Life Care Center Of Hilo

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Glucose Control Solutions used in the facility were labeled in accordance with professional standards and facility policy, and failed to ensure all drugs and biologicals are secured in a locked compartment. Proper labeling of Glucose Control Solutions is necessary to ensure the efficacy of the solutions used to test the facility's glucose monitors/test strips for accuracy. This deficient practice has the potential to affect all residents in the facility requiring point-of-care blood glucose tests. Findings include: 1) On [DATE] at 09:15 AM, the 3 South medication cart was inspected with Registered Nurse (RN)27 standing by. Observed an unlabeled box of Glucose Control Solution. RN27 validated that the box should have been labeled with the date it was opened as the solution(s) were considered expired 90 days after opening. RN27 stated he would discard the opened box and put a new one in the cart. 2) On 11//30/23 at 09:28 AM,…

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 monitor the temperatures to ensure the dishes used to serve food were appropriately sanitized in accordance with professional standards for food service safety. This deficient practice placed all the residents in the facility at risk for possible foodborne illnesses. Findings include: On 11/28/23 at 09:52 AM, initial tour of the kitchen area was conducted with Food Service Director (FSD). Observed clipboards on the wall by the dishwashing machine area. FSD said that was where the staff document the temperatures for the dishwasher. Review of the log titled High Temperature Dish Machine Log was done and noted an entry for 11/13/23 was missing. Below the space where the staff write the month and year for the log, the document stated, Check and record temperatures results before washing dishes. Wash needs to be per manufacturers' specification and rinse at 180 degrees to 194 degrees Fahrenheit. Asked FSD how often the staff record the temperatures on the log. FSD said the staff record it three times a day when 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 ensure the Binding Arbitration Agreements ([NAME]) they asked the residents (or their representatives) to enter into, were explained in a form and manner that they could understand, and that the [NAME] explicitly granted the residents/representatives the right to rescind the agreement within 30 calendar days of signing it. This is evidenced by 1 of 3 residents (Resident 7) sampled stating she did not have the BAA explained to her in a way that she understood what it meant, 2 of 3 residents (Residents 7 and 101) sampled could not remember signing it or what it was about, and the Facility BAA granting residents only 10 days to rescind. Findings include: 1). On 11/29/23 at 12:08 PM, an interview was done with Resident (R)7 at her bedside. When asked about the BAA, R7 reported that the Director of Social Services (SSD) had visited her earlier that morning and asked her about the BAA as well, showing her a blank copy of the form. R7 stated that she told SSD…

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

Based on a Resident Council interview and policy review, the facility failed to protect and promote quality of life for the residents by ensuring they were treated with respect and dignity. Specifically, the facility failed to ensure that English was consistently spoken in all resident care areas, exposing residents to frustrating and awkward situations that impede their ability to attain or maintain their highest practicable well-being. This deficient practice has the potential to affect all residents at the facility. Findings include: On 11/17/22 at 09:20 AM, an interview was done with two regularly-attending members of the Resident Council, and one former member and interested resident. The interview was conducted in the second floor private Dining Room. All three residents complained that numerous kitchen staff, certified nurse aides (CNAs), and housekeepers speak to each other in front of the residents in their native language, a language other than English. It was reported that these staff members speak in their native tongue all the time even though they know they not…

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 required postings were placed in a manner accessible to all residents and resident representatives. Specifically, there were no postings observed on the first floor listing the contact information for pertinent State agencies and resident advocacy groups, nor were there any postings observed on the first floor regarding a resident's right to file a complaint with the State Survey Agency (SA). In addition, despite the required postings being available on the second and third floor, not all residents residing there are aware where to find them. As a result, residents who have the capacity to comprehend their resident rights potentially are not aware of them, how to exercise them, or where they can find information about them. This deficient practice has the potential to affect all residents in the facility with the functional capacity to exercise their resident rights. Findings include: On 11/14/22 at 12:45 PM, observations were made on the One South unit that there were no postings found regarding resident rights…

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 make information on how to file a grievance or complaint available to all residents. Specifically, there were no postings observed on the first floor providing information on how to file a grievance for the first two days of the survey, nor were there comment cards available on the first floor to assist a resident in filing a written complaint or grievance. As a result, the process of filing a grievance is unclear for residents and resident representatives residing on the first floor. This deficient practice has the potential to affect all residents with the functional capacity to file a grievance. Findings include: On 11/14/22 at 12:45 PM, observations were made on the One South unit that there were no postings found regarding how to file a grievance. A subsequent tour of the remainder of the first floor revealed no postings at the elevator, staircase, hallways, or on the One North unit. Blue comment cards that assist residents in filing a written grievance, available in central areas on the second and third floor, could…

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 record reviews, the facility failed to ensure that the care plans for nine residents (R), R131, R152, R151, R180, R55, R98, R169, R26 and R76, out of a sample of 36 residents, were appropriately developed and/or implemented to promote the highest practicable physical, mental, and/or psychosocial well-being of these residents. This deficient practice has the potential to affect all residents. Findings includes: 1) During an observation and interview with R131 on 11/15/22 at 10:33 AM noted resident with right lower extremity swelling and redness. R131 was lying in bed with her right lower leg elevated onto the pillow, her eyes were closed. On 11/15/22 at 10:45 AM, state agency (SA) asked the Charge Nurse (CN)6 why her right lower leg is swollen and red. Per CN6, she scratches her leg, and she would rather be up in her chair watching television, which doesn't help with the swelling of her leg. On 11/16/22 at 08:04 AM, an interview with licensed nurse (LN)5 was done. Asked her…

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 record reviews, the facility failed to ensure that there was an ongoing resident-centered activities program that fully identified and met the residents' needs for four residents, Resident (R)55, R98, R169, and R151, out of a sample of 12 residents, and for over half of the total of 26 residents in a secured dementia unit. Specifically, the facility failed to act on the residents' need for social engagement, failed to identify activities the residents found meaningful, and failed to develop and/or implement a person-centered activities program. Residents on the dementia unit were not engaged in group activities, they were not singing along or exercising and there were residents sitting in the multi-purpose (room for dining and activities) with their eyes closed. As a result of this deficient practice, these residents were placed at risk of experiencing a decline in their psychosocial well-being, self-esteem, and comfort. This deficient practice has the potential to affect…

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 record reviews, the facility failed to ensure four residents (R), R55, R169, R26, and R76, in a sample of five residents were free from accident hazards by thoroughly assessing and developing a plan to keep them safe once they had been identified as elopement risks with wandering behavior. As a result of this deficient practice, the residents (R55, R169, R26, R76) were placed at risk of an avoidable accident, interpersonal altercation, and/or injury. This deficient practice has the potential to affect all the residents at the facility displaying wandering behavior. Findings include: 1) Cross-reference to F679 Activities Meet Interest/Needs of Each Resident. The facility failed to ensure there was an ongoing resident-centered activities program that fully identified and met the residents' needs, for two residents in the sample, Resident (R)55 and R169. Specifically, the facility failed to act on the residents' need for social engagement and activities despite identifying…

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 and interviews, the facility failed to ensure there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, in addition to their physical, mental, and psychosocial well-being. As a result of this deficient practice, the residents experienced a decreased quality of life and were unable to attain their highest practicable well-being. Findings include: 1) Cross-reference to F679 Activities Meet Interest/Needs of Each Resident. The facility failed to provide staff to adequately monitor and redirect residents identified with wandering behavior. 2) On 11/14/22 at nbh2:39 PM, an interview was done with Resident (R)98 at her bedside. When asked about staffing levels, R98 stated that she feels they could do with more staff. R98 explained that staff seem to be rushing all the time, no matter what shift. R98 gave one example about her shower schedule. R98 stated she showers on her assigned days, Tuesday, and Saturday, and it is done when staff has the time. R98 also…

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 and interviews, the facility failed to ensure its nurse staffing information was prominently posted in a clear and visible place accessible to all residents and visitors. Specifically, the facility posted the nurse staffing information at the central nurses' station (fishbowl) on the second floor only, in a place not readily accessible to residents and visitors of the first and third floors. Moreover, the residents of the first floor reside in secured units, making the second floor posting completely inaccessible to them. This deficient practice has the potential to affect all residents and visitors to the first and third floors. Findings include: 1) On 11/14/22 at 12:45 PM, observations were made on the One South unit that there were no postings found regarding nurse staffing. A subsequent tour of the remainder of the first floor revealed no postings at the elevator, staircase, hallways, or on the One North unit. On 11/16/22 at 09:39 AM, an interview was done at the One South nurses' station (NS) with the Charge Nurse (CN) on duty, CN8. When asked about 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 observations, interviews, and record reviews, the facility failed to ensure all medications and biologicals used in the facility were labeled, stored, and/or disposed of in accordance with professional standards. Proper labeling and storage of medications and biologicals is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility receiving medications or biologicals. Findings include: 1) On 11/16/22 at 09:14 AM, an inspection of a medication storage room was done with the Charge Nurse (CN) on duty, CN8. While inspecting the treatment cart, two opened and undated medicated gauze 4x4 packets were found with unused gauze remaining. The first one found, CN8 stated he had just used a portion of it to conduct a dressing change, and he should have thrown it [the unused portion] away. In the opened pack used by CN8, observed three tiny squares, approximately 1-centimeter by 1-centimeter in size, of unused gauze remaining in the foil packet. When asked, CN8 stated…

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, interviews with staff members, and review of the facility's policy and procedures, the facility did not assure food was stored under sanitary conditions and did not ensure staff members were accurately checking chemical ratio for sanitizing of dishes in the three-compartment sink, the staff member inaccurately identified the parts per million (ppm) of the solution and the new test strips were expired. This deficient practice encourages food-borne illnesses and has the potential to affect all residents, visitors, and staff who receive meals from the kitchen. Findings include: 1) On 11/14/22 at 10:30 AM an initial brief tour of the kitchen was done with the Food Services Director (FSD). Observation of the walk-in refrigerator found an opened bottle of horseradish with a disposal date of 09/30/22, an opened bottle of mustard with no label, six unopened containers of buttermilk with a manufacturer's expiration date to use by 09/09, and there was a clear plastic container of blueberry compote with lid ajar that was labeled 09/28/22. FSD stated the facility'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 interview and record review, the facility failed to identify, support, and honor one Resident's (R) bathing schedule preference. As a result of this deficient practice, R98 did not have her needs met and was placed at risk of not attaining her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: On 11/14/22 at 2:44 PM, an interview was done with Resident (R)98. When asked about whether she is allowed to make choices that are important to her, R98 replied, no. R98 explained that she can only shower twice a week, it's something I just can't get used to, I like to shower every day. R98 stated she showers on her assigned days, Tuesday, and Saturday, and it is done when staff has the time. R98 also stated that she was never asked how often or what days she would like to shower, and when she does have a shower, she is rushed through it, it feels like they're herding cattle, just in and out. On 11/14/22 at 3:00 PM, a review of R98's Minimum Data Set (MDS) admission Assessment with an Assessment…

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 (RR), the facility failed to ensure valid Advance Health Care Directives were obtained and documented in two residents' medical records. As a result of this deficient practice, both Resident (R)98 and R162 were placed at risk of not having their (or their valid representatives') wishes honored for future health care decisions, should they become (or be determined) with diminished or no capacity. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 11/15/22 at 12:05 PM, during a review of Resident (R)98's electronic health record (EHR) and hard chart, documentation of a General (financial) Power of Attorney (POA) was found, but none for health care. On 11/16/22 at 2:28 PM, an interview was done with the Director of Social Services (DSS) at the 1 South nurses' station. The DSS confirmed that the facility did not have a Durable Power of Attorney (DPOA) for health care on file and she had only just realized that. The DSS stated she was trying to contact R98's POA. On 11/17/22 at 1:20 PM,…

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, the facility failed to assure comfortable sound levels for residents on a locked/secured dementia unit during dining and activities and for one resident (R)5 on another nursing unit. The residents residing on the secured unit are diagnosed with Alzheimer's disease and dementia with/without behavioral disturbances. R5 complained that the roommate's television was too loud. This deficient practice fails to provide a homelike environment and has the potential to affect all residents. Findings include: 1) Observation on 11/14/22 of lunch found residents seated in the multi-purpose room (activity/dining room). Music was being played. The volume was so loud, observed residents weren't talking to one another. The sound of the chairs being pulled out or dragged on the ground was startling loud. Second observation on 11/15/22, observed a resident shouting to another resident over the music. Observations during morning activities on 11/14/22 and 11/15/22 found the volume of the videos being shown on the television was loud. The residents are provided with routine…

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, and interview with staff member, the facility did not ensure one (Resident 82) of one resident sampled was free from physical restraints. This deficient practice has the potential to affect the resident's psychosocial well-being. Findings include: Resident (R)82 was admitted to the facility on [DATE]. Diagnoses include but not limited to, Alzheimer's disease, unspecified; dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; other seizures; abnormal posture; muscle weakness (generalized); anxiety disorder due to known physiological condition; adjustment disorder with mixed anxiety and depressed mood; and personal history of healed traumatic fracture; and wandering in diseases classified elsewhere. On 11/14/22 at 12:33 PM, observed R82 seated in the multi-purpose room for lunch. R82 was in a wheelchair placed in the corner of the room, the back push handles were up against the wall and the table was placed in the front 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, in a sample of three residents (R), R454, R167, and R111, out of six residents, the facility failed to implement their abuse prohibition policies and procedures to: 1) screen employees for a history of abuse and, 2) to prevent abuse for two residents (R), R167 and R111, involved in a friendship/relationship. The facility's failure to follow their own abuse prohibition policies and procedures could potentially cause irreparable harm to their residents. Findings include: 1) A request of the facility's policy and procedures on abuse/neglect was done during the entrance interview on [DATE]. With regards to screening, the facility provided a Human Resources policy entitled, Background Screening Policy: Associates, with an effective date of [DATE] and revisions on [DATE], [DATE], [DATE], [DATE], and [DATE]. The Purpose section documents the following, This policy provides . supervisors and managers with the necessary guidance and instructions to conduct background…

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 reviews and interviews, the facility failed to appropriately protect two Residents (R), R199 and R454, out of a sample of three residents, from further abuse by failing to report to Adult Protective Services (APS) incidents that involved alleged staff-to-resident abuse. R454's staff-to-resident abuse incident was not reported to the Administration and state agency (SA) within the prescribed timeframes deemed by federal and state regulations. This deficient practice may result in the failure to identify abuse and can potentially affect all residents. Findings include: 1) On 11/14/22 at 07:30 AM, reviewed from the Aspen Complaints/Incidents Tracking System (ACTS) the completed Office of Health Care Assurance (OHCA) Event Report document dated 10/28/22 for ACTS #9859. The document described an alleged staff-to-resident abuse with an ensuing investigation involving Certified Nurse Aide (CNA)80 who assisted R199 roughly when he helped her to the restroom. R199 sustained a bruise on her left hand. A police report was filed, but no report was made to APS. The facility'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to develop a care plan that addressed the behavioral and emotional health needs of one newly admitted resident (R), R406, out of a sample of three residents. This deficient practice fails to provide non-pharmacological interventions for the behavioral and emotional health needs of a newly admitted resident and can potentially affect all incoming residents suffering from behavioral and emotional health issues. Finding includes: On 11/15/22 at 1:23 PM, an observation of R406 was done. R406 lay in bed with his eyes closed wearing a hospital gown and tubing into his nostrils that delivered oxygen from an oxygen compressor next to his bed. R406 opened his eyes when the state agency (SA) approached him. SA tried to initiate a conversation with R406, but his eyelids kept drooping closed. R406 spoke with a flat affect and soft tone. Reviewed R406's electronic health record (EHR). The admission Record document revealed that R406 was admitted 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 observation, interview and record review, the facility failed to update the care plan with treatment of one Resident (R)131 osteoarthritis of the left wrist. The deficient practice increased the resident's pain and discomfort, and updated interventions improve outcomes of the treatment plan for residents' osteoarthritis. Findings include: On 11/14/2022 at 10:50 AM, surveyor reviewed the completed incident report that was received by the state agency (SA) via fax on 11/03/22 at 4:18 PM. Resident complained of right wrist pain and was noted to have bruising. Resident was taken to acute care for an X-ray. During an observation and interview with R131 on 11/14/22 at 1:30 PM, when asked about her injured wrist, she held up her hand and said, I had a brace for my sore wrist, but it's better now and I don't need it. When asked what happened to cause her sore wrist, she shrugged her shoulders and said she didn't remember. The facility internal investigation report for the unknown injury to the resident's wrist was reviewed on 11/16/22 at 12:38 PM. Report made to Police Department…

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 with staff members, the facility did not assure a resident with dementia received appropriate interventons to attain or maintain her highest practicable psychosocial well-being. Findings include: Resident (R)180 was admitted on [DATE]. Diagnoses include, unspecified dementia, unspecified severity with agitation; depression (06/23/22); psychotic disorder with delusions due to known physiological condition (04/26/22); mood disorder due to known physicaological condition with depressive features (04/26/22); anxiety disorder (04/26/22); and restlessness & agitation (04/26/22). Record review notes R180 is prescribed psychotropic medications (used to treat mental health disorders): alpralozam, 1 mg (miligram), give one tablet three times a day for anxiety disorder; risperdal tablet 0.5 mg, give 0.25 mg by mouth one time time a day for dementia with psychosis; citalopram hydrobromide, 20 mg, give 20 mb by mouth one time a day for depressive disorder secondary to dementia; 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to adequately monitor one resident (R)131 for pain management out of a sample of three residents. R131 was prescribed a stronger form of the medication (opioid) versus acetaminophen without indication for its use and for an excessive duration. The deficient practice potentially increases the likelihood for an adverse medication effect. Findings include: Cross reference to F657 Care Plan Timing and Revision. During record review on 11/17/22 at 9:30 AM, noted in the Physician orders, R131 had Norco Tablet (Hydrocodone-Acetaminophen) 7.5-325 mg (milligram) give 1 tablet by mouth at bedtime for pain. Ace Wrap to left wrist, no directions specified for order, 11/03/2022. Resident is at risk for falls related to (r/t) chronic bilateral knee pain, generalized weakness, etc.administer pain medications as ordered, evaluate pain med's effectiveness. Reviewed MDS quarterly assessment dated [DATE]. Section J. Resident assessed for pain. Ask resident:…

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 assistance in obtaining emergency dental care for pain and bleeding gums for one Resident (R)188 of two residents investigated. The deficient practice potentially increases risk of illness due to the severity of R188's gingivitis (inflamation of the gums) and has the potential to affect all residents in the facility. Findings include: During an observation and interview with R188's spouse on 11/14/22 at 12:06 PM when asked if she has any concerns about her husband's care since he was admitted to the facility, responded, he has very bad gingivitis, we have been asking them to take him to the dentist. Sometimes when I come in his gums are bleeding. I had to brush his teeth and clean all around his gums. I asked them a few times if he can get a dental appointment, but they never got back to me. Observed an electric toothbrush on top of R188 dresser. Spouse stated, since my husband has been here, I come in to visit him every day to…

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

Based on record review and interview with staff member, the facility failed to assure a medical record was maintained in accordance with accepted professional standards and practices to ensure accurate documentation. This deficient practice has the potential to affect all residents in the facility. Findings include: Record review found documentation of a power of attorney document in the misc tab for Resident (R)151. The document was very dark, and the name of the resident and the identified power of attorney (POA) was difficult to read. The left side of the pages were darker, making that information illegible. On 11/16/22 interview and concurrent record review was done with the Assistant Director of Social Services (ADSS). The ADSS reviewed the document and stated this was sent to the facility by the POA and acknowledged the clarity of the document was hindered by the dark shading. We were able to decipher the POA's name. ADSS commented that parts of the document cannot be read as it is too dark.

Based on record review and interview, the facility failed to ensure one resident (R)131 of five residents in the sample had the pneumococcal vaccine. The deficient practice has the potential to increase the resident's risk for illness and may potentially affect all residents. Finding includes: On 11/17/22 at 2:58 PM electronic health record reviewed for R131. Vaccine information reviewed. R131received the following vaccines: Influenza vaccine 11/04/2022. SARS-COV-2 (COVID-19) (Dose 1) 01/6/2021 Complete SARS-COV-2 (COVID-19) (Dose 2) 02/3/2021 Complete SARS-COV-2(COVID-19) Moderna Booster 05/18/2022 Complete On 11/17/22 at 3:07 PM, requested the Pneumococcal vaccine information for R131 from the Unit Manager (UM)4, who stated that it is in the hard chart, and she provide the information to the surveyor. At 3:48 PM the Nursing Manager/ Supervisor, informed surveyor there was no documentation that R131 had the Pneumococcal vaccine in her hard chart, and there was no documentation that she had a history of having the pneumococcal vaccine.

Based on observations, the facility failed to provide one or more rooms designated for resident dining and activities, ensuring enough space is available and adaptable for a variety of uses and meet resident's needs. Findings include: On 11/14/22 during the lunch meal, observed there were 22 residents in the multi-purpose room seated at six tables. The dining area did not allow spaces to walk through the dining room. There were three residents that required assistance with their meals resulting in 25 people seated at the tables (including staff members). There was one set of chairs that were back-to-back with the spacing too small to walk between. There were three tables placed against the wall resulting in three residents seated alongside the wall. On 11/15/22 observed Resident (R)82 self-propelling up and down the hall in a wheelchair. At 10:25 AM, R82 was assisted by Certified Nurse Aide (CNA)33 into the multi-purpose room. R82 started to wheel herself in the room, however, was redirected and removed from the room. CNA stated there is not enough room in there for R82 to wheel…

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, policy review, observation, and resident and staff interviews, the facility failed to ensure two Residents (R) R5 and R6 of three residents who were reviewed for positioning and mobility were provided with restorative services per their plan of care. R5 and R6 did not receive assistance to apply their splints per their plans of care, creating the potential for pain, skin breakdown, or contracture development. Findings include: 1. Review of the facility's Restorative Nursing Policy dated 08/07/21 revealed, The facility is responsible for providing maintenance and restorative programs as indicated by the resident's comprehensive assessment to achieve and maintain the highest practicable outcome; and Restorative Nursing can be within one of the following categories: . Splint or brace assistance. Review of R5's undated Resident Face Sheet, located under the Admissions tab of the Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including…

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 adverse reactions were consistently monitored for antipsychotic medication use for one of five residents (Resident (R) 87 reviewed for unnecessary medications. This failure created the potential for R87 to experience worsening involuntary muscle movements. Findings include: A review of R87's admission Record, provided on 10/21/21, revealed the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbances, paranoid schizophrenia (a mental illness that has symptoms that blur the line between what is real and what isn't, making it difficult for the person to lead a typical life), and subacute dyskinesia (a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs.) Review of R87's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/16/21 revealed the resident was unable to…

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