Liliha Healthcare Center

Based on interviews and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, for one of one sampled residents (Resident (R) 5) for restraints. This deficient practice placed R5 at risk for physical harm and has the potential to affect all the residents in the facility. Findings Include: During a Facilty Reported Incident (FRI) investigation, interview was conducted on 01/30/25 with Unit Manager (UM) 2. UM2 stated that Certified Nurse Aide (CNA) 10 approached her on 12/31/24. CNA10 had informed her that while providing personal care, R5 was resisting care by pushing down with her hands. CNA10 decided to wrap R5's hands with the lower portion of her gown so that CNA10 can finish changing her incontinence brief. Interview was conducted on 01/31/25 at 09:35 AM with the Administrator. The Administrator stated that during an investigation interview, CNA10 had mentioned wrapping up R5's hands with the lower portion of her gown. CNA10 confirmed that R5 continued to push her hands down while it was wrapped and 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 record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for one Resident (R)76 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication. Findings include: Review of the Electronic Health Record (EHR) indicated that R76 was discharged to the hospital on [DATE]. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 10/31/25 at 11:00 AM, Social Services Director acknowledged that the facility did not provide written notification of discharge on [DATE]. Review of facility policy on Transfer and Discharge (including AMA) read; Policy, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Emergency Transfers/Discharges, initiated by the facility for medical reasons to an acute care setting such as 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 review of records and staff interviews, three of ten staff sampled for cardiopulmonary resuscitation (CPR) competency were not properly trained to provide basic life support subject to accepted professional guidelines. This deficient practice could result in the facility not providing the necessary care, placing residents at risk for decline in health status and/or death. Findings Include: A review of Cardiopulmonary Resuscitation (CPR) documentation for three staff was done on [DATE] at 11:15 AM. Documentation for Registered Nurse (RN) 11, Certified Nurse Aide (CNA) 12 and CNA13 reflects training from an online training course that does not provide hands-on practice and in-person skills assessment. Interviewed the Administrator on [DATE] at 11:49 AM, in his office, regarding CPR requirements for the facility. Administrator stated there is nothing in writing for CPR training requirements. Administrator stated on [DATE] at 11:59 AM that he spoke to the Infection Preventionist (IP), who provided…

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 one of one resident sampled (Resident (R) 22) for elopement, received adequate supervision to prevent accidents when he was an elopement risk. As a result of this deficient practice, R22 left the facility without authorization. This put R22 at risk of injury or getting hit by a car at a busy street. Findings include: R22 was admitted to the facility on [DATE] with diagnoses, but not limited to, pyogenic arthritis, muscle weakness, difficulty in walking, other abnormalities of gait and mobility, anxiety, depression, cognitive communication deficit, and attention-deficit hyperactivity disorder. Review of R22's admission Minimum Data Set (MDS) with assessment reference date of 12/16/24 found R22's Brief Interview for Mental Status (BIMS) score a 15 (cognitively intact). In Section GG. Functional Abilities and Goals, mobility devices used were cane/crutch and wheelchair. Further documented R22 needed supervision or touching assistance when walking…

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 facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment for one out of four medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. Findings Include: Concurrent observation and interview with Registered Nurse (RN) 10 were conducted on 01/28/25 at 01:46 PM on the second-floor hallway. One of the medication carts was left unlocked and two staff members were observed passing the unlocked cart. A few minutes later RN10 returned to the medication cart and locked it. RN10 then confirmed that the medication cart should have been locked and secured when left unattended. Interview was conducted with Unit Manager (UM) 2 on the second floor. UM2 confirmed that unattended carts should be locked and secured. A review of the facility policy titled, Medication Storage, with a revised date of 06/01/23 was conducted. The policy documented, All drugs and biologicals will be stored in locked…

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 ensure a clean working area before initiating wound care for one of one sampled resident (Resident (R) 35) for wounds. This failed practice has the potential to place a resident at risk for the development of infection and has the potential to affect all the residents that require dressing changes. Findings Include: Observation was conducted on 01/29/25 at 10:13 AM in R35's room during wound care rounds. R35 was turned to her side in bed and noted to have bowel movement on her buttocks, extending to the bottom edge of the resident's dressing located over her sacral area. Physician Assistant (PA) 1 proceeded to remove the dressing to the sacral area, and assessed the wound area before the bowel movement of R35 was cleaned, and before a clean brief was placed under the resident. Certified Nurse Aide (CNA) 11 proceeded to clean the bowel movement after PA1 was done with the wound assessment. Interviewed the Infection Preventionist (IP) on 01/29/25 at 12:50 PM at the second-floor nurse's station. IP confirmed that the CNA…

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

Based on 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 3 of 25 residents (Residents 33, 60 and 139) in the sample. 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) Cross-reference to F688 Increase/Prevent Decrease in ROM/Mobility. Despite identifying positioning/mobility needs for Resident (R)33, the facility failed to develop a care plan to effectively address those needs. 2) During interview with R60 on 01/23/2024, R60 expressed a desire to mobilize more with the Hemi-Walker available to R60. R60 feels confident this could be achieved if staff walked him daily. R60 had a care plan in place for altered ADL function, with an approach/intervention stating uses…

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 the facility failed to provide a comfortable environment for residents, staff and the public by not maintaining the environment in good repair. Findings include: Observations on 01/23/2024 - 01/26/2024, showed wallpaper on upper half of walls in the hallway of 1st floor, is lifting off in several areas and curling over. Outside of room [ROOM NUMBER] there is patch of wallpaper missing, approximately 12 x 18. It appears this patch has been torn off. On the opposite wall a picture has been removed with the area underneath significantly lighter in color than the rest of the wallpaper, providing an appearance of unkept cleaning of walls. The disrepair of the state of the wallpaper, is unkept and not conducive to a homelike environment. Watermarks are apparent on several areas of the wallpapered area of the hallway on the 1st floor unit.

Based on resident interviews and policy review, the facility failed to treat two Residents (R) 9 and R139, 68 of eight residents sampled, with respect and dignity. Findings include: Resident interview on 01/23/24 at 01:30 PM, R68 said that Staff would respond to the call bell and say they would be back but not return until several hours later. R68 said that this made him/her feel ignored. Resident interview on 01/24/24 at 08:45 AM, R9 revealed the following: Staff would respond to the call bell and say they would be back but it would take several hours for them to return, Staff would ignore and not pass on a request to speak to the doctor or other person, Staff would speak to each other in a language other than English and it felt as if they were talking about him/her. Review of policy on Resident Rights read Policy; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights; 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 record review and interview, the facility failed to ensure 2 of 6 residents sampled (Residents 33 and 55) were informed of their right to develop an advance health care directive, aided in doing so, and/or was periodically reassessed in his/her decision-making capacity to do such. As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 01/24/24 at 11:23 AM, during a review of Resident (R)33's electronic health record (EHR), an advance health care directive (AHCD) was not found. A review of the social services progress notes revealed no mention of an AHCD. The documentation was requested from the facility. On 01/25/24 at 02:22 PM, an interview with the Social Services Director (SSD) was done in his office. The SSD confirmed that R33 was admitted to the facility in August of 2023, and that there was no documentation available indicating that R33…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Resident (R)33 received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in range of motion (ROM) of her neck/head. As a result of this deficient practice, R33 was hindered from reaching her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits. Findings include: Resident (R)33 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. R33's diagnoses include but are not limited to left-sided hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) following a stroke, anarthria (complete loss of speech), and gastrostomy status (a surgical opening into the stomach made for a feeding tube). A review of R33's most recent Occupational Therapy (OT) Discharge Summary on 04/19/23 notes a discharge impairment of 100% . This score indicates that she [R33] requires 27…

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 4 residents in the sample (Resident 52) was free from accidents hazards. Resident (R)52 was observed ambulating with slippers oversized for her feet, placing her at increased risk for an avoidable fall. Despite previously being identified as a high risk for falls, the facility failed to recognize R52's oversized footwear as a potential hazard until pointed out by the State Agency (SA). This deficient practice has the potential to affect all ambulating residents at the facility. Findings include: Resident (R)52 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her current diagnoses include but are not limited to dementia, difficulty in walking, history of syncope (fainting) and collapse, and restlessness and agitation. On 01/23/24 at 10:53 AM, observed R52 sitting in the second-floor dining room at activities. Noted a bright yellow Falls Risk identification bracelet around her right ankle, 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 (RR), the facility failed to ensure nurse competency in pain assessment for 1 of 1 resident (Resident 64) sampled for pain management. As a result of this deficient practice, Resident (R)64 remained on a narcotic with a high risk of addiction and dependence for pain that could potentially have been managed with non-narcotic medication. This deficient practice placed R64 at risk for avoidable addiction and dependence in addition to other adverse effects of taking Fentanyl, and has the potential to affect all the residents at the facility receiving narcotic pain medication. Findings include: Resident (R)64 is a [AGE] year-old female admitted to the facility on [DATE]. Her current diagnoses include but are not limited to Alzheimer's disease, muscle weakness, an almost healed sacral pressure ulcer (pressure sore on the lower back), and severe protein-calorie malnutrition. A review of her electronic health record (EHR) noted that R64's primary language is Cantonese,…

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 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: Resident (R)27 is an [AGE] year-old female admitted to the facility on [DATE]. During an interview with her family representative (FR)5 on 01/23/24 at 01:34 PM at her bedside, FR5 reported that R27 had not received any routine dental visits since her admission. On 01/25/24 at 10:20 AM, a review of R27's electronic health record (EHR) found no documentation of any dental visits or exams since admission. On 01/25/24 at 11:15 AM, an interview was done with Unit Manager (UM)3 in her office. When asked, UM3 reported that the facility dentist had not been in for routine or emergency dental services since COVID began in 2020. UM3 confirmed that for dental emergencies, residents were sent out to his office, but that routine dental services…

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 ensure to post the most recent survey conducted by State surveyors in a place readily assessable to residents, family members and legal representatives of residents. Findings include: 1) On 02/08/23 at 03:17 PM, this surveyor inspected the second-floor nursing unit and was unable to locate the most recent survey results conducted by the State surveyors. Inquired with Unit Manager (UM)1 where the results were located. UM1 stated that if the survey results were available, it would be located in the designated box on the outside of the nursing station. UM2 walked to a medication cart, moved the medication cart and pointed out the survey result box. UM1 confirmed that there were no survey results located in the box and if the results were in the box, residents and resident representatives would not be able to see the results because the medication cart blocked the entire result's box. At 03:20 PM, this surveyor inspected the first-floor unit and was unable to locate the most recent State surveyor's results. Inquired with 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 observations, record review and interviews the facility failed to provide sufficient dietary staff to safely and effectively carry out the functions of food and nutrition services. As A result of this deficiency, there is the potential for more than minimal harm. Findings include: 1) On 02/13/23 at 01:54 PM, Resident (R)28's Family Member (FM)1 reported she was frustrated because breakfast and lunch has frequently arrived to the dining area late. FM1 reported dinner sometimes comes early and sometimes comes late. FM1 also reported the lunch today just came at 01:50 PM, and R28 is a diabetic and it is important for R28 to eat timely, so her blood sugar does not drop. 2) On 02/07/23 at 12:47 PM, observed broccoli and green beans served to R14 and R53 at bedside for lunch was not cut into half-inch pieces. Both meal tickets taped to meal trays stated that food consistency is chopped. On 02/08/23 at 08:29 AM, observed cranberry juice served to R53 at bedside for breakfast was not thickened. Meal ticket taped to R53's meal tray stated that liquids be nectar thick consistency. 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 observations and interviews, the facility failed to provide nourishing snacks at bedtime, for meals more than 14 hours between a substantial evening meal and breakfast the following day. Findings include: Review of the facility's policy and procedure Dietary Services documents Three meals plus a bedtime snack shall be serves at regular intervals with no more than 14 hours between dinner and breakfast. 1) During a group interview with resident council members (Resident (R) 47, R26, R58, R50) on 02/09/23 at 10:09 AM, R58 reported and R26, R47, and R50 concurred, the residents eat dinner at 05:30 PM and breakfast comes late at 08:30 AM and they have not received a snack in between for about a month. The facility will sometimes offer soda crackers or graham crackers, but it is not enough. R58 stated they used to serve sandwiches but that has stopped and reported starting Tuesday or Wednesday they were provided sandwiches again but believe it is because surveyors are here. On 02/13/23 at 10:20 AM, conducted an interview with Certified Nursing Aide (CNA) 6. CNA6 stated she…

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.

2) During lunch dining observation on 02/08/23 at 12:43 PM, observed 11 of 15 residents on the second-floor dining room with meal trays underneath residents plates, bowls, and cups while eating and not removed. During the meal pass, observed one Certified Nursing Aide (CNA) remove the trays as he was passing meals to four residents. During dining observation on the second floor on 02/08/23 at 12:44 PM observed nine residents eat lunch with their meal trays not removed. Based on observations and interview with staff member, the facility failed to provide a homelike environment for residents receiving meal service in the first and second floor dining room. The facility failed to remove trays when passing meals to residents. As a result of this deficiency, resident is at risk of a negative psychosocial outcome. Findings include: 1) On 02/07/20 at 12:18 PM, observed 12 residents in the first-floor dining room. 11 of the 12 residents had their meals and beverages remain on the meal trays until they were done eating lunch. On 02/13/23 at 02:33 PM, interviewed Administrator. She confirmed…

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 residents receive foods in the appropriate form as prescribed by a physician for 2 of 2 residents (Resident (R)28 and R14). As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: Review of the facility's policy and procedure Dietary Services documents All diets shall be meet the nutrient, texture, and fluid needs of each resident. 1) R28 was admitted to the facility with hospice on 12/05/22 with diagnoses that include Alzheimer's disease, dementia, and Parkinson's disease. Review of R28's comprehensive person-centered care plan documented .Provide diet as ordered: Regular diet, chopped texture and thin liquids . Review of R26's dietary order documented Chopped texture was prescribed. On 02/07/23 at 12:34 PM, observed R28 in the dining room, eating lunch, with her personal caregiver (PCG). The mixed vegetables on R28's lunch plate included pieces of whole broccoli and green beans…

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 failed to ensure three of 21 residents sampled exercised their right to a dignified existence. Resident (R) 60 and R45 were not provided privacy when receiving care requiring them to lift their shirt and a staff member was standing over R21 and R53 while providing assistance during breakfast. Findings include: Review of the facility's policy and procedure Promoting/Maintaining Resident Dignity reviewed/revised 05/20/22 documents It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as are for each resident in a manner and in an enviroment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy's compliance guidelines include 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .5. When interacting with a resident, pay attention to the resident as an individual .12. Maintain 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 record review and interview with staff members, the facility failed to inform three of five residents (Resident (R) 58, R7, and R74) reviewed for unnecessary medications, the risks and benefits of the use of psychotropic drugs and obtain consent. As a result of this deficiency, residents are at risk for more than minimal harm. Findings include: 1) R58 was admitted to the facility on [DATE] with diagnoses of depression and anxiety disorder. Review of R58's physician orders document R58 was receiving the following psychotropic medications; diazepam 5 milligrams (mg) twice a day as needed for anxiety and mirtazapine 15 mg once a day for depression. Review of R58's Electronic Health Record (EHR), consent for use of psychotropic medications including the risk and benefits were not found. On 02/09/23 at 12:29 PM, interview with Regional Nurse and Infection Preventionist (IP) was done. Regional Nurse confirmed the facility did not obtain consent for the psychotropic medications and was not able to find 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.

Based on interviews and document review, the facility failed to report two reportable events of suspected resident (R) abuse events to the State Agency (SA) Adult Protective Services (APS) as mandated by law. On 12/13/23 the facility identified R33 had an unobserved/unexplained dislocation of the left shoulder. On 10/28/22, R10 was allegedly abused by R7. As a result of this deficient practice the SA did not have information to determine if an investigation by their agency was needed, and there is the potential incidents are not thoroughly investigated, putting all residents of potential abuse at risk. Findings include: 1) The facility provided a policy titled Resident Rights-Freedom from abuse, neglect and exploitation last revised 04/11/2018. Review of the policy included: - Policy header had a different (sister) facility (F2) name on it. - Section Procedure for Investigation of allegations of abuse, neglect, exploitation or mistreatment: An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation, or mistreatment, including injuries…

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 document review, the facility failed to thoroughly investigate the unobserved/unexplained injury of R33, diagnosed as a dislocated shoulder. In addition there was lack of evidence administration was involved as necessary in the investigation. If thorough investigations are not completed and appropriate action taken, it increases the risk of reoccurrence of a similar event to residents who are totally dependant on staff for Activities of Daily Living (ADL's). Findings include: 1) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body) and dysphasia (swallowing disorder) following a cerebral infarction (stroke) affecting her left non-dominant side. In addition her diagnosis included, but not limited to dementia, mood disturbance, sacral stage 3 pressure ulcer and age related osteoporosis without pathological fractures. R33 was totally dependent on staff 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 record review and interviews, the facility failed to notify the family or resident representative of one resident's (R), R39's, transfer to the hospital. The facility failed to provide a written notification to the resident's close contacts about R39's transfer out of the facility for emergent care. This deficient practice does not protect the resident from an inappropriate discharge and has the potential to affect all residents transferred out of the facility. Finding includes: On 02/07/23 at 08:47 AM, R39 was observed to be lying in bed in his room. R39 did not respond to verbal stimulation. On 02/08/23 at 11:30 AM, R39 was observed to be assessed by an Emergency Medical Technician (EMT). Record review revealed that R39 was transferred to a local area hospital for acute care. Nurse (N)12 tried notifying R39's close contacts but was unable to reach them via phone and was unable to leave a voicemail. On 02/13/23 at 2:22 PM, queried the Area admission Director (AAD). AAD stated that the Social Services Director (SSD) is responsible for notifying the family and Long Term 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one residents (R)33 functional ability and required staff support was accurately documented on the MDS (Minimal Data Sheet) dated 12/20/2022. In addition two of four weekly (from 01/14/2023 to 02/02/2023) assessments did not accurately reflect R33's need for two staff support for activities of daily living (ADL's). As a result of this deficiency, R33 may not have received the necessary support to meet her goals. This deficient practice has the potential to affect all residents. Findings include: 1) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body), dysphasia (swallowing disorder) and dsyarthria (speech disorder caused by muscle weakness) following a cerebral infarction (stroke) affecting her left non-dominant side. In addition her diagnosis included, but not limited to dementia, stage 3…

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) R38 is a [AGE] year-old resident admitted on [DATE]. Diagnoses that include traumatic subdural hemorrhage (bleeding in the area between the brain and the skull) and dementia with agitation. Observation on 02/07/23 at 09:10 AM, R38 was awake lying on specialty mattress, face appeared oily and started yelling in Korean and waving his arms when we knocked on door to ask permission to enter room. According to another surveyor that understands Korean, R38 was using curse words. On 02/08/23 at 12:48 PM, this surveyor knocked on door to ask permission to enter room, no response from R38. As soon as he saw us approach his bed, he started yelling in Korean so we exited the room. Interview with Certified Nurse Aide (CNA) 6 and Nurse (N) 11 on 02/09/23 at 12:52 PM. CNA6 said R38 yells a lot when the staff care for him, he sometimes refuses care. He only speaks Korean, and the staff sometimes use Google Translate on their phones to communicate with him. The staff understand some common words like change and turn. N11…

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 revise two Resident (R)33 and R58's care plans (CP) in a timely manner. Specifically the facility failed to ensure Resident (R) 58's comprehensive CP plan was person-centered and does not include safe approaches for smoking, expressing the facility's current designated smoking area is unsafe and prefers to smoke at a non-designated smoking area. R33's CP was not revised in a timely manner after it was determined she needed more staff assist for activities of daily living (ADL's). Findings include: 1) Cross reference to F689. The facility failed to identify and assess hazards and risks for Resident (R) 58's smoking environment, designated by the facility and non-designated by the facility, and implement interventions to reduce hazards and risks. On 02/07/23 at 01:46 PM interview with R58 was done. R58 stated the facility's designated smoking area is at the back of the facility and is difficult to access. R58 stated she smokes on the side walk once or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews the facility failed to identify and assess hazards and risks for Resident (R) 58's smoking enviroment, designated by the facility and non-designated by the facility, and implement interventions to reduce hazards and risks. This deficient practice effects R58's individual safety, as well as the safety of others in the facility. Findings include: (Cross reference to F657- Care Plan Timing and Revision) The facility failed to revise and ensure Resident (R) 58's comprehensive care plan was person-centered. R58's care plan for smoking does not include approaches when expressing the facility's current designated smoking area is unsafe and prefers to smoke at a non-designated smoking area. R58 was readmitted to the facility on [DATE] with diagnoses of embolism and thrombosis of arteries of the lower extremities, acquired absence of right leg above knee, history of falls, difficulty in walking, depression, and anxiety disorder. Review of R58's Electronic Health Record…

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 record review, the facility failed to adhere to professional standards of practice and infection prevention and control measures for one resident with an indwelling urinary catheter. This deficient practice has the potential to affect all residents that have an indwelling urinary catheter putting them at risk to develop complications including urinary tract infections. Finding Includes: On 02/07/23 at 09:10 AM, observed Resident (R)53 lying in bed with indwelling urinary catheter tubing and collection bag touching the floor. Then at 12:35 PM when the resident was being brought to the dining area via wheelchair, observed the urinary catheter tubing being dragged on the floor during transport. On 02/08/23 at 11:29 AM, observed R53 lying in bed and no longer has the indwelling urinary catheter. Review of records revealed that on 02/07/23 at 13:19 PM, Progress Notes documented: received report from floor nurse that resident is not at her baseline, with noted confusion, foul smelling dark colored urine with sediment. MD (attending physician) made aware received…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to identify and verify a significant weight loss/gain and ensure a resident maintained acceptable parameters of body weight for 1 of 4 residents (Resident (R)64) sampled. R64 had a significant weight loss of 19.30% from 10/27/22 to 11/10/22 and a significant weight gain of 20.62% from 11/10/22 to 01/29/23 that was not verified and/or addressed. As a result of this deficiency, residents are at risk for the potential of negative outcomes due to unidentified changes. Findings include: R64 was admitted to the facility on [DATE] with diagnosis that include dementia, with behavioral disturbances, diabetes mellitus type 2 without complications, anxiety disorder, major depressive disorder, and insomnia. On 02/10/22 at 10:10 AM, conducted a review of R64's Electronic Health Record (EHR). Review of the resident's weights documented: 10/27/22- 120.2 lbs (pounds); 11/10/22- 97.0 lbs; 12/22- Refused weights; and 01/29/23- 117 lbs. Indicating R64 had a significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure an account (route and time) of a controlled medication for one resident (Resident (R)23) sampled. As a result of this deficiency, the resident is at risk for more than minimal harm and provides an opportunity for diversion of a controlled medication. Findings include: R23 is a [AGE] year-old resident admitted with type 2 diabetes mellitus, end stage renal disease and dependence on renal dialysis, non-pressure chronic ulcers to both heels, cellulitis (bacterial skin infection causing redness, swelling and pain) to both lower limbs, chronic osteomyelitis (bone inflammation or infection) to both left and right ankles. Resident is transported to an incenter dialysis clinic three times a week and is on oxycodone (narcotic pain medication) 10 milligrams (mg) every 3 hours routinely for pain. Review of R23's electronic health record (EHR) included scanned communications between the facility and the incenter dialysis clinic in Resident…

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

Based on observations and interviews, the facility failed to ensure medication error rates are not 5 percent (%) or greater. The survey team observed a total of 28 medications, the total number of errors were 2, and the medication error rate was 7.14%. As a result of this deficient practice, there is potential for more than minimal harm. Findings include: On 02/09/23 at 08:24 AM, conducted observation of medication administration on the second-floor unit with Registered Nurse (RN)71 for R33. RN71 prepared the residents medication and crushed all medications (Acetaminophen 325 mg (2 tablets, total dose 650 mg); Laxatives (2 tablets); and Vitamin C 500 mg (1 tab, not factored into percent rate)) and mixed the crushed medications with applesauce in a medication cup. RN71 administered the crushed medications to R33 then proceeded to walk towards the trash in the resident's room. This surveyor inquired if RN71 completed administering the medication to R33. RN71 confirmed he/she had administered the medication and was going to throw the medication cup away. Asked RN71 if there were 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.

Based on observations, interviews, and record review, the facility failed to ensure all drugs are stored in locked compartments and intravenous (IV) fluid was discarded when IV therapy was discontinued. A treatment cart with topical medications was not kept locked or under the direct observation of authorized staffing in an area where residents could access it. No medications were taken by the resident but the potential for more than minimal harm exist. Findings include: 1) On 02/08/23 at 08:15 AM, observed the treatment cart on 1 of 2 units was unlocked in the main dining/activity room. The treatment cart was unsupervised, there were two residents in the area, unsupervised, and no staff in the immediate area. This surveyor opened the treatment cart and documented the cart had topical creams that included Clotrimazole cream, Ketoconazole cream, and Triamcinolone Acetonide ointment. On 02/08/23 at 2:35 PM, conducted a review of R48's Electronic Health Record (EHR). Review of R48's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/09/22 Section G.…

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

Based on observations, interview, and record reviews, the facility failed to ensure Resident (R) 58's menu was followed to meet her choices and preferences. Findings include: On 02/09/23 at 08:08 AM, observed R58 receive her breakfast tray and inform nursing staff she did not get milk on her tray. At 08:20 AM, inquired with R58 how breakfast was, R58 reported her milk was not on her tray. On 02/09/23 at 10:09 AM, interview with R58 with resident council members was done. R58 reported sometimes their meal tickets (menu) are not followed. R58 stated For instance, my meal ticket said milk and on the meal tray, I did not get milk this morning. R58 stated she had to let nursing staff know so she could get her milk but is worried about those who cannot speak for themselves. On 02/10/23 at 09:28 AM, observed R58 eating breakfast. R58 stated she received papaya and hot cereal although her meal ticket says no papaya and no hot cereal. R58 reported she gave her papaya to the resident next to her. Observed papaya on a plate with the resident next to R58 and hot cereal on R58's tray. 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.

3) On 02/09/23 at 08:15 AM, observed RN71 using a wrist blood pressure cuff on R33. RN71 did not disinfect the wrist blood pressure cuff before or after use. Inquired with RN71 how the wrist blood pressure cuffs should be disinfected due to the porous material that is in direct contact with the resident's skin and if it should have been disinfected before and/or after use. RN71 stated the wrist blood pressure cuff should have been cleaned before it was used on R33 but was not and purple wipes are used to clean the reusable equipment and had not thought about the band of the cuff is fabric and the purple wipes may not be an appropriate way to disinfect it. Conducted an interview with the facility's IP and shared my observation of staff not disinfecting the reusable wrist blood pressure cuff. The IP confirmed reusable medical equipment should be disinfected before and after use, at a minimum, before it is used. IP also confirmed that due to the fabric on the wrist blood pressure cuff, the purple wipes is not an appropriate disinfectant and staff should use blood pressure cuffs 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 observation, interviews, and record review, the facility failed to provide a safe, clean equipment for a resident (Resident(R14) sampled. R14 is dependent on supplemental oxygen and the filter of the oxygen concentrator machine had a layer of dust on it. As a result of this deficient practice, the resident is at risk for more than minimal harm. Finding includes: R14 is a [AGE] year-old resident admitted on [DATE] with diagnosis that include chronic obstructive pulmonary disease (disease that blocks air from entering the lungs making it harder to breath), chronic respiratory failure, and dependence on supplemental oxygen. On 02/07/23 at 09:47 AM, Observed R14 lying in bed, receiving oxygen 2 liters (L) of oxygen via nasal cannula. The external filter located on the right side of the machine, was covered with a layer of whitish/grayish dust. On 02/08/23 at 08:42 AM, conducted a concurrent observation and interview with Unit Manager (UM) 4 of R14 and the oxygen concentrator filter. It was observed to be…

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