Hale Nani Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interviews, document and record review, the facility failed to report to the physician that one Resident (R)16, of a sample of one, had a trend of significantly lower intake than baseline. In addition, R16's last documented weight indicated a significant weight loss, which was not confirmed with a reweigh according to standards of care and their own policy. As a result of this deficient practice, timely medical review to determine of these signs were a part of a broader decline in health status was not done and increased the risk of a negative outcome. This deficient practice could affect any Resident in the facility and prevent them from maintaining the highest practicable level of well-being. 1) R16 was a [AGE] year-old female long-term resident at the facility. She had a history that included but not limited to a stroke with paralysis of the right side of her body, aphasia (difficulty communicating), oropharyngeal dysphagia (swallowing disorder), behavioral disturbance, history of seizures,…

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 assure one of one resident (R) 40, sampled for respiratory care, was provided oxygen assuring the O2 tubing was connected to the O2 concentrator. This deficient practice puts all residents who are using oxygen at risk for respiratory distress and complications related to not receiving lifesustaining O2. Findings Include:On 04/28/2026 at 11:08 AM went into R40's room and observed her resting in her bed with her oxygen concentrator running at 3L with the nasal cannula placed on resident's face with tongs placed in resident's nostrils. Went to check date on oxygen (O2) tubing and noticed O2 tubing was not attached to the O2 concentrator and tubing was on the ground. Went out and got resident's nurse, Registered Nurse (RN)105, asked her to bring her pulse oximeter which she placed on the resident. First reading of R40's oxygen saturation was 85% and resident was not in any distress. Asked RN105 to look at the oxygen tubing and she noticed it was on the ground, nurse stated It's not connected. RN105 applied new tubing and put…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide access site care as ordered by the physician for one of one resident (R) 138, sampled for Dialysis. The deficient practice puts all residents who receive dialysis at risk for complications related to improper care of resident's hemodialysis access site potentially putting the resident's at risk for reduced blood flow, clotting, and narrowing or stenosis of the Arteriovenous Fistula (AVF). Findings Include:On 04/29/2026 at 11:53 AM interviewed R138 in his room. Surveyor inquired about his access site which is used for hemodialysis. R138 explained it is on his right arm. Inquired of R138 when do the nurses at the facility take off the dressing on his access site after he returns to the facility from dialysis and R138 stated nurses take the dressing off the day he comes back or the next morning. On 05/01/2026 during record review of R138's Electronic Health Record (EHR) found resident has an order for the following: When back 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 attending Physician's (MD1) post hospitalization visit examination notes for one Resident (R)16 of a sample size of one, did not reflect a thorough examination of R16's current health status on return to the facility Each visit must document review of resident's current, progress and problems in maintaining or their health status. Specifically, the progress note did not include R16 had been hospitalized for sepsis, hypernatremia (high sodium and low water in blood), or that she had a Peg tube inserted (feeding tube inserted directly into the stomach to provide nutrition). This deficient practice could affect any resident in the facility and increase the risk that Residents would not meet their highest practicable physical, mental and psychosocial well-being. Findings include:1) R16 was a [AGE] year-old female long-term resident at the facility. She had a history of a stroke in 2000 with paralysis of the right side of her body, aphasia (difficulty communicating),…

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 sufficient nursing staff were available to provide nursing and related services necessary to meet residents' needs in a safe manner and in a manner that promoted each resident's rights and physical, mental, and psychosocial well-being for five Residents (R) 170, 187, 222, Anonymous 1, Anonymous 2 of thirty five residents sampled. These failures placed residents at risk for unmet care needs, delays in assistance, decline in hygiene and psychosocial well-being, and diminished quality of life.Findings Include: 1) On 04/28/26 at 08:51 AM, an interview was conducted with R170. R170 stated the facility was short staffed and when there were not enough staff, Certified Nurse Aides (CNAs) did not have time to provide showers and instead provided bed baths. R170 further stated it takes nursing staff longer to answer call lights when staffing is short. The resident reported there should be at least five CNAs on the unit, however, at times there were only three CNAs working. On 04/28/26, review of the daily…

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 safe administration of medications in accordance with standards of nursing practice when four residents (Residents (R) 44, R170, R169, and R203) of a sample size of 38 were not directly observed taking their medications and licensed staff left them at the bedside. As a result of this deficient practice, there is a risk of hoarding, diversion, inaccurate timing of administration, and omission, which increases risk of an adverse outcome. This deficient practice could affect any resident in the facility.1) On 04/28/26 at 12:04 PM, during an interview with R44 observed Registered Nurse (RN) 42 enter R44's room, hand a cup of medication to R44 and tell her one of the medications was tums, then left the room without observing R44 take the medication. R44 then put the cup of medication on her bed without taking the medication given. Review of R44's Medication Administration Record (MAR) for 04/28/26 revealed R44 was administered Renvela…

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 ensure the attending physician documented review of the consultant pharmacist's monthly medication regimen review (MRR) recommendations, including actions taken in response to the pharmacist's recommendations, for one of five residents (Resident (R) 5) reviewed for unnecessary medications. This deficient practice placed R5 at risk for unresolved medication-related concerns, including adverse drug reactions, medication interactions, continued use of unnecessary medications, ineffective treatment, and potential decline in health status. Findings Include: Review of R5's MRR notes from April 2025 to April 2026, revealed the pharmacist documented the MRR was complete and included Sending rec [recommendation] regarding fluid restrictions on 07/09/25. Requested from the facility the July 2025 MRR to review what the pharmacist recommended regarding fluid restrictions and physician's response. The July 2025 MRR was not provided. Review of R5's MRR notes from April 2025 through April 2026 revealed that the consultant pharmacist…

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

Based on interview and record review, the facility failed to ensure that antipsychotic and antidepressant medications received adequate documented behavior monitoring for one of five residents (Resident (R) 5) reviewed for unnecessary medications. This failure placed R5 at risk for ineffective treatment monitoring and continued unnecessary medication use. Findings Include:Review of R5's physician orders revealed R5 is taking Abilify 5 milligrams (mg) one tablet in the evening for depression, trazadone 50mg one tablet at bedtime for depression/anxiety, and vilazodone 10mg two tablets at bedtime for depression. On 04/30/26 at 12:38 PM, an interview was conducted with the Director of Nursing (DON) in training. The DON stated behavior monitoring is usually documented on the treatment administration record for nursing staff to monitor. The DON was unable to locate behavior monitoring documentation related to the resident's psychotropic medications Review of the facility's policy and procedure Use of Psychotropic Medication(s) reviewed on 04/2026, documented A psychotropic drug is any…

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 staff interviews, the facility failed to ensure one Resident (R)52 of sixteen residents selected for review, is free of medication errors. List of wrong medications given to R52 included psychiatric medications, antihypertensive (medications to control high-blood pressure), furosemide, and blood thinner. As a result of this deficiency, R52 was at risk of experiencing potential side effects, adverse health issues and harm. Findings include:R52 is a [AGE] year-old male admitted to the facility on [DATE] and is currently receiving Intermediate Care Facility level of Care. Diagnoses included but not limited to hemiplegia (severe or complete paralysis/loss of voluntary movement on one side) and hemiparesis (mild-to-moderate weakness or reduced sensation on one side) following cerebral infarction affecting left dominant side. On 04/19/26, Office of Health Care Assurance (OHCA) received complaint report with Intake #2994297. Complainant reported that, .On 04/16/26.my father, a resident at…

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

Based on observations and staff interview, the facility did not properly secure two Medication and Treatment Carts, of six reviewed, which contained various medications and medical supplies. As a result of this deficiency, there was an increased chance of missing equipment/medications and/or accident hazards.Findings include: 1) Observation, on 04/30/26 at 08:30 AM, of the Treatment Cart on Lewalani Unit, the cart lock was broken and anyone could open the cart/drawers and have access to all the medications and medical supplies. During staff interview on 04/30/26 at 08:45 AM, Treatment Nurse acknowledged the cart was not secured and said there was a work order for it to be repaired. Treatment Nurse said they would check again to have the lock repaired as soon as possible. 2) On 04/28/26 at 08:45 AM, during initial tour of the facility, observed the medication cart in the hallways unlocked and unsecured. As Registered Nurse (RN) 25 walked out from the resident's bedroom, RN observed going back to the medication cart, but left medication cart unlocked. When RN25 was asked if medication…

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 residents food preferences were honored for one of four residents (Resident (R) 187) reviewed for food services. This failure placed R187 at risk of dissatisfaction with meals and overall quality of life. Findings Include: On 04/28/26 at 12:54 PM, during a dining observation and interview, R187 stated that she was not supposed to have gravy or chicken skin but the facility continued to serve foods with gravy on her plate. Observation of R187 lunch tray revealed chicken with the skin on and gravy covering the chicken. Review of R187's meal card on the meal tray revealed R187 was ordered a No Added Salt (NAS) diet with instructions for no sauce, gravy, or chicken skin. On 04/29/26 at 07:56 AM, Resident 187 reported that her dinner plate the previous evening had a lot of gravy. When asked whether she reported the concern to staff, the resident stated she did not want to complain and instead tried to work around the food because otherwise her meal would arrive later. Review of the facility's daily dinner…

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 assure their sanitation solution kept in their sanitation buckets in the kitchen were maintained at the correct sanitation level. The deficient practice places the residents at risk for spread of foodborne illness. On 04/28/26 at 9:02 AM requested staff, Dietary Aide (DA) 5, check the sanitation level of the red sanitation bucket. DA5 used the Hydrion QT-40 test strip, which she dipped in the bucket. Inquired of DA5 how long the strip must be kept in the sanitation bucket and she said, 15 seconds. Showed DA5 the Hydrion QT-40 test strip container which states Dip paper in quat solution, not foam surface, for 10 seconds. Don't shake. Compare colors at once. DA5 retested the first sanitation solution in the red bucket, and the strip was compared to the test strip container and found to be out of range, not reaching the 150-400 parts per million (PPM). Surveyor requested DM5 test the second sanitation solution in the second red bucket and also found the sanitation solution to be out of range. On 04/30/2026 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and review of policy, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary environment and to prevent the transmission of communicable diseases and/or infections. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings Include:1) R58 was a [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation services to include physical and occupational therapy. Diagnoses included but not limited to generalized muscle weakness, bacterial pneumonia and positive for Clostridioides difficile (C. diff - bacterium that causes an infection of the colon). On 04/28/26 at 11:54 AM, observed signage outside R58's room with a heading that stated, Stop, Contact Precautions. At 11:55 AM, observed Registered Nurse (RN)31 enter R58's room after donning a gown and gloves. R31 checked R58's blood pressure and temperature, wiped 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 there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely for 6 of 9 residents (Residents 1, 2, 3, 4, 7, and 8), and 4 of 7 floors sampled. Specifically, residents were not receiving their showers or restorative nursing services as scheduled, residents were not being transferred by mechanical lift per the facility policy and protocol for safety, and a resident requiring an around-the-clock one-to-one (1:1) sitter did not consistently have one. As a result of this deficient practice, residents were placed at risk of a preventable accident/injury or decline in mobility.Findings include: 1) Resident (R) 4 is a [AGE] year-old male with a readmission date of 09/06/25 and diagnoses that include paraplegia (loss of sensation and motion in the lower part of the body), central cord syndrome (spinal cord injury affecting arms and hands), and restless leg syndrome (irresistible urge to move…

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 its nurse staffing information was posted in a prominent place readily accessible to all residents. In addition, the facility failed to ensure the staff information that was posted met the data requirements, specifically, facility name, resident census, and the total number and actual hours worked by licensed and unlicensed staff. Findings include:On 11/17/25 at 11:53 AM, observations made on the ground floor of the main building noted a staff assignment posting on the table at the main entrance, and a copy posted near the time clock. Review of the staff posting noted it did not include the facility name, resident census, or the total number and actual hours worked by licensed and unlicensed staff. A tour of the facility later that day noted the staff assignment (still lacking the aforementioned data) was also posted by the time clocks on the first floor of the main building, and the first floor of 1 of 2 other buildings. The same observations were made during tours of the facility on 11/18/25 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 interview and review of the current Facility Assessment, the facility failed to review and update the assessment when there was a change to a six-hour Certified Nurse Aide (CNA) shift schedule on 11/02/25. As a result of this deficient practice, the assessment did not reflect that the facility assessed how many CNAs were needed on each shift to safely care for the needs of the residents.Findings include:On 11/17/25 at 06:15 AM, a memo posted on the wall by the main building time clock was reviewed. The memo dated 09/29/25 contained the following information:Addressed to: CNA(s) at [Facility]From: [Facility] LeadershipRegarding: Implementation of six (6) hour shift schedule for CNA(s)Content: .facility will be moving to a six (6) hours schedule for CNA(s).effective 11/2/25The new CNA schedule was listed as: 06:00 AM -12:30 PM, 12:00 PM - 06:30 PM, 06:00 PM - 12:30 AM, 12:00 AM - 06:30 [NAME] 11/17/25 at 10:25 AM, the Facility Assessment was reviewed. The Date Completed/Updated was documented as 11/17/25…

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 2) On 05/12/25 at 12:54 PM observed Certified Nurse Aide (CNA) 11 assist Resident (R) 56 with her lunch. CNA11 uncovered R56's food, mixed some of the food together and took a spoonful and offered it to R56. Right afterwards CNA11 left R56 and went into room [ROOM NUMBER] and retrieved a used meal tray and placed it in the cart. CNA11 returned to R56, stirred her food some more, took another spoonful and offered it to the resident which she took. CNA11 left R56 and walked down the hall to another resident and pushed the resident down the hall past R56 to help move him out of the way while a delivery was coming down the same hallway. CNA11 returned to R56, did not perform hand hygiene and proceeded to assist R56 with her lunch again by offering her more spoonful of food. On 05/12/25 at 02:00 PM interviewed Director of Nursing (DON) in her office. Inquired if staff are to perform hand hygiene between tasks and DON confirmed staff are to perform hand hygiene between tasks. Requested a copy of facility policy 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, for the facility failed to ensure the disharge/transfer form used by the facility included all of the Ombudsman's address or the resident's appeal rights and provide written notification of transfer/discharge to the resident and the resident representative for two of three Residents (R)187 and R166 sampled. Finding include: Review of the facility's Transfer/Discharge Notice policy, 7.Before a facility transfers or discharges a resident: a. Notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .the facility must send a copy of the notice of transfer or discharge to the representative of the Office of the state Long-Term Ombudsman. 9. Content of Notice to include, d. A statement of the resident's appeal rights .e. The name and address of the Office of the State Long-Term Care Ombudsman . 1) On 05/13/25 at 03:25 PM, review of R187's Electronic Health Record (EHR)…

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 two Residents (R) 166, 216, out of two sampled, the amount of treatment/services to maintain and/or prevent a decline in range of motion (ROM) as evidenced by inconsistent application of splint and ROM exercises. This puts the residents who have limited mobility at risk for decline in ROM and further contractures. Findings include: 1) R166 was admitted to the facility on [DATE] with diagnosis, not limited to, Hemiplegia, unspecified affecting left non-dominant side (weakness or paralysis on the left side of the body). R166 has contractures to left hand and bilateral elbow. On 05/12/25 at 08:58 AM, observed resident with bilateral arm contractures. Noted a towel hand roll to left hand, but no splint to right arm noted. On 05/13/25 at 12:25 PM, observed hand roll to left hand, but no splint to right arm noted. On 05/14/25 at 08:45 AM, observed no hand roll on left hand and no right arm splint. On 5/14/25 at 09:15, interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of policy, the facility failed to ensure two Residents (R)201 and R49, of six residents sampled for accident hazards, had their risk of preventable accidents occurring minimized. R201 who wanders didn't receive adequate supervision from the staff and R49 did not have a safe designated smoking area for him to smoke. As a result of this deficient practice, there was increased risk of avoidable accidents and injuries by not providing the appropriate planning, monitoring and/or implementing the interventions to meet their identified needs. Findings include: Cross reference to F641. 1) The following observations were made of R201 on the Piikoi 2 unit between 05/12/25 to 05/15/25: 05/12/25 at 12:30 PM on the Piikoi 2 unit. R201 walked briskly up and down the hall from her room at the end of the hall toward the nurse's station. 05/13/25 at 09:07 AM on the Piikoi 2 unit. R201 was unaccompanied by staff when she walked around in the hall at the end of the hall…

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 manage pain adequately for 2 Residents (R)9 and R44 of 4 residents sampled for pain. Specifically, the facility failed 1) accurately assess and monitor R9's pain in a manner that she understood, resulting in inadequate pain control and 2) failed to manage R44's pain while being provided passive range of motion (PROM) exercises by the Restorative Nursing Assistant (RNA) and had not been pre-medicated prior. 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) Cross-reference to F676 Activities of Daily Living (ADLs)/Maintain Abilities. Despite identifying that Resident 9's preferred language is Vietnamese and would like interpreter services to communicate with health care staff, the facility failed to assess and monitor her pain in a way that she understood. Resident (R)9 is an [AGE] year-old female admitted on [DATE] for…

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

Based on resident/representative interviews, staff interview, record review and review of policy, the facility failed to ensure that three Residents (R)9, 54, 140 of three residents sampled understood the Binding Arbitration Agreement. As a result of this deficiency, R9, 54 and 140 did not fully understand the details of the Agreement. Findings include: Interview with R9's Family Representative on 05/14/25 at 01:30 PM, stated that he did not remember signing the Binding Arbitration Agreement and did not know what the Agreement was about. Family Representative said there were a lot of admission forms to sign and it was difficult to know what they were all about. R54 interview on 05/14/25 at 01:15 PM, stated that she signed all admission papers but did not remember the discussion of the Binding Arbitration Agreement. R54 was not familiar with any details of the Agreement and revealed that she would not have signed the Agreement had she known that she was waiving her right to a traditional court trial. R140 interview on 05/14/25 at 12:55 PM, stated that he did not remember signing 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 3) On 05/12/25 at 12:54 PM observed CNA11 assist R56 with her lunch. CNA11 was observed standing up while assisting R56. CNA11 uncovered R56's food, mixed some of the food together and took a spoonful and offered it to R56 as she stood near R56. Right afterwards CNA11 left R56 and went into room [ROOM NUMBER] and retrieved a meal tray and placed it in the cart. CNA11 returned to R56, stirred her food some more, took another spoonful and offered it to the resident which she took. CNA11 continued to stand near resident during this time. CNA11 left R56 and walked down the hall to another resident and pushed the resident down the hall past R56 to help move him out of the way while a delivery was coming down the same hallway. CNA11 returned to R56, and proceeded to assist R56 with her lunch again by offering her more spoonful of food. At this time the facility Administrator in training appeared with a stool for CNA11 to sit on and he asked her to sit down and stay with R56 while she assisted her with her meal. 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 interview and record review, the facility failed to facilitate the inclusion of the resident's representative in the resident's care planning for 2 of 5 residents Resident (R) 203 and 532. As a result of this deficient practice, the resident's representative was not able to support and provide input on the resident's goals, choices and preferences. Findings include: 1) R203 is a [AGE] year-old male, admitted to the facility on [DATE]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/25 noted that R203 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated that R203 has severe cognitive impairment. On 05/12/25 at 02:48 PM, interviewed R203's family representative (FR) 10, over the phone, who was listed as R203's responsible party on the facility's admission record. FR10 stated that the care planning meetings for R203 is sporadic and formal meetings are not conducted. On 05/13/25 at 08:53 AM, interviewed the Minimum Data Set Nurse (MDS) 1 in her office along…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 1 of 36 residents Resident (R)9 in the sample had been determined clinically appropriate to self-administer her medications before leaving them at the bedside for her to take independently. This deficient practice placed R9 at risk of adverse effects related to unsafe medication administration practices. Findings include: R9 is an [AGE] year-old female admitted on [DATE] for long-term care. Review of R9's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 03/31/25 revealed that staff had determined her Cognitive Skills for Daily Decision Making were Moderately impaired - decisions poor, cues/supervision required. On 05/12/25 at 08:52 AM, observation made while at the bedside of R9. Observed at least six different medications (tablets and capsules) at the edge of the bedside table in front of her. Attempted to ask R9 about the medications but she did not respond verbally to questions, only smiled. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor the shower preferences of 1 of 2 residents Resident (R)9 sampled for accommodation of needs by having a shower gurney available. In addition, the facility failed to ensure the continuous availability of a mechanical lift for the transfer of the 9 of 40 residents on the floor who require it. As a result of these deficient practices, R9 did not have her needs met and was placed at risk of not attaining her highest practicable well-being. Findings include: R9 is an [AGE] year-old female admitted on [DATE] for long-term care. Review of R9's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 03/31/25 revealed that R9 is fully dependent on staff for transferring in/out of bed and moving from a sitting to a lying position and vice versa. While in bed, R9 needs maximal assistance (staff do more than half the effort) to roll from side to side. On 05/12/25 at 03:05 PM, a phone interview was done with R9's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to identify and support the shower preference of 1 of 2 residents Resident (R)9 sampled for Self-Determination/Choices. As a result of this deficient practice, R9 did not have her needs met and was hindered from attaining her highest practicable well-being. Findings include: Cross-reference to F558 Accommodation of Needs. The facility failed to secure the equipment necessary to honor Resident (R)9's shower preferences and meet her needs. R9 is an [AGE] year-old female admitted on [DATE] for long-term care. Review of R9's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 03/31/25 revealed that R9 is fully dependent on staff for toileting and requires maximal assistance (helper does more than half the effort) for showering and personal hygiene. Further review noted that in Section F0400 Interview for Daily Preferences, the question, How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the individual financial records of 2 of 3 residents Residents (R)104 and R49 sampled for personal funds were made available to them through quarterly statements. As a result of this deficient practice, the residents were not aware of their current account balances and were not afforded the opportunity to periodically reconcile their accounts. Findings include: 1) R104 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. A review of R104's most recent Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/31/25 noted a Brief Interview for Mental Status (BIMS) score of 12 out of 15, reflecting a determination that he falls just short of cognitively intact. The previous two MDS assessments, on 08/18/24 and 12/30/24, both have R104 assessed with a BIMS of 15 out of 15. On 05/12/25 at 10:31 AM, an interview was done with R104 at his bedside. R104 confirmed that the facility holds money 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.

Based on observation and interviews, the facility failed to ensure that the personal information and clinical records of Resident (R)134 were protected. As a result of this deficient practice, residents are at risk of their health information not remaining private. Findings include: On 05/14/25 09:40 AM, while surveyor was walking down the hallway on Piikoi 1, observed ICARE station #10784 (station where Certified Nurse Assistants (CNA) and Restorative Nurse Aides (RNA) document their tasks and interactions with residents) left open and accessible with R134's information to include code status, allergies, diet, and required treatment monitoring. ICARE station was located near the entrance of the wing where there is heavy traffic of other residents and family entering in and out through that area to get to the lanai. On 05/14/25 at 09:45 AM, interview with Registered Nurse (RN)1 completed. When asked if the ICARE station should be left open, RN1 confirmed that it should be closed and exited out for privacy reasons and to comply with the Health Insurance Portability and Accountability…

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 provide a clean area inside and outside of two of four Residents (R) 75, 159 sampled for Environment. R75's bed side mats were dirty with black marks and R159 sat underneath a dirty ceiling tile with a large black spot. 1) On 05/12/25 at 08:57 AM observed R75 resident in her room in her bed. R75 has fall mats on both sides of her bed. Closer inspection of fall mats found them to be dirty with black marks. On 05/14/25 at 05:38 PM observed R75 in her bed. Observation of fall mats on either side of her bed do not appear to have any changes, appears dirty with black marks. On 05/15/25 at 06:12 AM observed R75 in her bed as a CNA provided care for her. At this time noted fall mats on either side of R75's bed continues to be dirty with black marks. On 05/15/25 at 07:27 AM interviewed Housekeeper 25. Inquired of housekeeper 25 when was the last time the floor mats were cleaned. Housekeeper 25 stated she was not sure when they were last washed. Housekeeper 25 confirmed the mats were dirty and stated she would clean them 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 interview and record review, the facility failed to conduct an assessment that accurately reflects the status of two Residents (R) 9 and R201 of 36 residents in the sample. As a result of this deficient practice, these residents did not have their needs properly identified or met and were hindered from attaining their highest practicable well-being. Findings include: Cross reference to F689 and F740. 1) R9 is an [AGE] year-old female admitted on [DATE] for long-term care. Review of R9's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 03/31/25 noted the question: Should Brief Interview for Mental Status [BIMS] be Conducted? had been marked No (resident is rarely/never understood). Further review of the 03/31/25 Annual Assessment revealed that R9 had indicated her preferred language was Vietnamese, and indicated yes to the question regarding . need or want an interpreter to communicate with a doctor or health care staff? On 05/12/25 at 03:05 PM, a phone interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) On 05/12/25 at 04:41 PM record review of R75's Electronic Health Record (EHR) revealed she is a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses that include, but are not limited to, vascular dementia, unspecified severity, with other behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pain, unspecified and constipation, unspecified. R75 had a Minimum Data Set (MDS), that was a quarterly review, with an Assessment Reference Date (ARD) of 11/12/24 with a Brief Interview for Mental Status (BIMS) Exam summary score of 99, indicating the interview was not successful and R75 has an MDS Significant Change that had an ARD of 02/20/25 with a BIMS asking Should Brief Interview for Mental Status be Conducted? and No (resident is rarely/never understood) was checked, indicating the BIMS exam was not done with R75. Review of R75's MDS Section GG - Functional Abilities and Goals revealed she is dependent upon staff for her toileting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to revise one Resident (R) 119 of four residents sampled for dialysis, Care Plan (CP). The facility also failed to provide an intervention to care for R119's dialysis access site after he returned from dialysis with a pressure dressing covering his access site. The deficient practice puts the resident at risk of decreased blood flow and/or occlusion of the access site. Findings include: On 05/13/25 at 09:22 AM R119 was observed in his room in his bed with a dressing on his upper left arm. Inquired of R119 where the dressing was applied and he stated it was applied at the dialysis center yesterday. Inquired if the nurses ever take off the dressing when he returns from dialysis and he confirmed sometimes they take it off and put on Band-Aids if it is still bleeding. Record review of R119's Electronic Health Record (EHR) revealed he is a [AGE] year-old was admitted to the facility on [DATE] and his diagnoses include, but are not limited to,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the proper care and treatment including assistive devices/tools to improve, promote the communication abilities and to communicate needs and express choices for 2 Residents (R)9 and 203 of 3 residents sampled. Despite identifying upon admission that their primary language was not English, the facility failed to implement the use of alternative communication methods, such as a communication board, non-verbal pain assessment tools or commonly used phrases in their primary language. As a result of this deficient practice, the residents were placed at an increased risk of not having their needs met, hindered from attaining their highest practicable well-being and placed at risk for decrease in quality of life. Findings include: Cross-reference to F641 Accuracy of Assessments. 1) Despite identifying that R9's preferred language is Vietnamese and would like interpreter services to communicate with health care staff, the facility failed…

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, the facility failed to ensure that residents who require dialysis services are consistent with professional standards of practice. The facility failed to remove the pressure dressing for one of one resident Resident (R) 73 sampled, who was on dialysis. This deficient practice puts residents on dialysis at high risk for access clotting and complications. Findings include: On 05/12/25 at 01:40 PM, observed R73, who went for dialysis in the morning at 05:00 AM and returned to the facility at 10:00 AM with left forearm fistula pressure dressing still on. R73 stated that the nurse will usually take it off after he comes back from dialysis. On 05/13/25 08:00 AM, observed resident left forearm fistula still with pressure dressing. Resident stated that they did remove it last night, but the nurse on the night shift reapplied a new dressing. On 05/13/25 at 11:35 AM, interview with Registered Nurse (RN) 2, when asked what the facility's process is in assessing the dialysis access, RN2 stated that they check the thrill, bruit, bleeding, 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 interview and record review, the facility failed to adequately assess for and identify past trauma experienced by one of one Resident (R) 211 sampled for Trauma-Informed care (TIC). As a result of this deficient practice, R211 did not have his trauma triggers identified placing him at increased risk of re-traumatization and was hindered from attaining her highest practicable mental and psychosocial well-being. Findings include: R211 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include major depressive disorder single episode, generalized anxiety disorder, and post-traumatic stress disorder. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/17/25 noted that R211 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated that R211 is cognitively intact. On 05/12/25 at 01:00 PM, a review of the facility's TIC policy stated, 1. Staff will receive training related to trauma-informed care; 2. Residents will be screened upon admission to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the necessary behavioral health care services that were person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety were provided for one Resident (R) 201 of four residents in the sample. This deficient practice has the potential to affect all of the residents residing on the unit. Findings include: Cross reference to F641 Interview on 05/12/25 at 12:30 PM with R2 and R103 on the Piikoi 2 dining area. R2 referred to R201 and said to the surveyor that she was upset because sometimes R201 goes into other people's rooms and takes their food. Sometimes she will take food off trays from the kitchen carts that sit in the hallway. R2 added that R201 sometimes drinks water from the pitcher on the tables in the hallway and dining area, because no one monitors her. Once she went into another resident's room, hit the resident and took her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to 1) Ensure the accurate administering of all drugs to meet the needs of 1 Resident (R) 9 of 36 residents sampled. R9 was given medications more than 2 hours early without consideration of safety/efficacy and 2) Assure licensed staff signed the narcotic log each time it was reconciled. The deficient practices placed R9 at risk of adverse effects related to unsafe medication administration practices and put other residents at risk for drug diversion. Findings include: 1) Cross-reference to F842 Resident Records - Identifiable Information. Despite intentionally giving her medication more than two hours early, the Registered Nurse documented it as being given on time. Resident (R)9 is an [AGE] year-old female admitted on [DATE] for long-term care. On 05/12/25 at 08:52 AM, observation made while at the bedside of R9. Observed at least six different medications (tablets and capsules) at the edge of the bedside table in front of her. Attempted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the consultant licensed pharmacist's (CLP) 1 medication regimen review (MRR) recommendations were acted upon for one of one Resident (R) 203 sampled for drug regimen review. As a result of this deficient practice the facility did not maintain the resident's highest practicable level of physical, mental, and psychosocial well-being and prevent or minimize potential adverse consequences related to medication therapy. Findings include: R203 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of, but not limited to, spinal stenosis (spaces between the spine narrows putting pressure on the spinal cord), atrial fibrillation (the upper chambers of the heart beats chaotically and rapidly), and anxiety disorder. On 05/14/25 at 07:18 AM, a review of R203's MRRs was conducted. One MRR recommendation was not followed-up timely and a follow-up for one MRR recommendation was unable to be located. On 05/14/25 at 07:25 AM, a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4) On 05/12/25 at 09:54 AM observed R116 sitting in his wheelchair in front of his room. Noticed R116 had a medication cup with pills and one loose pill on his table. At this time R116's assigned nurse, RN 50 was at the medication cart, to R116's left side. RN50 was focused on who he was talking to, with his back to R116. Surveyor stood in front of R116 to observe what he was going to do with the medication. RN50 noticed surveyor in front of R116 and stated, I have my eye on him. Once RN50 was done talking with the male person he was addressing he walked over to R116. RN50 looked down at R116 and did not say anything. Inquired of RN50 what he would do in such a situation and he said put the medication in the med cart. RN50 picked up the medication cup and started to walk away. Surveyor stopped RN50 and let him know there was a loose pill on R116's table. RN50 picked up the loose pill. On 05/15/25 at 01:25 PM interviewed DON in her office. Inquired how nurses are to administer medication and DON stated use 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 observations, interviews, record review and review of policy, the facility failed to accommodate one Resident (R)250, of four residents sampled, preference of food and drink. As a result of this deficiency, R250 did not like the food and/or drink provided by the facility and would not eat it or would have other food, from outside the facility, brought in. Findings include: R250 was admitted to the facility on [DATE] with diagnosis including Diabetes, End Stage Renal Disease, Hemodialysis, Heart Failure, High Cholesterol. Observation on 05/12/25 at 01:45 PM, R250 was in the dining room eating outside food with family member. R250 said he did not like what was being served that day and preferred food from outside. Further inquiry revealed R250 had been requesting turkey sandwich with cheese for lunch, tea (instead of milk) and dry cereal for breakfast for several weeks. The request was not being followed and since then R250 would not eat causing him to feel malnourished and weak. Staff interview 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 and interview, the facility failed to store food in accordance with professional standards for food service safety. The deficient practice placed the residents residing on the unit at a potential risk for illness. Findings include: Observation with the Restorative Nurse Aide (RNA) 40 on 05/15/25 at 10:42 AM in the kitchenette on Piikoi 2. One container with food inside was labeled with a name and did not have a date. The second container that was found in the refrigerator was labeled with Resident (R) 52s name and room number and a date of 05/08/25. The surveyor asked RNA40 what the process is for storing the residents food in the refrigerator and how long is it kept. RNA40 said we write the residents name, date and room number on the package. It should be thrown out after three days. The surveyor showed her the food items that were not dated and the one dated for 05/08/25. She said, yeah, I will check with the resident. The surveyor asked her if it should be discarded, and she agreed. The surveyor confirmed the findings with Licensed Practice Nurse (LPN) 2 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 interview and record review, the facility failed to maintain medical records on one Resident (R) 9, of 36 residents sampled that were accurately documented, in accordance with accepted professional standards and practices. Findings include: Cross-reference to F755 Pharmacy Services/Procedures/Pharmacist/Records. Although giving Resident (R)9 her 09:00 AM medications more than 2 hours early, Registered Nurse (RN)5 documented that he gave them on time. On 05/12/25 at 08:52 AM, observation made while at the bedside of R9. Observed at least six different medications (tablets and capsules) at the edge of the bedside table in front of her. At 08:54 AM, during an interview with RN3 at R9's bedside, RN3 confirmed that the medications on the bedside table were given by RN5 before 07:00 AM when RN3 began her shift. During a concurrent review of R9's Medication Administration Record (MAR), RN3 confirmed that the medications were due at 09:00 AM, and that RN5 had signed off/documented the medications as administered at approximately 08:50 AM. RN3, who frequently serves as the Nurse…

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 interviews, the facility failed to maintain the following equipment in safe operating condition: 1) medication refrigerator, and 2) medication refrigerator thermometer. This deficient practice puts residents who are prescribed medications that needs refrigeration at risk for receiving ineffective medications and unexpected reactions. Findings include: 1) On 05/14/25 at 08:23 AM, conducted an inspection of the Pensacola third floor medication storage room. Observed the freezer of the medication refrigerator was completely frozen through with ice. A clear plastic bag with an object was frozen into the ice and unable to identify the contents stored in the bag. Registered Nurse (RN) 81 was present and confirmed the freezer needs to be defrosted and was also unable to identify the content of the frozen bag. 2) On 05/14/25 at 08:30 AM, walkthrough of the medication storage room on Piikoi 1 completed with RN2. Observed thermometer temperature setting for the medication refrigerator at 60 degrees. The refrigerator contained IV (intravenous) antibiotics,…

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

Based on interviews and record review, facility did not employ a qualified social worker on a full-time basis as required for a facility with more than 120 beds and this facility was licensed for 288 beds. This deficient practice has the potential to affect all residents in the facility. Findings include: On 04/23/25 at 08:53 AM, the Administrator stated that the current Social Services Director (SSD) did not have the required credentials for a social worker (minimum of bachelor's degree in social work or a bachelor's degree in a human services field). On 04/23/25 at 09:55 AM, a review of employment documentation for the social services staff was conducted. The following was noted: Social Services Assistant (SSA) 1 with a hire date of 05/30/24 had less than a year of supervised social work experience in a health care setting. A review of a listing of her previous jobs on the facility's work application reflected experience other than that as a social worker and was not in a health care setting working directly with individuals. SSA2 and SSA3 with recent hire dates of 03/20/25 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 interview and record review, the facility failed to document and provide evidence that 2 of 5 resident-to-resident abuse investigations (ASPEN Complaints/Incidents Tracking System (ACTS) #11610 and #11159) conducted by the State Agency (SA) had been thoroughly investigated. This deficient practice potentially compromised the safety of Residents (R)10, R7, R5, and R6, and affects all residents at the facility with abuse allegations. Findings include: 1) Cross-reference to F600 (Free from Abuse and Neglect) The facility failed to obtain witness statements from all staff who responded to a resident-to-resident abuse allegation that occurred on 02/24/25 between R10 and R7. On 02/24/25 at 03:07 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11519, documenting an allegation of resident-to-resident abuse of Resident (R)10 by R7. On 04/22/25, the SA entered the facility to investigate the allegation. Review of the facility's investigation packet noted the witness statement from the first staff member on…

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

Based on interviews and record review the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of services covered by Medicare for 1 of 3 residents (Resident (R) 11) sampled for discharge notification. This deficient practice did not allow R11 and responsible party the right to file an immediate, independent medical review (appeal) of the decision to end Medicare services and did not allow R11 and responsible party time to make decisions regarding future care. Findings include: On 04/22/25, the State Agency (SA) investigated a complaint, for ASPEN Complaints/Incidents Tracking System (ACTS) #11610. On 04/22/25 at 08:08 AM, interviewed R11's family member (FM) 1 who was listed on the facility's admission record as the responsible party. FM1 stated that he received the Notice of Medicare Non-Coverage (NOMNC) via email on 04/08/25 stating that services would end on 04/08/25. On 04/22/25 at 02:50 PM, interviewed the Social Services Director (SSD) and Social Services Assistant (SSA) 1, in the SSD's office. A concurrent review 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.

Based on interview and record review, the facility failed to report to law enforcement, allegations of resident-to-resident abuse that included physical assault for 3 of 5 resident-to-resident abuse investigations (ASPEN Complaints/Incidents Tracking System (ACTS) #11519, 11204, and 11090) conducted by the State Agency (SA). This deficient practice potentially compromised the thoroughness of the facility's investigations into these events and placed Residents (R)10, R8, R7, R1, and R2's safety at risk. Findings include: 1) Cross-reference to F600 (Free from Abuse and Neglect) The facility failed to protect R10 from resident-to-resident physical abuse by R7 despite identifying a history of physical aggressiveness. On 02/24/25 at 03:07 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11519, documenting an allegation of resident-to-resident abuse of Resident (R)10 by R7. On 04/22/25, the SA entered the facility to investigate the allegation. Review of the facility's Freedom for Abuse, Neglect and Exploitation…

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 provide medically-related social services to 1 of 3 residents (Resident (R)10) in the sample. Specifically, the facility failed to ensure psychosocial follow-up for R10 following an allegation of physical abuse. As a result of this deficient practice, R10 was hindered in his ability to attain or maintain his highest practicable psychosocial well-being. Findings include: On 06/09/25, the State Agency (SA) entered the facility to conduct an onsite revisit to determine compliance with federal and state requirements related to deficient practices found on an earlier abbreviated survey at CFR (Code of Federal Regulations), Title 42, 483.12, Freedom from Abuse, Neglect, and Exploitation. Review of the facility's implemented plan of correction found no documentation that psychosocial follow-up had occurred for Resident (R)10, following a finding of deficient practice, at the level of harm, related to an allegation of resident-to-resident physical abuse where…

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

Based on interview and record review, the facility failed to maintain a medical record for 1 of 3 residents (Resident (R) 11) sampled for accurate documentation in accordance with accepted professional standards and practices. This deficient practice has the potential to affect all residents in the facility. Findings include: On 04/22/25 at 08:08 AM, interviewed R11's family member (FM) 1 who was listed on the facility's admission record as the responsible party. FM1 stated that he received the Notice of Medicare Non-Coverage (NOMNC) via email on 04/08/25 stating that services would end on 04/08/25. On 04/09/25, prior to entering the facility, State Agency (SA) received a copy of the NOMNC issued by Social Services Assistant (SSA) 1 to FM1 via email on 04/08/25. On 04/22/25 at 09:00 AM a scanned copy of the NOMNC for R11 was found in the Electronic Health Record (EHR). On this copy, additional handwritten information was noted in the Additional Information (Optional) section which stated, .issued NOMNC 4/4/25 . On 04/22/25 at 09:00 AM, during review of R11's medical record, a social…

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, although informed of an allegation of neglect, the facility failed to document the verbalized complaint as a grievance for 1 of 3 residents sampled (Resident 1). As a result of this deficient practice, Resident (R)1's right to have her grievance investigated, resolved, and be informed about the resolution were violated, and she was placed at risk for psychosocial harm and unmet medical and/or physical needs. This deficient practice has the potential to affect all residents with the functional capacity to file a grievance. Findings include: On 08/21/24 the State Agency (SA) received a facility-reported incident (FRI), ACTS#11153, documenting an allegation of staff-to-resident neglect of Resident (R)1. On 08/29/24 the SA received a complaint, ACTS #11168, about the same incident and how it was investigated. On 10/22/24, the SA entered the facility to investigate the allegations. R1 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation…

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 implement their policy to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property for 1 of 2 employees sampled. Findings include: On 08/21/24 the State Agency (SA) received a facility-reported incident (FRI), ACTS#11153, documenting an allegation of staff-to-resident neglect of Resident (R)1. On 08/29/24 the SA received a complaint, ACTS #11168, about the same incident and how it was investigated. On 10/22/24, the SA entered the facility to investigate the allegations. R1 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation following a loss of consciousness and resulting fall. On 08/16/24 R1 reported to the Unit Manager (UM)1 that both a Certified Nurse Aide (CNA)1 and a Registered Nurse (RN)1 on the overnight shift had refused to change her adult incontinence brief when she asked. A request of the facility's policy and procedures (P&Ps) on abuse/neglect…

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 interviews, the facility failed to provide written transfer notification to the resident or the resident's representative for five out of five sampled residents (Resident (R)29, 49,128,182, and 266). This deficient practice has the potential to affect all the residents that are transferred to an acute care hospital. Findings include: A review of the facility's policy titled, Admission, Transfer, and Discharge, dated 03/2023 was conducted. The facility policy noted, Before the facility transfers or discharges a resident, the facility will notify the resident and the resident's representative of the transfer/discharge and the reasons for the move in writing, in a language and manner they understand. 1) R266 is a [AGE] year-old female transferred and later admitted to an acute care hospital on [DATE]. A review of R266's Electronic Health Record (EHR) was conducted. R266's EHR did not contain documentation that R266 or R266's representative was provided a written notification of her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for five out of five sampled residents (Resident (R) 29, 49,128,182, and 266). This deficient practice has the potential to affect all the residents that are transferred to an acute care hospital. Findings include: A review of the facility's policy titled, Admission, Transfer, and Discharge, with a revised date of 03/2023 was conducted. The policy noted, The facility will provide written information to the resident or resident representative specifying the duration of the state bed-hold policy, if any, during which time the resident is permitted to return and resume residence in the facility .This information will be provided to the resident and the resident representative before a transfer or therapeutic leave and at the time of transfer of a resident for hospitalization or therapeutic leave. 1) R266 is a [AGE] year-old female transferred and later…

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 the nurse staffing data was posted daily at the beginning of each shift, in a prominent place readily accessible to residents and visitors, and ensure staffing information was complete with specific units reflected on the posting. Findings include: On 07/15/24 at 08:13 AM, during observation of Unit 3, including the nurse's station, the bulletin board, and the elevators, the nurse staffing data posting was not found. Inquired with other surveyor team members if postings were found on their assigned units to screen, Unit 2 and Unit 4 were observed to not have the postings. The postings were not found at the entrance of the facility, near the facility elevators, or on the bulletin boards on the ground level. On 07/15/24 at 08:32 AM, during a tour of Unit 2, no staff posting was observed near the elevators, on the bulletin board, or at the Nurses' Station. On 07/15/24 at 10:43 AM, observed a staff posting had been brought up and placed on the bulletin board near the Unit 2 Nurses' Station. Review 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.

Based on interview and record review, the facility failed to ensure resident's care plan meetings were completed quarterly, and resident's care plans was revised and prepared by an Interdisciplinary (IDT) team, that includes but is not limited to the attending physician, registered nurse, nurse aide, and the resident's representative(s) for four residents (Resident (R) 58, R168, R253, and R38) sampled. Findings include: 1) Reviewed R58's EHR. Reviewed documentation of R58's most recent IDT meeting, conducted on 06/25/24 and 03/21/24, revealed the disciplines represented in the IDT meetings were social services and recreation services staff and did not include the resident's attending physician, registered nurse, or a nurse aide. During an interview with R58 on 07/18/24 at 09:43 AM, it was confirmed the resident's attending physician, a registered nurse, and a nurse aide did not attend or participate the resident's IDT meeting conducted on 06/25/24. On 07/18/24 at 01:14 PM, conducted a concurrent record review and interview with the Director of Nursing (DON) regarding R58's IDT care…

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 there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, in addition to their physical, mental, and psychosocial well-being. As a result of this deficient practice, the residents experienced a decreased quality of life and were unable to attain their highest practicable well-being. Findings include: 1) Cross-reference to F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide Restorative Nurse Assistant (RNA) and other services as scheduled to help prevent/minimize the formation and worsening of contractures in Residents (R)199 and R20. 2) On 07/18/24 at 01:57 PM, during an interview with resident council members, R50 reported during their monthly resident council meetings, residents expressed the facility is short staffed and it has not been resolved. Resident council members reported that the residents have been told there should be at least six certified nurse's aides…

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 appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed standard precautions by performing hand hygiene, implemented enhanced barrier precautions when appropriate, and sanitized shared medical equipment after each use. 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 07/16/24 at 10:15 AM, an observation was done of Registered Nurse (RN)16 changing the dressing on the gastric tube insertion site for Resident (R)199. RN16 was wearing gloves and a procedure mask, but no gown. Once the dressing was completed, observed RN16 change her gloves with no hand hygiene in between. She then administered a nasal spray to R199, after which he requested some oral medication. Observed RN16 doff her gloves right before leaving the room but performed no hand hygiene after that. On 07/16/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and facility policy review, the facility failed to ensure residents were treated with respect and dignity in an environment that promotes maintenance or enhances his or her quality of life, recognizing the resident's individuality for four out of 37 sampled residents (Resident (R)50, R113, R29, and R126). Findings Include: Review of the facility's policy and procedure RESIDENT RIGHTS Respect and Dignity revised on 03/2023, document The resident has a right to be treated with respect and dignity. 1) Review of R50's most recent quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/06/24, documented R50 had a score of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition is intact (a reliable source of information). Section GG- Functional Abilities and Goals documented R50 has functional limitation in Range of Motion (ROM) with impairment on both sides of the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot)…

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 Representative's (RR) 21 right to exercise the resident's rights to the extent provided by state law for one Resident (Resident (R) 5) sampled. RR21 is the Durable Power of Attorney (DPOA) for R5 and identified by the facility as the R5's healthcare decision-maker. R5 has a diagnosis of Alzheimer's Disease and does not have the capacity to make medication related decisions. Review of R5's Electronic Health Record (EHR) documented an informed consent for the use of an antidepressant medication signed by R5 and not RR21. Also, an Interdisciplinary (IDT) care plan meeting form documented RR21 attended the meeting on 04/23/24 and participated via phone and declined dental, vision, podiatry, and hearing services for R5. Closer review of the IDT care plan meeting form documented a voicemail was left for RR21 and he/she had not participated in the meeting, but services were declined. Findings include: Review of R5's EHR documented R5 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to honor the shower preferences of 2 of 3 residents (Residents 171 and 199) sampled for accommodation of needs. As a result of this deficient practice, Resident (R)171 and R199 did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)171 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R171's admitting diagnoses include, but are not limited to, heart disease, diabetes, dementia, depression, and history of a right above the knee amputation. A review of R171's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 02/05/24 noted R171 had been assessed with a Brief Interview for Mental Status (BIMS) score of 13, indicating a determination that he was cognitively intact. On 07/15/24 at 10:52 AM, observed R171 lying…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the individual financial record of 1 of 1 resident sampled for personal funds was made available to Resident (R)20 through quarterly statements. As a result of this deficient practice, R20 was not aware of her current balance and was not afforded the opportunity to periodically reconcile her account unless she made a request. Findings include: Resident (R)20 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. R20's admitting diagnoses include, but are not limited to, left-sided paralysis and weakness following a stroke, heart disease, peripheral vascular disease, and lymphedema (swelling that generally occurs in an arm or leg, caused by a blockage in the lymphatic system). A review of R20's Minimum Data Set (MDS) Annual Assessment with an Assessment Reference Date (ARD) of 05/29/24 noted R20 had been assessed with a Brief Interview for Mental Status (BIMS) score of 14, indicating a determination that she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure the resident's right to a clean and homelike environment. The facility's wallpaper/paint was peeling off the wall, ceilings had water damage, and toilets were not properly working. As a result of this deficient practice, there is the potential to affect the resident's overall mood and psychosocial well-being. Findings include: Review of the facility's policy and procedure RESIDENT RIGHTS, Safe, Clean and Comfortable Environment, dated 03/2023, documented The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. 1) During an interview with R50 on 07/16/24 at 08:30 AM, the resident stated that the building is falling apart and does not feel homelike. R50 pointed out in the restorative room, the wallpaper was peeling off the wall, observed patches of exposed drywall in the restorative room and throughout the unit. Ceiling tiles in the hallway, near room [ROOM NUMBER] on Unit…

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 that 1 of 2 residents (Resident 92) sampled was free from physical restraints that were not required to treat her medical symptoms. As a result of this deficient practice, Resident (R)92's patient rights were violated, and she was placed at risk of avoidable injury and/or a decline in her psychosocial well-being. Findings include: Resident (R)92 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. On 07/15/24 at 11:05 AM, the state agency (SA) observed R92 quietly lying at the far end of the Unit 2 hallway in a Geri-chair that was fully reclined, with a wheelchair wedged under the extended/elevated footrest of the Geri-chair in such a way that even if R92 could physically put the Geri-chair down (using the side handle to set the chair upright), the chair would not go down. A review of the facility's Physical Restraint policy and procedure (P&P), last revised 03/2023, revealed the following: The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, after receiving report of an injury of unknown origin from Resident (R)25's wife, the facility failed to report the allegation to the State Survey Agency (SA) and adult protective services (APS). In addition, the facility failed to report an allegation of abuse for one other Resident (R209), out of three residents sampled for abuse, to other officials, including Adult Protective Services (APS). As a result of this deficiency, the facility did not allow the resident further review of the abuse by APS. Findings include: 1) Resident (R)25 is an [AGE] year-old male admitted to the facility on [DATE] for long-term care. R25's diagnoses include, but are not limited to, dementia, heart failure, muscle weakness, and lack of coordination. A review of R25's Minimum Data Set (MDS) Quarterly Review Assessment with an Assessment Reference Date (ARD) of 04/24/24 noted R25 had been assessed as completely dependent for all eating, hygiene, toileting, and mobility activities.…

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, after being informed by adult protective services (APS) of an allegation of abuse of 1 of 3 residents (Resident 569) sampled, the facility failed to document and provide evidence that the allegation had been thoroughly investigated. Findings include: Resident (R)569 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation and skilled nursing services. R569 was transferred to an acute care hospital on [DATE] with a diagnosis of hyperkalemia (a high level of the electrolyte potassium in her blood), and after refusing to go to hemodialysis. On 05/21/24, the State Agency (SA) received a referral from APS (ACTS #10973) as a result of allegations of neglect made by R569 against facility staff. A review of the referral from APS revealed possible indicators that R569 had been physically and/or sexually abused at the facility as well. On 07/16/24 at 10:45 AM, the SA requested from the Assistant Administrator the facility's investigation packet…

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 complete a comprehensive assessment for one resident sampled for being a smoker. As a result of this deficient practice, the facility failed to identify resident (R) 38 as a smoker and no plan of care was developed to address the health and safety risks associated with smoking. Findings Include: On 07/15/24 at 12:24 PM, observed R38 up in his wheelchair in the hallway at Unit 4, propelling himself to one of the doors that open to the parking lot. R38 stopped to talk to Registered Nurse (RN) 6 as she was preparing medications. R38 then proceeded to exit Unit 4 and went to the parking lot unsupervised. Asked RN6 where R38 was going, she said he was going to the parking lot to smoke. At 01:13 PM, observed R38 come back into Unit 4. R38 had a pack of cigarettes and a lighter in his shirt pocket. Asked R38 how long he has been smoking. R38 responded, Since I was [AGE] years old. On 07/16/24, a review of R38's Electronic Health Record (EHR) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a comprehensive person-centered care plan for one of 37 residents sampled (Resident (R) 29). R29's was not care planned for diabetic foot nail care. Findings include: Cross reference to F677. The facility failed to carry out daily living activities (ADLs) to maintain good grooming for R29 dependent on ADL care. R29 did not receive proper foot nail care. This puts the resident at risk for cuts and wounds on her feet. R29 was admitted to the facility on [DATE] with diagnoses, not limited to, restless legs syndrome, type 2 diabetes, hyperlipidemia, hypertension, dementia, and peripheral vascular disease. On 07/16/24 at 10:11 AM, an interview with Family Member (FM) 4 was done. FM4 reported R29's left big toe was amputated due to an infection and gangrene. FM4 was not sure how she got the wound on her toe in the first place because R29 was not mobile and stated after the facility informed her of the wound and the progression to an…

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 carry out daily living activities (ADLs) to maintain good grooming for one of two residents sampled (Resident (R) 29) dependent on ADL care. R29 did not receive proper foot nail care. This puts the resident at risk for cuts and wounds on her feet. Findings include: R29 was admitted to the facility on [DATE] with diagnoses, not limited to, restless legs syndrome, type 2 diabetes, hyperlipidemia, hypertension, dementia, and peripheral vascular disease. Review of R29's Electronic Health Record (EHR) found on 06/16/24 R29 had a wound to her left big toe. A nursing progress note dated 06/16/24 documented a skin check and assessment of R29 left big toe done, .a small amount of pus came out when .cleaned .up .dry skin on the front of the toe came out, showing a pinkish red color. Bottom of the resident left big toe was reddish purplish in color. On 06/28/24, R29 was sent to the emergency room for further evaluation of an infection of the left…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that fully identified and met the resident's needs, for 2 of 3 residents sampled for activity (Residents 171 and 198). As a result of this deficient practice, both residents were placed at risk of experiencing a decline in their psychosocial well-being and quality of life. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) Resident (R)171 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R171's admitting diagnoses include, but are not limited to, heart disease, diabetes, dementia, depression, and history of a right above the knee amputation. A review of R171's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 02/05/24 noted R171 had been assessed with a Brief Interview for Mental Status (BIMS) score of 13, indicating a determination that he was cognitively…

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 the nursing treatment and care provided met the needs of 2 of 37 residents (Residents 188 and 171) in the sample and was in alignment with standards of good clinical practice. As a result of this deficient practice, the residents were placed at risk of avoidable injury and/or complications and were hindered from attaining their highest practicable well-being. Findings include: 1) R188 was returned to the facility on [DATE] from an acute hospital. Review of the acute hospital's discharge summary, R188 presented on 04/03/24 with sepsis with suspected sacral Skin and Soft Tissue Infection (SSTI) and associated complications. A blood culture confirmed bacteremia with gram positive cocci which is known to cause skin infections, pneumonia, endocarditis (life-threatening inflammation of the inner lining of the heart's chambers and valves), septic arthritis (painful infection in a joint that travel through the bloodstream to other parts of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Residents 199 and 20) sampled for limited range of motion (ROM) received the appropriate treatment and services to prevent, or delay, further decrease in their ROM, mobility, and independence. As a result of this deficient practice, Resident (R)199 can no longer be transferred into his motorized wheelchair, and R20 now has contractures to her left hand that were not present at admission. These outcomes hinder both their abilities to reach their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)199 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care related to his diagnosis of Amyotrophic Lateral Sclerosis (ALS), a disease affecting nerve cells in the brain and spinal cord, causing progressive loss of voluntary movements and muscle control, and eventually leading to death. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to ensure that one of the licensed nurses had the specific competencies and skill sets necessary to care for residents' needs. This failed practice has the potential to affect all the residents on one of the five nursing units. Findings include: R239 is an [AGE] year-old female admitted to the facility on [DATE]. A review of R239's Brief Interview for Mental Status (BIMS), with an Assessment Reference Date (ARD) of 05/09/24 was conducted. R239's BIMS score was an 11, meaning R239 had moderate cognitive impairment. Observation was conducted on 07/15/24 at 09:00 AM in R239's room. R239 was lying in bed watching television. On her bedside table was a medication cup with four different pills. When asked about the medication cup, R239 stated that she forgot it was there. She stated it was her morning medications that were left there by Registered Nurse (RN) 10. State Agency (SA) then exited the room to look for RN10. RN10 was observed at the other end 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.

Based on observation, interview, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation. 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. Findings include: On 07/17/24 at 09:22 AM, an inspection of the Unit 2 Medication Cart #1 was done with Nurse Manager (NM)2. While reviewing the narcotic log, the following discrepancies in narcotic log documentation and actual narcotic count were observed by the State Agency (SA) and confirmed by NM2: Oxycodone IR [immediate release] 5 milligrams (mg). Narcotic log shows there should be twenty-three (23) tablets remaining in the blister pack; only twenty-one (21) tablets observed. Clonazepam 0.5 mg. Narcotic log shows there should be sixteen (16) tablets remaining in the blister pack; only fifteen (15) tablets observed. Interview done with NM2 at the time confirmed that all narcotics should be signed out on the narcotic log when pulled from the medication…

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 all medications used in the facility were labeled in accordance with professional standards. Proper 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 [DATE] at 08:54 AM, an inspection was done of the Unit 2 medication cart #2 with Registered Nurse (RN)15. Observed a vial of Lantus insulin for Resident (R)8 where the open dates and discard dates written on both the vial itself, and the box it was in, were completely unreadable. RN15 confirmed that since the information was indecipherable, the insulin vial needed to be discarded to ensure R8 would not be administered expired insulin. At 09:03 AM, observed an Admelog Solostar insulin pen for R8 that was labeled with an open…

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, the facility failed to date and label a food item to prevent the potential for foodborne illness. This deficient practice has the potential to affect all the residents on one of the five nursing units. Findings include: Observation was conducted on 07/17/24 at 09:22 AM in one of the facility nutrition rooms. The freezer contained an unlabeled brown colored ice cream. Interview was conducted with Registered Nurse Supervisor (RN) 12. RN12 stated that nursing staff usually checks expiration dates and throws them away if needed. When shown the unlabeled ice cream, RN12 stated that it must have been from one of the resident's food trays and one of the staff had placed it in the freezer. RN12 added that the staff should have labeled the ice cream with the resident's name and date. A review of the facility's policy titled, Food Safety, dated 03/2023 was conducted. The policy noted, Food, including leftovers, will be labeled and dated in the refrigerator.

Based on observation, staff interview, and review of policy, the facility failed to safeguard medical record information against unauthorized use by not logging off of the Electronic Health Record (EHR) on a computer laptop left unattended in a nursing unit hallway. As a result of this deficiency, there was risk for violations of the Health Insurance Portability and Accountability Act (HIPAA) privacy or security rules. Findings include: During observation of the second-floor nursing unit hallway on 07/16/24 at 08:15 AM, a computer laptop showing resident EHR was left unattended. No staff was in the immediate vicinity and there was risk of unauthorized access to the information. During staff interview on 07/16/24 at 08:20 AM, the Unit Manager was made aware of the situation and acknowledged that the EHR should have been logged off when left unattended. Review of facility policy on Resident Rights Privacy and Confidentiality read, Purpose, each resident has the right to privacy and confidentiality of personal care and medical records. Policy, the facility will respect the resident's…

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

Based on record review, staff interview and review of policy, the facility did not document the refusal of an influenza vaccine for one Resident (R)63 out of five residents sampled. As a result of this deficiency, there was a risk for miscommunication and misadministration of the influenza vaccine. Findings include: Record review for R63 showed no documentation of influenza vaccination administration or refusal for the last immunization time period '23-'24. During staff interview with the Infection Preventionist (IP) on 07/18/24 at 10:20 AM, IP said that R63's representative consented to the influenza vaccination and later R63 refused but that was not recorded in the Electronic Health Record. Review of policy on Infection Prevention and Control Influenza and Pneumococcal Immunizations read, Purpose, to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza and pneumococcal disease. Policy, the facility will provide influenza and pneumococcal immunizations to minimize the risk of residents acquiring, transmitting or experiencing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observation and record review (RR), the facility failed to have an effective process to support each resident/representative's grievance. The facility did not have a process in place to capture all complaints/grievances, did not promptly address and thoroughly investigate two of five sampled Residents grievances (R3 and R4), and the three complainants (R1, R3 and R4) were not appropriately apprised of progress toward resolution. Findings include: 1) Reviewed the facility policy number 585, titled Resident Rights Grievances last revised 03/29/2023. The policy purpose was To support residents' right to voice grievances and receive follow-up related to those grievances. The guidelines included: 3. Grievances may be submitted orally or in writing. No specific form or format is required to file a written grievance. 5. The Administrator is the Grievance Officer. The Grievance Officer, with the assistance of social services, had the responsible to oversee the grievance process, receive and track…

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 develop and implement a comprehensive person-centered care plan for one resident (R)1 of a sample size of three. R1's primary language was Ilocano and spoke only a few English words. His care plan (CP) did not identify the need for an interpreter. As a result of this deficiency there was the potential R1 did not understand the staff and physician who cared for him. If communication barriers are not identified and included in the CP, there is the potential residents may not attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: 1) R1 was a [AGE] year old man admitted to the facility on [DATE] for short term rehabilitation after hospitalization. His primary language was Illocano and he spoke only a few words of English. He was able to feed himself independently, but required assistance for bed mobility, transfers, dressing, and toilet use. R1 was frequently incontinent of urine, and always…

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 discharge summary was completed for one resident (R)1 out of a sample size of three. As a result of this deficient practice, there was no concise summary of R1's stay and course of treatment at the facility available to continuing care providers. Findings included: 1). R1 was a [AGE] year old male admitted to the facility on [DATE] for short term rehabilitation after hospitalization. His primary language was Illocano and he spoke only a few words of English. R1 was able to eat independently, required assistance for bed mobility, transfers, dressing, and toilet use. He was frequently incontinent of urine, and always incontinent of bowel. Prior to hospitalization, he used a walker. R1 had memory problems, and was moderately impaired. His past pertinent medical history included but not limited to hypertension and stroke without deficits. On 08/07/2023, R1 was transferred to an acute care hospital for a change in condition. 2). Review of R1's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the nursing staff failed to demonstrate competency when caring for one resident (R)1. The nursing staff did not: 1. Report a critical blood sugar (BS) to the physician (MD1), 2. Notify MD1 when R1's mental status changed, 3. Did not notify MD1 to obtain an order for pain medication, and 4. three progress notes did not accurately reflect R1's condition. As a result of these deficiencies, R1's physician (MD)1 did not have critical information to make treatment decisions, which resulted in harm. R1's pain was not treated in a timely manner and his transfer to acute care was delayed. These deficiencies have the potential to affect all residents if staff do not have identify and report critical values, trends and changes in condition, so interventions can be made to prevent further decline. Findings include: 1) R1 was a [AGE] year old man admitted to the facility on [DATE] for physical and occupational therapy, post acute care, due to deconditioning and generalized weakness.…

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.