Ava Nursing And Rehab Center

Based on review of clinical records, and staff interviews, it was determined that the facility failed to obtain appropriate physician's orders for two of 68 residents reviewed (Resident 6 and Resident 108) who had a urinary catheter.Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6 dated August 29, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included dementia. A nurse's note for Resident 6 dated September 3, 2025, indicated that staff obtained a urine sample using a straight catheter procedure (temporarily inserting a sterile, flexible, hollow tube through into the bladder to drain urine, and then removing it once the bladder is empty) without difficulty. There was no documented evidence to indicate that a physician's order was obtained prior to the procedure. Interview with the Director of Nursing on September 18, 2025, at 12:20 p.m. confirmed that there was no documented evidence that a physician's order…

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that dietitian recommendations for dietary supplements were accurately ordered for one of 68 residents reviewed (Resident 98).Findings include:The facility's policy regarding nutritional supplements, dated January 18, 2025, revealed that a physician's order would be required for residents who are underweight, who are on therapeutic diets, and those with poor intakes.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 98, dated August 7, 2025, indicated that the resident was cognitively intact, required partial assistance from staff for care needs, had diagnoses that included stage four chronic kidney disease, received hemodialysis (a process removes waste and extra fluids from the blood), and was ordered a therapeutic diet. Resident 98's care plan for a risk for weight gain or loss related to dialysis, dated August 8, 2025, included an intervention to include him to be…

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, as well as staff interviews, it was determined that the facility failed to ensure that residents who were receiving enteral feedings received appropriate treatment and services to prevent complications for two of 68 residents reviewed (Residents 118 and 130). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 118, dated August 8, 2025, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, had a gastrostomy tube (G-tube/peg tube/feeding tube-a thin flexible tube inserted into the gastrointestinal tract to provide nutrition to individuals who cannot eat or absorb enough nutrients orally) and had a diagnosis of dysphasia (difficulty swallowing). Physician's orders for Resident 118 dated May 12, 2021, included an order to cleanse the area around the peg tube with soap and water and apply drain dressing daily and as needed every day shift.…

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, as well as staff interviews, it was determined that the facility failed to ensure that physician orders were obtained to flush intravenous catheters (small tube inserted into a vein to deliver fluids or medication) for one of 68 residents reviewed (Resident 130).Findings include: Review of clinical records for Resident 130 revealed that he was admitted to the facility on [DATE], with a diagnosis of hemiparesis (weakness or paralysis on one side of the body) following a stroke and esophageal cancer. He was transferred to the hospital on September 7, 2025, and returned to the facility on September 10, 2025. Physician's orders for Resident 130 dated September 14, 2025, included for staff to administer 2 grams of Ceftriaxone (an antibiotic) intravenously every 12 hours for five days for pneumonia. Review of the Medication Administration Record for Resident 130 dated September 2025, revealed 2 grams of Ceftriaxone was administered intravenously on September 14 at 10:24 a.m.,…

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 manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in accordance with currently accepted professional principles for one resident (Resident 88, in one of three medication carts reviewed (Oak Medication Cart). Findings include: The facility's policy regarding storage of medications, dated January 18, 2025, revealed The facility stores all medications and biologics on locked compartments under proper temperature, humidity and light controls and only authorized personnel have access to keys. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location. medications are stored separately from food and are labeled accordingly. Manufacturer's directions for the use of Liraglutide (a once daily, non-insulin injectable medication specifically formulated for type 2 diabetes mellitus (a chronic condition where high blood glucose levels result 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 review of facility policy, clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for two of 68 residents reviewed (Residents 49 and 130). Findings include:A facility policy dated January 18, 2025, regarding charting and documentation revealed that events, incidents, or accidents involving the resident were to be documented in the residents' medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated July 2, 2025, revealed that the resident was moderately cognitively impaired, was understood, could understand, required supervision for care needs, and had diagnoses that included fractures and other trauma. A fall investigation report dated August 14, 2025, indicated that Resident 49 was found on the floor and had sustained a skin tear. The investigation concluded that she slid off the side of 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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include:The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending October 24, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 18, 2025, identified repeated deficiencies related to comprehensive assessments and timing, quarterly assessments and timing, development and implementation of comprehensive care plans, quality of care, and labeling and storage of drugs and biologicals.The facility's plan of correction for a deficiency regarding comprehensive…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for 57 of 138 residents reviewed (Residents 6, 10, 11, 13, 23, 27, 28, 30, 32, 38, 39, 43, 56, 57, 69, 70, 81, 83, 84, 85, 86, 89, 90, 94, 96, 97, 98, 99, 100, 101, 102, 103, 110, 113, 115, 118, 120, 121, 124, 129, 130, 131, 132, 133, 134, 137, 139, 140, 141, 143, 145, 147, 149, 150, 151, 153, 154). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission. A comprehensive admission MDS assessment for Resident 6, dated July 12, 2024, revealed that 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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for 42 of 138 residents reviewed (Residents 1, 2, 3, 7, 12, 16, 18, 19, 20, 21, 25, 29, 31, 34, 35, 36, 37, 41, 44, 46, 47, 49, 50, 52, 53, 55, 59, 60, 63, 65, 71, 78, 82, 87, 91, 92, 93, 114, 116, 117, 125, 144). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2024, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days). A quarterly MDS assessment for Resident 1, with an ARD of June 27, 2024, was completed…

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 the Resident Assessment Instrument, clinical records, and the Minimum Data Set validation report, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for 31 of 138 residents reviewed (Residents 6, 12, 22, 37, 52, 80, 84, 96, 111, 112, 114, 118, 119, 123, 124, 128, 130, 131, 132, 133, 135, 136, 138, 140, 141, 142, 143, 145, 150, 152, 153). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that Entry/Reentry and Death in Facility tracking record must be completed within seven days of the Event date (section A1600 for Entry/reentry records plus seven days…

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 the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for five of 56 residents reviewed (Residents 37, 43, 84, 88, 91). Findings include: The RAI User's Manual, dated October 2023, revealed that Section N0415A1 Antipsychotic Medications (medications used to treat mental health disorders) was to be coded if the resident took the medication during the seven-day look-back period. Section N0450A Antipsychotic Medication Review was to be coded (0) if the resident did not receive an antipsychotic medication and was to be coded (1), (2) or (3) if the resident received an antipsychotic medication. Section N0450B was to be coded (0) if a gradual dose reduction (GDR) was not attempted or (1) if a GDR had been attempted. Section N0450C was to be coded to indicate the date of the last attempted GDR. Physician's orders for Resident 37, dated August 15, 2024,…

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, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for four of 138 residents reviewed (Residents 67, 97, 100, 311). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 67, dated September 23, 2024, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis of hypotension (low blood pressure). Physician's order for Resident 67, dated October 7, 2024, included an order for the resident to receive 10 milligrams (mg) of Midodrine HCL (treats hypotension) every Monday, Wednesday, and Friday, hold if systolic blood pressure (top number) is greater than 130. Physician's order for Resident 67, dated October 19, 2024, included an order for the resident to receive 5 mg Midodrine every Tuesday, Thursday, Saturday, and Sunday and to hold if the systolic blood pressure is greater than 130. Review of Resident 67's Medication…

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 reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs for two of 138 residents reviewed (Residents 74, 81). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 74, dated August 23, 2024, revealed that the resident was cognitively intact and had diagnoses that included diabetes. Pharmacy Medication Regimen Review for Resident 74, dated August 10, 2024, included recommendation for the physician to discontinue the resident's Arixtra (blood thinner) and to taper the resident's fingerstick monitoring with sliding scale insulin coverage. The physician agreed with the pharmacist recommendations and discontinued the Arixtra and the fingerstick monitoring with sliding scale coverage on September 15, 2024, 36 days later. Resident 74's Medication Administration Records (MAR's) for August and September 2024 revealed that the resident received the Arixtra and the fingerstick monitoring 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 138 residents reviewed (Resident 43). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated September 11, 2024, indicated that the resident was cognitively impaired, received an antianxiety medication, and had diagnoses that included anxiety. Physician's orders for Resident 43, dated June 6 and October 19, 2024, included orders for the resident to receive 0.5 milligrams (mg) of Ativan (an antianxiety medication) every four hours as needed for mild anxiety and shortness of breath. Resident 43's care plan, dated July 25, 2023, revealed that the resident used an antianxiety medication related to anxiety. Resident 43's Medication Administration Records (MAR's) for September and October 2024 revealed that staff administered as needed Ativan to 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 review of facility policies and dishwasher temperature logs, as well as staff interviews, it was determined that the facility failed to record proper dishwasher temperatures for each meal in the main kitchen. Findings include: The facility policy for dish machine temperatures, dated January 16, 2024, revealed that dietary aides were responsible for recording dish machine temperatures each meal period. The wash temperature was to be 150 degrees Fahrenheit (F) and the rinse temperature was to be 180 degrees F. To ensure that the wash and rinse temperatures were properly monitored and controlled, a log was to be completed by those who were directly involved in the dish washing process. Entries were to be made for each meal. Review of the Dish Machine Temperature Log, dated August 21 through October 21, 2024, revealed that from August 21 to September 13, September 15 to September 28, September 29 to October 12, and October 14 to October 21, 2024, there was no documented evidence that proper dish machine temperatures were obtained and recorded for each meal. Interview with 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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if a resident was safe to self-administer medications for one of 138 residents reviewed (Resident 69). Findings include: The facility's self administration of medication policy, dated January 16, 2024, indicated that self-administration was permitted when the interdisciplinary team has determined that it was clinically appropriate and safe for the resident to do so. An annual Minimum Data Set (MDS) for Resident 69, dated July 12, 2024, indicated that the resident was cognitively intact, required assistance for daily care needs, and had diagnoses that included stroke, anxiety, depression, and hypertension (high blood pressure). Physician's orders for Resident 69, dated October 19, 2024, included an order for the resident to receive 25 milligrams (mg) of metoprolol twice a day for hypertension, and to receive 20 mg of omeprazole twice a day for gastroesophageal reflux (GERD - heartburn). Physician's orders for Resident 69, 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.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to document the opportunity for the resident and/or resident representative to formulate advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), and failed to document the resident's and/or resident representative's decision to accept or decline assistance to formulate advance directives for three of 138 residents reviewed (Residents 37, 40, 53). Findings include: The facility's policy regarding advance directives, dated January 16, 2024, indicated that upon admission, the resident or resident representative will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or resident representative indicates that he or she has not established advance directives, the healthcare center staff will offer assistance in establishing advance…

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 reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for one of three residents reviewed (Resident 101) who remained in the facility for long-term care. Findings include: A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated September 12, 2024, revealed that Medicare coverage for Resident 101 started on August 2, 2024, and that his last covered day was September 16, 2024. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. There was no documented evidence that Resident 101 was provided with an Advance Beneficiary Notice of Noncoverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case). Interview with the Director of Social Services on October 24, 2024, at 10:58 a.m. revealed that 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 clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian, in writing, regarding the reason for hospitalization for three of 138 residents reviewed (Residents 12, 74, 106). Findings include: A nursing note for Resident 12, dated July 18, 2024, at 1:49 p.m., revealed that the resident was admitted to the hospital with respiratory failure. There was no documented evidence that a written notice of Resident 12's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. A nursing note for Resident 74, dated May 15, 2024, at 11:03 a.m., revealed that the resident was admitted to the hospital with uncontrolled bleeding. There was no documented evidence that a written notice of Resident 74's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer. A nursing note for Resident 106, dated September 28, 2024, 2024, at 7:26 p.m., revealed that the resident was admitted to the hospital with chronic obstructive…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for two of 138 residents reviewed (Residents 37, 84). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated January 16, 2024, included that the interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change. A quarterly MDS assessment for Resident 37, dated September 27, 2024, indicated that the resident was cognitively impaired, was able 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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 138 residents reviewed (Residents 33, 81). Findings include: A facility policy for Comprehensive Person-Centered Care Plans, dated January 16, 2024, included that the interdisciplinary team, in conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated July 18, 2024,…

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 facility assessment reports, as well as staff interviews, it was determined that the facility failed to provide the correct consistency of food to one of 138 residents reviewed (Resident 71) and failed to complete safety assessments for two of 138 residents reviewed (Residents 85, 100) who used an air mattress. Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 71, dated September 10, 2024, revealed that the resident was cognitively intact and required a mechanically-altered diet. Physician's order for Resident 71 included an order, dated March 15, 2024, for the resident to receive a pureed texture diet, add sauce and gravy, with nectar consistency liquids (thickened liquids). A nursing note for Resident 71, dated July 25, 2024, revealed that the resident was choking and that the licensed practical nurse had performed the Heimlich maneuver. The resident was choking on his lunch. A witness statement by the Speech Therapist, dated July 25,…

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 reviews and staff interviews, it was determined that the facility failed to respond timely to a pharmacy recommendation for one of 138 residents reviewed (Resident 74). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 74, dated August 23, 2024, revealed that the resident was cognitively intact and had diagnoses that included diabetes. A pharmacy medication regimen review, dated June 4, 2024, revealed that the pharmacist recommended that the physician change the resident's Allopurinol from 50 milligrams (mg) twice per day to 100 mg once per day and that the resident's Zoloft (antidepressant) be moved to morning as it causes insomnia. The physician agreed to the recommendations and made the changes on July 6, 2024, over a month later. An interview with the Nursing Home Administrator on October 23, 2024, at 3:49 p.m. confirmed that the pharmacy medication regimen reviews were not addressed timely for Resident 74 and they should have been. 28 Pa. Code…

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 facility policies, as well as observations and staff interviews, it was determined that the facility failed to label insulin with the date is was opened in one of three medication carts reviewed (Walnut hall); failed to discard two expired multi-dose vials of insulin in one of three medication carts reviewed (Maple hall); failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in one of two medication rooms reviewed (medication room on East Wing); and failed to ensure that medications were properly stored and labeled for one of 138 residents reviewed (Resident 69). Findings include: The facility's policy regarding medication labeling and storage, dated [DATE], indicated that controlled substances (medications with the potential to be abused) and other drugs subject to abuse are separately locked in permanently-affixed compartments. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and…

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

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending November 16, 2023, as well as a complaint visit on May 13, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending October 24, 2024, identified repeated deficiencies related to inaccurate Minimum Data Set (MDS) assessments, failing to create an individualized plan of care, quality of care, safety/accidents, label/store drugs and biologicals, and food procurement/storage/preparation. The facility's plan 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 review of established infection control guidelines and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 138 residents reviewed (Resident 81). Findings include: CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance…

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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and/or received the influenza immunization for one of 138 residents reviewed (Resident 43). Findings include: The facility's policy regarding the influenza vaccine, dated January 16, 2024, indicated that all residents and employees who had no contraindications to the vaccine would be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1 and March 31 each year, the influenza vaccine would be offered to residents and employees. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated September 11, 2024, revealed that the resident could make himself understood and could usually understand others, was cognitively impaired, and did not have the influenza vaccine information assessed.…

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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for two of six residents reviewed (Residents 1, 2). Findings include: The facility's policy regarding care plan development, dated January 16, 2024, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 25, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, and had no skin impairments. Physician's orders for Resident 1, dated May 4, 2024, included an order for contact precautions (precautions put in place when a resident has a known or suspected illness that is easily transmitted by direct or indirect contact with the resident or items in 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 review of established infection control guidelines, facility policies, documents, residents' clinical records, and employee files, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for three of six residents reviewed (Residents 4, 5, 6). Findings include: CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 42 residents reviewed (Resident 51) Findings include: A facility policy for the management of hypoglycemia, dated November 1, 2022, indicated that for asymptomatic (no symptoms) responsive residents with hypoglycemia (blood sugar less than 70 milligrams per deciliter (mg/dl)) staff were to give the resident an oral form of rapidly absorbed glucose (sugar), recheck the blood sugar in 15 minutes, and notify the physician for further orders. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 51, dated August 30, 2023, indicated that he was cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included diabetes. Review of the September and October 2023 Medication Administration Record (MAR) for Resident 51 revealed that on September 2, 2023, at 8:00 a.m. the resident's blood sugar was 69 milligrams per…

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 reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident had effective interventions in place for fall prevention for one of 42 residents reviewed (Resident 18), failed to safely transfer one of 42 residents reviewed (Resident 20) who required assistance from staff for transfers, and failed to complete safety assessments for one of 42 residents reviewed (Resident 37) who used an air mattress. Findings include: The facility's policy regarding falls, dated November 1, 2022, indicated that the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated October 31, 2023, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure. A fall care plan, dated October…

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 staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 42 residents reviewed (Resident 51). Findings include: A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident's abilities and care needs) for Resident 51, dated August 30, 2023, indicated that he was cognitively impaired, was dependent on staff for personal care needs, and had diagnoses that included diabetes (a disease that interferes with blood sugar control), and received insulin. Physician's orders for Resident 51, dated July 3, 2023, included an order for the resident to receive 2 units of insulin aspart (fast acting) insulin if his blood sugar was between 111 milligrams per deciliter (mg/dL) and 149 mg/dl; 3 units of insulin aspart insulin if his blood sugar was between 150 mg/dL and 199 mg/dL; 4 units of insulin aspart insulin if his blood sugar was between 200 mg/dL and 249 mg/dL; 8 units of insulin aspart insulin if his blood sugar was between 250 mg/dL and 299 mg/dL; 10 units 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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by not dating opened food items and not storing food under sanitary conditions. Findings include: The facility's policy regarding food labeling and dating, dated November 1, 2022, revealed that all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Observations in the walk-in freezer on November 13, 2023, at 9:55 a.m. revealed that a portion of frozen ham was dated March 39, 2023, and a bag of frozen cheese was opened and exposed to air and not sealed. The cheese had ice crystals throughout the portion of frozen cheese. Interview with the Dietary Manager at the time of observation confirmed that the frozen ham was dated for the time it was frozen and did not have a use by date and it should have. She also confirmed that the bag of cheese should have been sealed and not open to air. 28 Pa. Code 211.6(f) Dietary services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or the responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for two of 42 residents reviewed (Residents 3, 5). Findings include: A facility policy for Bed Holds and Returns, dated November 1, 2022, included that all residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payor source, are provided written notice about these policies. A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 20, 2023, revealed that the resident was cognitively impaired, required supervision with daily care needs, and had diagnosis that included chronic respiratory failure. Nurses' notes for Resident 3, dated December 22, 2022, at 6:45 p.m.,…

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 the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 42 residents reviewed (Residents 3, 11, 56). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0410H Opioid Medications (narcotic medications used to treat pain) was to be coded for the number of days the resident used an opioid during the seven-day assessment period. Physician's orders for Resident 3, dated June 28, 2023, included an order for the resident to receive 50 micrograms Fentanyl (an opioid used for pain) every three days. The resident's Medication Administration Record (MAR) for September 2023 revealed that the resident received Fentanyl three out of the seven-day look-back assessment period. A quarterly MDS for Resident 3, dated September 20,…

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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 42 residents reviewed (Resident 11). Findings include: A facility's policy regarding care plans, dated November 1, 2022, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated October 31, 2023, revealed that the resident was cognitively intact and required assistance from staff for daily care needs and had diagnosis that included hypertension and end-stage renal disease. A physician note for Resident 11, dated October 19, 2023, at 4:17 p.m., stated that the resident had presence of a cardiac pacemaker. Physician's orders for…

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 Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to clarify physician's orders for one of 42 residents reviewed (Residents 51) and failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 42 residents reviewed (Residents 69). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. A quarterly Minimum Data Set (MDS) assessment (mandated to assess the resident abilities and care needs) for Resident 51, dated August 30, 2023, indicated that he was cognitively impaired, was dependent on staff for personal care needs, had an indwelling catheter (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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) was flushed as ordered by the physician for one of 42 residents reviewed (Resident 76). Findings include: admission records for Resident 76 revealed that she was admitted on [DATE], was cognitively intact, and had diagnoses that included chronic respiratory failure and bacteremia (presence of bacteria in the bloodstream). Physician's orders for Resident 76, dated November 3, 2022, included an order for the resident's PICC line to be flushed with 10 cubic centimeters (cc) of normal saline solution (NSS) every shift to maintain patency. Review of the November 2023 Medication Administration Record (MAR) for Resident 76 revealed no documented evidence that the resident's PICC line was flushed as ordered on November 6 on evening…

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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 42 residents reviewed (Resident 325). Findings include: The facility's policy regarding the administration of oral medications, dated November 1, 2022, indicated that the nurse will document on the Medication Administration Record (MAR) with their initials, at the appropriate date and time for the medication administered, after witnessing the ingestion of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 325, dated August 3, 2022, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included a Stage 3 pressure ulcer and acute myeloblastic leukemia in remission. Physician's orders for Resident 325, dated July 23, 2023, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (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.

Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin with the date they were opened in two of three medication carts reviewed (Walnut Medication Cart on East Wing and Maple Medication Cart on [NAME] Wing). Findings include: Manufacturer's directions for the use of Levemir insulin (a long-acting insulin used to lower blood sugar levels), dated December 2022, revealed that unused Levemir should be stored in a refrigerator between 36 degrees Fahrenheit (F) to 46 degrees F. After initial use it may be kept at temperatures below 86 degrees F for up to 42 days. Manufacturer's directions for the use of Lantus insulin (a long-acting insulin used to lower blood sugar levels), dated December 2020, revealed that unused Lantus should be stored in a refrigerator between 36 degrees F to 46 degrees F. After initial use it may be kept at temperatures below 86 degrees F for up to 28 days. Manufacturer's directions for the use 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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending November 10, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 16, 2023, identified repeated deficiencies related to accuracy of Minimum Data Sets (MDS), creating and implementing care plans, quality of care, pharmacy services, food procurement/storage/preparation. The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending…

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 manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition on the facility's emergency cart in two of two the medical storage areas (East and West) reviewed. Findings include: Manufacturer's directions for Powerheart Automated External Defibrillator (AED - a device that delivers an electric shock through the chest to the heart when it detects an abnormal rhythm), dated 2010, revealed that the AED pads have a limited shelf life and should not be used beyond the expiration dated. Keep a fresh, unopened pair of pads plugged into the AED at all time. Using pads that are damaged or expired may result in improper AED performance. Observations in the East storage area behind the nurses' station on [DATE], at 5:03 p.m. revealed that the crash cart had an AED. The AED pads were connected to the machine and had a expiration date of [DATE]. Interview with Licenced Practical Nurse…

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.