indicated the facility initially admitted Resident #254 on 09/23/2020 and readmitted the resident on 08/23/2022 with a diagnosis that included transient cerebral ischemic attack. The admission Record indicated the resident was discharged to the hospital on [DATE] and returned on 08/23/2022. During an interview on 08/10/2023 at 5:00 PM, the Social Services Director (SSD) stated notification to the ombudsman was not made when Resident #254 was discharged to the hospital. During an interview on 08/10/2023 at 5:35 PM, the Administrator indicated his expectation was to follow 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 document review, the facility failed to ensure that, in January 2023, there was a Director of Nursing (DON) on staff at the facility and failed to ensure a registered nurse (RN) was working eight consecutive hours a day, seven days a week. Findings included: Review of the facility's schedule, revised on 01/01/2023, revealed the facility did not have a DON in January of 2023. The schedule also revealed the facility had only one RN scheduled to work during the day shift, two days per week. Review of the facility's Daily Schedule for January 2023 revealed an RN did not work at the facility on 01/02/2023, 01/03/2023, 01/04/2023, 01/05/2023, 01/6/2023, 01/09/2023, 01/10/2023, 01/12/2023, or 01/13/2023. During an interview on 08/10/2023 at 1:42 PM, Licensed Practical Nurse (LPN) #5 stated there had been days during her shift when the facility did not have an RN scheduled or working at the facility. LPN #5 noted she usually worked during the day shift but also covered night shifts. During an interview on 08/10/2023 at 5:56 PM, the DON stated she expected 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 observations, interviews, and facility policy review, the facility failed to maintain a clean environment in the laundry area. This affected 1 of 1 laundry room in the facility and was observed on 2 of 4 days of the survey. Findings included: A review of the facility's policy titled, Environmental Services - Waste - Laundry, from the Infection Control Manual 2019, revealed, Environmental Services 1. Environmental Services will develop protocols, including schedules for cleaning and decontamination of the work site. A tour of the laundry department on 08/08/2023 at 7:27 AM with Laundry Aide (LA) #1 revealed two large rugs in front of the washers that had numerous papers and lint debris. The floor area under the sink had dark discolorations with visible dust build-up and paper debris. During an interview on 08/08/2023 at 7:30 AM, LA #1 confirmed the floor under the sink was dirty. LA #1 said she did not know how often housekeeping staff cleaned the laundry area. During an interview on 08/08/2023 at 9:30 AM, the Housekeeping and Laundry Director stated laundry staff did their…

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 the range hood baffles and the ovens were clean and free of debris, failed to store scoops outside the food containers; failed to ensure serving trays and plate covers were not put away wet; and failed to ensure kitchen staff had all their hair covered with hairnets. The facility census was 42. Observation on 12/17/19 between 10:48 A.M. and 12:27 P.M. in the kitchen showed the following: -The range hood baffle filters were covered with a thick layer of grease and debris; -The bottoms of both ovens had a thick layer of debris; -A scoop was stored in the sugar bin. The handle of the scoop touched the sugar; -The tray covers were stacked wet on the counter, and the serving trays used during the noon meal service were wet; -Dish Washer H, Dish Washer I, [NAME] K, the dietary manager, and Dietary Aide J were in the kitchen during meal preparation and did not ensure their hair was completely covered with a hair restraint. During interview on 12/17/19 at 1:11 P.M., the dietary manager said she expected 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 interview and record review, the facility failed to obtain within an appropriate timeframe Nurse Aide (NA) registry/background screenings for two new employees, in a review of five newly hired employees prior to employment to determine if any had a Federal indicator with the nurse aide registry that would prohibit employment at the facility. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding NA registry or background screenings. The facility should follow the state regulation requirements. Review of the facility's policy Abuse, Prevention, and Prohibition and Policies and Procedures, revised 11/2018, showed the following: -The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties; -All employees will have criminal background checks, state, and federal required checks, employment reference checks (previous and current) and license/certification confirmation; -The facility will make…

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 ensure staff provided two of 14 sampled residents (Resident #31 and #16) and two additional residents (Resident #15, and #40) that were unable to do their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding providing ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual and procedure learned in CNA training. Review of the facility's undated policy, Incontinence Care, showed the following: -Female: Cleanse lower abdomen, wiping from side to side, fold cloth over and cleanse remaining lower abdomen as above; Cleanse on side of inner leg surface with a downward stroke and place cloth in bag when all four sides are used. Repeat on other side. Cleanse labia using downward stroke. Use a new side of wash cloth…

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 sufficient nursing staff on the behavioral unit, to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by the resident assessments and individual plans of care for four of 14 sampled residents (Resident #25, Resident #31, Resident #4 and Resident #14), and for one additional resident (Resident #18) out of eight residents who resided on the facility's special care unit (SCU). The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding staffing on the SCU. 2. Review of Resident #18's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 10/23/19 showed the following: -Cognitively intact; -Independent in walking in room and corridor; -Independent in locomotion on and off the unit; -Independent in Activities of Daily Living (ADLs);…

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 serve food that was palatable and at a safe and appetizing temperature. The facility census was 42. Review of the facility's policy for meal service temperatures, dated January 2019, showed temperatures of hot food shall be supported to promote service temperatures of hot food to about 120 degrees. Record review on 12/17/19 of the noon meal menu showed beef ravioli, marinara sauce, mixed vegetables, garlic bread stick, and pudding. Observation on 12/17/19 between 12:06 P.M. and 12:55 P.M. of the noon meal service showed staff prepared and served all residents the lunch meal. Observation on 12/17/19 at 12:55 P.M., of the test tray received after the last resident was served, showed the following food tempertures: -The ravioli was 98 degrees F; -The pureed ravioli was 112 degrees Farenheit (F); -The mixed vegetables were 97 degress F. -The pureed vegetables were 100 degrees F; The food was cool to taste. During interview on 12/17/19 at 1:11 P.M., the dietary manager said at the time of service, the food should…

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 ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for five residents (Resident #30, #16, #37, #13 and #48) in a sample of 14 residents and one additional resident (Resident #15) and failed to maintain and implement a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) and failed to provide documented assessments for such an outbreak. The facility census was 51. 1. Review of the facility policy Infection Prevention and Control Manual, dated 2019 showed the following: Appropriate hand hygiene is essential in preventing transmission of infectious agents. Definitions: Hand Hygiene (HH), Alcohol Based Hand Rub (ABHR), visibly soiled hands (hands are showing visible dirt or visibly contaminated with blood, fecal…

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 follow professional standards of practice for two residents (Residents #42 and #46), in a review of 13 sampled residents. Staff failed to obtain ordered medications including Xarelto (a blood thinning medication) and Acyclovir (treatment for herpes virus, shingles) for Resident #42, and failed to obtain ordered medications including Primidone (a seizure preventing medication) and Seroquel 25mg (an antipsychotic used for depression) for Resident #46. The facility census was 51. 1. During interview on 12/20/19 at 1:00 P.M. the administrator said the facility did not have a policy regarding following physician's orders. Review of the facility policy Medication Ordering and Receiving from the Pharmacy, dated June 1, 2018, showed the following: -Emergency pharmacy service is available on a 24-hour basis; -Telephone/fax numbers for emergency pharmacy service are posted at nursing stations; -The dispensing pharmacy supplies emergency or stat…

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.