Edenbrook of Oshkosh

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure an allegation of neglect was thoroughly investigated for 1 resident (R) (R2) of 15 sampled residents. R2 alleged that Certified Nursing Assistant (CNA)-H left R2 naked and without a gown on the 6/18/25 night shift. The facility did not thoroughly investigate the allegation of neglect.Findings include: The facility's Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, revised 3/25/25, indicates: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. The facility will follow the federal guidelines dedicated to the prevention of abuse and timely and thoroughly investigate allegations .residents and staff will be protected from abuse, neglect, and harm while they are residing at the facility. There is zero tolerance for abuse or harm of any type .The facility will strive to educate all participants 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.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe manner. This practice had the potential to affect more than 4 of the 71 residents residing in the facility. Holding temperatures were not completed for all items served. Findings include: During an initial kitchen tour on 3/24/25 at 9:08 AM, Dietary Manager (DM)-I indicated the facility follows the State of Wisconsin Food Code. The facility's Hospitality and Dining Services (Accuracy and Quality of Food Service 1-8) policy, dated 1/1/20, indicates: .Hot foods will be kept hot (>135 degrees Fahrenheit (F)) and cold foods will be kept cold (<41 degrees F) prior to and during service. Cooking of hot foods should be completed no more than 30 minutes prior to meal service. The Wisconsin State Food Code documents at 3-501.16, Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) .Time/temperature control for safety food shall be maintained: (1) 135 degrees F or above, except that roasts cooked to a temperature and for a time specified in paragraph…

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, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 5 residents (R) (R121, R124, R127, R58, and R19) of 6 sampled residents observed during medication administration and the provision of care. During observations of medication administration and/or care for R121, R124, R127, and R58, Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene. Staff did not abide by enhanced barrier precautions (EBP) when providing catheter care for R19. Findings include: The facility's Infection Control Program, revised 5/8/24, indicates: The infection control program exists to ensure a safe and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection .Preventing Spread of Infections: The facility must require staff to clean their hands after…

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 staff and resident representative interview and record review, the facility did not ensure 2 residents and their representatives (R) (R1 and R6) of 20 sampled residents were informed of care conferences. R1 and R6's representatives were not informed of R1 and R6's care conferences. Findings include: The facility's Care Conference Policy, revised 6/20/23, indicates: .To provide interdisciplinary communication with the resident and/or their legal representative for purposes of the development of an individualized comprehensive plan of care .2. A calendar of resident conferences shall be distributed to the interdisciplinary team. 3. The resident and/or their responsible party will receive communication in advance of the scheduled care conference .7. The Care Conference UDA .should be completed for attendance for tracing and record of discussion. 1. From 3/24/25 to 3/26/25, Surveyor reviewed R1's medical record. R1 received Hospice services and was admitted to the facility on [DATE]. R1 had diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interview and record review, the facility did not ensure written notification for a roommate was provided for 1 resident (R) (R6) of 2 sampled residents. R6 received a roommate on 3/20/25. R6's representative was not notified prior to the move. Findings include: The facility's Room Change policy, revised 3/17/23, indicates: The facility will move the resident and their belongings safely and with the least possible confusion for the resident. The resident's preferences should be considered when making a room or roommate change. Whenever a resident is transferred from one room to another within the facility, a written notice of transfer must be given to the resident and/or family prior to the move according to state law .1. If a resident is moving at the request of staff, a written explanation of why the move is necessary needs to be provided to both residents/families/representatives as one is getting a room change and the other is getting a new roommate. 2. Obtain 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 observation, staff interview, and record review, the facility did not ensure a clean or home-like environment for 1 resident (R) (R41) of 20 sampled residents. R41's bedside tray table was not in a clean condition. Findings include: The facility did not have a policy regarding a clean, comfortable, and home-like environment. The facility provided an untitled and undated cleaning list that indicated: Resident Room Over-Bed Tables, scrub all areas of table (legs, base, stand, table top and table bottom). Polish if necessary. From 3/24/25 to 3/26/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, bipolar type, bipolar disorder, anxiety disorder, dementia, muscle weakness, lymphedema, and pain in right and left knee. R41's Minimum Data Set (MDS) assessment, dated 3/15/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R41 had moderately impaired cognition. R41 had a corporate…

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 staff and resident interview and record review, the facility did not ensure care plans were updated for 3 residents (R) (R41, R10, and R37). R41 had an order to float heels. R41's care plan was not updated with the order and R41's heels were not floated. R10 and R37 had a known conflict with each other. R10's and R37's care plans did not reflect the conflict and did not contain interventions for redirection or how to avoid altercations. Findings include: The facility's Care Plan-Baseline and Comprehensive policy, dated 6/20/23, indicates: .12. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. From 3/24/25 to 3/26/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, bipolar type, dementia, patients non-compliance with medical treatment and regimen, muscle weakness, bilateral primary osteoarthritis of knee, peripheral vascular…

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 staff interview and record review, the facility did not ensure range of motion exercises were completed in accordance with a range of motion program for 1 resident (R41) of 20 sampled residents. Documentation for R41's range of motion (ROM) program was not completed accurately and/or was not completed. Findings include: From 3/24/25 to 3/26/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder, bipolar type, dementia, patients non-compliance with medical treatment and regimen, muscle weakness, bilateral primary osteoarthritis of knee, peripheral vascular disease (PVD), and pain in right and left knee. R41's Minimum Data Set (MDS) assessment, dated 3/15/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R41 had moderately impaired cognition. R41 had a corporate Guardian for decision making. A care plan (revised 12/19/24) indicated R41 had limited physical mobility related 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 staff interview and record review, the facility did not ensure 1 resident (R) (R56) of 5 sampled residents received influenza and COVID-19 vaccines as indicated. Upon admission to the facility, R56's Power of Attorney for Health Care (POAHC) signed a consent form for R56 to receive influenza and COVID-19 vaccines. The vaccines were not administered. Findings include: The facility's Seasonal Influenza Vaccine Policy, revised 9/19/24, indicates: The Centers for Disease Control and Prevention (CDC) guidelines and recommendations are followed for the prevention and control of seasonal influenza .6. For residents and/or legal representatives consenting to receiving the seasonal influenza vaccine, the facility shall obtain a physician's order for the administration of the vaccine .8. Administration of the vaccine will be done upon a signed consent and valid physician's order and shall be recorded in the medical record. The facility's COVID-19 Vaccine Policy, revised 9/19/24, indicates: The CDC recommends…

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, staff interview, and record review, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents on 3 of 3 units. Utility rooms on all 3 units contained dust, debris, stains, and an odor of bodily waste, In addition, Surveyor observed risks of cross-contamination. Findings include: On 8/21/24, Surveyor completed a tour of the facility, including the soiled utility rooms (enclosed spaces meant to remove waste generated by resident care and soiled cleaning materials). On 8/21/24 at 11:31 AM, Surveyor toured the soiled utility room on unit 2. Upon opening the door, Surveyor noted an odor of human waste. Surveyor observed two uncovered trash containers that contained garbage bags with resident waste. Surveyor also observed dust, debris, and stains on the floor, stains on the walls, and several small garbage cans stacked to the side with an empty soda bottle. On 8/21/24 at 11:38 AM, Surveyor toured the soiled utility room on unit 4. Upon opening the door, Surveyor noted an odor of human waste. Surveyor observed two brooms with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 2 Residents (R) (R14 and R18) of 7 residents observed during medication pass were assessed as able to safely and accurately self-administer medication. On 8/21/24, Licensed Practical Nurse (LPN)-E left medication at R14 and R18's bedsides for R14 and R18 to self-administer. R14 and R18 did not have physician orders, self-administration of medication assessments, or care plans that indicated R14 and R18 could safely and accurately self-administer medication. Findings include: The facility's Medication Self Administration policy, dated 2/12/24, indicates: Purpose: To provide guidelines for the Interdisciplinary Team to determine that the practice of self-administration of medications is safe .1. The resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medication .3. Residents who have been deemed appropriate to self-administer medication independently or 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 staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 of 8 staff reviewed for background checks. The facility did not ensure a thorough and timely caregiver background check was completed for Certified Nursing Assistant (CNA)-F. Findings include: The facility's Vulnerable Adult Abuse and Neglect Prevention policy, with a revision date of 10/4/23, indicates: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation .Screen potential employees for a history of abuse, neglect, exploitation, or mistreatment .This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries .A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks, using the state specified criminal background check system . On 8/21/24, Surveyor…

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 staff interview and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R2) of 8 sampled residents. On 2/24/24, Licensed Practical Nurse (LPN)-C gave R2 another resident's medication. Following the medication error, the facility did not ensure blood pressures were taken per the physician's order and provide education to LPN-C. Findings include: The facility's Medication Error and Drug Interactions policy, with a revision date of 2/12/24, indicates: .2. A detailed account of the error will be recorded in the resident's medical record. Such documentation must include, but is not limited to: .f. Date and time the physician was notified and what instructions were given. On 8/21/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery. R2's Minimum Data Set (MDS) assessment, dated 2/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 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 observation, staff interview, and record review, the facility did not ensure medications were labeled and stored in accordance with manufacturers' recommendations for 3 Residents (R) (R12, R17, and R18) of 7 residents observed during medication pass. On 8/21/24, Registered Nurse (RN)-D left a medication cup that contained eleven medications on R12's bedside table while RN-D left the room to attend to another resident. During observations of medication administration, Licensed Practical Nurse (LPN)-E administered open and undated medication to R17 and R18. Findings include: The facility's Labeling Medication policy, dated 1/22/24, indicates: Purpose: To ensure all medications maintained in the facility are properly labeled in accordance with current state and federal regulations .Procedure: .7. Medication vials/bottles will be labeled with the date they were opened (seal broken) to ensure proper tracking for expiration purposes . 1. On 8/21/24, Surveyor reviewed R12's medical record. R12 was admitted 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 observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 2 Residents (R) (R12 and R13) of 7 residents observed during the administration of medication. On 8/21/24, Registered Nurse (RN)-D did not complete proper hand hygiene during medication administration for R12. In addition, RN-D did not wear gloves as ordered during the administration of methimazole (used to treat hyperthyroidism). On 8/21/24, RN-D did not complete proper hand hygiene during medication administration for R13. Findings include: The facility's Hand Hygiene policy, dated 5/8/24/24, indicates: Purpose: To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the preventions of the transmission of infections .Using Alcohol-Based Hand Gel: .c. Before preparing or handling medications . 1. On 8/21/24 at 8:38 AM, Surveyor observed RN-D prepare medication for R12. Following medication preparation, RN-D did…

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, staff interview, and record review, the facility did not ensure menu serving sizes were followed for protein, vegetable, and starch servings for mechanically altered (minced and moist) and regular consistency diets. This practice had the potential to affect 67 of 70 residents residing in the facility. During the lunch meal on 2/4/24, the facility served smaller serving portions than the lunch menu and diet tray cards indicated for 6 residents who received mechanically altered diets and 61 residents who received regular consistency diets. Findings include: During a continuous kitchen observation of lunch service beginning at 11:14 AM on 2/4/24, Surveyor noted diet tray cards for the lunch meal indicated: One pork rib, 4 oz. (ounce) serving of green beans, 4 oz. serving of roasted potatoes for regular consistency diets and 4 oz. serving of mashed potatoes (substitute for roasted potatoes) for mechanically altered diets (minced and moist). Surveyor observed Dietary Manager (DM)-D load the steam table with one container of roasted potatoes, one container of pork…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff and resident interview, the facility did not provide a safe, clean, comfortable, home-like environment for 4 Residents (R) (R40, R46, R34, and R10) of 20 sampled residents with the potential to affect other residents who use common areas in the facility. During an observation of R40's room, Surveyor noted garbage, dried spills, and a urine odor. During an observation of R46's room, Surveyor noted dirt and debris on the floor. During an observation of R34's room, Surveyor noted debris on the floor. During an observation of R10's room, Surveyor noted food and debris on the floor and a urine odor. During an observation of the 100 wing activity room, Surveyor noted food, garbage, debris, and peeled wallpaper. During an observation of the 100 wing dining room, Surveyor noted garbage, debris, and structural damage to the walls and floors. During an observation of the 400 wing hallway and nursing station, Surveyor noted garbage, structural damage, and dried spills. Finding include: The…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect multiple residents residing in the facility. The facility did not ensure proper methods to rapidly cool or document cooling temperatures of time/temperature control for safety food not held hot or not for consumption within 4 hours. Findings include: During an initial kitchen tour that began at 9:04 AM on 2/4/24, Dietary Manager (DM)-D indicated the facility follows the Wisconsin Food Code. The facility's Cooling Temperature Log policy and procedure, dated 6/19/23, indicates: Purpose: To monitor cooling temperatures in order to ensure that all food is cooled within specified guidelines for the prevention of foodborne illness. Procedure: 1. Cooked foods shall be cooled under refrigeration within two hours from 135 degrees Fahrenheit (F) or greater to 70 degrees F and within a total of six hours from 135 degrees F to 41 degrees F or less. Temperatures of food placed in the cooler shall be recorded by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility did not provide appropriate care services for 1 Resident (R) (R48) of 2 sampled residents with an indwelling catheter. R48's uncovered catheter drainage bag was observed in direct contact with the floor. Findings include: On 2/6/24 at 1:10 PM, Surveyor reviewed the facility's policy and procedure for catheter care, dated 2/27/18. The policy did not address positioning/placement of tubing or catheter drainage bags. On 2/6/24, Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] with diagnoses including history of neuromuscular dysfunction of bladder and epilepsy. R48's Minimum Data Set (MDS) assessment, dated 1/3/24, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R48 was not cognitively impaired. R48 had a legal Guardian. On 2/6/24 at 8:19 AM, Surveyor observed R48 lying in bed and noted R48's uncovered Foley catheter drainage bag was in direct contact with the floor and visible from…

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, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 Resident (R) (R49) of 20 sampled residents. On 2/4/24, Surveyor observed medication left at R49's bedside. R49 did not have a self-administration of medication assessment or a physician's order to self-administer medication. Findings include: The facility's Administering Medications policy, revised on 1/22/24, indicates: Only licensed staff, or permitted by the State may prepare, administer, or record the administration of medication .Medications may be self-administered by residents who have been assessed and determined to be safe, and must have a physician's order. On 2/5/24, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), acute on chronic diastolic (congestive) heart failure, and pulmonary hypertension. R49's Minimum Data Set (MDS) assessment, dated…

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.