Ozarks Methodist Manor, The

Based on interview and record review, the facility failed to complete a significant change assessment within 14 days of the significant change when facility staff did not complete the assessment for one resident (Resident #228) after being admitted to hospice services. A sample of 21 residents were reviewed. Review of the facility's Resident Assessment Instrument policy, revised September 2010, showed the assessment coordinator is responsible for ensuring that the interdisciplinary assessment team conduct timely resident assessments and reviews when there has been a significant change in the resident's condition. 1. Review of Resident #228's admission Record, located in the Profile tab of the Electronic Medical Record (EMR) showed the following: -admission date of 07/29/22; -Diagnoses included hypertensive (high blood pressure) heart disease, diabetes, and myocardial infarction (heart attack). Review of the resident's Census tab showed there resident began on hospice care on 11/20/24. Review of the resident's Social Services Note, dated 11/20/24, and located in the Prog Notes tab 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 observation, interview, and record review, the facility failed to provide pressure ulcer care per standards of practice when staff failed to document full and accurate assessments of a pressure ulcer and failed to care plan the pressure ulcer and interventions in place to prevent and/or treat pressure ulcers for one resident (Resident # 19), for three residents reviewed for pressure ulcers, in a total sample of 21 residents reviewed. Review of the facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised April 2018, showed the following: -During resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. -The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. -Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, 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 interviews and record review, the facility failed to ensure residents' medical records were complete and accurately documented when the facility failed to ensure physician progress notes were documented and available for review in the electronic medical record (EMR) for one resident (Resident #133), reviewed out of a total sample of 21 residents. 1. Review of Resident #133's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 06/19/23; -Diagnoses included atherosclerotic heart disease (thickening or hardening of the arteries), chronic obstructive pulmonary disease (COPD - a condition caused by damage to the airways or other parts of the lung), low-tension glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve), and osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Review of the resident's quarterly Minimum Data Set (MDS - 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 record review and interviews, the facility failed to conduct ongoing review for antibiotic stewardship for one resident (Resident #15), of three residents reviewed for antibiotic stewardship, who received multiple antibiotics over multiple months. Review of the facility's policy titled, Antibiotic Stewardship, revised December 2016, showed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of the facility's policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, showed the following: -All clinical infections treated with antibiotics will undergo review by the infection preventionist (IP), or designee; -The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; -All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The…

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

Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services when the dietitian was not employed full-time by the facility. The facility census was 59. Review of the facility's policy titled Director of Food and Beverage Services, revised 07/2014, showed the following: -The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training and supervision all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. (The policy did not address the requirements of being a Certified Dietary Manager, Certified in Food Services Manager, or education/training related to service management or hospitality.) 1. During an interview on 05/15/23, at 9:00 A.M., the Dietary Manager (DM) said the following: -He/she was not a Certified Dietary Manager and not enrolled in a training/certification course; -He/she was not a Certified Food Services Manager and did not have an associate's degree or…

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

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards of practice and protect all food from possible contamination when the facility staff failed to ensure foods were held at an appropriate temperature to inhibit the growth of pathogens that can cause foodborne illness; staff failed to discard dented cans when staff stored dented cans on the shelves along with cans of food staff used to prepare resident food; staff failed to discard expired food stored on the shelves along with food used to prepare resident food; staff failed to clean the floor in the dry storage rooms, dishwashing and food preparation area, refrigerators and freezers that stored food used to prepare resident food; staff failed to wear hairnets appropriately while preparing resident's food; staff failed to use proper hand washing and glove use while preparing residents food; and staff failed to regularly test the sanitation levels of the dishwashing machines. The facility census was 59. 1. Review of the Food and Drug Administration…

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, record review, and interview, the facility failed to dispose of empty card board boxes in the kitchen area on the north hall to prevent the harboring of pests. The facility census was 59. Review showed the facility did not provide a policy related to cleaning or refuse disposal. 1. Observation on 05/15/23, at 8:52 A.M., showed in the kitchen area on the north hall, an empty box of oatmeal cream pies laid on the floor on the right side of the washing sink and behind the trash can. Observation on 05/16/23, at 7:50 A.M., showed the following: -One empty box with used gloves, cellophane, and pieces of cardboard laid on the floor in front of the hand washing sink; -Two empty oatmeal cream pie boxes laid on the floor on the right side of the hand washing sink behind the trash can. -In the dry storage area, two empty cardboard boxes laid on the floor in front of the wire shelving on the west side and eleven empty soda flats sat on the top shelf of the wire shelving on the west side. Observation on 05/17/23, at 7:39 A.M., showed the following: -In the dry storage area,…

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 and interview, the facility failed to maintain an effective pest control program when dead and live roaches and brown beetles were observed on the floors in the main kitchen, kitchen on the north hall, and in a freezer in the kitchen on the north hall. The facility census was 59. Review of the facility's Pest Control Policy, undated, showed the following: -The pest control company agrees to furnish regularly scheduled monthly services. Each service can normally be performed during normal working hours on a set date. Each service trip our technician will check with the responsible person and leave an invoice indicating the day they were there, materials used, and any activity noted; -Emergency Maintenance, can call back at no additional cost, will be available for covered pest and services if service is provided monthly. The policy is to initiate corrective measures within 24 hours from notification. When possible, this will be sooner; -The intention in servicing your operation will be to establish a preventative maintenance service; -Covered pests include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident's (Resident #1) code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was signed by a person capable of making an informed decision for the resident, failed to ensure a code status form was signed by the resident for one resident (Resident #17), and failed to ensure one resident's (Resident #212) had a code status present in the medical record A sample of four residents was selected for review out of a facility census of 59. Review of the facility's policy titled, Advanced Directives (written instruction such as a living will or durable power of attorney for health care (DPOA - a person established to make health care decisions if a person is unable to make their own), relating to the provisions of health care when the individual is incapacitated (unable to care for self or affairs)), dated [DATE], showed the following: -The facility will respect advance directives in accordance…

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

Based on interview and record review, the facility failed to report an allegation of abuse to the state licensing agency (Department of Health and Senior Services- DHSS) within the required time frame when one resident (Resident #48) alleged staff were assaulting him/her. A sample of two residents was selected in a facility with a census of 59. Review of the facility's policy titled Abuse, Neglect Exploitation and Misappropriation Prevention Program, revised 04/2021, showed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. ReviewofthefacilityspolicytitledAbuse Neglect ExploitationorMisappropriation- ReportingandInvestigating, revised09/2022, showedthefollowing -Ifaresidentabuse neglect exploitation misappropriationofresidentpropertyorinjuryofunknownsourceissuspected…

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

Based on interview and record review, the facility failed to complete an investigation of an allegation of abuse when one resident (Resident #48) alleged staff assaulted him/her A sample of two residents was selected in a facility with a census of 59. Review of the facility's policy titled Abuse, Neglect Exploitation and Misappropriation Prevention Program, revised 04/2021, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 09/2022, showed the following: -All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required 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.

Based on observation, record review, and interview, the facility failed to identify, develop, implement, and care plan new interventions in attempt to prevent falls for one resident (Resident #23) who had a decline in his/her function resulting in multiple falls. A sample of three residents were reviewed in a facility with a census of 59. Record review of the facility's Fall - Clinical Protocol Policy, revised March 2018, showed the following information: -Staff will evaluate and document falls that occur while the individual is in the facility including when and where they happen and any observations of the events;. -Falls should be categorized as: those that occur while trying to rise from a sitting or lying to an upright position; those that occur while upright and attempting to ambulate; and other circumstances such as sliding out of a chair or rolling from a low bed to floor; -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Often multiple factors contribute to a falling problem; -If 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, interview, and record review, the facility failed to ensure one resident (Resident #10) who had a history of chronic (recurring) urinary tract infections (UTI-an infection in any part of the urinary system) received timely treatment and care after the resident voiced symptoms of a urinary tract in a sample of three residents. The facility census was 59 residents. Record review of the facility's Lab and Diagnostic Test Results-Clinical Protocol, revised November 2018, showed the following information: -The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs; -The staff will process test requisitions and arrange for tests; -The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility; -When test results are reported to the facility, a nurse will first review results; -If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident's received behavioral health services to maintain the highest practical psychosocial well-being when the facility failed to care plan and implement resident specific interventions for and failed to have social services follow-up with one resident (Resident #32) who had a history of depression and had expressed signs of possible depression. A sample of three residents were reviewed in a facility with a census of 59. 1. Review of Resident #32's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included major depressive disorder and anxiety disorder. Review of the resident's social services initial note, dated [DATE], showed the resident was widowed and lived alone prior to entering the facility. The resident received Lexapro (a antidepressant) for depression prior to his/her admission. Review of the resident's care plan,…

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 and interview, the facility failed to adequately equipped with a full call light system when call light pull cords in two residents' (Resident #23 and Resident #10) rooms were too short where residents not always easily access the pull cord for staff assistance. The facility census was 59. Review of the facility's policy titled Resident Call System, dated September 2022, showed the following: -Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station; -Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor; -The resident call system is routinely maintained and tested by the maintenance department. 1. Observation on 05/18/23, at 8:23 A.M., of Resident #23's room, showed the call light pull cord in the resident's bathroom next to the toilet was not long enough to reach the floor. During an interview on 05/18/23, at 10:30 A.M., the resident said restorative staff work 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 observation and interview, the facility failed to ensure the prior survey results were posted in a readily accessible public location for residents, family members, and residents' legal representatives. The facility census was 60. 1. Observation on 1/21/20 at 2:00 P.M., showed several binders, including the binder containing the 4/7/18 annual survey results, placed on a shelf located above a small table, near the South nurses' station. The binder, containing the survey results, would not be easily accessible to residents, or anyone else, in a wheelchair or who had difficulty walking, without asking for assistance. During an interview on 1/21/20 at 2:10 P.M., Certified Nurse Aide (CNA) A said the survey results should be at the nurses' desk but he/she did not know the exact location of the survey results book. An interview and observation on 1/21/20 at 2:12 P.M., showed the following: -The Director of Nursing (DON) said she thought the past survey results were located at the nurses' station. -The DON looked through the various binders placed on the shelf near the South…

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 record review and interview, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessments were completed within the required timeframe for three residents (Resident #7, Resident #11, and Resident #15) out of a sample of 18 residents. The facility census was 60. Record review of the facility policy, titled Electronic Transmission of the MDS from the Nursing Services Policy and Procedure Manual for Long-Term Care, dated 2001 and revised September 2010, showed the following information: -All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into the facility's MDS information system and transmitted to Centers for Medicare/Medicaid Services' (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System in accordance with current OBRA regulations governing the transmission of MDS data. -All staff members responsible for completion of the MDS receive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to electronically transmit encoded data Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, assessments from the facility to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within 14 days on one resident (Resident #3) out of a sample of 18 residents selected for review. The facility had a census of 60 residents. Record review of the facility policy, titled Electronic Transmission of the MDS from the Nursing Services Policy and Procedure Manual for Long-Term Care, dated 2001 and revised September 2010, showed the following information: -All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into the facility's MDS information system and transmitted to Centers for Medicare/Medicaid Services' (CMS)…

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

Based on interview and record review, the facility failed to ensure a registered nurse certified the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, completion date (Z0500B) no later than 14 days after the assessment reference date (ARD - A2300) for three residents (Resident #3, Resident #5, and Resident #12). The facility census was 60. Record review of the Resident Assessment Instrument (RAI) manual, dated 10/1/17, showed the following: -Z0500B description: MDS Completion Date - date of the RN assessment coordinator's signature, indicating that the MDS is complete; -In accordance with the requirements at 42 CFR 483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: -For all non-admission Omnibus Budget Reconciliation Act of 1987 (OBRA) and Prospective Payment System (PPS) assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300). 1. Record review of Resident #3's MDS…

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 interview, the facility failed to maintain the residents' bathroom exhaust ventilation system in proper working condition when 23 residents' bathrooms did not have functioning exhaust vents. The facility had a census of 60. 1. Observation on 01/23/2020, beginning at 8:30 A.M., showed the exhaust ventilation system in the following rooms did not work when tested: -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]; -room [ROOM NUMBER]. During an interview on 01/23/2020, at approximately 1:15 P.M., the maintenance supervisor (MS) said he did not know the residents' bathroom exhaust system…

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, record review, and interview, the facility failed to document monitoring of antibiotic use for one resident (Resident #39) with a urinary tract infection. A sample of 18 residents were selected for review in a facility with a census of 60. Record review of the facility's policy titled Infections-Clinical Protocol, revised March 2018, showed the following: -The nursing staff and physician or provider will monitor the progress of a resident with an infection until it is resolved. 1. Record review of Resident #39's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 11/8/19, showed the following: -admitted to the facility on [DATE]; -Moderately impaired cognition; -Required supervision/assistance of one staff with toileting; -Had an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine); -Had a urinary tract infection in the last 30 days. Record review of the resident's January 2020 physician order sheet showed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #19) with a CPAP (continuous positive airway pressure) ventilation machine had a physician order for the use and care of the machine. A sample of 18 residents were selected for review in a facility with a census of 60. Record review of the facility's policy titled, Continuous Pressure Airway Pressure (CPAP) Administration, undated, showed: -Purpose to administer CPAP to maintain open airway to the resident with obstructed sleep apnea or respiratory problems breathing when sleeping; -Check physician's order for pressure setting and method of administration; -CPAP machine should be placed on table near bed; -Fill humidifier with distilled water to appropriate level (optional may use tap water); -Assist resident as needed to applying and adjusting CPAP mask and head strap; -Use a wet cloth or cleaning cloth to wipe the outside surface of the CPAP machine; -Clean the back filter weekly by running it under warm…

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 record review and interview, the facility failed to ensure the record was accurate and complete when staff did not document one resident's (Resident #52) decline in condition for seven days before the resident's death. A sample of 18 residents was selected for review in a facility with a census of 60. Record review of the facility's policy, undated, titled Charting and Documentation showed the following: -The purpose of these guidelines is to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, as well as the resident's progress; -Guidance to the physician in prescribing appropriate medications and treatments; -The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident; -Nursing services personnel with a record of the physical and mental status of each resident; -Assistance in the development of a plan of care for each resident; -The elements of quality medical nurse care; -A legal record that…

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