Kuakini Geriatric Care, INC

Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by staff. Three residents reviewed, Resident (R) 12 and R26 reported allegations of abuse by staff and R33 was witnessed by a staff being abused by another staff. This deficient practice could affect all residents in the facility, placing the residents at risk of harm, if the facility fails to protect resident's right to be free from abuse by staff. Findings Include: Cross Reference F580 - Notify of Changes (injury/decline/room, Etc.) 1) On 07/17/24 at 10:47 AM interviewed Registered Nurse (RN) 1. Inquired if she was working with R12 on 03/20/24 and she said yes, stated on March 20th it was resident's Care Plan day meeting and during the meeting they discuss with the family any concerns and they (the family member) mentioned R12 had told them that a staff had pushed her head down while she was showering her, that the staff had pushed her head against the wall. Family member was not sure what day this occurred. R12 told the family member that she did not like 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 interviews and record reviews the facility failed to report allegations of abuse to the state agency within two hours of being reported to the Charge Nurse (CN), Nursing Supervisor (NS), or Assistant Director of Nursing (ADON) and Director of Nursing (DON). During the review of two Residents (R) 26 and 33 allegations of abuse were reported to a NS, or ADON and DON. Initial reports submitted by the facility were sent to the state agency two days after the incidents were reported to the CN, NS, or ADON and DON. This deficient practice could affect all residents in the facility who have a reported or witnessed incident of abuse and the facility fails to notify the state agency within two hours. Findings Include: Cross Reference F600 Free From Abuse and Neglect 1) On 07/17/24 at 11:54 AM interviewed ADON for R26's incident that was reported on 03/20/24. ADON stated the resident (R26) did not specify a time the incident occurred and reported that it was her night shift nurse aide that was in question. Inquired when night shift is and ADON stated our night shift is from 11:30 PM…

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

Based on interview and record review the facility failed to provide sufficient nursing staff on 02/07/24 and 07/05/24 during their second shift (03:00 PM - 11:30 PM) on the skilled nursing unit. The deficient practice puts the residents at risk for harm such as abuse by staff and staff working outside of their scope of practice. Findings Include: Cross Reference F600 - Free From Abuse and Neglect and F726 Competent Nursing Staff On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. ADON confirmed he and DON met with the staff (RN3 and CNA5) to discuss their scope of practice and what was allowed and not allowed at the facility. Continuation of interview with ADON…

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 assure a Registered Nurse (RN) and a Certified Nurse Aide (CNA) practiced within their professional scope of practice. This deficient practice could affect all residents and put them at risk for harm if licensed staff delegate tasks to unlicensed staff such as medication administration, which is outside their scope of practice. Findings Include: On 07/17/24 at 11:54 AM interviewed Associate Director of Nursing (ADON) who was able to provide copies of staffing on 02/07/24. Inquired if ADON was working on 02/07/24 and he confirmed he was. Inquired if he was informed of an RN delegating medication administration to a CNA to pass medication to Resident (R)40 and he stated the Director of Nursing (DON) notified him. Inquired if the facility teaches the nurses to delegate medication pass to the CNA's and he denied this. ADON confirmed he and DON met with the staff (RN3 and CNA5) to discuss their scope of practice and what was allowed and not allowed at the facility. On 07/18/24 at 2:25 PM interviewed Certified Nurse Aide (CNA)5…

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 assure staff accurately documented medication offered to and refused by resident (R)40. This deficient practice could affect all residents who receive medication in the facility if their medication administration is not documented accurately. Findings Include: On 07/18/24 at 03:50 PM interviewed RN3 and inquired if she had asked CNA5 to give R40 her medication and RN3 confirmed this. RN3 stated there was an incident the day before, on 02/06/24, with R40 and per RN3 R40 yelled at her. RN3 stated she did not feel comfortable going into R40's room. Inquired if RN3 asked the other nurse who was working with her to pass the bedtime medication to R40 and RN3 stated The other nurse was busy. Inquired if she asked the Shift Coordinator for help and RN3 denied this. RN3 stated she gave CNA5 the medication cup and she (RN3) stayed at the resident's door as CNA5 offered the medication to R40. Inquired if R40 took the medication the CNA offered and RN3 stated R40 refused the medication. Record review on 07/19/24 of R40's 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 interviews and document review, the facility failed to ensure the grievance policy included all the required elements. In addition, the facility was unable to provide documentation that Residents were informed they have the right to file a grievance anonymously and the right to obtain a written decision regarding the grievance. There was lack of documentation of the pertinent findings or conclusions regarding the care concerns of two Residents (R), R1 and R2. As a result of these deficiencies, there was the potential residents do not know how to file an anonymous complaint and grievance findings may not be adequately communicated to the complainant, resulting in dissatisfaction. Findings include: 1) Review of the facility policy titled Resolution of Patient/Resident grievances, complaints, and concerns, effective date 02/2023 revealed the following: 1. The policy did not include a reasonable timeframe the resident can expect a completed review of the grievance; 2. The policy did not identify the grievance official who was responsible for overseeing the grievance process,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review (RR), the facility failed to revise Care Plans (CP) of two Residents (R)1 and R2, of a sample size of three in a timely manner. The facility did not 1) update R1's CP to include use of the abduction pillow or the skin condition on right forearm, and 2) did not update R2's CP in a timely manner to include parameters for oxygen administration when ordered. As a result of this deficiency, there was the potential the residents may not meet their highest potential of physical and mental well-being. This deficiency had been corrected prior to the survey, and met the criteria for past noncompliance. Findings include: 1) R1 was a [AGE] year old female admitted to Skilled Nursing Facility on 10/28/2023 for rehabilitation services following right hip surgery after sustaining a right hip fracture from a fall at home. She was COVID + on admission. R1's medical history included but not limited to Diabetes mellitus, hypertension, congestive heart failure, Stage 3b chronic kidney disease…

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 proper notification of transfer/discharge for five of 11 residents sampled for Hospitalization (Residents (R) 9, R37, R71, R89, and R74). Specifically, the facility failed to issue written notification of transfer/discharge to the residents or their representatives and/or failed to send notification of the transfer/discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings include: 1) Resident (R) 9 is a [AGE] year-old female originally admitted to the facility on [DATE]. During a review of her electronic health records (EHR) on 01/11/24 at 09:30 AM, it was noted that R9 was sent and admitted to an acute care hospital on [DATE]. There was no discharge notification or LTCO notification found in the EHR for this discharge. On 01/11/24 at 09:40 AM, an interview was done with Unit Clerk (UC) 1 in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to 10 of 11 residents sampled for Hospitalization (Residents (R) 9, R69, R37, R71, R89, R74, R66, R86, R58, and R55). This deficient practice has the potential to affect all residents at the facility who are discharged to an acute care hospital. Findings include: 1) R9 is a [AGE] year-old female originally admitted to the facility on [DATE]. During a review of her electronic health records (EHR) on 01/11/24 at 09:30 AM, it was noted that R9 was sent and admitted to an acute care hospital on [DATE]. There was no written notification of the Bed Hold Policy found in the EHR for this discharge. On 01/11/24 at 09:40 AM, an interview was done with Unit Clerk (UC)1 in the Conference Room. UC1 reported that she had informed R9's daughter of the Bed Hold Policy and offered it by phone, but the daughter had declined. When asked about documentation of the phone conversation, UC1 responded…

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 facility policy review and staff interview the facility failed to review it's infection and control program (IPCP) annually which included annually reviewing their facility policies including Infection Control and Prevention and Antibiotic Stewardship, Influenza Quarantine Protocol DON/Medical Director Guide, Influenza Prevention and Control Program, and Pneumococcal Vaccine Administration. The deficient practice could affect the residents and staff at the facility if appropriate guidelines are not included and followed in the facilities' IPCP and policies to guide the care of the residents and provide guidance for staff to follow when using personal protective equipment, assuring proper hand hygiene is being performed and resident care is being monitored to assure outbreaks are caught and controlled to prevent mass outbreaks such as influenza or COVID which could be detrimental to the residents and staffs health. Findings Include: On 01/11/24 at 03:05 PM met with facility Infection Preventionist (IP) and Director of Nursing (DON). DON stated she was attending this meeting…

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

Based on record review (RR) and staff interview the facility failed to inform Resident (R) 55 or their public guardian in advance, by the physician or other practitioner or professional, of the risks and benefits of taking an antipsychotic and antidepressant medication, of treatment alternatives or treatment options and to choose the alternative or option she prefers. Findings Include: On 01/11/24 at 05:47 PM, RR of R55's Electronic Health Record (EHR) found her diagnoses include, but are not limited to, dementia in other diseases classified elsewhere, moderate, with psychotic disturbance; depression, unspecified psychosis not due to a substance or known physiological condition. R55 has doctors orders for the following medications: Seroquel oral tablet 50 milligrams (mg) (Quetiapine Fumarate) (antipsychotic) give 1 tablet by mouth two times a day for behavioral disturbances. Mirtazapine (antidepressant) oral tablet 15 mg give 1 tablet by mouth one time a day for appetite stimulant. During this record review found the resident has an appointed public guardian. On 01/12/24 at 10:16 AM…

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

Based on record review (RR) and staff interview the facility failed to update Resident (R) 58's comprehensive care plan to include antidepressant as an intervention for the medication he is receiving to treat his depression, correctly identify R58 is taking a blood thinner (Eliquis) to treat his pulmonary emboli (blood clot in the lung) and discontinue Mirtazapine as an intervention on his care plan for his poor intake when it was discontinued on 10/30/2023. Findings Include: During RR on 01/11/24 at 04:44 PM found R58 had doctor's orders for the following medications: Duloxetine HCL DR (antidepressant) 60 milligrams (mg) give one capsule by mouth one time a day related to depression, unspecified, Eliquis (blood thinner) 5 mg tablet give one tablet by mouth two times a day for PE (pulmonary emboli which is a blood clot in the lung). Also noted resident had a doctor's order discontinuing his Mirtazapine order on 10/30/23. Review of R58's CP found no mention of resident taking an antidepressant to help treat his depression and a care plan was found for Resident at risk for bleeding…

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 provide appropriate services to prevent urinary tract infections for one of the residents (Resident (R) 13) in the sample. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter. Findings include: On 01/09/24 at 08:22 AM, observed R13 lying on bed with head slightly elevated. R13 had a urinary catheter that was connected to a urine collection bag hung on the right side of the bed. The tubing connecting the urinary catheter and the collection bag was touching the floor. At 01:36 PM, R13 was sitting up in her bed with her television on. Observed both catheter tubing and collection bag touching the floor. Asked Registered Nurse (RN) 14 if the tubing and the bag are supposed to be touching the floor. RN14 said, No, I'll move them now so it will not be touching the floor. Review of facility policies titled, Urinary Catheter Care and Guidelines for Care of Urinary Catheterization does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review (RR), the facility failed to ensure nurse competency in medication administration and assessing for risk of falls. This deficient practice places the residents at increased risk for medication errors and avoidable falls. Findings include: 1) Cross-reference to F761 Label/Store Drugs and Biologicals. The facility failed to ensure nurses check for medication expiration dates prior to administering them. 2) Resident (R) 9 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include, but are not limited to, history of syncope (fainting) and collapse, difficulty in walking, muscle weakness, and dementia. On 01/09/24 at 09:09 AM, observed R9 from the hallway outside her room, sleeping in bed. A large bruise was visible to her left cheek/temple/forehead, with a 2x2 gauze above her left eyebrow. During an interview with her family representative (FR) at the bedside on 01/09/24 at 01:29 PM, FR described how her mother had fallen out 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 observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled, administered, and stored in accordance with professional standards. Proper labeling, safe administration practices, and timely reconciliation of stored medications is necessary to decrease the risk for medication errors. The facility failed to dispose medications after the expiration stated by the manufacturer, an insulin pen stored in the medication cart was not labeled to include the resident's name, medication dosage and route of administration and properly store a resident's medication after declining to take the medication during administration time. This deficient practice has the potential to affect all residents in the facility who receive medications. Findings include: 1) On [DATE] at 08:25 AM, observed medication administration with Registered Nurse (RN) 7. As she was preparing medications for Resident (R) 29, observed her prepare a Lisinopril 40mg [milligrams] tablet. Of…

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

Based on observation and interview the facility failed to store and label food in accordance with professional standards for food service safety. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. Findings include: On 01/09/24 at 08:31 AM, while conducting an initial tour of the kitchen with the Food Service Supervisor (FSS), the state agency (SA) observed a large metal container of approximately nineteen (19) cartons of completely thawed Egg Beaters Original in the walk-in refrigerator. Clearly displayed on the front of each carton are the manufacturer's instructions to KEEP FROZEN. No date was visible anywhere indicating when the products were pulled from the freezer to thaw. When asked about the thawing and labeling process for the product, the FSS stated that it takes 2-3 days to thaw the product from its frozen state, so they pull a case at a time from the freezer. The FSS was unaware…

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 the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis. Findings Include: During the entrance conference on 01/09/23 at 08:12 AM, Patient Care Coordinator (PCC)1 stated the facility currently does not have a DON effective 01/01/23 but the previous DON, Consultant Director of Nursing (CDON), was hired as a consultant. On 01/11/23 at 3:26 PM interview with CDON was done. CDON stated she was supposed to work two days per week, a total of 16 hours a week, as a consultant DON.

Based on observations, interviews, and record review, the facility failed to store food that was identifiable and/or had an expiration date and failed to provide a clean area to prepare food. This deficient practice has the potential to infect residents, visitors, and staff, who have meals served to them by the facility's kitchen, with a food-borne illness. Findings include: 1) On 01/09/23 at 08:29 AM, an initial concurrent observation of the facility's kitchen and interview with the Kitchen Manager (KM) were done. The walk-in freezer contained a large metal pan covered with plastic wrap that had unidentifiable slabs of food. No label indicating the food contents or date was found on the plastic wrap. Kitchen staff (KS)15 was queried as to the food contents in the metal pan and KS15 stated that it was baked salmon from a few days ago. KM confirmed that the food contents in the large metal pan should have the name of the food contents and the date of expiry written on the plastic wrap covering the metal pan. 2) On 01/09/23 at 08:40 AM, continued concurrent observation and interview…

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 upon record review and interview with staff member, the facility failed to assure the facility assessment accurately reflected the resident and staffing ratios needed in the facility to ensure that the staffing resources met the needs of the resident population. The deficient practice affects all residents in the facility to maintain and attain the highest practicable physical, mental, and/or psychosocial well-being. Findings include: A review of the Facility Assessment Tool provided by the facility and approved by the Director of Nursing (DON) and Medical Director on 11/03/22. The assessment did not include nursing resources to meet the acuity of the facility's resident population. The assessment documents the facility is licensed for 187 beds with an average daily census of 160 to 168 residents. A review of the payroll base journal, noted the facility with low weekend staffing for Fiscal Year 2022, first quarter (October to December) and fourth quarter (July to September). On 01/12/23 at 09:33 AM an interview was conducted with the Consultant Director of Nursing (CDON). CDON…

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 protective and preventive measures for COVID-19 and other communicable infections. Facility staff did not follow protocols for standard and transmission-based precautions (TBP); did not wear the proper personal protective equipment (PPE); did not thoroughly clean and sanitize shower equipment after use; did not ensure an indwelling catheter tubing was correctly stored, and did not clean hands between glove use. These deficient practices have the potential to affect all residents, healthcare personnel, and visitors at the facility. Findings include: 1) On 01/09/23 at 09:05 AM, observed room [ROOM NUMBER] with a Droplet Plus sign. The sign described the PPE required for entering the room as: Gown, Gloves, Goggles [or face shield] & N95 mask [respirator] (if available) . At 09:10 AM, observed Certified Nurse Aide (CNA)8 enter the room without changing out her procedure mask for an N-95 respirator. At 09:19 AM, asked CNA8 about the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly conduct COVID-19 testing following the identification of a direct-care staff member and a resident diagnosed with COVID-19 in the facility. As a result of this deficient practice, the facility placed the residents at an increased risk of COVID-19 transmission. This deficient practice has the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: On 01/12/23 at 10:06 AM, an interview was done with the Consultant Director of Nursing (CDON), who also served as the only certified Infection Preventionist for the facility, in room [ROOM NUMBER]. Regarding COVID-19, the CDON reported that the facility had last experienced an outbreak in December of 2022 with outbreak testing beginning on 12/16/22. When asked to describe the facility's process for outbreak testing, the CDON stated that the facility practice was to do broad-based or mass testing (as opposed to contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to provide the services necessary to maintain a clean, sanitary, and homelike environment for multiple residents (R) in the sample, as evidenced by a dirty room for R16, multiple rooms on the third floor with part or all of the room numbers missing, and dirty shower equipment in use on the fifth and third floor. As a result of this deficient practice, the residents were placed at risk for a decreased quality of life. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) On 01/10/23 at 10:00 AM observation of the shower room across room [ROOM NUMBER] found a shower chair with metal framing encrusted with white and black substance. The metal frame under the seat and by the footrest appeared rusted. The commode bucket was observed with a few brown substances adhered to the side of the bowl. The nylon straps attached to the chair were wet. Observation in the shower room across room [ROOM NUMBER] found a shower…

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

Based on observations, record review, and interview with staff members, the facility did not ensure that the development and implementation of comprehensive person-centered care plans were done for three of 27 residents (Residents (R) 86, R55, R83) in the sample. Specifically, a resident identified with significant weight loss for two consecutive months had no care plan to address it. A resident with liver cancer who was admitted to Hospice for end-of-life care had no care plan to manage her pain. Activity care plans were not developed to include person-centered interventions that would engage the resident in meaningful activities. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Multiple observations (01/09/23 at 08:58 AM, 09:45 AM, 11:45 AM, 12:35 PM, 3:06 PM; 01/10/23 at 09:05 AM, 12:03 PM, 12:54 PM;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that the staff was competent in performing quality control (QC) testing for the blood glucose meter. The QC solutions that were used for QC testing expired (as indicated by the manufacturer's expiration date) before the date the vials were opened. QC testing of the glucose meter verifies that precision of residents' glucose test results. As a result of this deficient practice, the facility placed all residents that need glucose testing at risk for potential harm as their medical care is dependent on precise glucose test results. Finding includes: On [DATE] at 09:40 AM, observed a box of QC solution with two vials inside that had a manufacturer's expiration date of [DATE] in the medication cart. Lot numbers for the vials were: 015921A for the normal level and 100720A for the high level. Handwritten on the box was the open date of [DATE] with a 90-day expiration date of [DATE]. No other box of control solutions were found in 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 promptly provide or obtain from their dental consultant, routine dental services to meet the resident's needs. This deficient practice has the potential to affect all residents currently residing in the facility. Findings include: On 01/09/23 at 09:29 AM, observations were done at the bedside of Resident (R)83. R83 was observed sleeping in her bed and appeared to have no teeth. On 01/10/23 at 09:44 AM, during a review of R83's electronic health record (EHR), it was unclear when her last routine dental exam/assessment had been done. No dental consults or exams were documented although there was a physician order from 10/11/22 that stated, dental consult on admission and annually. On 01/10/23 at 02:20 PM, an interview was done at the third-floor Nurses' Station (NS) with Unit Clerk (UC)3, Registered Nurse (RN)38, and Licensed Practical Nurse (LPN)1 present. All confirmed that the facility contracted Dentist had not come in to do routine dental exams since the COVID-19 pandemic began in 2020. UC3 reported that…

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

Based on record review and interview with staff members, the administration failed to provide support effectively and efficiently to the facility and staff members to ensure residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure all areas of the facility's Plan of Correction (POC) were corrected and/or worked toward compliance by the corrective action date the facility chose, 02/28/23. Findings include: (Cross-reference to F791 Dental Services) 1) Review of the facility's POC documented for the deficient practice in Dental Services Dental services to be provided by the dental consultant was scheduled for all . residents. The Unit Clerks will schedule annual dental appointments for all . residents and submit the schedule to the Patient Care Coordinator by the 31st of January on an annual basis. The ADON/DON or designee will review and ensure that all . residents are scheduled for dental consults annually. On 03/22/23 at 03:05 PM, conducted concurrent interview and record review (RR) with Director of Nursing…

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

Based on observations and interviews, the facility failed to provide a functioning call system for one Resident (R)260, in a sample of 32 residents. The facility failed to ensure that the visual alerts outside of R260's room and at the nursing station lit when she initiated her call device. This deficient practice has the potential to affect all residents who can utilize their call devices for help due to the lack of processes to identify a broken call system, other than the direct patient care employees, and a lack of follow up on repairs done by their Biomedical department, Findings include: On 01/09/23 at 12:45 PM, an interview was made with R260 and family member (FM)5. During the interview, R260 repeatedly stated she wanted a urinary tube to help drain her bladder because she had difficulty voiding and had urinary urgency. FM5 stated that R260 was newly admitted into the facility, and they were waiting for test results to find out what was the cause of R260's voiding difficulty and urinary urgency. On 01/09/23 at 12:55 PM, after the interview with FM5, an observation was made…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff member, the facility failed to assure one of two residents (R)44 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes. Findings include: R44 was admitted to the facility on [DATE]. On 01/10/23 at 08:08 AM reviewed R44's Electronic Health Record (EHR) and health record at the nurse's station for documentation of an AHCD. AHCD was not found. Review of R44's Declaration of Authority to Act as Surrogate for Patient form documented R44's adult child as an Appointed (Non-Designated) Surrogate signed on 03/13/17. Documentation of persons who took part in the selection were not documented. Under additional facts and circumstances to establish claimed authority was not documented. The form defined non-designated surrogate as a selected person .to make health care decisions for a patient has been…

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 interviews the facility failed to follow the facility's grievance policy to ensure prompt resolution of all grievances for two sampled residents (R)58 and R85. Findings include: Review of the facility's policy and procedure (P&P) 5021 RESOLUTION OF PATIENT/RESIDENT/VISITOR GRIEVANCES, COMPLAINTS AND CONCERNS effective 12/2021 defines complaint as a verbal expression of dissatisfaction .regarding care or services which can be resolved at the point which it occurs by the staff present. Most complaints will have simple solutions that can be promptly addressed and are considered resolved when patient/patient's representative is satisfied with the action taken on their behalf. The facility's policy defines grievance as a .formal verbal or written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/patient's representative's satisfaction at the point of service. The P&P further documents The complaint, findings and resolution of the complaint shall be communicated by the immediate supervisor or to Risk…

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 complete a comprehensive assessment of functional capacity within fourteen (14) days of admission, for two of 27 residents (R)103 and R83 in the sample. As a result of this deficient practice, the facility failed to identify R103's cognitive status which is important in defining care and staff did not have the information necessary to adequately care for R83 so that she could meet her highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all newly admitted residents to the facility. Findings include: 1) Reviewed the electronic health record (EHR) of R103 who was admitted on [DATE], and the initial Minimum Data Set (MDS) was completed on 12/21/22. While reviewing the initial MDS, noted that section C of the MDS, which covers cognitive patterns, was not completed. Question 0100 asked, Should Brief Interview for Mental Status (C0200-C0500) be conducted?, the answer was yes. There were no answers for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff members, the facility did not assure resident assessments were electronically transmitted within 14 days after completion. There was no record of successful transmittals to reflect the discharge for 3 (Residents 96, 88, and 64) of 3 residents identified. Findings include: The Long-Term Care (LTC) software identified three residents that did not have assessments transmitted for over 120 days. Residents (R) 96, R88, and R64. On 01/11/23 at 3:01 PM, record review with concurrent interview was done with the Minimum Data Set Coordinator (MDSC)1. The MDSC1 reported she started doing the assessments in October 2022. The review found: -R96 was admitted to the facility on [DATE] and discharged on 07/30/22. -R88 was admitted to the facility and readmitted on [DATE]. MDSC1 reported a quarterly assessment was done on 07/16/22. R88 later went out of the facility on 08/07/22 with return on 08/10/22. R88 was discharged on 08/14/22 to acute hospital, therefore, an admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to accurately complete a comprehensive assessment of functional capacity for two residents (R) in the sample. As a result of this deficient practice, resident-specific care areas were not triggered for further evaluation and staff did not have the information necessary to adequately care for the residents (R55 and R83) so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) Resident (R)55 is a [AGE] year-old female admitted to the facility on [DATE] for skilled care following a physical decline and weakness related to chemotherapy treatment. R55's admitting diagnoses include liver cancer, diabetes, chronic kidney disease, and history of breast and colon cancer. On 12/29/22 R55 was admitted to Hospice for end-of-life care. On 01/11/23 at 1:40 PM, a review of R55's electronic health record (EHR) noted that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to identify residents' medical needs and failed to provide caregivers important interventions on the initial care plan to give personalized and effective care to treat these medical needs for two residents (R), R259 and R260, in a sample of two. This deficient practice has the potential for ineffective and unindividualized care to be given to all newly admitted residents. Findings include: 1) Cross Reference to F684 Quality of Care. The facility failed to provide the needed medical care for R259, who has kidney failure, and was not receiving hemodialysis (a life-saving treatment involving a machine to clean the individual's blood of toxins). R259's specialized medical needs were not timely identified by the facility. On 01/10/23 at 08:18 AM, observed R259 sitting up in bed with her bedside table that contained her breakfast tray pushed to the side. R259 was sleepy, but responded to verbal stimulation. R259 requested to have oxygen applied…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure the comprehensive person-centered care plan was reviewed and/or revised by the interdisciplinary team after each assessment and as needed for two of 27 residents (Resident (R)91 and R85) sampled. Findings include: 1) Cross Reference to F689- Free from Accident Hazard, F756- Drug Regime Review, and F758- Free from Unnecessary Psychotropic Medication Facility Reported Incident (FRI) #HI00009469 (#9469) in the Aspen Complaints/Incidents Tracking System (ACTS) was investigated. The completed report submitted by the facility documented R91 was admitted to the facility on [DATE]. On 04/22/22 at approximately 3:45 PM, R91 was observed by staff in bed, quiet, no restlessness and declined an offer to go to the bathroom. At 4:35 PM, staff went back to check on the resident and found her sitting in bed. R91 informed staff that she fell when she went to the bathroom. R91 informed staff that she needed to use the bathroom again, stood up and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to provide the necessary care and services to maintain the activities of daily living, including grooming and personal hygiene for one resident (Resident 45) in the sample. As a result of this deficient practice, Resident (R)45 was hindered from attaining his highest practicable well-being and was placed at risk for a decreased quality of life. This deficient practice has the potential to affect all the residents at the facility. Findings include: Resident (R)45 is an [AGE] year-old male admitted to the facility on [DATE] for long-term care. Admitting diagnoses include high blood pressure, diabetes, depression, and left-sided weakness following a stroke. On 01/09/23 at 09:39 AM, observations were done at R45's bedside. R45 was alert with his hair uncombed and in disarray and he was wearing a facility gown that had a large yellow spill stain that had dried, covering his chest area and extending down to his abdomen. When asked what happened to his gown, R45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility did not ensure bowel regimen was provided in accordance with the physician's order for Resident (R)40 and the facility failed to appropriately provide the needed medical care for R259, who has kidney failure. R259 has kidney failure and was not yet receiving hemodialysis (a life-saving treatment involving a machine to clean the individual's blood of toxins). This deficient practice has the potential to affect all residents and residents who have kidney failure but are not yet receiving their life-saving treatment. Findings include: 1) Resident (R)40 was admitted to the facility on [DATE]. Diagnoses include Wernicke's encephalopathy; depression; psychotic disorder; and Post Traumatic Stress Disorder. Resident interview on 01/09/23 at 10:33 AM, R40 reported she sometimes experiences constipation. Inquired whether the facility provides any treatment. R40 responded a suppository is administered which is effective. Record review done on 01/12/23 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, interviews, and record reviews, the facility failed to provide treatment to prevent or improve pressure ulcers/injury for one Resident (R)259, in a sample of six residents. R259 was at risk to develop pressure ulcers, and due to the lack of timely repositioning, she developing a worsened skin wound. This deficient practice has the potential to affect the health of residents in the facility who are dependent on the staff for positioning. Findings include: On 01/09/23 at 10:27 AM, an initial observation was made of R259 who laid in bed with her eyes closed, lying on her right side. R259 did not arouse to verbal stimulation. On 01/09/23 at 1:13 PM, observed R259 lying in the same position in bed with her eyes closed and she still did not arouse to verbal stimulation. On 01/10/23 at 2:05 PM, interviewed R259's family member (FM)12. FM12 stated that the staff do not turn R259 while lying in bed every two hours. On 01/12/23 at 10:00 AM, a concurrent observation and interview were done with Registered Nurse (RN)10 during R259's pressure ulcer dressing change on 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, interviews, and record review, the facility failed to ensure the resident's environment remains free of accident hazards for one resident (Resident (R)91) sampled. Findings include: Cross Reference to F657- Care Plan Revision, F756- Drug Regime Review, and F758- Free from Unnecessary Psychotropic Medication On 01/09/23 at 08:45 AM, conducted an initial observation of R91 in the resident's assigned room. R91 was resting on an air mattress and the resident's feet was positioned higher than her head. A wedged cushion was placed under the left side of the air mattress and aligned with the area of the resident's legs. As a result of the wedge cushion under the mattress, R91's feet (heels in contact with the bed) pointed toward the right side of the bed. On the left side of the mattress, wedge cushions were placed under the sheet starting from the bedrail down to the foot of the bed. As a result of placing the wedge cushions under the sheet, the resident's sheet did not properly fit the mattress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews the facility failed to ensure a resident (Resident (R) 85) with an indwelling catheter was removed as soon as possible after a successful void trial. The facility failed to ensure R85 received appropriate interventions to restore as much urinary function as possible without use of a catheter and education on implications and risks associated with the use of a catheter without an indication for continued use. As a result, all residents are at risk of unnecessary use of indwelling catheters. Findings include: Cross Reference to F657. The facility failed to revise R85's care plan to address education to be provided on risks associated with the use of a catheter without an indication for continued use and include interventions to restore as much urinary function as possible without the use of catheter. R85 was admitted to the facility on [DATE] with diagnoses that include but not limited to gastrointestinal hemorrhage and benign prostatic hyperplasia with lower…

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 with staff members, the facility failed to assure two Residents (R)72 and R83 of two residents sampled, maintained acceptable parameters of nutritional status as evidenced by significant weight loss. As a result of these deficient practices, the facility placed this resident at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents at the facility. Findings include: 1) R72 was admitted to the facility on [DATE] from an acute hospital. Diagnoses includes but not limited to dementia with behavioral disturbance, myocardial infarction, chronic kidney disease, and Type 1 diabetes mellitus. On 01/10/23 at 10:20 AM, record review noted on 11/29/22, R72 weighed 125.4 lbs. and on 12/23/22, the resident weighed 116 pounds indicative of a 7.5% weight loss. A comparison of subsequent weights noted on 11/29/2022, the R72 weighed 125.4 lbs. and on 12/25/2022, the resident weighed 119 pounds which is indicative of a 5.10 %…

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 with staff member, the facility did not ensure enteral formula for two Residents (R)5 and R81, of two residents sampled, receiving enteral nutrition (also known as tube feeding, a way of delivering nutrition directly to the stomach or small intestine) did not exceed the expiration date. Findings include: 1) On 01/09/23 at 09:21 AM, conducted an observation of Resident (R)5 lying in bed and a bottle of Jevity tube feeding (TF) formula hanging with 400 milliliters (ml) left. The label on the Jevity bottle documented that bottle of TF formula was started on 01/08/23 at 05:00 AM, administration instructions for the formula was a bolus of 180 ml/hr (hour), and a beyond use date of 01/09 at 05:00 AM. At 10:25 AM, the same bottle was actively infusing and the infusion pump display documented 272 ml of formula had been administered to the resident. On 01/10/23 at 09:15 AM, conducted an interview with Nursing Staff (NS)22 regarding R5's TF formula. This surveyor shared…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to prevent and manage pain adequately for one resident Resident (R)55, in the sample. Specifically, the facility failed to recognize and act upon indicators of unmanaged pain, failed to evaluate, or assess what (R)55's pain management goals were, and failed to develop a resident-centered care plan for pain management. As a result of this deficient practice, R55 was prevented from attaining or maintaining her highest practicable level of well-being. Findings include: Cross-reference to F641 Accuracy of Assessments. The facility failed to accurately complete a comprehensive assessment that included an assessment of pain. As a result of this deficient practice, resident-specific care areas were not triggered for further evaluation and staff did not have the information necessary to adequately manage R55's pain. R55 is a [AGE] year-old female admitted to the facility on [DATE] for skilled care following a physical decline and weakness related to…

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

Based on interviews with residents, a family member, and a staff member the facility did not ensure enough nursing staff is provided to respond to each resident's basic needs. Findings include: 1) Cross reference to F584. The facility did not assure residents on the third and fifth floor were provided with clean and safe shower equipment. Cross reference to F880. The facility failed to thoroughly clean and sanitize shower equipment after use for the third and fifth floors. On 01/09/23 at 2:51 PM interview with Resident (R)9's family member (FM)1 was done. FM1 reported the Certified Nursing Aides (CNA) are short-staffed. FM1 stated F9 needs less care than she did before because she is in hospice but when she needed more care, FM1 would physically sanitize and wash the facility's shower chair because they were filthy with mildew and mold. FM1 reported the CNAs are busy and short-staffed that they don't have time to clean and maintain the shower chairs after resident use. FM1 stated she used to come to the facility four times a week to assist feed F9 and provide other care R9 may need…

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 who use psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, receives gradual dose reductions (GDR) unless clinically contraindicated and documented in the clinical record for one of five (Resident (R)91) residents sampled. Findings include: Cross Reference to F657- Care Plan Revision, F689- Free from Accident Hazard, and F756- Drug Regimen Review On 01/09/23 at 3:11 PM, conducted a record review of R91's Electronic Medical Record (EMR) that documented R91 was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease, dementia with behavioral disturbances, diabetes mellitus type 2, and hypertension. Review of the R91's physician orders documented an order for Mirtazapine 7.5 milligrams (mg) at bedtime for sleep disturbances (ordered on 07/18/22). Review of the admission Minimum Data Set (MDS) with 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.

Based on interview and record review (RR), the facility failed to ensure documentation that all residents who were eligible for the pneumococcal vaccine were offered or received it. Coupled with advanced age and chronic conditions, this deficient practice made one out of the five residents sampled potentially vulnerable to the bacteria that causes pneumonia. This deficient practice has the potential to affect all residents at the facility. Findings include: On 01/10/23 at 10:25 AM, a review of Resident (R)95's electronic health record (EHR) was done. Documentation of his pneumococcal vaccination status could not be found in his immunization record or progress notes. On 01/11/23 at 3:10 PM, during a review of immunization records provided by the facility, it was noted that Resident (R)95 had no documentation on whether he had been offered or received his pneumococcal vaccination. On 01/12/22 at 3:00 PM, an interview was done with the Consultant Director of Nursing (CDON) in the first-floor Conference Room. The CDON stated that after looking further into it, she had found that R95 had…

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.