Legacy Hilo Rehabilitation & Nursing Center

Based on observations, resident interview, staff interview, and review of policy, the facility did not have the call bell in reach for one Resident (R)14 out of six Residents sampled. As a result of this deficiency, R14s ability to call out for help was limited and the deficient practice has the potential to affect all the residents that uses the call bell for assistance. Findings Include: During observation and interview on 10/22/24 at 10:18 AM, R14's call bell was attached to the bed but was dangling and out of reach. R14 said that he/she had hard time finding the call bell to call out to staff. Observation and interview on 10/23/24 at 02:30 PM, R14's call bell was dangling over head of the bed and out of reach. R14 wanted to call to ask staff a question. Observation on 10/25/24 at 09:22 AM, R14 was sitting in a wheelchair next to the bed and the call bell was out of reach, dangling from the bed rail. R14 was trying to get the attention of staff. Staff interview on 10/23/24 at 02:51 PM, Certified Nurse Assistant (CNA)4 acknowledged that the call bell was out of reach and moved it…

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 exercise reasonable care for the protection of the property from loss or theft for one out of 22 sampled residents (Resident (R) 9). As a result of this deficiency, R9's psychosocial wellbeing was negatively affected. R9 did not think the facility took his statement seriously. This deficient practice has the potential to affect all the residents whose property is lost or missing. Findings Include: Interview was conducted with R9 on 10/22/24 at 01:45 PM in his room. R9 stated that a couple of months ago, five bottles of supplements went missing after taking just one pill. R9 explained that a family member had ordered the supplements for him and had it delivered to the facility. R9 had informed a couple of the facility staff of the missing items and staff had helped him search for it. R9 was not sure if the staff had taken his statement seriously. R9 did not think the facility had opened an investigation regarding his missing items because no one had spoken to him regarding the missing bottles. Interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one out of 22 sampled residents (Resident (R) 66). R66 experienced frequent pain and the facility failed to develop a care plan for R66's pain. The deficient practice has the potential to negatively affect R66's wellbeing and has the potential to affect all the residents who experiences pain in the facility. Findings Include: R66 is a [AGE] year-old female admitted to the facility on [DATE]. R66 has medical diagnosis that includes, but not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, aphasia, low back pain, and pain. Observation and interview were conducted with R66 on 10/23/24 at 09:53 AM in R66's room. R66 was observed rubbing/massaging her left thigh area. R66 stated that she experiences constant pain in her left thigh area and needs to take medications for it. A review of R66's Minimum Data…

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 (RR) the facility failed to assure one of the sampled residents (Resident (R) 132) received appropriate treatment and services with care for his urinary indwelling catheter. The deficient practice included R132's urinary catheter tubing being left on the ground, urinary catheter flush for blood in the tubing performed by licensed staff without a physician order, and licensed staff not performing proper hand hygiene before flushing R132's urinary catheter. This deficient practice has the potential to affect all the resident with urinary catheter. Findings Include: Cross-reference to F880 Infection Prevention & Control On 10/22/24 at 11:30 AM R132 was observed sitting in his wheelchair near his bed with his urinary catheter tubing on the ground. Interview was conducted with the Certified Nurse Assistant (CNA) 1 who was working with R132. Inquired if the tubing should be on the ground and she confirmed it is not supposed to be left on the ground and she put on…

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 controlled medication was reconciled for one of four medication carts sampled. Review of the Controlled Medication Reconciliation Log (CMR Log) documented on 10/02/24, nursing staff did not sign the log with the on-coming evening shift nurse indicating all controlled medications for medication cart was reconciled at change of shift and on 10/24/24 and 10/25/24, nursing staff pre-signed the CMR Log prior to reconciling and verifying the controlled medications count with the on-coming evening shift. As a result of this deficient practice, the facility is at potential risk for diversion of controlled medications. Findings Include: On 10/24/24 at 08:40 AM, conducted an inspection of medication cart # 4 with Nursing Staff (NS)3. Review of the CMR Log documented NS3 had already signed the box which indicated the controlled medication count was completed with the on-coming evening shift nurse which attested the count was accurate, prior to doing the actual count. Inquired with NS3 regarding when the CMR Log should 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.

Based on observations, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. This deficient practice has the potential to affect all the residents in one of the four units in the facility. Findings Include: Concurrent observation and interview were conducted on 10/22/24 at 11:00 AM. One of the facility's medication carts was observed unlocked and unattended. The cart was assigned to Licensed Practical Nurse (LPN) 10, who was observed in one of the resident's rooms. Once LPN 10 exited the resident's room, she was asked about the unlocked and unattended medication cart. LPN10 confirmed that the medication cart should not have been left unlocked and unattended. Concurrent observation and interview were conducted on 10/23/24 at 03:17 PM. One of the facility's medication carts was observed unlocked and unattended. The cart was assigned to Registered Nurse (RN) 11. Once…

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 (RR) of Resident's Electronic Health Record (EHR) and interview, the facility failed to assure one of the sampled resident's (Resident (R) 132) urinary catheter tubing did not rest on the ground, failed to have staff remove dirty gloves, perform hand hygiene and put on clean gloves before flushing R132's urinary catheter, and perform hand hygiene after disposing of dirty gloves before putting on clean gloves during a dressing change for R58. The deficient practice puts the residents at risk for facility acquired infections. Findings Include: 1) On 10/22/24 at 11:30 AM R132 was observed returning to his room in his wheelchair with staff pushing his wheelchair. R132 was observed in his wheelchair near his bed and his urinary catheter tubing was observed resting on the ground. Inquired with Certified Nurse Assistant(CNA) 1, if the tubing should be on the ground and she stated it should not be on the ground. CNA1 put on gloves and moved the tubing so that it was not resting on the ground. On 10/23/24 at 10:01 AM observed R132 sitting in his wheelchair…

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 nursing staff had the appropriate competencies and skill sets to provide nursing services that assured resident (R) safety for 1 of 6 residents sampled (R1). As a result of this deficient practice, R1 was placed at risk of a decrease in her physical well-being related to receiving morphine sulfate (a strong narcotic most commonly used to treat moderate to severe pain) on a routine basis, scheduled every one hour, as opposed to being used as needed. Findings include: Resident (R)1 was an [AGE] year-old female admitted to the facility on [DATE]. On 05/23/24, R1 was admitted to hospice for end-of-life care. On 05/28/24, R1 passed away at the facility while on hospice. On 06/24/24, the State Agency (SA) received an anonymous complaint (ACTS #11034) regarding the care R1 received at the end of her life. Amongst the allegations made was a concern that R1 had received too much morphine sulfate on 05/26/24. On 07/09/24, a review of R1's electronic…

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 pharmacy services included a thorough process to assure accurate reconciliation and accounting for all controlled medications in order to promptly identify loss or potential diversion. Findings include: Resident (R)1 was an [AGE] year-old female admitted to the facility on [DATE]. On 05/23/24, R1 was admitted to hospice for end-of-life care. On 05/28/24, R1 passed away at the facility while on hospice. On 06/24/24, the State Agency (SA) received an anonymous complaint (ACTS #11034) regarding the care R1 received at the end of her life. Amongst the allegations made was a concern that R1 had received too much morphine sulfate on 05/26/24. On 07/09/24, while investigating the complaint, a review of R1's medication administration record (MAR) and progress notes was done while comparing it to the Controlled Drug Record (log) for the morphine sulfate. Several discrepancies were found while attempting to reconcile the MAR and log. The MAR documents…

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 observations, record review (RR) and staff interview the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 19 residents sampled (Residents 8, 57, 68 and 69), to meet and maintain their needs for indwelling catheter care, dementia care, and activities of daily living (ADL). As a result of these deficient practices, these residents were placed at risk for a decline in their quality of life and were prevented from attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 10/24/2023 while rounding with assigned residents, observed Resident (R)68 had an indwelling catheter. The indwelling catheter appeared to be draining and was covered by a privacy bag which was hanging from his bed. Minimum Data Set (MDS) admission assessment completed on 09/14/2023 confirmed resident has an indwelling catheter. RR of R68's care plan found he did not have a care plan for indwelling…

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 label food in accordance with professional standards for food service safety as evidenced by the following observed practices: the facility failed to maintain a clean standing fan in the kitchen, correctly test the temperatures on the tray line, correctly test the sanitizer level of their three-compartment sink in the kitchen, failed to maintain a clean refrigerator in 1 of 2 resident nourishment rooms, and failed to maintain the proper temperature for food safety in the refrigerator of the other resident nourishment room. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility able to consume food orally. Findings include: 1) On 10/24/2023 at 10:23 AM while doing the initial tour of the kitchen noted the standing fan facing the three-compartment sink area was heavily soiled with a thick layer of dust. Inquired…

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 (RR), the facility failed to accommodate 1 of 3 Residents' (Resident 69) needs by not ensuring that his whiteboard (for communication), and remote for the TV, was always placed within his reach on his left side (the mobile side). As a result of this deficient practice, R69 was prevented from achieving independent functioning with regards to the TV, and he was hindered from attaining his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with deficits in mobility. Findings include: Resident (R)69 is a [AGE] year-old male admitted to the facility on [DATE] following a stroke with hemiplegia (paralysis of one side of the body) affecting his right side. Other admitting diagnoses include, but are not limited to, dysphagia (swallowing difficulties), adjustment disorder with mixed anxiety and depressed mood, deaf nonspeaking, and cognitive communication deficit (results in difficulty with thinking 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 record review (RR), staff interview and facility policy review, the facility failed to notify the physician when Resident (R)70 became COVID positive and had a significant change in physical condition becoming unresponsive requiring transfer to hospital emergency room. The deficient practice has the potential to affect all residents in the facility that has a significant change in physical condition that could be life threatening. Findings include: During RR of R70's electronic health record (EHR) noted there was no documentation that R70's physician was notified of his COVID positive status on 07/24/2023 or 07/25/2023. RR of R70's EHR found Registered Nurse (RN)6's progress note which included Resident on alert charting for COVID positive. was e-signed, dated and timed on 07/25/2023 at 00:29 AM. There was no documentation by RN6 that R70's physician was notified of his COVID positive status. RR found a progress note e-signed, dated and timed 07/25/2023 at 07:27 AM by Licensed Practical Nurse (LPN)9 that R70 was sent to the hospital emergency room at 05:46 AM via ambulance…

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 facility document review, the facility failed to implement their written abuse policy and procedure for an alleged physical abuse of one of the facility residents (Resident (R) 23). This deficient practice had the potential to compromise the safety of the resident and places all residents in the facility at risk for potential physical and psychosocial harm. Findings include: Interview was conducted on 10/24/23 at 02:09 PM with R23's roommate, R66. R66 stated that she witnessed Certified Nurse's Aide (CNA) 35, shove R23's head in the sink and attempted to rip her teeth out of her mouth. R66 stated that the incident occurred three to four months ago and that she had told everyone about the incident. R66 also added that CNA35 was also in the room when the incident occurred. R66 stated that a registered nurse supervisor had come to talk to her immediately after the incident. R66 had informed the nurse supervisor about what she had witnessed but nothing happened after that conversation. A telephone interview was conducted on 10/25/23 at 01:55 PM with CNA35. CNA35…

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, staff interview, and review of policy, the facility failed to provide written notice of discharge for one Resident (R)35 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication. Findings include: Review of the Electronic Health Record (EHR) indicated that R35 was discharged to the hospital on [DATE]. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 10/26/23 at 02:00 PM, Administrator acknowledged that the facility did not provide written notification of discharge for R35. Review of facility policy on Transfer or Discharge read the following: Policy Statement, when a resident/guest is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care community or provider . When a resident/guest is transferred or discharged from the community, 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 record review, staff interview, and review of policy, the facility failed to provide written notice of bed-hold policy for one Resident (R)35 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication of the bed-hold policy. Findings include: Review of the Electronic Health Record (EHR) indicated that R35 was discharged to the hospital on [DATE]. Further review did not show any written notice of bed-hold policy to the resident and/or representative. During staff interview on 10/26/23 at 02:00 PM, Administrator acknowledged that the facility did not provide written notification of bed-hold policy for R35. Review of facility policy on Bed Holds and Returns read the following: Policy Statement, prior to transfers and therapeutic leaves, resident/guests or resident/guest representative will be informed of the bed-hold and return policy. Policy interpretation and implementation, resident/guests may return to and resume residence in the community after…

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

Based on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record that one Resident (R)65 of two residents sampled was receiving Hospice Services in the RAI, Minimum Data Set (MDS). As a result of this deficiency, the facility put R65 at risk for further RAI, MDS inaccuracy. Findings include: During review of R65's most recent MDS, Assessment Reference Date 07/13/23, there was no indication that R65 was receiving Hospice Services. Review of R65's progress notes showed R65 was admitted to Hospice on 03/30/23. During staff interview on 10/25/23 at 09:20 AM, MDS Coordinator (MDSC1) acknowledged that R65 was not marked as receiving Hospice Services. MDSC1 stated that they would do the necessary correction. Review of the Long-Term Care Facility RAI 3.0 User's Manual read the following: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status .…

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 develop and/or implement a baseline care plan that provided effective and person-centered care for 2 of 7 residents (Residents 89 and 16) reviewed for falls. As a result of this deficient practice, the facility placed these residents at risk for avoidable declines and injuries. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F689 Accident Hazards. The facility failed to ensure the Baseline Care Plan for Falls was implemented for Resident (R)89. 2) On 10/25/2023 at 11:42 AM during record review (RR) found R16 had a fall with no injury on 10/23/2023. Reviewed R16's care plan and noted there was no care plan for risk for falls. Reviewed R16's assessment for falls and noted she had one filled out on 08/28/2023 when she was admitted , also on 09/13/2023 and on 10/24/2023 the day after she fell. All three fall assessments has resident rated as high risk for falls. On 10/27/2023 at 09:28 AM met with Resident Care Manager (RCM)2 to discuss…

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 provide the necessary care and services to meet the activities of daily living (ADLs) needs of 2 of 3 residents (Residents 57 and 69) sampled for ADLs. Specifically, the facility did not ensure Resident (R)57's hygiene needs were met, and failed to provide the proper care and treatment to improve or maintain the communication abilities of R69. As a result of this deficient practice, these residents were not having their needs met, and were placed at risk of a decline in their physical well-being, psychosocial well-being, and quality of life. This deficient practice has the potential to affect all residents at the facility with hygiene or communication needs. Findings include: 1) Resident (R)69 is a [AGE] year-old male admitted to the facility on [DATE] following a stroke with hemiplegia (paralysis of one side of the body) affecting his right side. Other admitting diagnoses include, but are not limited to, dysphagia (swallowing…

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 there was an ongoing resident-centered activities program that fully identified and met the resident's needs, for 1 of 3 residents sampled for activities (Resident 69). As a result of this deficient practice, Resident 69 was placed at risk of experiencing a decline in his psychosocial well-being and quality of life. This deficient practice has the potential to affect all residents at the facility. Findings include: Resident (R)69 is a [AGE] year-old male admitted to the facility on [DATE] following a stroke with hemiplegia (paralysis of one side of the body) affecting his right side. Other admitting diagnoses include, but are not limited to, dysphagia (swallowing difficulties), adjustment disorder with mixed anxiety and depressed mood, deaf nonspeaking, and cognitive communication deficit (results in difficulty with thinking and how someone uses language). In addition, R69 receives all nutrition, fluids, and medication (except…

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 1 of 10 residents (Resident 89) sampled for accidents was free from accident hazards. Specifically, after identifying a newly admitted resident as a Falls Risk, the facility failed to ensure his bed was kept in the lowest position, in alignment with his Baseline Care Plan. As a result of this deficient practice, Resident (R)89 was placed at an increased risk of an avoidable injury, should he suffer a fall out of bed. Findings include: Resident (R)89 is a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses include, but are not limited to, a wedge compression fracture (a fracture which usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape) of the first lumbar (lower back) vertebra, following a fall on 10/09/23. On 10/26/23 at 08:43 AM, observations were done of R89 as…

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 interviews and record review, the facility failed to provide Gradual Dose Reduction (GDR) to one out of five sampled residents (Resident (R) 27) who is currently on a psychotropic medication. This failed practice has the potential to negatively affect all residents on psychotropic medications which may be clinically contraindicated at a higher dose. Findings include: R27 was admitted to the facility on [DATE]. R27 has the diagnosis of but not limited to neurocognitive disorder, Parkinson's disease, dementia, and anxiety disorder. A review of R27's Electronic Health Record (EHR) indicated that R27 has been prescribed Lexapro tablet 10mg/once a day for anxiety disorder since being admitted to the facility on [DATE]. Further review of the R27's EHR showed no indication that a GDR was attempted since 11/29/22. Interview was conducted with Resident Care Manager (RCM) 1 on10/27/23 at 12:35 PM in her office. RCM1 stated that there was no GDR attempt for R27's Lexapro prescription and he has had the same dose…

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 observations, interviews, and policy review, the facility failed to ensure proper glove use procedures were followed by a staff member. This deficient practice places the residents at risk for the development and transmission of communicable diseases and infections. Findings include: Observation was conducted on 10/24/23 at 02:32 PM. Registered Nurse (RN) 8 was observed walking in the hallway from his medication cart parked outside room [ROOM NUMBER] to room [ROOM NUMBER] with gloves on. RN8 then knocked and entered room [ROOM NUMBER] and closed the door. Concurrent observation and interview were conducted on 10/24/23 at 02:51 PM. RN8 was observed leaving room [ROOM NUMBER] with gloves on, walked down the hallway, and removed the gloves at the nurse's station. When asked if he was supposed to have gloves on in the hallway, RN8 answered, no. A review of the facility document titled, Glove Use, dated 10/01/22 was conducted. The document indicated, Used gloves should be discarded into the waste receptacle…

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.