Hale Malamalama

Based on record review (RR), interviews with family and staff, the facility failed to involve and notify resident's representative(s) of scheduled care plan meetings for Resident (R)6, R7 and R29. The facility also failed to revise care plans. Findings include: 1) On 09/13/23 at 09:38 AM an interview was conducted with R7's Power of Attorney (POA)1 and POA2, who requested that the facility use bed alarms and bedrails to help prevent R7 from falling from or out of bed. POA1 was asked if they ever attend R's care plan meetings and POA1 said no they do not participate in resident's care planning and have not been notified of scheduled care plan meetings. POA1 was asked if he was given a copy of R7's care plan and he stated the facility might have given them a packet when his father-in-law was first admitted . On 0913/23 at 10:30 AM, R29 was interviewed in her room and was found to be alert and oriented to person, place, time, and situation. R29 stated that she was never invited to and has not attended her care plan meeting. On 09/15/23 during RR of R6, R7 and R29 found 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.

Based on interview with staff, the facility did not assure a system was in place to review the performance/competency of certified nurse aides (CNA) at least once every 12 months. This systemic deficient practice has the potential to affect the care residents receive to maintain and attain their highest practicable physical, mental, and psycho-social level. Findings include: On 09/14/23 at 02:15 PM interviewed the Administrator, Assistant Administrator, and Director of Nursing (DON) in their office. Inquired whether the facility does competency checks for certified nurse aides (CNA). For example, use of Hoyer lift or peri care. DON responded the Charge Nurse may perform observations of the CNAs. And if needed, on the spot correction is done. The Administrator reported the facility does not have documentation of CNA performance/competency evaluations.

Based on observations, interviews, and record reviews, the facility failed to provide safe storage for foods in the kitchen refrigerators and freezer and failed to develop a process to ensure that their low water temperature and chemical dishwasher was operated and monitored correctly. This deficient practice has the potential to cause harm to their residents, staff, and visitors who receive meals from the kitchen due to the possibility of contracting a food borne illness. Findings include: 1) On 09/12/23 at 08:10 AM, conducted an initial observation of the kitchen and concurrent interview with the Kitchen Manager (KM). Refrigerator #1 contained a tray with cut carrots located on the bottom shelf that was not labeled with the name of the food item and preparation date. KM confirmed that the items were carrots that were cut in the morning and will be cooked today. Refrigerator #2 contained a tray filled with meat located on the left side of the bottom shelf and a blue plastic bag containing meat on the bottom right of the shelf. KM confirmed that the meat was defrosting chicken 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 observations, record review, and interviews the facility's nursing administration did not assure the facility was administered in a manner that enabled it to develop and maintain systems for residents of the facility to attain or maintain their highest practicable, physical, mental, and psychosocial well-being. The facility failed to: support residents' right to organize and participate in a resident group; support a residents' right to voice grievances; support residents' right to have visitors; create a system for checking the sanitizing of dishes and cookware; and ensure nurse aide competencies/evaluations are being done. Findings include: 1) On 09/12/23 at 07:58 AM an entrance interview was conducted with the Assistant Administrator. Inquired who is the resident council president? The Assistant Administrator replied the facility does not have a resident council president. On 09/14/23 at 02:15 PM interviewed the Administrator and Director of Nursing (DON). The Administrator reported resident council meetings are not done formally as nobody wants to be the president.…

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 the Administrator, the facility did not assure the governing body oversees the Administrator's management and operations of the facility. Findings include: On 09/15/23 at 01:13 PM an interview was conducted with the Administrator. Inquired who are the members of the governing body, the Administrator replied, it is mainly comprised of family members. The President is her son, the [NAME] President is her mother, the Treasurer is her husband and she is the Secretary. Also, her two daughters are the stake holders. Inquired how does the governing body oversee the Administrator's management of the facility. Further inquired how does she report to the governing body and the governing body hold her accountable for the operations of the facility. The Administrator responded this is a family owned facility and very small, what are they supposed to do.

Based on record review and interview, the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The facility does not have a system to collect and use data to identify areas of improvement. Therefore, there is no evidence of performance improvement projects with monitoring of the efficacy of the project. This deficient practice has the potential to affect the quality of life and quality of care of all residents to maintain or attain their highest practicable physical, mental, and psycho-social well-being. Findings include: On 09/15/23 at 12:50 PM an interview was conducted with the Administrator. Inquired how does the facility identify issues which require quality improvement. The Administrator responded each department completes a questionnaire for their specific area and will bring the completed questionnaire to the QAPI meeting. Based on the issues brought forth, the committee will come up with a resolution.…

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, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program to include review and update their Infection Prevention & Control-Infection Surveillance Criteria policy annually, did not establish process and outcome surveillance such as monitoring for proper handwashing, use of hand sanitizer, monitoring wound care, monitoring appropriate use of antiseptic prior to use of sterile straight catheter on a resident with iodine allergy and establishing and maintaining a water program to prevent the growth of Legionella and other opportunistic pathogens. The facility also failed to ensure that a wound dressing change for one resident (R), R3, out of a sample of one, was done utilizing clean technique. This deficient practice encourages the development and transmission of communicable diseases and infections and has the potential to affect all residents needing wound dressing changes in the facility. Findings include: 1) On 09/14/23 at 01:08 PM interviewed the Infection Control Coordinator (ICC) who was able…

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, the facility failed to ensure the safety of their residents and staff by not providing accessible means to trigger the call light system should they fall in the restroom and shower room. This deficient practice could potentially cause harm to residents and staff. Finding includes: On 09/12/23 at 08:45 AM, conducted an initial observation of a shared bathroom in between two resident's rooms on a nursing unit. A small rectangle Code Alert panel with a small red button was located on the wall approximately 3.5 feet from the floor next to the toilet. On 09/13/23 at 01:14 PM, conducted a concurrent observation of the call light system in a resident's restroom and interview with the facilities maintenance staff (MS). MS confirmed that the current resident call system is the Code Alert panel containing a small red button located on the wall next to the toilet. MS stated that pushing the small red button on the Code Alert panel triggered an audio alert heard throughout the facility and a visual alert of the location of where the alarm 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 record review (RR) and staff interview the facility failed to inform three of three residents reviewed for the use of psychotropic medications, Resident (R)7, R9 and R25, or the residents' representative, in advance, by the physician or other practitioner or professional, of the risks and benefits of taking medication such as an antidepressant or antipsychotic and alternative treatment options available. Findings include: On 09/15/23 during RR for R7, there was a diagnosis of vascular dementia, unspecified severity with other behavioral disturbance, and restlessness and agitation. The following medications were ordered, Risperidone (antipsychotic) tablet 0.25 milligrams (MG), give one tablet by mouth two times a day for agitation with a start date of 05/13/2023. This was given at 08:00 AM and 05:00 PM. R7 was also ordered Citalopram Hydrobromide (antidepressant) oral tablet, give 15 MG by mouth one time a day for Dementia with behavior disturbance with a start date of 05/14/2023. R7 received this medication at 08:00 AM. On 09/15/23 during RR for R9, there was a diagnosis of…

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

Based on interview, the facility failed to ensure the residents of the facility exercised their right to organize and participate in a resident group. Findings include: On 09/14/23 at 07:58 AM, an Entrance Conference was conducted with the Assistant Administrator. The Assistant Administrator reported there is no Resident Council President. It was further explained that the council does not meet regularly due to the restriction of group size. On 09/14/23 at 02:15 PM, Administrator reported resident council meetings are not done formally as nobody wanted to be the president. Administrator further reported in the past they would gather residents and ask if they had any concerns. Administrator confirmed there is no documentation of these discussions with the residents. Administrator identified the Social Worker (SW) as facilitating these discussions. There were no minutes or documentation of these informal meetings that occurred and what may have been discussed in the meetings.

2) On 09/12/23 at 10:47 AM went into Resident (R)23's room to introduce self to resident and make observations of his living environment. Observed closet had no door and the closet top shelf had what appeared to be water damage with blackened edges on the shelf facing the resident. On 09/13/23 at 09:02 AM while making observations of R23's room noted the damaged closet shelf was still there. On 09/13/23 at 12:50 PM met with facility maintenance staff (MS) to look at the shelf in R23's room. He noted the shelf was damaged, appeared water damaged and dry which he was able to confirm by touching the shelf and acknowledged the shelf was damaged probably from water from the AC pipes. It was noted there were two pipes coming from the wall behind this shelf. MS reported this is an easy fix as the shelf rests on the rails and he pushed up on the loose shelf showing it is not fixed in place. On 09/14/23 at 08:57 AM while speaking with R23 noted the damaged closet shelf had been taken away and told R23 the facility is replacing the damaged shelf in his closet, and he replied yes. Based 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 record review and interview with staff, the facility failed to implement a grievance system to assure residents exercised their right to file a grievance. The facility did not have an identified grievance officer, and did not maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. The facility also did not implement their policy and procedure by accepting an oral grievance. This deficient practice denies the residents' right to file a grievance with an acceptable resolution. Findings include: A request was made to review the facility's grievance policy and procedures and provide documentation of grievances for the past three years. On 09/14/23 at 02:18 PM an interview was conducted with the Social Worker (SW). The SW reported that she has been employed at the facility for 1-1/2 years and there has not been any grievances. SW also confirmed the facility does don't have a log of grievances, and the facility does not have a grievance officer. SW explained when residents have a complaint,…

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 reviews, and interview, the facility failed to ensure that one resident (R), R28, out of two residents sampled, was able to fulfil her right to make choices about her medical treatment by completing an Advance Health Care Directive (AHCD). This deficient practice could potentially cause harm to residents as they may be given medical treatment that they do not want. Finding includes: On 09/12/23 at 01:22 PM, observed R28 in her room after being up in her wheelchair in the activity/day room until after lunch. R28 was very conversive and found to be alert and oriented to person, time, place, and situation. R28 stated that she does not have an Advance Health Care Directive (AHCD). Record review of R28's electronic health record (EHR). Diagnosis Report revealed that R28 was admitted on [DATE] and included the conditions of having a non-cancerous tumor formed from the membrane covering the brain and the inability to move due to a severe disability, not caused by damage to the spinal cord.…

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

Based on record review and interview with staff member, the facility failed to ensure one (Resident 7) of three residents selected for liability notice review received Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered stay. This deficient practice has the potential to deny residents' right to appeal the facility's decision for discharge. Findings include: Resident (R)7's skilled nursing facility services (Part A) started on 05/13/23. A review of the NOMNC documents skilled nursing facility services ended on 06/22/23. The form was not signed and dated by the resident's representative. There was additional documentation the Social Worker (SW) contacted the family representative on 06/22/23 at 09:22 AM regarding the ending of skilled nursing services on 06/22/23 with liability to begin on 06/23/23. On 09/12/23 at 01:56 PM interview with the Office Manager found that NOMNCs are usually issued 72 hours prior to discharge. The Office Manager reported the SW will review the NOMNC with resident or representative. On 09/12/23 at 02:02 PM 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 reviews and interview, the facility failed to ensure that a complete medical summary documented by the physician, provided appropriate transfer information for the acute care of one resident (R), R20, out of a sample of one, was sent to the receiving provider. This deficient practice fails to convey R20's development of an acute medical condition and medical care received at the facility to treat the acute medical condition to ensure R20's continuity of care. Finding includes: Record review of R20's electronic health record (EHR). admission Record revealed that R20 was initially admitted to the facility on [DATE] and then re-admitted on [DATE]. R20's diagnoses for her re-admission included acute bleeding with low blood count and fainting. Reviewed progress notes and a Social Services Note documented on 05/31/23 at 02:12 PM stated that R20 was sent to the emergency room (ER) by her primary care physician (PCP) because she was found to have a low blood count. Another Social Services Note documented…

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 staff interview the facility failed to develop and implement a baseline care plan within 48 hours for two sampled residents upon admission, Residents (R)6 and R7. The facility was aware residents were prescribed psychotropic medications and failed to develop interventions for the use of these medications. Findings include: On 09/14/23 at 05:03 PM, Director of Nursing (DON) provided copies R6's baseline care plan from 11/7/2022 and under Behavior/Mood the Psychotropic Use box was checked off but intervention lines were left blank. DON agreed this area should have been filled out with interventions. Continued interview with DON, who also provided copies of R7's baseline care plans, from 05/13/23 and 08/25/23. It was noted on the 05/13/23 baseline care plan under Behavior/Mood, Behaviors and Psychotropic Use was checked off with no interventions. On R7's baseline care plan, dated 08/25/23, under Behavior/Mood, Behaviors was also checked off but left blank, psychotropic use and other interventions were left blank. RR found resident was ordered Risperidone 0.25…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff members, the facility failed to assure discharge planning was done prior to resident's discharge. There was no evidence to support this was a resident-initiated discharge and the facility did not ensure the resident had durable medical equipment, assess the home, and/or assess whether the resident would benefit from community services to support the resident in the home. This deficient practice has the potential to affect safe discharge. Findings include: Resident (R)38 was admitted to the facility on [DATE] from a hospital for diagnosis of acute fracture of right superior and inferior pubic ramus and right iliac wing related to a mechanical fall on 08/6/23. R38 received physical and occupational therapy services. Review of R38's Notice of Medicare Non-Coverage (NOMNC) documents skilled services to end on 08/25/23, however, R38 was discharged home on [DATE]. Review of notification to the Ombudsman documents, family requested discharge after completion of therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff member, the facility did not ensure one (Resident 38) of one residents reviewed for discharge had a discharge summary which included a recapitulation of the resident's stay, concise summary of the resident's stay and course of treatment in the facility. Findings include: Resident (R)38 was admitted to the facility on [DATE] and discharged on 08/25/23. On 09/14/23 at 08:53 AM, the facility provided a copy of R38's discharge summary. The Discharge Summary form was completed by the physician. The summary included the resident's name, final diagnosis and where he was admitted from. The form also included spaces to document the following, pertinent findings, significant lab data x-ray and consultation, instruction for further care, discharge medications, and prognosis. The physician drew a line in the space provided. The physician documented for course of stay in the facility SNF LOC and condition of discharge as stable. On 09/14/23 at 09:00 AM interview was done with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to assure one of two residents sampled had an effective pain management program. The resident's pharmacological interventions, including the parameters for use of prn pain medications were not clarified to guide staff in identifying which medication to provide to manage resident's pain. Also, staff was unaware of prn medications that were available to manage the resident's pain. This deficient practice has the potential to affect the resident's well-being (i.e. mood, mobility, sleep). Findings include: Resident (R)89 was admitted to the facility on [DATE] with admitting diagnoses of rectal pain/anal fissure and unspecified dementia, unspecified severity, with other behavioral disturbance. On 09/12/23 at 09:35 AM met R89 during the initial tour. R89 was observed lying in bed and reported having pain to her okole (buttock) and private area. She was asking for Tylenol. On 09/12/23 at 01:11 PM interviewed R89 in her room. She reported that she has problems…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, the facility failed to assure 2 (Residents 31 and 23) of 5 residents had the opportunity to receive the pneumococcal vaccines, unless medically contraindicated, refused or was already immunized. Residents consented to the administration of the pneumococcal vaccine and at most, 1-1/2 years later, the facility was not aware of the vaccine status or provided the vaccine. This practice has the potential to place residents at risk for developing pneumonia. Findings include: 1) Resident (R)31 was admitted to the facility on [DATE]. A review of the Vaccine Consent/Declination Form noted the resident's representative gave consent for the pneumococcal vaccine on 10/26/22. However, the documentation of the date the vaccine was given was blank. Further review found no documentation of the administration status of the pneumococcal vaccine. 2) R23 was admitted to the facility on [DATE]. A review of the Vaccine Consent/Declination Form noted the resident's representative gave…

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 complaint report and interview, the facility failed to ensure residents of the facility had the right to receive visitors. Findings include: On 11/28/22, the Office of Health Care Assurance (OHCA) received a complaint alleging the facility was not allowing visitors due to identification of COVID-19 cases. The complainant provided photos of signage in the window which read, Please No Visitors At this time. Thank you. There was also a stand with a posted sign, COVID-19 cases have been identified in the facility. No visitors are allowed at this time until further notice. On 09/14/23 at 01:00 PM an interview was conducted with the Infection Control Coordinator (ICC). ICC reported the facility had a COVID-19 outbreak at the end of last year. ICC was agreeable to check on when the facility had the outbreak. Inquired whether the facility did not allow visitors at this time. ICC reported during an outbreak, the facility would notify families and strongly discourage visitation. Further queried were signs posted during this time to restrict visitors. ICC responded she could not…

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

Based on observations, record review, interviews, and document review, the facility's nursing administration failed to ensure processes were in place to promptly identify resident-specific care needs including range of motion/contracture management and feeding assistance. Specifically, the facility: - failed to ensure licensed nursing staff regularly assessed residents to determine if their range of motion (ROM) was intact and determine if additional interventions were needed to address declines in range of motion. This failed practice affected 2 (Residents #14 and #28) of 2 sampled residents who had hand contractures. - failed to ensure a process was developed and implemented to ensure a paid feeding assistant provided dining assistance only for residents with no complicated feeding problems. This failed practice affected 2 (Residents #24 and #30) of 2 sampled residents reviewed for feeding assistance. Findings included: 1. During an interview on 10/06/2022 at 8:20 AM, the Director of Nursing (DON) stated there was no facility policy related to contractures or restorative 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 staff implemented appropriate infection control practices during 3 of 3 meals observed. Specifically, staff opened and handled residents' straws and chopsticks with their bare hands while preparing residents' beverages and setting up residents' meal trays. Findings included: On 10/05/2022 at 4:30 PM, Activity Aide (AA) #1 was observed placing straws in two beverages on a resident's meal tray with her bare hands, touching the ends that would go into the resident's mouth. On 10/06/2022 at 7:09 AM, Registered Nurse (RN) #1 was observed preparing water and juice for a resident. RN #1 opened straws and placed them in the cups, touching the straws at the ends that would go into the resident's mouth with bare hands. On 10/06/2022 at 11:17 AM, Certified Nursing Assistant (CNA) #1 was observed opening disposable chopsticks for Resident #15; CNA #1 touched both ends of the chopsticks with bare hands before giving them to the resident. On 10/06/2022 at 11:21 AM, CNA #1 opened straws for two drinks for a resident and touched…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to ensure a dependent resident was dressed in a manner to maintain the resident's dignity for 1 (Resident #14) of 2 sampled residents reviewed for dignity. Findings included: Review of an undated facility policy titled, Resident [NAME] of Rights, revealed, The facility will treat you with dignity and respect in full recognition of your individuality. Review of an admission Record revealed Resident #14 had a diagnosis of essential (primary) hypertension (high blood pressure). Review of a significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #14 was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS indicated the resident was totally dependent on one-person assistance for dressing. Observation on 10/03/2022 at 11:00 AM revealed Resident #14 in bed, wearing non-skid socks on both hands. Observation on 10/06/2022 at 10:46 AM revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to provide a homelike environment for 3 (Residents #9, #22, and #24) of 34 residents whose rooms were observed. Specifically, the facility failed to ensure the shared room of Residents #9, #22, and #24 was not used for storage of supplies and equipment. Findings included: Review of a facility policy titled, Safe/Clean/Comfortable/Homelike Environment Policy, dated 1/2012, revealed, The facility must provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #9 was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. Review of a quarterly MDS, dated [DATE], revealed Resident #22 was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. Review of 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, record review, and interviews, the facility failed to develop a care plan to address hand contractures for 1 (Resident #28) of 2 sampled residents who had hand contractures. This had the potential to affect 11 residents who had contractures, per the Resident Census and Conditions of Residents form dated 10/03/2022. Findings included: During an interview on 10/06/2022 at 3:57 PM, the Director of Nursing (DON) stated she was looking for a care plan policy. A care plan policy had not been provided as of the end of the survey. Review of an admission Record revealed Resident #28 had diagnoses that included Alzheimer's disease. Review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS indicated the resident was totally dependent for activities of daily living (ADLs). According to the MDS, the resident had no functional limitation in range of motion in the upper…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure nursing care was provided in accordance with accepted standards of practice for Resident #2 and Resident #24. Specifically, the facility: - failed to ensure assistance with repositioning was promptly provided to promote comfort for 1 (Resident #2) of 1 sampled resident reviewed for positioning. - failed to ensure neurological (neuro) checks were consistently conducted and documented after an unwitnessed fall for 1 (Resident #24) of 3 sampled residents reviewed for accidents. Findings included: 1. During an interview on 10/06/2022 at 3:02 PM, the Director of Nursing (DON) stated she was looking for the facility's policy on positioning. No policy was provided by the end of the survey. Review of an admission Record revealed the facility admitted Resident #2 on 06/07/2022 with diagnoses that included unspecified dementia with behavioral disturbance and history of falling. Review of a quarterly Minimum Data Set (MDS), dated [DATE],…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to ensure care and services were provided to prevent further potential decline in range of motion (ROM) for 2 (Resident #14 and Resident #28) of 2 sampled residents who had hand contractures. Specifically, the facility failed to: - regularly provide passive range of motion (PROM) exercises for Resident #14 and Resident #28. - promptly identify and address a contracture to Resident #14's right hand. - promptly identify and address bilateral hand contractures for Resident #28. - ensure licensed nursing staff regularly assessed to determine if range of motion was intact for Resident #14 and Resident #28. Findings included: 1. Review of an admission Record revealed Resident #14 had diagnoses including age-related osteoporosis and essential hypertension. Review of a significant change in status Minimum Data Set (MDS), dated [DATE], revealed Resident #14 scored a three on the staff assessment for mental status, indicating severe cognitive…

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 document review, interviews, and facility policy review, the facility failed to ensure a nursing assistant (NA) who was a full-time employee completed the required competency exam for certification within four months of hire for 1 (NA #1) of 1 NA reviewed for competencies. Findings included: Review of the facility's staffing schedule for October 2022 revealed the facility employed a non-certified nursing assistant (NA #1) on a full-time basis. Review of an untitled and undated facility document with staff credentials and hire dates revealed NA #1 was hired 01/24/2022 and was not certified. During an interview on 10/05/2022 at 12:45 PM, the Director of Nursing (DON) was asked when NA #1 would be certified. The DON stated NA #1 was working on getting her certification, but the DON was not sure what her plan is. The DON indicated she was not sure what training the NA had received or whether she had taken Certified Nursing Assistant (CNA) courses. The DON stated NA #1 assisted the CNAs with feeding, toileting residents, assisting with transfers, and changing incontinent briefs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and document review, the facility failed to ensure a paid feeding assistant provided dining assistance only for residents who had no complicated feeding problems and that decisions regarding which residents were appropriate to receive assistance from the paid feeding assistant were based on residents' assessments and plans of care for 2 (Resident #24 and Resident #30) of 2 sampled residents reviewed for feeding assistance. Findings included: During an interview on 10/06/2022 at 3:57 AM, the DON stated there was no feeding assistant policy. Review of a Certificate of Completion, revealed Activity Aide (AA) #1 completed a Temporary Feeding Assistant program on 12/04/2021. 1. Review of an admission Record revealed Resident #30 had diagnoses that included Alzheimer's disease and severe protein-calorie malnutrition. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #30 was severely impaired in cognitive skills for daily decision-making per…

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.