Yukio Okutsu State Veterans Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide competent nursing services for one resident (Resident (R)166) sampled. Specifically, nursing staff did not take immediate action and seek a higher level of care for R166's respiratory distress. As a result of this deficient practice, R166 was placed at risk of more than minimal physical harm. Findings include: Review of R166's Electronic Health Record (EHR) documented the resident was admitted to the facility on [DATE] with diagnosis which included hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, dysphagia, and hypertension. R166 was at the facility for physical, speech, and occupational therapy services after experiencing a cerebral infarction (condition that occurs when brain tissue dies as a result of a lack of blood flow). Review of R166's oxygen saturations documented R166's oxygen saturation as: 10/06/24 at 11:15 PM- 91.0 % on room air 10/07/24 at 06:07 AM- 92.0% oxygen via nasal cannula 10/07/24…

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 (RR) and interview, the facility did not provide a written notice to specify a bed-hold at the time of transfer. In addition, the facility failed to provide written information to the resident and/or resident representative at the time of transfer. Findings include: RR of resident (R)37 reveals multiple hospitalizations to an acute facility. R37 was initially admitted to the facility on [DATE]. Most recent admission was 10/27/23 at 11:46 AM. Unable to locate via record review documentation regarding bed-hold policy except on admission and notice of transfer to resident or resident representative. Interview with Nursing Home Administrator (NHA) and Direction of Nursing (DON) regarding admission to the hospital for R(37). He was admitted on [DATE] for aspiration and then most recently on 10/27/23. NHA stated that they have a weekly communication every week and the facility still has a bed for him. NHA stated that they have no written communication that goes out to patient representative…

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 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: An observation and concurrent interview was done on 10/24/23 at 09:47 AM. The initial tour of the kitchen area was conducted with Dining Services Director (DSD). Observed a log on the wall by the dishwashing machine that DSD identified as the temperature log. DSD added that the staff use the log to record the temperatures for the dishwasher to make sure that the dishes are disinfected properly after use. Review of the log titled Dishwashing/Warewashing Machine Temperature Log and noted an entry for 10/23/23 was missing. Asked DSD how often the staff record the temperatures on the log. DSD said the staff record it three times a day since they use the dishwashing machine after each meal service. Asked DSD if the dishwasher was used after dinner on 10/23/23. DSD…

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, interviews and record review (RR), two residents of the three sampled resident (R)38 and R43, failed to receive accurate assessments, reflective of their status at the time, to identify relevant care areas. As a result of this deficiency, their care plans (CP) did not identify focus areas needed to ensure they maintain or attain their highest medical, functional, and psychosocial potential. All residents are at risk of not receiving an accurate assessment. Findings include: 1) On 10/27/2023 at 08:00 AM, observed R38 in his room, lying in bed. During the interview, he said he had a cracked tooth, for some time. R38 said he wanted to have the tooth taken out. The MDS (Minimum Data Set), used for standardized assessments (comprehensive, quarterly, significant change in status) includes a Dental Section L. which assesses for any Obvious or likely cavity or broken natural teeth. On R38's annual assessment completed on 02/07/2023, this was checked off, indicating he did have a current issue with…

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

Based on observations, interviews and record reviews, the facility failed to implement person-centered comprehensive care plan for one of two sampled residents (Resident (R) 39). An intervention to prevent falls for R39 was not implemented. As a result of this deficient practice, the R39 was placed at risk for potential harm from avoidable falls and has the potential to affect all resident at the facility on close monitoring. Findings include: On 10/24/23 at 11:37 AM, observed R39 lying in bed, awake, with Certified Nurse Assistant (CNA) 11 sitting at bedside. CNA11 said R39 is on one-on-one close observation during the day due to a history of frequent falls. Review of R39's care plan documented that he is at risk for falls and interventions included but not limited to, 1:1 (one-on-one) observation and supervision, Q-15 (every 15) minute check QHS (every night at bedtime). Further review of progress notes for the past six months revealed R39 has had falls on the following dates: 04/03/23, 04/15/23, 04/25/23, 05/19/23, 05/30/23, 05/31/23, 06/06/23, 06/13/23, and 06/14/23. One-on-one…

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 meet the standards of good clinical practice and ensure timeliness of revisions to the Care Plan (CP) of two Residents (R) of a sample size of 3, R9 and R43. Specifically, R9's dental issue, was not addressed in his CP and R43's hearing aid was not being used. As a result of these deficiencies there was the potential they would not meet their highest level of medical, physical and psychological well-being. This deficient has the potential to affect all residents. Findings include: 1) R9 was admitted to the facility on [DATE], and is a long term resident. His medical history includes, type 2 diabetes, hypertension, Parkinson's disease, dementia without disturbance, major depressive disorder, and acute kidney failure. On 10/27/2023 at approximately 08:30 AM, during an interview with R9 in his room, he said he had been having tooth pain, and pointed to the upper tooth. He went on to say, he wanted it removed because he had a bad experience…

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, observation and record review, the facility failed to provide consistent repositioning for one of the one sampled residents (R) 45 in the sample. R45 had an existing Stage 4 (Full-thickness skin and tissue loss) Pressure Ulcer (PU) on the sacrum. As a result of this deficiency, R45 was at increased risk for new PU's and the potential of healing the current PU was decreased. This deficient practice could affect any resident identified at risk for the development of PU, and those with current PU's, resulting in preventing them from reaching their highest physical and psychosocial well-being. as ordered, and consistent with professional standards of practice. Findings include: R45 is a [AGE] year old male admitted to the facility on [DATE]. He has a pertinent medical history that includes a history of paraplegia (paralysis, loss of function in the lower part of body) due to astrocytoma (tumor of the spinal cord) with a neurogenic bladder (lack of control of bladder). He has a chronic 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 ensure that the medication error rate was less than 5 percent for one of five sample residents Resident (R)46. This deficient practice has the potential to harm other residents and failure for R46 to reach their highest practicable level of health and well-being. Findings include: Observation and concurrent record review (RR) on 10/26/23 at 08:36 PM was done during medication pass with Registered Nurse (RN)4. Doctor's orders for Metoprolol 100 mg extended release (ER) to give one tab twice a day for hypertension. RN4 reported blood pressure was 96/64 mmHg and stated that she was going to hold the medication from the resident. Surveyor asked if there were parameters to hold the medications and RN4 stated there were no parameters. Surveyor asked if this was a common practice of other nurses for this blood pressure reading. RN4 stated I am not responsible for what others do. RN4 stated that she was going to hold blood pressure medication Lisinopril/hydrochlorathiazide 50 mg which is given one tablet by mouth…

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 appropriate temperatures for one of its two medication refrigerators that are monitored and maintained. This deficient practice has the potential to negatively affect the efficacy and integrity of medications that require storage at proper temperatures. Findings include: On 10/26/23 at 03:27 PM, observation and concurrent interview of the medication refrigerator was done with Registered Nurse (RN) 6 on the first-floor unit. The refrigerator contained insulin, suppositories and vaccines. Further review of the instructions on the temperature log stated, Refrigerator temperature to be monitored and documented on day shift and NOC [night] shift to maintain a desired refrigerator temperature of 36-46 degrees Fahrenheit (F). Temperature log for the month of October was on the door of the refrigerator. Review of the log showed that the temperature readings for 10/18/23 was missing. RN6 confirmed that the nurses assigned to work on that day should have checked and documented the temperatures on the log.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure shared medical devices were properly disinfected after use. Specifically, the facility did not use the appropriate disinfectant to wipe the shared blood glucose meter (device used to measure blood sugar levels). The facility also failed to ensure proper hand hygiene was used to prevent the transmission of commumnicable diseases and infections. The deficient practice have the potential to spread communicable diseases and infections to other residents that use the same device to have their blood sugar levels checked. Findings include: 1) On 10/26/23 at 03:27 PM, observation and review of the medication cart was conducted with Registered Nurse (RN) 6. Observed a blood glucose meter in the top drawer of the cart that RN6 said the staff use to check blood sugar levels of multiple residents on the unit. Asked RN6 how often is the device disinfected. RN6 replied the staff disinfect it immediately after each use with alcohol wipes. When…

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 develop resident-centered comprehensive care plans supporting resident's choices and interventions to achieve the resident's goals for 9 residents (R), R16, R27, R109, R11, R54, R13, R22, R34, and R56, out of a sample of 19 residents. This deficient practice failed to recognize individualized care and medical needs of each resident with measurable objectives and timeframes to help them attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding includes: 1) Cross Reference to F684. On 10/11/22 at 10:43 AM, R16 was observed while an interview was conducted with family member (FM)6. R16 sat up in a 45 degree angle in his wheelchair with pillows on either side of him, under his head, and under his legs. R16's skin to his arms and neck had red bumps that R16 occasionally scratched. FM6 stated that R16 returned here after spending the last two weeks of September in the hospital. R16's tube feeding…

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 interview with residents and staff, the facility failed to ensure there were sufficient nursing staff to assure residents' highest practicable physical, mental and psychosocial well-being was attained or maintained. Findings include: 1) On 10/12/22 at 09:00 AM an interview was conducted with the resident council representatives. The representatives were asked if they receive the help and care needed without waiting a long time. A representative reported the facility doesn't have enough workers, they leave faster than they are coming. The representative commented, the certified nurse aides are the backbone of the company. A representative reported waiting quite a while for call light response, at times for 30 minutes or more, for assistance with urinal or going to the toilet. The late response often results in bowel incontinence. The representative noted it is usually around mealtimes when there aren't enough staff as they are occupied with assisting other residents with their meals and passing out trays. A representative reported there are times when a…

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

Based on review of the facility's assessment, the facility failed to include the facility's assessment of the facility's resources to meet the needs of their resident population. Findings include: The facility assessment was reviewed as interviews with residents indicated the facility does not have enough staff to provide care in a timely manner. Review of the facility assessment found documentation that describes the facility's resident population, however, based on the acuity level of the residents, there was no documentation of the staffing levels, contract services required, and equipment, supplies required to meet the residents' needs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, in response to a COVID-19 outbreak identified on 12/15/22, the facility failed to ensure appropriate protective and preventive measures for COVID-19 were executed, as evidenced by the facility failing to follow and implement their infection prevention and control policies and procedures, including standard and transmission-based precautions to control and prevent the spread of COVID-19. In addition, the facility failed to ensure staff conducting point-of-care (POC) COVID-19 self-testing conducted the testing per CDC and manufacturer guidelines and failed to ensure staff handling the collected specimens followed standard precautions. This deficient practice has the potential to contribute to the transmission and spread of COVID-19 in the facility, compromising resident, staff, and visitor safety. Findings include: 1) Cross-reference to F761 Medication Storage and Labeling. The facility failed to ensure the proper storage of collected COVID-19 test samples 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.

Based on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment as evidenced by repeated instances of resident (R) urinal(s), both partially filled and empty, being placed/left on the top of the resident's bedside table(s). As a result of this deficient practice, resident safety was compromised as the residents' food and hydration items were also placed on the bedside table(s). This deficient practice has the potential to affect all residents at the facility who are using urinals. Findings include: 1) On 10/10/22 at 11:30 AM during the initial screening of residents, Residents (R)54 and R2 were observed with empty urinals placed on their overbed trays. On 10/12/22 at 08:30 AM, R32 was interviewed. Observed a plastic urinal containing urine and a plastic bed pan lined with paper towel on his overbed tray. R32 stated nobody emptied his urinal since he used it at 07:00 AM. He ate breakfast and staff removed his tray but did not empty his urinal. Observed two open containers of dietary supplements next to the used urinal. 2) On 10/10/22 at…

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 treat residents with respect and dignity to promote maintenance or enhancement of his or her quality of life. Findings include: 1) On 10/12/22 at 09:30 AM the resident council interview was conducted. R8 reported not receiving a response from a grievance that was filed regarding the facility withholding his electric wheelchair. R8 reported his electric wheelchair was taken away in April related to an incident with another resident. Record review found an entry dated 06/16/22 at 10:09 by the Licensed Clinical Social Worker (LCSW) documenting meeting with R8 three times during the month. LCSW asked R8 whether he would intentionally use his electric wheelchair to harm another resident. R8 reported stated that he would intentionally use his wheelchair to harm another resident. LCSW documents with assistance, R8 still participates in activities of choice and eats in the dining room. LCSW planned to reassess the use of the electric wheelchair quarterly. The facility provided a list of the grievances they received.…

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 with residents, the facility did not assure staff provide ongoing communication to residents about their rights. Findings include: On 10/12/13 at 09:00 AM an interview was conducted with resident council representatives. The representatives were asked whether staff periodically review their resident rights with them. The representatives were unable to confirm their rights are reviewed with them. A review of the Residents Advisory Council Meeting minutes found no documentation resident rights were reviewed during their meetings.

Based on resident interview, the facility failed to ensure residents are provided with informational notice of how to contact the Ombudsman or the State Agency. Finding includes: On 10/12/22 at 09:30 AM, an interview was conducated with six resident council representatives. Residents were asked if they know where the contact information is posted for the Ombudsman. The residents did not answer. Residents were asked whether they have been informed of their right and given informaiton on how to formally complain to the State Agency. Further asked if they were aware they can call the State Agency to complain. None of the residents in attendance were able to confirm they know where to find informaiton to contat the Ombudsman or State Agency to complain or request support.

Based on resident interview, the facility did not assure residents were aware of their right to examine the results of the most recent survey of the facility conducted by State or Federal surveyors. Findings include: On 10/12/22 at 09:00 AM an interview was conducted with resident council representatives. The representatives were asked if they were aware the results of the State inspection are available to read. None of the representatives were able to acknowledge awareness of State inspection results or where to locate the report.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to timely update the care plans for two residents (R), R21 and R49, out of a sample of 19 residents. This deficient practice does not assure interventions were revised to meet the care needs of the residents. Findings include: 1) On 10/11/22 at 10:43 AM, R21 was observed to be in his room lying on his bed with a specialty mattress watching television. Boots were noted to be on both of his feet. On 10/11/22 at 2:05 PM, an interview was done with R21. R21 stated that he looked forward to going home to Maui, but the wounds on his feet are slow to heal because of his diabetes (high blood sugar medical disorder). On 10/13/22 at 11:22 AM, R21's electronic health record (EHR) was reviewed. The Medical Diagnosis screen revealed that R21 is an [AGE] year old resident initially admitted to the facility on [DATE] for TYPE 2 DIABETES MELLITUS WITH FOOT ULCER [high blood sugar disorder with foot wound] and then readmitted to the facility on [DATE] for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide appropriate medical care for four residents (R), R27, R109, R39, and R16 residents. The facility failed to manage bowel regimen to treat constipation for R27 and R109; obtain weights for R39 who has a complex medical history and is on medication to help rid his body of excess fluid; and medically treat and manage R16's rash. These deficient practices affected residents' ability to attain or maintain their highest practicable physical well-being. Findings include: 1) Cross Reference F656 (Comprehensive Care Plan). R27 was admitted to the facility on [DATE]. Diagnosis includes, bipolar disorder, benign prostatic hyperplasia without lower urinary tract symptoms, severe obesity due to excess calories, and borderline personality disorder. On 10/10/22 at 01:29 PM, R27 reported that he gets constipated, clarified in the past he was stopped up three times. R27 further reported he is provided a red pill and pudding for constipation.…

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 did not assure 2 of 5 residents (Resident 109 and 34) received necessary behavioral health services to attain or maintain their highest practicable mental and psychosocial well-being. As a result of this deficient practice, these residents did not have their needs met, and were placed at risk for a decline in their quality of life. This deficient practice has the potential to affect all the residents at the facility in need of behavioral health services. Findings include: 1) R109 was admitted to the facility on [DATE]. Diagnoses include necrotizing fasciitis, cellulitis of right lower limb, cellulitis of left lower limb, and bacteremia. On [DATE] at 08:06 AM, R109 reported his mother died and while picking [NAME] leaves for her funeral he fell and was impaled by a tree branch. He did not seek medical attention, then went to the beach where he contracted bacteria from the water. R109 was hospitalized , reported almost losing his foot but 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 observation and record review, the facility failed to ensure one resident (R) diagnosed with dementia, received the appropriate treatment and services to attain or maintain her highest practicable physical, mental, and psychosocial well-being. As a result of this deficient practice, R56 did not have her needs met, and was placed at risk for a decline in her quality of life. This deficient practice has the potential to affect all the residents at the facility with a diagnosis of dementia. Findings include: R56 is an [AGE] year-old female admitted to the facility on [DATE] with admitting diagnoses that include Parkinson's Disease, major depressive disorder, generalized anxiety disorder, and dementia with agitation, behavioral disturbances, and anxiety. On 10/11/22 at 10:38 AM, during a review of R56's comprehensive care plan (CP) the following intervention was noted: Resident prefers to have STOP SIGN placed on her door. There were no observations made throughout the survey period of a stop sign placed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that one resident (R) was free from a significant medication error as evidenced by R47 being administered an insulin pen that was labeled as expired for six days. In addition, the insulin would have been administered for a seventh day had the state agency (SA) not intervened. Safe medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, R47 was placed at risk of inadequate glucose control as a result of being administered expired insulin. This deficient practice has the potential to affect all residents in the facility receiving insulin. Findings include: On [DATE] at 09:30 AM, Registered Nurse (RN)5 was observed preparing medications for Resident (R)47. One of the medications prepared was an insulin pen that RN5 removed from a plastic bag labeled with the prescription label. In addition to the prescription label identifying the medication, dose ordered, and 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.

Based on observation and interview, the facility failed to ensure all medications used in the facility were stored in accordance with professional standards. Proper storage practices of all medications and biologicals are necessary to ensure their integrity, safety, and efficacy. Findings include: On 12/20/22 at 07:45 AM, observed eight (8) boxes of Influenza Vaccines, each containing ten (10) single-dose pre-filled syringes for a total of eighty (80) doses, on one of the refrigerator (fridge) shelves in the Adult Day Health (ADH) Room. On the same shelf in the fridge was a brown paper bag with half of a moldy egg salad sandwich in a plastic container with a date label that read 10.17, and a large plastic bag with approximately twenty (20) laboratory (lab) specimen bags, each bag containing a specimen swab sealed in a labeled specimen tube and a lab slip. At 08:12 AM, observed Certified Nurse Aide (CNA)1 enter the ADH Room and collect some lab specimen bags from the Quiet Room [a small room within the larger ADH Room]. Prior to CNA1's exit from the ADH Room, asked her if she needed…

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 ensure that the health record for one resident (R)7, out of a sample of 19 residents, accurately conveyed R7's current wishes for medical treatment. This deficient practice has the potential to confuse caregivers to ensure the resident's wishes are executed. Findings include: On [DATE] at 12:25 PM, a concurrent observation and interview were done with R7. R7 laid in bed at a 45 degree angle watching television, his body leaning to the left and his feet towards the right lower edge of his mattress. Both feet were noted to have foot drop (toes pointing down with the inability to lift that part of the foot) and he wore padded boots on both feet. R7 wore tubing in his nares that delivered oxygen from the oxygen compressor located next to his bed. On [DATE] at 10:57 AM, R7's electronic health record (EHR) was reviewed. The Medical Diagnosis screen revealed that R7 is a [AGE] year-old resident who was admitted on [DATE] for heart failure. R7 has…

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.