Form CMS-2567, Statement of Deficiencies Instructions

Provide the signature of the representative for the facility surveyed.

Enter the title of the person signing the form.

Enter the date when the survey was completed.

Enter the ID Prefix Tag associated with the deficiency.

Provide a concise but complete description of the deficiency observed, including relevant regulatory citations, circumstances, and specific details needed to identify the issue.

Enter the short regulatory or survey identifier (for example an F‑tag or LSC code) that labels this deficiency row.

Describe the corrective actions to address the deficiency, including steps to be taken, responsible persons, timelines, and how recurrence will be prevented, and cross‑reference the related deficiency ID.

Enter the date when the corrective actions for this deficiency were completed or are expected to be completed.

Enter the name of the facility that was surveyed.

Enter the facility's full street address including city, state, and ZIP code.

If applicable, enter the full name of the accrediting organization that performed the survey; otherwise leave this field blank.

Enter the full official name of the facility being surveyed.

Enter the short ID or regulatory/LSC tag that identifies the deficiency being reported in this row.

Provide the full narrative description of the deficiency, including any regulatory or LSC identifying information and details of the finding. Fill only if 'Deficiency ID Prefix (left)' is filled.

Enter the ID prefix or tag used to cross-reference the specific deficiency to the corresponding plan of correction. Fill only if 'Deficiency ID Prefix (left)' matches field 2.

Describe the corrective actions to be taken to address the deficiency, including steps, responsible parties, and how the action maps to the deficiency ID. Fill only if 'Summary Statement of Deficiencies', 'Deficiency ID Prefix (P.O.C. reference)' are filled (all).

Enter the date by which the corrective action is expected to be completed for this deficiency. Fill only if 'Plan of Correction' is filled.

Enter the identifier for the building involved in the multiple construction (e.g., building name or number).

Enter the identifier for the wing involved in the multiple construction (e.g., wing name, letter, or number).

Enter the current page number of the form.

Enter the total number of pages in the form.

Enter the number of this page in the document (the current page index for the continuation sheet).

Enter the total number of pages in this continuation sheet set (the final page count for the document).

Enter the facility's Provider, Supplier, or CLIA identification number exactly as assigned by the agency, including any leading zeros, letters, or punctuation.

Enter the date when the form was signed by the facility's representative. Use the format MM/DD/YYYY.

Enter the date the survey was completed by the surveyor (the final day of the on-site survey).