Ozark Care & Rehab Center

Based on observation, record review, and interview, the facility failed to ensure medications were not left at bedside for a resident that was not assessed to self-administer medications for one resident (Resident #36) out of 21 residents in the sample. Review of the facility's policy titled, Medication Administration undated, showed the following regarding self-administration of medication by residents: -The resident must be alert and oriented and be familiar with taking his/her own medication. The medication must be kept in a locked box or locked drawer. -The resident must have a physician's order for self-administration. -A list of the medication was kept in the resident's MAR and his/her medical record. This list was monitored by the charge nurse every month and when there was any change of orders. -The charge nurse will also check the lock box periodically, but at least weekly. -The resident had a medication administration sheet that he/she kept to document when he/she took any medication. 1. Review of Resident #62's Face Sheet, located in the electronic medical record (EMR)…

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 develop and implement a complete care plan for each resident when staff failed to care plan smoking on the facility's property for two residents (Resident #12 and #62) of two residents reviewed for smoking. Review of the facility's policy titled, Care Plan Policy, dated 03/23/18, showed initial care plans are written shortly after admission (or re-admission) and are reviewed every three months so new problems can be dealt with at the time. 1. Review of Resident #12's Face Sheet tab of the electronic medical record (EMR) showed the following: -admission date on 01/31/24; -Diagnoses included nicotine dependence. Review of the resident's Care Plan, dated 03/21/24 and located in the Care Plan tab of the EMR, showed the staff did not care plan related to the resident's nicotine dependence and smoking. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 08/14/24, and located in the Resident Assessment Instrument (RAI)…

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 ensure effective pain management was provided for every resident when staff failed to keep pain medication in stock and failed to follow-up on pain relief after administering as needed pain medication for one resident (Resident #14) reviewed for pain of 21 sampled residents. 1. Review of Resident #14's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 01/18/24; -Diagnoses included multiple sclerosis (MS - a chronic autoimmune disease that affects the central nervous system, which includes the brain, spinal cord, and optic nerves) and lower back pain. Review of the resident's Care Plan, dated 10/30/20, located in the resident's EMR under the Care Plan tab, showed the resident had had chronic pain. Interventions included for staff to address complaints of pain promptly and administer as needed (PRN) medication for breakthrough pain. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed 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 interview and record review, the facility failed to ensure the Director of Nursing (DON) did not serve as a charge nurse or certified nurse aide (CNA) when the facility census was greater than 60. The facility census was 68. Review showed the facility did not provide a policy regarding the responsibilities of the DON position. 1. Review of the facility provided nurse schedules and staff rosters, dated August 2024, showed the following: -On 08/09/24, the DON worked as a charge nurse on the 3:00 P.M. to 7:00 P.M. evening shift. The facility census was 72; -On 08/13/24, the DON worked as a certified nurse aide (CNA)/nurse aide (NA) on the 6:30 P.M. to 11:00 P.M. evening shift. The facility census was 71; -On 08/16/24, the DON worked as a Licensed Practical Nurse (LPN)/Certified Medication Technician (CMT) on the 6:30 A.M. to 3:00 P.M. day shift. The facility census was 71; -On 08/19/24, the DON worked as a CNA/NA on the 6:30 P.M. to 11:00 P.M. evening shift. The census was 73; -On 08/23/24, the DON worked as a CNA/NA on the 6:30 P.M. to 11:00 P.M. evening shift. The census was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the facility promoted each resident's right to self-determination when staff failed to provide bath/showers as preferred for four residents (Resident #5, Resident #6, Resident #7 and Resident #8) out of a sample of 14 residents. The facility had a census of 68. Review of the facility's policy titled, Shower Protocol, undated showed the following: -A and B wing shower schedule: Monday and Thursday hall one and two receive showers and Tuesday and Friday hall three and four receive showers. Wednesday is a make up day; -Document in the computer if shower given or not; -If resident refuses, fill out refusal form and have charge nurse chart refusal; -Shower list should be done daily and turned into front office with refusal forms. 1. Review of Resident #5's face sheet (admission data) showed the following: -admission date of 07/15/22; -Diagnoses included chronic obstructive pulmonary disease (COPD-a group of lung disease that blocks airflow and makes…

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 provide care per standards of practice when staff failed to consistently assess and document complete, thorough, and accurate weekly skin assessments and when staff failed to complete weekly wound tracking for three residents (Resident #1, Resident #2, and Resident #3) with pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of a sample of four residents. The facility census was 68. Review of the facility's policy titled Skin Integrity/Wound Policy, dated 01/19/24, showed the following: -The Director of Nursing (DON)/designee will perform weekly skin assessments for all reported residents with alteration of skin integrity related to ulceration of skin and document stage, size, description, color. and odor; -Weekly skin assessments on all residents will be completed and documented by the charge nurse. Weekly skin assessment documentation…

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 maintain a current and accurate facility assessment when facility staff failed to review and update the comprehensive facility assessment at least annually. The facility census was 71. Review showed the facility did not provide a policy regarding the facility assessment. 1. Review of the facility assessment showed staff completed the current facility assessment in 2023. The staff did not document a review of the facility assessment since April 2023. During an interview on 07/26/24, at 4:40 P.M., the Administrator said the following: -The facility assessment is supposed to be updated annually and the last time she updated it was 04/26/23. -She did not do the annual update in 2024. -She is responsible for reviewing and completing the facility assessment. -The facility staff should review the facility assessment yearly. -Departments heads and the physician should be involved and discuss the facility assessment. -The facility assessment should have been reviewed and updated in April 2024.

Based on observation, interview, and record review, the facility failed to protect all residents from misappropriation of resident property when staff could not account for a missing narcotic for one resident (Resident #1) that had been in the possession of the facility. The facility census was 68. On 10/06/23, at 7:25 P.M., the facility staff discovered the missing narcotic card and notified facility management. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance and began inservicing of all certified medication technicians and nurses regarding the narcotic count policy and procedures on 10/07/23. The Director of Nursing (DON) audited all narcotic carts and found no other missing medications. The noncompliance was corrected on 10/10/23. Review of the facility's policy titled Abuse and Neglect Definition and Policy, undated, showed the following: -All allegations of abuse and neglect or allegations of neglect, exploitation or mistreatment, misappropriation of resident property, including of unknown origin injury will be reported 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to immediately report all allegations of abuse to management immediately and within two hours to the State Survey Agency (Department of Health and Senior Services- DHSS when staff reported one resident's (Resident #1) allegation of sexual abuse from another resident (Resident #2) five days after the facility staff became aware of the allegation. A sample of six residents was reviewed in a home with a census of 67. Review of the facility's policy titled Abuse and Neglect Definition and Policy, undated, showed the following: -Abuse is the infliction of physical, sexual, or emotional injury or harm including financial exploitation by any person, firm, or corporation; -All employees are given a copy of mandated reporting in their personnel file upon hire; -All staff are required to report any concerns regarding resident to resident, staff to resident, or visitor to resident without fear of retaliation; -Families and staff are encouraged to report immediately…

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 designate one or more individuals, qualified by completing specialized training in infection prevention and control, as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program The facility had a census of 74. Review showed the facility did not provide a policy regarding the role of Infection Preventionist. 1. During an interview on 05/09/23, at 9:10 A.M., the Associate Director of Nursing (ADON) said the facility did not have an actual active Infection Preventionist for about the last 30 days. During interviews on 05/12/23, at 9:25 A.M. and 1:27 P.M., the Director of Nursing (DON) said in April 2023, the IP quit suddenly. They did not have a current trained IP. They did not have a policy for the IP. The IP position is full time position. During an interview on 05/12/23, at 3:46 P.M., the Administrator said their IP quit suddenly and she immediately posted it when it happened. She has hired a new nurse who has not had the training. The new nurse did not have the required…

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 staff treated residents with dignity and respect to enhance each residents' quality of life when staff stood while assisting residents, including five residents (Residents #62, #46, #11, #45, and #38) out of six sampled residents when assisting the residents with meals. The facility had a census of 74. Review of the facility policy Resident Rights, undated, showed the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality; Review of the facility policy, Feeding the Resident (Dependent Eating), undated, showed the following: -Take tray to resident and place tray directly in front of the resident; -Assist resident to proper sitting position unless contraindicated; -If the resident cannot see the tray, tell him/her the position of each item on the tray; -Cut or divide food into small portions and give resident a small amount at a time. Do not force the resident to eat. Select…

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 have physician orders for use of oxygen for two residents (Resident #74 and #44) and failed to have physician orders of when to change the oxygen tubing,failed to have documentation of when the oxygen tubing was changed, and failed to date the oxygen tubing when last changed for three residents (Resident #74, #44, and #60). A sample of 22 residents were selected out of a facility census of 74. Review of the facility policy titled Oxygen Administration, undated, showed the following: -The purpose of the policy is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; -Procedure for oxygen administration included check the physician's order for the liter and method of administration; -At regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; -At regular intervals, check liter flow contents of oxygen cylinder, fluid level in the humidifier and assess resident's…

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

Based on observation, record review, and interview, the facility failed to ensure dietary staff stored, prepared, and served food in a manner that protected it from possible contamination in accordance with professional standards when staff failed to ensure pots and pans were cleanable, that staff wore beard nets as appropriate, and that vents, shelves, cords, lights, and ceilings were kept clean. The facility census was 74. Review of the Food and Drug Administration (FDA) 2017 Food Code showed that food shall be protected from environmental sources of contamination. 1. Review showed the facility did not provide a policy regarding maintaining kitchen equipment. Review of the FDA 2017 Food Code showed equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Observation on 05/08/23, beginning at 09:40 A.M., showed three large cooking pots had a build-up of black grime on the outside of the pots. Observation on 05/10/23, beginning…

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 adequately equip and maintain the resident call light system in resident bathrooms when call light cords were broken or tied up where residents could not access the pull cord for staff assistance. The facility census was 74. Review of the facility policy titled Call Light, Use of, undated, showed the following: -Check all call lights daily and report any defective call lights to the charge nurse immediately; -Log defective call lights, with exact location, in maintenance log if the facility has such a log; -Consider a quality assurance and assessment program to check call light system at regular intervals. 1. Observations on 05/08/23, beginning at 10:30 A.M., showed the following: -room [ROOM NUMBER] and 102, where two residents resided, in the resident bathroom next to the toilet the call light pull cord was broken and only approximately one inch long. The call light could not be easily accessed and triggered by the resident; -room [ROOM…

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 dietary staff maintained non-food contact surfaces in the kitchen in the a sanitary fashion when there was an accumulation of food, grime, trash, and stains throughout the floors in the kitchen. The facility census was 74. Review showed the facility did not provide a policy regarding cleaning and maintaining the kitchen floors. Review of the Food and Drug Administration (FDA) 2017 Food Code showed non-food contact sufaces shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 1. Observations on 05/08/23, starting at 9:41 A.M., showed the following: -The floors behind and under the ice machine located in the kitchen had an accumulation of black grime and dirt and various trash items including paper and plastic cups, a paper muffin liner, and a marker; -The floors around the doors to the kitchen had a build-up of black grime; -The floors in the dry pantry under the metal storage shelves had a build-up of grime, food crumbs, and condiments packets; -The floor underneath 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 failed to complete a baseline care plan for two residents (Residents #129 an #13) out of a sample of 22 residents including two closed records. The facility had a census of 74. 1. Review of Resident #129's face sheet (a document that gives resident admission information at a quick glance) showed an admission date of 04/14/23. Review of the resident's medical record showed the following: -A tab for the baseline care plan; -A blank Baseline Care Plan Summary page; -The temporary/baseline care plan showed a place for staff to document initial goals, discharge plan, code status, diet order, current medications, therapy, and personal care and how often and provided by whom. During an interview on 05/12/23, at 1:10 P.M., the Director of Nursing (DON) said the resident did not have a baseline care plan - facility staff never completed it. 2. Review of Resident #13's face sheet showed an admission date of 03/14/23. Review on 05/12/23, at 10:48 A.M., of the resident's medical record showed the following: -A tab for the baseline care plan; -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 interview and record review, the facility failed to ensure all residents had a comprehensive care plan that addressed each resident's needs when staff failed to care plan one resident's (Resident #1's) use of antidepressant and antipsychotic medications with related monitoring and interventions and failed to care plan two residents' (Resident #1 and #2) elopement risk/wandering risk with related interventions. The facility census was 65. Review of the facility's policy titled Policy for Condition Changes, Hospitalizations, Related to MDS (MDS - a federally mandated assessment tool completed by facility staff) Process, undated, showed all residents will have MDS and care plans completed in a timely manner. Review of the facility's procedure titled, CAA (Care Area Assessment) Process and Care Planning, dated 10/2019, showed the following: -The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and describe the services that are 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 observation, interview, and record review, the facility failed to ensure a resident's choice of code status was accessible to staff in the event of an emergency and matched throughout one resident's (Resident #230) medical record. Sample size was 22 residents in a facility census of 74. Review of the facility's policy titled Advanced Directive, undated, showed the following: -The facility will respect advance directives in accordance with state law; -Upon admission of a resident to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive; -Upon admission, a resident, and/or his/her family members, will be asked the existence of any written advance directives; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical…

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 all residents were free from significant medication errors when staff administered insulin medication (used to help control blood sugar levels) without priming the insulin pen per standards of practice prior to administering insulin to one resident (Resident #7) out of two residents administered insulin during a medication pass administration. The facility census was 74. Review of the facility policy, Insulin Administration Policy and Procedure, undated, showed if the insulin is available in a pen device, then a safety needle must be used, and the staff should prime the pen two units before use. Review of the How to Use Your Lantus SoloStar Pen, dated 2022, showed the following: -Dial a test dose of two units; -Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose; -Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will…

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 all medication were stored in accordance with accepted professional standards when staff stored intravenous medication (IV) in one resident's (Resident #53) unsecured room while the resident was in the hospital. The sample size was 22 residents in a facility census of 74. 1. Review of Resident #4's face sheet (brief information sheet about the resident) showed an admission date of 01/31/23. Review of the resident's Physician's Order Sheet (POS), current as of 05/06/23, showed the following: -An order, dated 04/25/23, to infuse ceftriaxone 2 gram IV over 30 minutes one time daily for 17 days for a urinary tract infection (UTI); -An order, dated 04/25/23, for sodium chloride reconstitute and infuse ceftriaxone 2 gram IV over 30 minutes one time daily for 17 days. Review of the resident's nurses' notes showed dated 05/07/23 showed the resident complained shortness of breath and tightness in his/her chest and requested to go to the emergency room for evaluation. Emergency Medical Services (EMS) transferred…

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 staff failed to practice acceptable standards of practice of infection control when failed to wash hands before applying gloves and after removing gloves during during incontinence care for one resident (Resident #62) and during wound care for one resident (Resident #4). A sample of 22 residents were reviewed in a facility with a census of 74. Review of the facility policy Handwashing, undated, showed staff were to thoroughly cleanse the hands with friction, soap, and water. Staff were to thoroughly wash hands before and after providing resident care. Review of the facility policy, Becoming a Certified Nurse Assistant, undated, showed the following: -Indications for hand hygiene included before and after all care procedures, before patient contact and donning gloves, between care activities, and after contact with patient's skin, contact with body fluids or excretions, non-intact skin, and wound dressings -When hands are visibly dirty,…

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 the residents' bathroom exhaust ventilation system in proper working condition when all residents' bathrooms did not have functioning exhaust vents. The facility had a capacity of 120 residents with a census of 58. 1. Observation on 1/9/2020, beginning at 8:30 A.M., showed the exhaust ventilation system, in all resident restrooms did not work when tested. During an interview on 1/9/2020, at approximately 1:15 P.M., the maintenance supervisor (MS) said he did not know the residents' bathroom exhaust system did not work The exhaust system worked off of a large fan located in the attic.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, and failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification or complete monthly log as requested, for five residents (Resident #12, #16, #24, #25, and #36) out of 18 sampled residents. The facility failed to develop a policy regarding written notifications upon transfer to a hospital. The facility census was 59. 1. Record review of Resident #24's nurses' notes showed the following information: -On [DATE], 7:00 P.M. to 7:00 A.M., staff documented the resident had an episode of extreme upper extremity tremors (an involuntary quivering movement), staff administered bedtime medications, including Klonopin (medication that works by calming your brain and nerves), the symptoms were alleviated, 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 staff failed to post the required daily nurse staffing hours in a prominent place readily accessible to residents and visitors, failed to post it at the beginning of each shift, failed to include the facility name on the posting, and failed to maintain the posted daily nurse staffing data for a minimum of 18 months. The facility census was 59. 1. Observation on 1/6/2020, at 2:32 P.M., showed the nurse staffing hours posted in an alcove to the left side of the reception window, approximately 5 ½ feet high on the wall, and to the right side of a bin on the wall that held the state survey results. The posted hours were not visible to residents and visitors entering the building or while standing in the main entry. The information was only visible when standing at the reception desk. Observation on 1/7/2020, at 8:14 A.M., showed the nurse staffing hours, dated 1/6/2020, posted to the left side of the reception window, with a facility census of 59. Observation on 1/7/2020, at 9:57 A.M., showed the nurse staffing hours,…

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 provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Resident #36 and #56) out of two sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 59. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following information: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these…

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.