Manor At St Luke Village,the

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to monitor, obtain physician orders, and develop and implement a person-centered comprehensive care plan in accordance with standards of practice for one resident out of six sampled residents (Resident CR1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the resident's status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals…

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 review clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary use of psychoactive drugs by failing to ensure the presence of clinical rationale for the continued use of an as needed (PRN) psychotropic medication for two of 19 residents reviewed (Residents 75 and Resident 77). Findings include: A review of Resident 75's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). A review of Resident 75's clinical record revealed a physician's order dated January 7, 2025, directed Lorazepam (anti-anxiety medication) 0.5 mg by mouth every eight hours as needed (PRN) for anxiety, for 167 days. A review of the physician's notes for the months 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.

Based on a review of scheduled facility mealtimes, resident committee meeting minutes, grievances filed with the facility, select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by seven out of nine residents during a group interview (Residents 1, 6, 9, 20, 25, 33, and 83). Findings include: A review of facility policy titled Snacks, last reviewed by the facility on January 23, 2025, revealed it is the facility policy that snacks and beverages will be provided as identified in residents' individual plans of care. Bedtime (HS- hour of sleep) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Nursing services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. A review of the facility's scheduled mealtimes revealed the time between dinner and breakfast the next…

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 a review of facility policy, resident grievance documentation, clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure a thorough and complete investigation of an allegation of sexual abuse for 1 of 19 sampled residents (Resident 63). Findings included: A review of a facility policy entitled Abuse, Neglect, Exploitation & Misappropriation revealed it is the policy of the facility to provide professional care and services in an environment that is free from abuse, neglect, mistreatment, exploitation, and/or misappropriation of property. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thorough investigations of allegations. Sexual abuse is defined as the nonconsensual sexual contact of any type with a resident which includes but is not limited to unwanted touching of any kind especially of breast or perineal area. Further review of the facility abuse policy revealed under the area of investigation…

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 a review of clinical records and staff interviews it was determined the facility failed to develop and implement an individualized discharge plan for one of 19 residents reviewed (Resident 58) to reflect the resident's discharge goals. Findings Include: Clinical record review revealed that Resident 58 was admitted to the facility on [DATE], with diagnoses to include Dysarthria (the muscles used for speech are weak or are hard to control. Dysarthria often causes slurred or slow speech that can be difficult to understand) following a cerebral infraction (stroke). Review of a significant change Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated March 2, 2025, indicated the resident had a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 indicating he was cognitively intact. A review of Resident 58's social service notes revealed no social service notes in regard to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policy, observation, and staff interviews, it was determined the facility failed to ensure oxygen therapy was administered in accordance with professional standards of care for one out of the 19 residents sampled (Resident 1). Findings include: A review of the facility policy titled Oxygen Therapy, last reviewed by the facility on January 23, 2025, revealed it is the facility policy and procedure to ensure the physician's order for oxygen therapy shall include all of the following: (1) oxygen administration modality, (2) liter flow, (3) as needed or continuous administration, and (4) as needed orders must include specific guidelines as to when the resident is to use oxygen. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). A review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the facility's infection control tracking logs and infection control and prevention policy and staff interviews it was determined the facility failed to develop and implement a comprehensive infection control program to prevent the spread of infectious diseases including upper respiratory infection for 1 of 23 residents reviewed (Resident 1). Findings include: A review of the facility's infection control policy, last revised on January 23, 2025, indicated that the policy was designed to facilitate a safe, sanitary, and comfortable environment while preventing and managing the transmission of infectious diseases The objectives of the infection control policies and practices were to: a. Prevent, detect, investigate and control infections in the facility. b. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors, and the public. c. Establish guidelines for implementing isolation precautions, including Standard and Transmission-Based precautions: d.…

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 a review of nurse staffing, clinical records, grievances lodged with the facility and the minutes from Residents Council meetings and staff, resident and family interviews, it was determined that the facility failed to provide sufficient nursing staff to provide timely and quality of care to residents, and in accordance with each resident's plan of care, to meet individualized needs and promote the resident's health and well-being. Findings included: A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short {of staff} to give her a shower. Resident Council Meeting minutes dated April 9, 2024, revealed that the Director of Nursing (DON) explained to residents in attendance that they are trying to find workers to hire. Residents in attendance indicated that they had concerns about needing more help in the facility to provide their care. Resident Council Meeting…

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 a review of grievances filed with the facility and minutes from resident group meetings, and resident, family, and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by two out of the 23 residents sampled (Residents 88 and 298) and three out of 10 residents interviewed during a group interview (Residents 23, 30, and 64). Findings include: A review of grievances filed with the facility revealed a grievance dated March 9, 2024, indicating that Resident 199 was not offered a shower because facility staff told her that they were too short {of staff} to give her a shower. Resident Council Meeting minutes dated April 9, 2024, revealed that the Director of Nursing (DON) explained to residents in attendance that they are trying to find workers to hire. Residents in attendance indicated that they had concerns about needing more help in the facility to provide their care. Resident Council…

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, clinical record review and staff interview it was determined that the facility failed to ensure consistent communication between the facility and dialysis center were completed, including weights and vital signs, and failed to monitor fluid intake for residents prescribed on fluid restrictions for two residents out of 23 residents sampled (Residents 76 and 54). Findings include: A review of a facility policy entitled Coordination of Hemodialysis Services that was last reviewed by the facility on January 25, 2024, indicated that residents requiring an outside End Stage Renal Disease [(ESRD) is a condition where the kidney reaches advanced state of loss of function. This causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite] facility would have services coordinated by the facility and that there would be communication between the facility and ESRD facility regarding the resident. The Dialysis Communication form would be initiated by the facility…

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

Based on clinical record review, resident and staff interview, it was determined the facility failed to ensure that in preparation for a room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for one out of 23 sampled (Resident 89). Findings include: Federal regulatory guidance under §483.10(e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A review of Resident 89's clinical record revealed admission to the facility on April 8, 2024, with diagnoses including gastro-esophageal reflux disease (GERD), diabetes, and heart failure. A review of Resident 89'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 a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for one resident out of 23 residents sampled with facility-initiated transfers (Residents 21). The findings include: A review of Resident 21's clinical record revealed that the resident was transferred to the hospital on December 13, 2023. There was no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, including contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and any other documentation, as applicable, to ensure a safe and effective transition of care. A review of Resident 21's clinical record revealed that the resident was transferred to the hospital on March 15,…

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 review of clinical records, the Resident Assessment Instrument, and staff interview, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of the 23 sampled (Resident 21). Findings include: A review of Resident 21's quarterly MDS assessment dated [DATE] revealed in Section I Active Diagnoses that Resident 21 has a Multidrug Resident Organism (MDRO- an organism that is resistant to one or more antimicrobial drugs). However, a clinical record review revealed no evidence that Resident 21 had an acute or colonized MDRO. During an interview on May 30, 2024, at approximately 10:30 AM, the Director of Nursing (DON) confirmed that Resident 21 did not have an acute or colonized MDRO. The DON indicated that the MDS entry was an error.

Based on review of clinical records and staff interview, it was determined that the facility failed to revise a comprehensive care plan in response to potential inappropriate behavior displayed by one resident out of 23 reviewed (Resident 13). Findings include: Review of the clinical record of Resident 13 revealed initial admission to the facility on December 15, 2021, with diagnoses to include chronic obstructive pulmonary disease (COPD), and diabetes. A Social Service Progress note dated March 25, 2024, at 1537 hours (3:37 PM), revealed that the social service staff member spoke with Resident 13 along with the Nursing Home Administrator (NHA), regarding another his roommate's (Resident 49) account that this resident (Resident 13) touched his (Resident 49) leg when he did not want him to. Resident 13, verbalized understanding of appropriate versus inappropriate touch and he denied that he touched anyone in this way. Resident 13 stated he feels safe here and has no concern. Will continue to monitor A review of information dated March 25, 2024, submitted by the facility revealed that…

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 a review of clinical records, select facility policy, and facility investigation reports, observation, and resident, staff, and resident family member interviews, it was determined that the facility failed to ensure that residents receive care consistent with professional standards of practice to prevent pressure sore development for one of 23 residents sampled (Resident 88). Findings include: A review of facility policy titled Skin and Wound, last reviewed by the facility on March 25, 2024, revealed it is the facility's policy to provide a system for identifying risk, and implementing resident centered interventions to promote skin health, prevention and healing of pressure injuries. A clinical record review revealed Resident 88 was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and acute kidney failure (kidneys are suddenly not able to filter waste products from 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 clinical record review and resident, and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of one of four residents sampled (Resident 75). Findings included: A review of the clinical record of Resident 75 revealed admission to the facility on June 30, 2022, with diagnoses to include reduced mobility, muscle wasting, muscle weakness, and unsteadiness on feet. A physician's order dated was March 22, 2024, for the resident to receive RNP ambulation. During interview with the alert and oriented Resident 75, on May 28, 2024, at approximately 12:45 PM, the resident stated staff are not walking her. Resident 75 further stated she kept track and in the past 29 days she was walked once. The resident further stated she had told staff that she is not being ambulated as ordered and nothing was done about it. A review of Resident 75's Physical Therapy Discharge summary dated [DATE], indicated that the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and select investigation reports, and staff interview, it was determined that the facility failed to develop and/or implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms to promote resident safety and highest practicable physical and mental well-being for one out of 23 residents reviewed (Resident 42). Findings include: A review of Resident 42's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), overactive bladder, and myasthenia gravis (a disorder that causes weakness of the skeletal muscles). A review of Resident 42's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December…

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 review of clinical records, and resident and staff interviews, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 23 sampled (Resident 89). Findings include: According to regulatory guidance under §483.40(d) Medically-related social services means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health, which include providing or arranging for needed mental and psychosocial counseling services and identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. A review of Resident 89's clinical record indicated admission to the facility on April 8, 2024, with diagnosis including gastro-esophageal reflux disease (GERD), diabetes, and heart failure. During interview with alert and oriented Resident 89 on May 30, 2024, at approximately 9:05 AM, the resident stated that some time ago, he had an incident that occurred while he was…

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

Based on a review of clinical records, the facility's plan of correction from the survey ending May 31, 2024, interviews with residents and staff, and the outcome of the activities of the facility's quality assurance committee, it was determined that the facility failed to develop and implement a quality assurance plan that was able to identify and correct ongoing quality deficiencies related to providing a safe, clean, orderly, and homelike environment for residents. Findings included: During the survey ending on May 31, 2024, deficient facility practice was identified related to the facility's failure to provide sufficient nursing staff to provide timely and quality care to residents and, in accordance with each resident's plan of care, to meet individual needs and promote residents' health and well-being. In response to these identified quality deficiencies, the facility developed plans of correction, which included quality assurance monitoring plans to ensure that solutions were sustained. In response to the deficiency cited related to the facility's failure to provide…

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 review of scheduled meal delivery times and resident and staff interviews it was revealed that the facility failed to ensure sufficient staffing to support the operations of the food and nutrition service department and timely meal service to residents. Findings include: During an interview on November 16, 2023, at 9:15 AM, Resident A2 stated that meal delivery times vary and are not consistent with the established schedule. Resident A2 stated that breakfast arrived on time today, but other times the meals are delivered over 30 minutes late. Resident A2 did not know why the meals were sometimes delivered late. During an interview on November 16, 2023, at 9:20 AM Resident A3 stated that meal delivery times have been from 45 minutes to an hour late recently. Resident A3 stated that the facility is understaffed and there are not enough workers to pass out the meals on time. Review of the facility's meal delivery schedule to residents revealed that established meal delivery times were in place for breakfast, lunch, and dinner. Interview with the food service director (FSD) on…

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

Based on a review of select facility policy, the minutes from Residents' Council meetings and grievances lodged with the facility and staff interviews it was determined that the facility failed to demonstrate their response to resident complaints/grievances raised at Resident Council meetings, including four of the four grievances raised at the October 2023 Resident Council meeting. Findings include: A review of the facility policy titled Complaint/Grievances, last reviewed by the facility on January 1, 2023, revealed that the facility will make prompt efforts to resolve grievances and inform residents of progress towards resolution. The policy also indicates that the facility's Grievance Officer or designee shall act on the grievance and begin follow-up on the concern or submit it to the appropriate director for follow-up. Furthermore, the policy states that the grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. A review of Resident Council Meeting minutes dated October 10, 2023, indicated that residents in attendance voiced…

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, review of clinical records and select facility policies, and staff interviews it was determined that the facility failed to ensure adequate staff supervision and effective safety measures were implemented to supervise wandering behavior resulting in an attempted/actual elopement and failed to evaluate the circumstances of an attempted elopement and the effectiveness of safety measures to prevent future elopement for one resident (Resident A1) with exit seeking behaviors out of three sampled residents. Findings include: Review of the facility Elopement/Wandering Risk Guideline Policy last reviewed by the facility January 2023, indicated staff are to evaluate and identify residents that are at risk for elopement and develop individualized interventions. Residents are to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool. If a resident is identified as being at risk complete an Elopement…

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.