Avalon Care Center - Honolulu, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to care plan and implement residents' individual activity preferences and accommodate special needs for two of two residents (Resident (R) 19 and R338) sampled for activities. This deficient practice has the potential of not supporting the physical, mental, and psychosocial well-being of residents and not creating a meaningful life for residents residing in the facility. Findings include: 1) R338 is an [AGE] year-old female admitted to the facility on [DATE]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/25 noted that R338 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that R338 had intact cognitive function. On 04/01/25 at 09:45 AM, R338 stated that no one comes to her room to offer activities and feels bored. She also stated that she cries when she is bored and proceeded to cry. A facility notice posted in the main elevator stated, Group Activities and Dining has been cancelled due…

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 interviews, the facility failed to provide resident centered needed care and services for two of six residents (Resident (R) 77 and R136), R77 who was one of one sampled for constipation/diarrhea and R136 who was one of four residents sampled for skin conditions (non-pressure). The facility did not follow the physician ordered bowel regimen for R77. This deficient practice put R77 at potential risk for discomfort and fecal impaction. The facility failed to treat R136's Moisture-associated skin damage (MASD) with fungal infection to her sacrum and to her bilateral buttocks from 03/29/25 until 04/03/25 which the facility identified as worsening. This put R136 at risk for harm from possibly developing a pressure injury and pain. Findings include: 1) R77 was admitted to the facility on [DATE] with diagnosis of, not limited to, constipation. Review of R77's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/25, assessed R77's Brief Interview of Mental 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure one of three residents (Resident (R) 29) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM, as evidenced by inconsistent application of splint and ROM exercises. This puts R29 at risk of a decline in ROM and further contractures. Findings include: Cross reference to F725, Sufficient Nursing Staff. The facility failed to ensure sufficient nursing staff were available to ensure restorative nursing assistance was provided. R29 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or paralysis on left side of the body) and neuralgia and neuritis (nerve inflammation or damage). R29's room was under Transmission Based Precautions (TBP), Droplet Precautions, due to her roommate with positive COVID-19 from 05/25/25 to 04/05/25.…

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 provide an environment free of accident hazard for one of two sampled resident (Resident (R) 25) observed for accidents. R25 was observed pushed in her wheelchair with her leg rests not in place putting the resident at risk for an accident that could result in harm. Findings include: On 03/31/25 at 10:43 AM, R25 was observed pushed in her wheelchair by Physical Therapy Assistant (PTA) 5 and Occupational Therapy Assistant (OTA) 7 from the end of the hall to the hallway where her room is located. R25 was seen pushed without her leg rests on her wheelchair and observed holding her feet up. Surveyor stopped staff and asked PTA5 and OTA7 where resident's leg rests were for her wheelchair. PTA5 stated they were crunched for time and leg rests are in her room. PTA5 and OTA7 proceeded to R25's room. On 03/31/25 at 10:46 AM, interviewed Physical Therapist (PT) 1 who was in the hallway outside of R25's room. Inquired of PT1 what rehab staff are to do with the foot rests for residents who are receiving PT services. PT1 explained there…

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 respiratory care was provided consistent with professional standards for two of two (Resident (R) 77 and R10) sampled for respiratory. R77's comprehensive assessment did not include oxygen (O2) therapy, it was not included in her care plan, her nebulizer and O2 tubing was not labeled with the date it was last replaced and the physician O2 orders did not include parameters and delivery method. R10's O2 tubing was not labeled with the date it was last replaced. This deficient practice put R77 and R10 at risk for respiratory complications. Findings include: 1) Cross reference to F641, Accuracy of Assessments. The facility failed to ensure R77's comprehensive assessment reflected she had O2 therapy. Cross reference to F656, Development of the Care Plan. The facility failed to ensure R77's comprehensive care plan included O2 therapy. R77 was admitted to the facility on [DATE] with diagnoses of, not limited to, cough, allergic…

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 that one of two residents (Resident (R) 390) sampled for dialysis, was provided with professional standards of practice. The facility failed to remove R390's pressure dressing after two hours from the completion of R390's Hemodialysis (HD) treatment. This deficient practice puts residents on dialysis at risk for access clotting and complications. Findings include: Cross reference to F656, Development of Comprehensive Care Plans. On 04/02/25 at 09:00 AM, observed R390 with right upper arm fistula pressure dressing still on from yesterday's HD treatment. R390 stated that staff will take it off when they have time and do not really check for the thrill and bruit (a thrill is a palpable sensation felt over the fistula and bruit is a swooshing sound heard with a stethoscope which indicates good blood flow and fistula function). R390 stated he will usually be the one that takes it off. R390 stated he came back from dialysis yesterday at 04:30 PM. On 04/02/25 at 9:30 AM, record review of R390's care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation for two of four medication carts observed. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of the controlled medications used to meet the needs of the residents. In addition, the facility failed to implement a process that assures the accurate and timely disposition of discontinued and/or expired medications. This deficient practice hinders the promotion of safe administration practices that decrease the risk for medication errors. These deficient practices have the potential to affect all residents in the facility who take medications. Findings include: 1) On 04/02/25 at 09:33 AM, an inspection of medication cart 1C was done with Registered Nurse (RN) 56. Observed a blister pack card of Oxycodone (a narcotic) IR 5 milligrams (mg) with 22 pills remaining for Resident (R) 236. Review of the Controlled Drug…

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

Based on record review and interview, the facility failed to document the rationale for not making any changes to the pharmacist's recommendations during a monthly medication regimen review (MRR) for one of five residents (Resident (R) 285) sampled for unnecessary medications. This puts R285 at risk for complications due to medications administered. Findings include: Review of R285's Interim Medication Regimen Review dated 03/13/25, the pharmacist documented the following action required and high-risk medication monitoring recommendations; Aspirin EC .Do not crush, On Antiplatelet: Aspirin, Clopidogrel .Monitor for s/s [signs and symptoms] of bleeding bruising; monitor for thromboembolism. On Diabetic agent: Degludec, R Insulin .Monitor for s/s of hypoglycemia; monitor for s/s hyperglycemia and On Opioid agent: Oxycodone .Monitor for constipation; monitor for s/s delirium/ over sedation/ change in mental status and reduced respirations. The facility documented they accepted the recommendation for do not crush aspirin and signed the MRR on 03/13/25. Review of R285's physician orders,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two medication errors observed out of 28 opportunities for errors, for an error rate of 7%. Safe and timely medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, Resident (R) 56 was placed at risk of negative outcomes due to medication errors. This deficient practice has the potential to affect all residents in the facility taking medications administered by staff. Findings include: On 04/01/25 at 08:30 AM, began observing Registered Nurse (RN)14 as he prepared and administered medications to a resident in room [ROOM NUMBER]. RN14 was observed completing medication preparation, entering room [ROOM NUMBER], and returning to the medication cart without entering any other rooms. RN14 was also not observed with a blood pressure monitor. On 04/01/25 at 08:40 AM began observation of RN14 preparing…

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 for one of four medication carts observed. Proper storage of medications 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 who take medications. Findings Include: On 04/01/25 at 08:22 AM, observed an unlocked medication cart left outside of a resident's room with no staff in sight. At this time the Infection Prevention Registered Nurse (RN) 94 was seen near by and inquired of RN94 if the medication cart is to be locked by the nurse before leaving it and she confirmed it is supposed to be locked. At 08:23 AM, RN85 returned to the medication cart. Inquired of RN85 if she was educated to lock her medication cart before she passes medication and she confirmed she had and acknowledged the medication cart was supposed to be locked before leaving it.

Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by performing hand hygiene in between glove changes. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) On 04/02/24 at 08:20 AM, an interview was done with the Infection Preventionist (IP) in her office. IP reported that Resident (R) 18 had shingles and was currently on Droplet and Contact Precautions. IP confirmed that the expectation was that staff entering R18's room would don an N-95 respirator, a face shield, a gown, and gloves. On 04/02/24 at 12:17 PM, observed two Certified Nurse Aides (CNAs), CNA42 and CNA84, assisting R18 back into bed from her wheelchair. Noted that CNA42 did not have a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to assure three of six residents sampled (Resident (R) 147, R67 and R48) who had surrogate forms filled out also included the physician's documentation stating R147, R67 and R48 did not have capacity to make their own healthcare decisions, as according to State Law. The deficient practice could affect other residents in the facility who do not have advanced healthcare directives and who have surrogate forms filled out incompletely. Findings include: 1) On 04/03/24, record review of R147's electronic health record (EHR) found no copy of her advanced healthcare directive. On 04/03/24 at 02:51 PM, interviewed Social Services Assistant (SSA) 6. Inquired if R147 had an advanced healthcare directive (AHCD). SSA6 stated R147's son stated he is R147's Power of Attorney (POA) but has not submitted the AHCD. SSA6 stated they have asked R147's son a couple of times for a copy of the AHCD and he has not provided a copy. SSA6 stated they had son fill out the form to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to provide, four of four sampled residents (Resident (R) 40, R48, R58, and R246) or their representatives, written notification of transfer/discharge as soon as practical or at least 30 days before residents are transferred or discharged Findings include: 1) On 04/02/24, Record Review (RR) of R246's Electronic Health Record (EHR) found he is a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses that include, but are not limited to, history of falling, presence of right artificial knee joint, other chronic pain, low back pain unspecified, difficulty in walking, not elsewhere classified, muscle weakness, unspecified diastolic (congestive) heart failure and need for assistance with personal care. During the RR found facility notified resident on 07/06/23 of upcoming discharge to home planned for 07/25/23 and resident had refused to sign the form. On 04/04/24 at 1:28 PM, requested copy of notification that was sent to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to three residents of four sampled (Residents (R) 40, R48, R58) and their representative. This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital. Findings Include: 1) R40 was transferred and admitted to the hospital on [DATE] for sepsis (blood infection). A review of the R40's Electronic Health Record (EHR) was conducted. The EHR did not contain documentation, that a written notification regarding the facility's bed hold policy was provided to R40's representative. Interview was conducted with the Administrator on 04/04/24 at 02:00 PM. During the interview, the Administrator failed to provide documentation that the facility's bed hold policy was provided to R40's representative. A review of the facility policy titled, Admission, Transfer and discharge: Notice of Bed Hold Policy Before/Upon Transfer, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent and manage pain adequately for 3 of 3 residents sampled for pain (Residents (R) 197, R146, and R13). Specifically, the facility failed to effectively evaluate pain on admission so that an effective, resident-centered care plan could be developed. As a result of this deficient practice, these residents were prevented from attaining or maintaining their highest practicable level of well-being. Findings include: 1) Resident (R) 197 is a [AGE] year-old female admitted to the facility for short-term rehabilitation on 04/01/24 following a loss of consciousness, and a fall at home. R197's current diagnoses include, but are not limited to, diabetes, chronic kidney disease with heart failure, leukemia, chronic pain, low back pain, and pain in both hips. As a result of her pain, R197 has current physician orders for routine acetaminophen 1000 milligrams (mg) every 8 hours, and as needed oxycodone (a powerful opioid) 5mg-7.5mg every 6 hours…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policy review, the facility failed to promote care for residents in a manner that maintains and enhances each residents' dignity for three of 22 sampled residents (Resident (R) 32, R47, and R40). Staff members referred to R47 and R32 as feeders; and a staff member stood over R40 and used her personal phone while providing assistance during meals. Findings include: 1) On 04/02/24 at 12:05 PM, during lunch observation at the Waikiki Dining Room, observed six residents in the dining room and five family members. At 12:07 PM, Director of Nursing (DON) was standing next to the tray cart and directed a staff member to serve one of the food trays last because it was for a feeder. R47 was observed to be sitting right next to the tray cart when DON made the statement. R47 was observed to need assistance with her meals and was served her tray last. 2) On 04/02/24 at 01:51 PM, interview with Certified Nurse's Aide (CNA) 42 was done. Observed R32 choking while eating, 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 interviews and facility document review, the facility failed to provide quarterly statements and provide statements upon request to one of one residents sampled (Resident (R) 45). Findings Include: R45 is a [AGE] year-old female, admitted to the facility on [DATE]. Interview was conducted with R45 on 04/02/24 at 11:05 AM. R45 stated that her personal funds are managed by the facility. When asked how often the facility provides account statements, R45 stated that she had never received a statement since she had been admitted . Additionally, R45 stated that she had requested a statement a while ago and had not received one thus far. R45 did not know the balance on her account. Interview and attempted record review was conducted with facility Business Office Manager (BOM) on 04/03/24 at 03:34 PM. BOM stated that she does not keep a recorded log or a tracking system to ensure that the residents are provided their account statements quarterly. BOM's current process is printing out the statements and placing…

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 staff interview the facility failed to assure the vent and ceiling outside of residents rooms were kept clean. This deficient practice could affect all residents in the facility if their environment is not kept sanitary, putting them at risk for exposure to increased risk of infection. Findings Include: On 4/02/24 at 12:34 PM, while standing in the hallway outside of a resident's room looked up and saw the ceiling and vent had black residue of an unknown source. The black residue was on the edge of the vent that meets the ceiling and spread across the ceiling spreading to both walls outside of the resident's rooms. On 04/03/24 at 11:38 AM, approached facility staff, Heavy Cleaner (HC) 1, in the hallway under the vent with black residue and inquired why the vent had black residue. HC1 stated It's from the AC, I think it's mold. HC1 stated he tried to vacuum it but vacuuming did not clean off the blackened areas. Requested to speak with his supervisor. HC1 left at 11:52 AM and returned at 11:55 AM with cleaning solution in a spray bottle and said I will try…

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 that the Discharge Assessment for Resident (R) 94 accurately reflected the resident's discharge status. Findings include: Record review done on 04/04/24 at 01:42 PM noted Resident (R) 94 was admitted to the facility on [DATE] and discharged to home on [DATE]. Review of Minimum Data Set (MDS) Discharge Assessment with an Assessment Reference Date (ARD) of 02/06/24 noted R94 was incorrectly documented as discharged to Short-Term General Hospital (acute hospitals, IPPS [inpatient prospective payment system]). On 04/04/24 at 02:07 PM, an interview was done with MDS Director (MDSD) 13 in his office. MDSD13 confirmed that R94's Discharge Assessment had been incorrectly documented and transmitted. MDSD13 stated that R94 had been discharged home with home health services.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered Comprehensive Care Plan (CP) for one of 22 residents (Resident (R) 25) sampled. As a result of this deficient practice, staff did not have the information necessary to adequately care for R25 contractures, ensuring the resident meets his highest potential of physical and psychosocial well-being. Findings include: Cross Reference to F688, Increase/Precent Decrease in ROM/Mobility. The facility failed to provide the proper care and treatment for the contracture in R25's left hand as ordered. Review of R25's nursing restorative monthly review dated 05/31/23 documented Resident completed OT [Occupational Therapy] services with recommendation .Left hand wound require rolled up towel under fingers. Will update care plan. Review of R25's CP found rolled gauze or towel to left hand every shift as ordered was not in the CP. On 04/05/24 at 09:33 AM interview with Director of Nursing (DON) was done. Concurrent review of R25's CP found treatment to left hand to prevent contractures…

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 a resident's person-centered comprehensive Care Plan (CP) was reviewed and revised for one resident (Resident (R) 48) sampled. As a result of this deficient practice, R48 was at risk of a decline in his quality of life, not attaining his highest practicable well-being, and the potential for serious harm and/or death due to complications with his new diagnosis of diabetes. Findings include: R48 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, dysphagia following cerebral infarction, vascular dementia, moderate, without behavioral disturbance, hypertension, chronic kidney disease, muscle weakness, and need for assistance with personal care. On 04/02/24 at 02:16 PM interview with Family Member (FM) 11 was done. FM11 reported R48 developed diabetes while living at the facility and did not have diabetes prior to admission.…

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 effectively assess, identify, and manage, constipation for 1 of 1 resident (Resident (R) 197) sampled. As a result of this deficient practice, R197 experienced no bowel movements for more than five days and abdominal pain/discomfort causing her distress. This deficient practice has the potential to affect all the residents at the facility at risk of constipation. Findings include: R197 is a [AGE] year-old female admitted to the facility from an acute care hospital for short-term rehabilitation on 04/01/24, following a loss of consciousness, and a fall at home. R197's current diagnoses include, but are not limited to, diabetes, chronic kidney disease with heart failure, leukemia, chronic pain, low back pain, and pain in both hips. As a result of her pain, R197 had physician orders for routine acetaminophen 1000 milligrams (mg) every 8 hours, and as needed oxycodone (a powerful opioid) 5mg-7.5mg every 6 hours for moderate to severe pain. One of 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, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for one of two residents (Resident (R) 25) sampled. R25 was not provided proper care and treatment for contracture to his left hand as ordered. Findings include: R25 was admitted to the facility on [DATE] with diagnoses of dysphagia, anemia, unspecified dementia without behavioral disturbance, and contracture to right and left hand. Review of R25's Electronic Health Record (EHR) found under physician's order to place rolled gauze or towel to left hand every shift, ordered on 11/18/20 and revised on 10/17/21. During observations on 04/02/24 at 09:46 AM, 12:29 PM, 12:35 PM, 12:46 PM, on 04/03/24 at 08:57 AM, 02:26 PM, on 04/04/24 at 08:13 AM, 10:19 AM, 12:39 PM, and on 04/05/24 at 08:58 AM, observed R25 in bed, both hands contracture with no rolled-up gauze or towel to left hand. On 04/04/24 at 10:34 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents to one of seven sampled residents (Resident (R) 40). This failed practice has the potential to negatively affect residents who require staff assistance with feeding. Findings Include: R40 is an [AGE] year-old male admitted to the facility on [DATE]. R40's medical diagnoses include but not limited to, hemiplegia (one sided paralysis), hemiparesis (one sided weakness) affecting the right side following cerebral infarction (reduced blood supply to the brain), and dysphagia (difficulty swallowing). Concurrent observation and interview were conducted on 04/03/24 at 08:01 AM with Certified Nurse's Aide (CNA) 40 in R40's room. CNA 40 was observed standing up near the head of R40's bed, looking down at her personal phone. When CNA40 looked up from her phone, State Agency (SA) asked CNA40 how R40 was doing with his breakfast. CNA40 stated that she feels it might be too dry for him,…

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 staff competency in narcotic log documentation and reconciliation. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of controlled medications. Findings include: On 04/04/24 at 08:45 AM, an inspection and reconciliation of the narcotic log on medication cart 2C was done with Registered Nurse 37. Noted blister pack for Resident (R) 3's Tramadol 50 milligrams (mg) had thirty-nine (39) tablets remaining while the narcotic log reflected a balance of forty (40) tablets remaining. At this moment, RN37 took the narcotic log from Surveyor and signed out one tablet of Tramadol for R3. When asked why he was only signing the Tramadol out at that moment (wrote signed out at 08:47 AM), RN37 stated he had just given it and got back to the cart. Surveyor pointed out that he did not just get back to the cart after administering the medication to R3, because Surveyor had just observed him…

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

Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications 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 taking medications. Findings include: On 04/04/24 at 08:27 AM, upon inspection of medication cart 2B with Registered Nurse (RN) 61, noted an albuterol inhaler pulled from the emergency kit (e-kit), with no name, and no date, despite it being clearly opened and used. RN61 confirmed that it had been used, as it would not have been pulled from the e-kit unless it was needed for immediate use but could not explain why it was not properly labeled. On 04/04/24 at 08:39 AM, an interview was done with Assistant Director of Nursing (ADON) 2 near medication cart 2B. ADON2 confirmed that the inhaler and the box that it was in should be labeled with a minimum of a resident name and the date it was opened. 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, record review, and interview, the facility failed to ensure a resident's (Resident (R) 25) medical record was accurately documented. Findings include: Cross Reference to F688, Increase/Precent Decrease in ROM/Mobility. The facility failed to provide the proper care and treatment for the contracture in R25's left hand as ordered. Review of R25's Electronic Health Record (EHR) found under physician's order to place rolled gauze or towel to left hand every shift, ordered on 11/18/20 and revised on 10/17/21. During observations on 04/02/24 at 09:46 AM, 12:29 PM, 12:35 PM, 12:46 PM, on 04/03/24 at 08:57 AM, 02:26 PM, on 04/04/24 at 08:13 AM, 10:19 AM, 12:39 PM, and on 04/05/24 at 08:58 AM, observed R25 in bed, both hands contracture with no rolled-up gauze or towel to left hand. Review of R25's Treatment Administration Record (TAR) in April, during the survey period, documented, administered, Place ROLLED GAUZE or TOWEL to LEFT HAND, on all shifts, day, evening, and night from 04/02/24 to 04/04/24. On 04/04/24 at 12:39 PM an interview with Certified Nurse Aide (CNA)…

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 staff interview, the facility failed to maintain resident (R)148's bed cord control, that raises and lowers the bed, in safe operating condition. The bed cord was frayed in multiple places putting the resident and staff at risk for electrocution. The deficient practice could affect all residents with a bed control. Findings Include: On 04/02/24 at 12:32 PM, observed R148's bed control was placed in her dresser drawer at the bedside. Noticed the cord for the bed control was frayed in multiple places. R148 stated she was tired and was going to sleep because she had a rough night so was not able to answer any questions about the bed control. On 04/05/24 at 09:58 AM, met with Unit Manager Registered Nurse (UMRN) 87 who confirmed the bed control cord was frayed, not safe and she would have maintenance fix this.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to notify in writing the transfer and discharge to hospital as indicated in regulation for two of two residents (Resident (R)14 and R20) sampled. Findings include: 1. On 03/16/23 at 02:20 PM, conducted Record Review (RR) of Resident (R)14's Electronic Health Record (EHR). A Social Services note dated 03/07/23. Social Services Manager (SSM) documented resident emergency contact was informed via telephone of R14's discharged because the resident was transferred to an acute hospital. There was no documentation that a written notice was provided to R14's emergency contact. 2. On 03/17/23 at 09:26 AM, conducted a concurrent RR and interview with facility administrator. She confirmed that the facility notifies residents, family, or representatives telephonically rather than providing written notifications of discharge. 2) Review of the EHR documented R20 was discharged to the hospital on [DATE] for sepsis and elevated troponin level. Further review did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review (RR), the facility failed to provide written notice of bed-hold policy as indicated in regulation for 2 of 2 Residents (R)14 and R20 sampled. Findings include: (Cross-Reference to F623 - Notice Requirements Before Transfer/ Discharge) 1) On 03/16/23 at 02:20 PM, conducted a RR of R14's Electronic Health Record (EHR). A Social Services note documented resident representative was verbally informed via telephone of the facility's bed-hold policy when resident was transported to an acute hospital. There was no documentation that a written notice was provided to the resident and/or resident's representative. On 03/17/23 at 09:26 AM, conducted a concurrent RR and interview with Administrator. The Administrator confirmed that residents and/or their representatives are notified via telephone regarding the facility's bed-hold policy, but currently the facility does not have a process for providing written notification of bed-hold policy the resident and/or their representatives. 2)…

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 infection control practices were implemented to help prevent the development and transmission of communicable diseases and infections. As a result of this deficient practice, residents are at risk of exposure and contracting communicable disease(s) that has the potential to result in harm. Findings include: 1) On 03/14/23 at 12:23 PM, observations were done of Certified Nurse Aide (CNA)26 as she passed lunch trays in Station 1. Observed CNA26 deliver three (3) trays to room [ROOM NUMBER] (which had all residents in the room marked as on TBP) with no hand hygiene or gloves worn/changed in between trays/residents. Then observed CNA26 deliver one (1) tray to room [ROOM NUMBER], and three (3) trays to room [ROOM NUMBER]. No hand hygiene or gloves were observed between trays/residents as CNA26 returned to the tray cart to grab and deliver each tray one by one. On 03/14/23 at 12:28 PM, an interview was done with CNA26 after delivering…

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 and interviews, the facility failed to ensure residents were treated with respect and dignity for seven (Resident (R) R38, R37, R67, R5, R76, R82, and R51) residents sampled. Staff member stood over R37, R38, and R51 while providing assistance during meals; staff members were speaking another language while providing care to R5 and outside of residents' rooms; after R76 followed up for a requested item with nursing staff, a nursing staff member stuck her tongue at R76 and a nursing staff offered R76 drinking water from a communal bathroom sink; and while a nursing staff member was providing assistance to R82, the nursing staff member did not communicate to her in a way that promoted a dignified existence. Findings include: Review of the facility's policy and procedure number 557 RESIDENT RIGHTS Respect and Dignity documents The resident has a right to be treated with respect and dignity. 1) On 03/14/23 at 12:46 PM, conducted an observation of R38 in the resident's room during lunch.…

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 the facility failed to update the nurse staffing data daily. Findings include: On 03/16/23 at 08:59 AM observed the facility's nurse staff data posting dated 03/15/23, the day before. On 03/16/23 at 09:06 AM concurrent observation and interview with Wound Care Nurse (WCN), WCN confirmed the nurse staff data posted was dated the posting from yesterday, 03/15/23 and was not updated. On 03/17/23 at 09:01 AM observed the facility's nurse staff data posting dated 03/16/23, the day before. On 03/17/23 at 09:06 AM interview with Director of Nursing was done. DON stated the nurse staff data should be posted every morning by the scheduler, and if the scheduler is late then night shift or managers should be instructed to update the posting. DON stated, there should be a new schedule up right now.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were securely stored in locked compartments, and failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper security and labeling of medications is necessary to promote safe administration practices, decrease the risk for medication errors, and decrease the risk for the diversion of resident medications. This deficient practice has the potential to affect all residents in the facility who take medications. Findings include: 1) On 03/16/23 at 07:23 AM, observed Nursing Staff (NS)2 walk away from medication cart (med cart) 1A, leaving it unlocked. State Agency (SA) reminded her to lock it before walking to the other end of the hall to med cart 1B. At 07:23 AM, observed NS2 walk away from med cart 1B, leaving it unlocked outside room [ROOM NUMBER]. SA again reminded her to secure her med cart before walking away. NS2 acknowledged that 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 review (RR), the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. This deficient practice has the potential to result in harm to residents on supplemental oxygen therapy. Findings include: (Cross-Reference to F842 Resident Records) On 03/14/23 at 02:51 PM, observed Resident (R)16's oxygen (O2) concentrator. Oxygen tubing and concentrator bottle were clean and labled 03/11/23 but outside cover of concentrator was visibly soiled with brown, sticky stain and gray dust on external filter casing. On subsequent observation on 03/15/23, oxygen concentrator was still not cleaned. On 03/16/23 at 10:54 AM, conducted concurrent observation and interview with maintenance director (MAD). MAD stated that an outside contractor is responsible for repair and maintenance of all O2 concentrators and stated that he would provide maintenance record for R16's O2 concentrator. On inspection with MAD, external cover had brown, sticky stain, filter casing and external filter were covered with gray,…

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 (RR), the facility failed to ensure the right to formulate an Advance Directive and/or ensure follow-up discussions regarding Advance Directives for four of six residents (Resident (R)50, R56, R5, and R76) sampled. As a result of this deficient practice, these residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 03/14/23 at 11:49 AM, a review of Resident (R)50's electronic health record (EHR) noted no advance health care directive (AD) found, and no documentation that it had been discussed. What was documented was a Durable Power-of-Attorney (DPOA) for finances, but none for health care. A review of the SS [Social Services] Quarterly & Annual Evaluation, completed on 02/11/22 noted the following: Advanced Directives? . Yes . Description: Names a DPOA. AD documentation requested from…

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 interviews, the facility failed to assure a resident has the right to a sanitary and comfortable homelike environment for two of five residents (Resident (R) 76 and R67) sampled. R76 was not comfortable leaving a communal bathroom to go back to her bed due to staff putting unsanitary items on the walkway floor and the sound level in the room while R67 is resting. Findings include: 1) Centers for Medicare and Medicaid Services (CMS) defined homelike environment and sanitary in the State Operating Manual (SOM) Appendix PP, A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible .A determination of homelike should include the resident's opinion of the living environment . and Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of 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 interviews and record review, the facility failed to ensure residents are free from abuse or deprived of services by staff, for three of four residents (Resident (R) 82, R11 and R76) sampled. The facility failed to respond to R82's call light timely; a nursing staff member turned off R11's call light multiple times without providing assistance; and a nursing staff member did not help R76 when she requested assistance. Findings include: Review of the facility's policy and procedure FREEDOM FROM ABUSE, NEGLECT and EXPLOITATION defines abuse as The willful .deprivation by an individual, including a caretaker, of foods or services that are necessary to attain or maintain physical, mental, and psychosocial; well-being . Willful is defined as The individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy further documents the types of abuse including deprivation of goods and services, Staff with the knowledge and ability to provide foods or…

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

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 person-centered Comprehensive Care Plan (CP) for three of five residents ((R)50, R8, and R77) sampled. As a result of this deficient practice, these residents were at risk of a decline in their quality of life, not attaining their highest practicable well-being, and the potential for serious harm and/or death due to adverse effects of an anticoagulant medication. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities. The facility failed to provide the proper care and treatment to maintain the ADLs for Resident (R)50, including a care plan for scabies and social isolation due to having scabies. As a result, R50 experienced a decline in her ADL function. 2) Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities. The facility failed to provide the proper care 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 observation, record review, and interview, the facility failed to ensure a resident's person-centered comprehensive Care Plan (CP) was reviewed and revised for one Resident ((R)50) sampled. As a result of this deficient practice, staff did not have the information necessary to adequately care for R50 ensuring the resident meets the highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities. The facility failed to provide the proper care and treatment to maintain the ADLs for Resident (R)50, including revising her activities and ADL care plans after identifying, isolating, and treating her for scabies. As a result, R50 experienced a decline in her ADL function. In addition, despite a functional decline being recently identified and referred to a Physical Therapist (PT), no revisions in R50's ADL CP had been done as a result.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide the proper care and treatment to maintain the activities of daily living (ADLs) for Resident (R)50. In addition, the facility failed to provide the proper care and treatment, including assistive devices, to improve the communication abilities of R8. As a result, R50 experienced a decline in her ADL function and R8 was placed at an increased risk of not having her needs met. Both residents were placed at risk of experiencing 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 placed on isolation in their rooms and/or with communication needs. Findings include: 1) Resident (R)50 is a [AGE] year-old female admitted to the facility on [DATE] following a stroke. On 03/14/23 at 12:08 PM, an observation was done of a Physical Therapist (PT) in R50's room conducting an evaluation of her. During an interview with R50 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 interviews and record review, the facility failed to ensure a resident was free of accident hazards for one of two residents sampled (Resident (R) 27). As a result of this deficient practice, the resident is at risk for potential harm. Findings include: R27 was admitted to the facility on [DATE]. Review of R27's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/23 documents R27's Brief Interview for Mental Status (BIMS) score at a 15, indicating the resident is cognitively intact. On 03/16/23 at 08:27 AM an interview with R27 was done. R27 stated he had a recent fall in the shower. R27 reported he sat on a previously known uneven and shaky shower chair when the shower chair broke, and he fell in the shower. R27 stated Certified Nurse Aide (CNA)31 witnessed the fall and was assisting him with showering. Review of R27's nursing note documents on 03/11/23, Today is resident's shower schedule. Co-RNs [Registered Nurses] heard a loud noise. The shower room was checked 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, interviews and record review, the facility failed to ensure nursing staff demonstrated competency skills for one resident (Resident (R)76). Staff did not competently apply a pain medication patch as ordered by the physician. As a result of this deficient practice, R76 is at risk of the potential for harm related to unrelieved pain. Findings include: R76 was admitted to the facility on [DATE] for short-term rehabilitation. Review of R76's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/23 documents R76's Brief Interview for Mental Status (BIMS) score at a 15, cognitively intact. On 03/14/23 at 10:25 AM during an interview with R76 and her roommate in their room, R76 was called by nursing staff members to come outside of the room, R76 was observed to have two long vertical incisions down both her knees with no bandage wrapped around them during the interview. R76 was then observed to be in front of the room door facing the hallway receiving care by nursing…

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 food was palatable, attractive, and at an appetizing temperature for two residents (Resident (R)51 and R54). As a result of this deficient practice, residents are at risk for the potential of negative psychosocial and/or a decline in weight. Findings include: On 03/14/23 at 12:34 PM, conducted an observation of R51's and R54's lunch and concurrent interviews with both residents. R51 looked at her food and inquired with this surveyor if her lunched looked good enough to eat? This surveyor inquired with the resident if she thought it looked good to eat? R51 stated that the food does not look good and it makes her not want to eat it. R51 reported that her food often comes cold because they (R51 and R54) are one of the last rooms to receive their food. R51 stated that the food often does not look appetizing. R54 confirmed with R51 in that the food often does not look appetizing and the hot food is not always hot. R54 stated that she likes to have butter in her oatmeal, however, she when she received the oatmeal it was…

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

Based on observations, interview, and record review (RR), the facility failed to accurately document medical equipment maintenance and cleaning records for one resident (Resident (R)16) sampled. As a result of this deficent practice, the resident is at risk for the potential for exposure to dust and allergens that could adversely affect the resident. Findings include: (Cross-Reference to F908 Maintain all mechanical, electrical, and patient care equipment in safe operating condition) On 03/16/23 at 10:54 AM, conducted concurrent observation and interview with maintenance director (MAD). Observed cover and filter of Resident (R)16's oxygen (O2) concentrator (Serial#08BF020637) visibly soiled. Conducted a RR on 03/16/23 at 15:33 PM of R16's treatment record showed nursing staff documented cleaning oxygen tubing, concentrator bottle, and filter on 03/11/23. On 03/17/23 at 11:20 PM, RR of service records documented inspection and service of other facility O2 concentrators but no documented service for the O2 concentrator assigned to R16.