Nuuanu Hale

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to assess the risk of entrapment from bed rails prior to installation for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. This deficient practice could place R56 and R38 at risk for harm from bed rail use. The deficient practice could affect all residents in the facility who are using bed rails if a risk assessment is not completed prior to use of their bed rails. Findings Include:Cross-reference to F909 Resident Bed. The facility failed to implement a regular maintenance program to identify areas of possible entrapment with bed rail use for residents observed using bed rails, Resident (R) 56 and R38. 1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed.On 02/25/2026 during record review, of R56's Electronic Health Record (EHR), found she is [AGE] years old and her last admission occurred on 12/05/2024. R56's diagnoses include, but are not limited to,…

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

Based on record review and interviews, the facility failed to ensure licensed nursing staff demonstrated the appropriate competencies and skill set to perform a timely, thorough, and accurate skin assessment for one of one resident (Resident (R) 70) reviewed for abuse. Specifically, staff were aware that R70 had a large bruise on left hip and thigh, first observed on 07/30/25, but an initial assessment was not conducted, and subsequent skin assessments did not document the presence, location, size, characteristics and/or progression of the bruise. This deficient practice places R70 at risk for unrecognized injury progression and delays in appropriate monitoring, intervention, investigation, and implementation of protective measures to safeguard the resident's health and safety.Findings Include: Cross Reference to F609, Reporting of Alleged Violation. The facility failed to ensure staff reported an injury of unknown source that resulted in serious bodily injury, large bruise to left hip and thigh, no later than two hours after discovery to the facility Administrator. The injury was…

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

Based on observation, interview, and record review, the facility failed to ensure medication carts were locked and under direct observation of authorized staff in an area where residents could access it for one of four medication carts observed. This practice does not ensure the protection and control of medications. Findings Include: On 02/26/26 at 10:12 AM, after exiting a resident's room, an unlocked medication cart was observed in the Ewa Unit hallway and left unattended. Facility staff were observed walking by the cart, and residents in wheelchairs were present in the hallway at the time.At 10:13 AM, Registered Nurse (RN)5 was observed walking from the Diamond Unit while carrying a pitcher of water. RN5 briefly spoke with another staff member while walking past the nurse's station to the Ewa Unit, not at direct observation of the medication cart. RN5 then introduced herself and confirmed that the medication cart was assigned to her. She stated that she had stepped away from the cart and acknowledged that it should have been locked.Review of the facility's policy and procedure…

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 conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for two of two residents reviewed for accident hazards, Resident (R) 56 and R38. The deficient practice puts all residents at risk for possible entrapment if they have bed rails and they are not inspected and maintained according to manufacturer's recommendations and requirements.Findings Include:1) On 02/24/2026 at 10:15 AM R56 was observed lying in her bed with bilateral upper quarter bed rails up on her bed. 2) On 02/25/2026 at 9:05 AM R38 was observed lying in her bed with bilateral upper quarter bed rails which were up in use. Inquired of R38 about the bed rails and she said she uses it if she needs to hold onto it and the staff use it.On 02/27/2026 at 10:55 AM interviewed Maintenance Supervisor in the conference room. Inquired if he or his staff do routine maintenance for the residents' bed rails and have logs of this and he stated they, tighten the bolt if it is loose…

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 safe discharge for one Resident (R)2 of a sample size of three. Specifically, prior to an inpatient hospitalization, R2 was moderately independent with some assistance, but his functional level changed. At discharge, he required maximum assistance for most activities of daily living. There was lack of evidence that R2's discharge home met his identified needs of 24/7 supervision. Caregiver availability, capacity and capability were not determined. As a result of this deficiency, R2 was at high risk of readmission and harm. This deficient practice has the potential to affect any resident discharged home. Findings include: 1) On 02/07/2025 the Office of Healthcare Assurance (OHCA) received a report from an external agency regarding concern of R2, self neglect and possible inappropriate discharge. The report included R2 lived with his girlfriend, but that she was disabled and not able to care for him. It also documented he does not have any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, the facility failed to have maintain a sanitary and clean shower room for two of the four shower rooms observed. This deficient practice could affect all residents at the facility if appropriate cleaning of the showers are not done. Findings include: On 02/03/25 at 09:00 AM, a walkthrough of the 2nd floor [NAME] Wing shower room noted black substance on the left bottom corner caulking through the bottom middle caulking, extending to the right corner side caulking of the shower stall. The Ewa Wing shower room also noted black substance on the bottom right corner caulking of the shower stall. On 02/05/25 at 09:20 AM, interviewed Certified Nurses Aid (CNA) 15 and identified that the black substance was mold and wasn't sure how housekeeping cleaned it. At 09:30 am, during an interview with Housekeeper (H)1 and H2, they housekeepers acknowledged the black substance and noted that they didn't know what it was and have tried to remove it by scrubbing it. On 02/05/25 at 12:40…

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 provide documentation that written notice of transfer or discharge was provided to the resident and resident's representative(s), and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for one of five resident samples. This deficient practice has the potential to affect resident or resident's representative(s) right to appeal the discharge. Findings include: Resident (R) 69 was sent to the Emergency Department and admitted to the hospital on [DATE]. Record review was done on 02/05/25 at 12:26 PM for two forms titled, Discharge/Transfer Notice and [Provider] Notice of Discharge. Information for R69 was noted on both forms, but no documentation was found that it was sent to the resident's representative or Long-Term Care Ombudsman. The Social Services Director (SSD) was interviewed, in her office, on 02/25/25 at 12:33 PM, and stated that there is nothing documented that the written…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a resident-centered Comprehensive Care Plan (CP) for 8 of 18 residents (R) sampled (R20, R21, R55, R37, R32, R24, R27, and R56). 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 well-being. This deficient practice has the potential to affect all the residents at the facility. Findings Include: 1) Cross-reference to F641 Accuracy of Assessments for R20. The facility failed to include R20's active diagnosis Contracture of muscle, left upper arm, in his Minimum Data Set (MDS) Quarterly Assessment. The facility failed to develop and implement a care plan to address R20's limited ROM needs of his left arm. 2) Cross-reference to F641 Accuracy of Assessments for R21. The facility failed to identify pressure ulcers (PUs) to bilateral heels on R21's Minimum Data Set (MDS) Quarterly Assessment after R21…

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 ensure the comprehensive person-centered care plan (CP) was reviewed and/or revised by the interdisciplinary team for four of 18 residents (Resident (R) 29, R55, R38, and R54) sampled for care plans. As a result of this deficit practice, R29's need for assistance with meals was not care planned for which was something new with the resident, R55's range of motion (ROM) was not addressed as recommended by physical therapy to prevent further contractures, R38's respiratory care was not person-centered and/or revised to appropriately reflect her status, and R54's pressure ulcer status was not updated to a Stage 4 with person-centered interventions. Findings include: 1) During record review of R29's Electronic Health Record (EHR) found she was hospitalized on ce in December 2024 and she returned to the facility on [DATE]. On 12/15/2024 at 14:37 the Minimum Data Set Coordinator (MDSC)1 documented R29 had a significant change for The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to ensure a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. The facility failed to: 1) ensure a pill cutter, used for multiple residents, was cleaned between patient use, observed from one of three medication carts; 2) ensure staff perform hand hygiene after discarding dirty gloves before assisting resident (R) 123 with her meal, one unsampled resident; 3) ensure clean medical supplies to be used are kept on clean surfaces and follow standard precautions by performing hand hygiene between glove change for one of five residents (Resident (R) 54) sampled for wound care; 4) ensure a nursing staff member providing care used appropriate Personal Protective Equipment and performed hand hygiene between gloves for one of six residents (R68) sampled with Enhanced Barrier Precautions (EBP); 5) ensure a lancet, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review (RR), the facility failed to identify and support the bathing schedule preference of 1 of 2 residents (R) sampled for Self-Determination. As a result of this deficient practice, R32 did not have his needs met and was hindered from attaining his highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: Cross-reference to F684 Quality of Care. Despite identifying and documenting an ongoing pruritic (itching) skin condition since September 2024, the facility failed to adequately address and provide relief for Resident (R)32's itching. Resident (R)32 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. A review of R32's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 07/11/24 notes that his admitting diagnoses include, but are not limited to, heart failure, high blood pressure, diabetes, and end-stage renal disease (on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide documentation that written notice of bed-hold policy was provided to the resident or resident's representative within 24 hours of emergency transfer for one of one resident (Resident (R) 69) reviewed for closed record. This deficient practice does not ensure the resident's right to have a place to return and does not provide continuity of care. Findings include: Resident (R) 69 was sent to the Emergency Department and admitted to the hospital on [DATE]. Record review was done on 02/05/25 at 12:26 PM for two forms titled, Resident Progress Notes and [Provider] Bed Hold Agreement At Time of Transfer/Discharge. The Resident Progress Note entry dated 01/02/25 noted, SS [Social Services) received call from sister/POA [Power of Attorney] informing facility that resident/family unable to pay to hold the bed for the resident . The bed-hold agreement noted oral notification was provided by the facility, but the section titled, Written Notification was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review errors on Minimum Data Set (MDS) Quarterly Assessments were found for two of 18 residents sampled, Resident (R)20 and R21. Error for R20 was made under section I. Active Diagnoses and error for R21 was made under section M. Skin Conditions. Findings Include: 1) Cross Reference to F656 (Comprehensive Care Plan). On 02/03/25 at 10:50 AM R20 was observed lying in his bed and surveyor noticed he had a contracture to his left hand. Asked R20 if he can open or close his hand and he reported it is not so well, resident was not able to do this. During record review of R20's Electronic Health Record (EHR) found he has an active diagnosis of Contracture of muscle, left upper arm dated 02/15/24. On 02/06/25 at 09:48 AM interviewed Director of Nursing (DON) and asked if R20's MDS Quarterly assessment dated [DATE] had the active diagnosis, Contracture of muscle, left upper arm, and she stated she was not able to find it. Inquired if this should have been included and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide the proper care and treatment, including assistive devices/tools, to improve and promote the communication abilities of 3 of 3 residents (R) sampled for Language/Communication. Despite identifying upon admission that their primary language was not English, the facility failed to implement the use of alternative communication methods, such as a communication board, non-verbal pain assessment tools, or commonly used phrases in their primary language, or an interpreter for Residents (R)37, R24 and R55. As a result of this deficient practice, the residents are at an increased risk of not having their needs met and experiencing a decline in their physical well-being, psychosocial well-being, and quality of life. This deficient practice has the potential to affect all residents at the facility with communication needs. Findings include: 1) Cross Reference to F656 (Comprehensive Care Plan) Resident (R)37 is a [AGE] year-old male…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that addressed the needs of 1 of 2 residents sampled for Activities. Despite identifying that he had a visual deficit, the facility failed to implement activities Resident (R)37 could perform. As a result of this deficient practice, R37 was placed at risk of a decline in his psychosocial well-being. This deficient practice has the potential to affect all residents at the facility. Findings include: Resident (R)37 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. A review of R37's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 12/09/24 notes that R37 had been identified as Vision Impaired - sees large print, but not regular print in newspapers/books. On 02/03/25 at 01:35 PM, concurrent observations and interview were done with R37 at the bedside. R37 stated he had reading glasses at home in Chuuk but did…

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 implement a hydration program that recognizes, evaluates, and addresses the hydration needs of 1 of 2 residents (Resident 37) sampled for hydration. Individuals who do not receive adequate fluids are more susceptible to urinary tract infections, pneumonia, pressure injuries, skin infections, confusion, and disorientation. In addition, despite identifying and documenting an ongoing pruritic (itchy) skin condition for 1 of 5 residents (Resident 32) sampled for non-pressure related skin conditions, the facility failed to adequately address and provide relief for his itching, impacting his comfort and psychosocial well-being. These deficient practices have the potential to affect all residents at the facility. Findings include: 1) Cross Reference to F656 (Comprehensive Care Plan) Resident (R)37 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. A review of R37's electronic health record (EHR) notes that he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide necessary treatment, consistent with professional standards of practice, to promote healing of a stage 4 pressure injury for one of five residents (Resident (R) 54) sampled for pressure injuries. R54 did not get the support she needed to turn and reposition every two hours causing discomfort. This deficient practice put R54 at risk for failed progress toward healing. Findings include: R54 was admitted to the facility on [DATE]. R54's diagnoses include, not limited to, stage 4 pressure ulcer of sacral region, posterior reversible encephalopathy syndrome, local infection of the skin and subcutaneous tissue, type 2 diabetes mellitus with other skin complications peripheral vascular disease, acquired absence of right leg above knee, type 2 diabetes mellitus with hyperglycemia, non-pressure chronic ulcer of other part of right lower leg with necrosis of bone, pain, and infection of amputation stump of right and left lower extremity.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) On 02/03/25 at 10:50 AM observed R20 in his room in bed. Observed resident with contracture to his left hand and inquired if he could open and close his hand and R20 reported it is not so well. Asked resident if staff put a splint on his hand or a rolled up wash cloth and he denied this. At this time neither were observed in/on R20's left hand. Record review of R20's Electronic Health Record found he has a diagnosis that include and is not limited to quadriplegia, unspecified (Primary, Admission), central cord syndrome at unspecified level of cervical spinal cord, subsequent encounter and contracture of muscle, left upper arm. Review of R20's CP found Resident's name is quadriplegic and has left arm and hand contractures related to this. R20's long term goal (LTG) date of 04/27/25 and LTG stating Resident's name will not exhibit signs of autonomic dysreflexia (life threatening syndrome with sudden and severe rise in blood pressure and other symptoms) or other complications related to quadriplegia 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, interview, and record review, the facility failed to ensure a resident's oxygen (O2) tubing was connected to the O2 concentrator consistent with professional standards of practice for one of one resident sampled (Resident (R) 38) for respiratory care. As a result, R38 was not receiving continuous O2 as physician ordered. This failure placed R38 at risk for respiratory distress. Findings include: R38 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hyperlipidemia, hypertension, and hypoxemia. Review of R38's physician orders for O2 included, continuous O2 at two liters per minute (LPM) via face mask, may titrate flow to keep saturation (SATS) greater than (>) 90 percent (%) and O2 at 0-5 LPM via nasal cannula or face mask (per resident preference) as needed, may titrate flow to keep SATS > 90%. On 02/06/25 at 08:01 AM observed R38 in her room, R38's O2 face mask was not covering…

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 manage and monitor the medication regimen for one of five residents sampled for unnecessary medications, by not implementing a physician ordered gradual dose reduction (GDR) for an antidepressant. This deficient practice does not protect residents from the possible side effects of overmedication and has the potential to affect other residents prescribed with psychotropic medications. Findings include: On 02/06/25 at 01:45 PM, a review of the Medication Regimen Review (MRR) for Resident (R) 18, dated 09/25/24, and done by the Consultant Pharmacist, recommended that R18's Citalopram 10mg be reviewed for an annual GDR versus clinical contraindication. On the same form, R18's physician (MD) 1 marked the option titled, Condition stable: Attempt dose reduction to and handwrote in 5 QD [milligrams daily]. The bottom of the form contained his signature and date of 9/27/24. Upon review of R18's September and October 2024 physician orders, no order change for Citalopram 10mg to 5mg was noted. There was also no indication of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure all medications administered were stored, labeled, and administered according to professional standards. Proper labeling and administration practices of medications are necessary to decrease the risk of medication errors. This deficient practice has the potential to affect all residents in the facility. Findings include: 1) On [DATE] at 07:56 AM, Medication pass observations were done with Registered Nurse (RN) 12. For Resident (R) 10, the Carvedilol 25mg order on the Medication Administration Record (MAR) was listed to be given twice a day at (08:00 AM and 05:00 PM). The label on the medication blister pack noted Carvedilol to be given every 12 hours. A review of the physician orders was done on [DATE] at 11:15 AM for R10's Carvedilol. The current physician order for R10's Carvedilol, dated [DATE], stated it to be given 25mg twice a day. An interview was done with RN12 on [DATE] at 11:30 AM. RN12 confirmed that R10's Carvedilol…

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 a resident's (Resident (R)2) environment was free from accident hazards related to elopement from the facility. R2 was able to exit the facility without authorization and was found at a driveway across the street. This deficient practice has the potential to affect ambulatory residents in the facility and result in injury related to falls or car striking resident. Findings include: Review of Aspen Complaint/Incidents Tracking System (ACTS) report #11273 revealed that on 10/20/24, R2 was last seen in the facility at 08:45 AM by multiple staff, sitting up in her bed talking to her roommate. At 09:38 AM, R2 was found across the street from the facility walking up the driveway of another property. An investigation was conducted on how R2 was able to exit the facility without authorization. R2 was interviewed and was not able to recall how she got out of the facility. A trail of the R2's belongings were found in the courtyard area and a short rock wall leading to the driveway exit. On 11/06/24 at 09:47 AM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the resident's right to a dignified existence for one of three residents (R)8 sampled. R8 is dependent on staff for toileting needs. R8 removed a soiled incontinent brief which staff removed from the room and did not apply another incontinent brief for the resident. R8 was found on the ground, naked, tangled in cords, calling out for help, in full view of the resident's roommate. As a result of this deficient practice, all residents dependent on care from staff are at risk of potential for physical and psychosocial harm. Findings include: On 03/07/24 at 01:45 AM, review of R8's electronic health record (EHR) documented R8 was admitted to the facility on [DATE]. R8's diagnosis included myocardial infarction (heart attack), Dementia with behavioral disturbances, spinal stenosis (narrowing of spaces in the spinal canal), dry eye syndrome, ocular laceration, and rupture with prolapse/loss of intraocular tissue (ruptured eye which…

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 post the results of the most recent survey of the facility. Findings include: On 01/22/24 at 10:14 AM, observed in a total of three binders of the State Survey Results on the second floor located in three different units and in one binder on the first floor located next to the reception desk, the last survey result posted was dated 12/22/22. On 01/24/23 at 02:13 PM, a concurrent observation and interview with Director of Nursing (DON) was done. DON confirmed the survey results posted was dated 12/22/22 and was not the most recent survey of the facility. Review of the most recent survey conducted at the facility was 02/06/23.

Based on staff interview and record review (RR) the facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full time basis, ensure that the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. Findings Include: On 01/26/24 at 08:44 AM met with DON to interview her about Sufficient and Competent Nurse Staffing. DON explained facility uses ABC, Prime Time, Express and a 4th agency to help supplement their staff. DON also stated they use a local agency. Facility staff sign up for overtime to cover the open shifts. DON stated when she first started working at the facility (date of hire 06/01/2023) she was helping to cover shifts to provide care to the residents as a floor nurse. RR found the DON was working 07:00 AM to 03:00 PM and 03:00 PM to 11:00 PM shifts. Inquired if DON was getting paid overtime compensation during this time and she replied, No. and that she is a salaried employee. Inquired if she was at the facility eight hours before or after her shift to do DON work and she replied,…

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, facility failed to implement and document a water management program minimizing the risk of Legionella and other opportunistic pathogens in their water system using nationally accepted standards. They failed to provide a facility assessment identifying where Legionella and other opportunistic water pathogens could grow and spread, and what measures they have in place to prevent the growth of opportunistic waterborne pathogens and how they would monitor them. This deficient practice could affect the residents, staff and visitors to the facility if exposed to Legionella and other opportunistic waterborne pathogens. Findings Include: On 01/26/24, reviewed facility policies titled Infection Prevention and Control Program and Legionella Surveillance which were both reviewed and revised on 08/05/23. Noted the Infection Prevention and Control Program policy stated 17. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure the attending physician reviewed and responded to the recommendations of the pharmacist on the monthly Medication Regimen Reviews (MRR) for four of the five residents (Resident (R) 5, R9, R29 and R30) sampled for medication review. As a result of this deficient practice, there was a potential to cause adverse consequences to residents where the consultant pharmacist had recommended actions to be taken for medication management. This deficient practice has the potential to affect all the residents in the facility taking psychotropic medications. Findings include: 1) Cross reference to F758 (Free From Unnecessary Psychotropic Meds/PRN Use) Resident was on PRN (as needed) psychotropic drugs for greater than 14 days without documentation from the attending physician or prescribing practitioner of the rationale for the extended use and no gradual dose reduction. R9 is an [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include…

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 all medications and blood glucose testing supplies were labeled in accordance with professional standards and stored in a locked compartment. Proper labeling and storage of medications are necessary to promote safe administration practices and decrease the risk for medication errors. Proper labeling of blood glucose testing supplies is necessary to ensure the efficacy of the supplies used to test the blood glucose meter for accuracy. This deficient practice has the potential to affect all residents in the facility. Findings include: 1) On 01/24/24 at 09:55 AM, concurrent inspection of the medication cart for the [NAME] wing of the facility and interview with Registered Nurse (RN) 2 was conducted. An insulin pen was found with no open and discard dates in the top drawer of the cart. A pink sticker was on the pen that stated, Discard 28 days after opening. Also found in the top drawer were two control solutions and a container 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, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Findings include: On 01/22/24 at 09:14 AM concurrent observation and interview was done with Lead [NAME] (LC). Observed a scooper inside a large clear plastic container of food thickener. LC confirmed the scooper should not have been in the container and immediately took the scooper out.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review (RR) the facility failed to provide care in a timely manner for a resident (R)52 who is dependant upon staff with activities of daily living (ADLs) who required assistance with changing his adult brief after he was incontinent of urine. The facility failed to treat the resident with respect and dignity and care for him in a manner and in an environment that promotes maintenance or enhancement of his quality of life. This deficient practice can affect all residents in the facility who are incontinent of bowel or bladder and are dependant upon staff and require staff assistance. Findings Include: On 01/23/25 while making observations on the second floor, met with and interviewed R52 who complained of having to wait for staff to assist him after he presses his call light. He reported it can take up to an hour for staff to respond to him. Record Review (RR) of R52's Electronic Health Record (EHR) found his diagnoses include, but are not limited to, encounter for…

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

Based on resident (R) 11's interview, observation and staff interview the facility failed to have maintenance maintain a sanitary, orderly, and comfortable room for the resident. This deficient practice could affect all residents at the facility if staff do not notify the maintenance department once the problem is found and maintenance does not address deteriorating walls in a timely manner. Findings Include: On 01/22/24 during observations of the second floor, met with and inquired with R11 if she had any concerns about the facility and she said yes and pointed at the wall in her room. The wall behind the surveyor was deteriorating, appeared damaged with some areas missing paint and there were some areas that been patched up. 01/23/24 at 10:19 AM, met with Mainteancne Manager and requested and reviewed work order to repair wall in R11's room. Noted the work order was submitted by nursing and was dated 1/18/24. Maintanance Manager stated it is hard to do the work with the resident in the room and surveyor told him that would be something he arranges with nursing. On 01/25/24…

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 Resident (R) 32 was free from abuse from another resident. Findings include: The definition of abuse included the willful inflection of in injury .with resulting physical harm, pain, or mental anguish . Willful in the definition of abuse .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility submitted a completed Event Report on 11/07/23 to the State Agency regarding an allegation of resident-to-resident abuse. On 11/01/23, a Certified Nurse Aide (CNA) witnessed, on 10/31/23, R35 holding R32's arm and hitting it. No visible injuries were noted. The report documented R35 has history of confrontational behaviors, verbally and physically aggressive towards other residents and staff. R35 was moved to another unit after the incident. R32 was admitted to the facility on [DATE] with diagnoses not limited to non-traumatic spinal cord dysfunction and depression. A review of…

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

Based on review of the facility's policy and procedures and staff interview, the facility failed to immediately report allegation of abuse to the Adult Protective Services (APS) in accordance with State Law for two of three facility reported incidents related to allegations of abuse or injury of an unknown origin. Findings include: Cross Reference to F610. The facility failed to thoroughly investigate facility reported incidents related to allegations of abuse or injury of an unknown origin for two of three facility reported incidents. A review of the facility's policy and procedure RESIDENT'S RIGHTS-FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION documented The Administrator or designee shall be notified immediately, who will immediately initiate the reporting to .Adult Protective Services .via the required reporting forms for each respective agency . Reportable incidents documented in the policy and procedure included injuries of unknown source and alleged/potential abuse. 1) The facility submitted a completed Event Report on 12/15/23 to the State Agency regarding an allegation 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 review of the facility's policy and procedures and staff interview, the facility failed to thoroughly investigate two of three facility reported incidents related to allegations of abuse or injury of an unknown origin. Findings include: A review of the facility's policy and procedure RESIDENT'S RIGHTS-FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION documented An investigation is immediately conducted when there are allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property and shall be immediately reported. 1) The facility submitted a completed Event Report on 12/15/23 to the State Agency regarding an allegation of staff to resident abuse. On 12/14/23, Resident (R) 52 called the police to report allegations of abuse against Certified Nurse Aide (CNA) 21. R52 reported to the police officer that CNA21 came into his room and began hitting him. During a facility interview with R52, R52 claimed CNA21 hit him on 12/13/23 and presented three different versions of the incident, including what was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered comprehensive care plan for two of the 18 residents (Resident (R)46 and R67) sampled. A comprehensive care plan was not developed to address R46's contractures and oxygen therapy was not included in R67's care plan. As a result of this deficient practice, the residents were placed at risk for not reaching their highest practicable physical, mental, and psychosocial well-being and has the potential to affect all residents. Findings include: Cross Reference to F688 (Increase/Prevent Decrease in ROM/Mobility). The facility failed to provide appropriate treatment and services for contractures to right arm and right leg. 1) R46 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses included but not limited to non-traumatic intracerebral hemorrhage (stroke) and hemiplegia (paralysis) and hemiparesis (weakness) affecting right dominant side. On 01/22/24 at 09:57 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 observations, interviews and record reviews (RR) the facility failed to provide appropriate treatment and services to two of the 18 residents (Resident (R) 32 and R46) in the sample with limited range of motion. The facility did not apply prescribed splint for R32's right hand and did not provide services for R46's contractures to right arm and right leg. As a result of this deficient practice, the two residents were put at risk for further decrease in range of motion. This deficient practice has the potential to affect all residents in the facility with contractures and limited range of motion. Findings Include: 1) On 01/23/24 at 10:09 AM observed R32 was wearing a splint on her right hand. Inquired if she wears this every day and she stated sometimes I wear it for 3 hours, the staff always forget to put it on. On 01/25/24 while talking to R32, noted she did not have her splint on in the morning and also after lunch. Asked R32 if staff had put her splint on today and she said No. Inquired with her assigned Registered Nurse (RN) 1, if R32's splint had been applied to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to implement interventions to ensure one resident (Resident (R) 222) was free from accident hazards related to possible elopement from the facility. As a result of this deficient practice, R222 was able to exit the facility without authorization and was found outside of the building. This deficient practice has the potential to affect residents that are able to ambulate independently. Findings include: Cross reference to F842 (Resident Records - Identifiable Information). The facility did not accurately document details of elopement event in the progress notes. Review conducted of the complaint document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10728. Initial report was submitted to the Office of Health Care Assurance on 01/12/24 as a fax from Adult Protective Services (APS) on 01/11/24. Details of the incident stated that in the early morning (between 01:00 AM and 04:00 AM) of 11/07/23, Certified Nurse Aide (CNA) 10 called…

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

Based on observations, interviews and record review (RR) the facility failed to provide fluids routinely and when requested by Resident (R) 32 to maintain proper hydration and health. This deficient practice could affect all residents who rely on staff to provide fluids to them throughout the day to maintain proper hydration and health. Findings Include: On 01/23/24 at 09:56 AM while interviewing R32, observed her pitcher, that was left on her bedside table, was empty. Inquired if staff fill this up for her and she stated her pitcher is always empty unless I ask them to fill it up. R32 stated sometimes the staff tell her they will fill it up later because there's no ice cubes and then they forget to fill it up. On the morning of 01/24/24, after observing R32's pitcher empty for a second day, on her bedside table, met with and interviewed Unit Manager (UM). Had UM go to R32's room and showed her R32's dry pitcher. UM stated that she had just put into place that night shift staff would fill up all resident's pitchers with water before the end of their shift. UM was surprised to see…

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 provide treatment and services to prevent complications of enteral feeding for two residents (Resident (R) 7 and R39) in the sample. The facility did not ensure the formula bags were properly labeled to indicate they are changed every 24 hours. This deficient practice has the potential to put residents on enteral feeding at risk for preventable complications. Findings include: 1) R7 is a [AGE] year-old resident admitted to the facility on [DATE] for hospice care. Diagnosis includes dysphagia (difficulty swallowing) following cerebral infarction (damage to tissue in the brain) thus requiring enteral tube feeding to provide nutrients to the resident. On 01/22/24 at 10:21 AM, observed R7 in bed. Noted an empty enteral feeding bag hanging on a pole by the head of his bed. Enteral feeding bag had a label that included resident's name, type of formula to be given including amount and frequency, initials of the staff and dated 01/22/24. No…

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

Based on observation, record review, and interview, the facility failed to ensure Resident (R) 67, receiving oxygen services, had a physician's order to receive oxygen therapy. Findings include: On 01/22/24 at 01:40 PM observed R67 using oxygen nasal cannula. R67 stated she needed oxygen therapy as a result of pneumonia she had. During review of R67's Electronic Heath Record (EHR), in the physician's order, no order was found for oxygen therapy. Further review of R67's EHR found her care plan did not include oxygen therapy. On 01/24/24 at 01:25 PM interview with Licensed Practical Nurse (LPN) 6 was done. LPN6 confirmed R67 was getting oxygen through a nasal cannula and found no physician's order for oxygen therapy in R67's EHR. On 01/24/24 at 02:26 PM interview with Director of Nursing (DON) was done. DON reported a resident using oxygen nasal cannula should have a physician's order. DON confirmed R67 has been using oxygen therapy since admission and confirmed there was no physician's order for oxygen therapy in the EHR and R67's care plan did not include oxygen therapy.

Based on record review and interview, the facility failed to ensure Resident (R) 30, who require dialysis services, had a physician's order to receive dialysis services. Findings include: On 01/23/24 at 08:38 AM an interview with R30 was done. R30 stated she received dialysis services outside of the facility three times a week in the afternoon. During review of R30's Electronic Health Record (EHR), in the physician's order, no order was found for dialysis services. On 01/24/24 at 02:30 PM a concurrent record review and interview with Director of Nursing (DON) was done. DON reported a resident with dialysis services should have a physician's order which includes the dialysis location and the days the resident is to go. DON confirmed R30 goes to dialysis on Tuesday, Thursday, and Saturday. Concurrent review of R30's EHR, in the physician's order, no order was found for dialysis services to include the location and days R30 receives the services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide adequate monitoring for the use of insulin (medication to lower blood sugar level) for one of the five residents (Resident (R) 47) sampled for unnecessary medications. The facility was not documenting if R47 was being monitored for signs and symptoms of hypoglycemia (low blood sugar levels) and hyperglycemia (high blood sugar levels). As a result of this deficient practice, R47 was put at risk for avoidable adverse health complications related to her condition and the use of insulin. This has the potential to affect all diabetic residents in the facility. Findings include: R47 is a [AGE] year-old resident admitted to the facility on [DATE]. During an interview with Family Member (FM) on 01/22/24 at 01:34 PM in the resident's room, FM said he did not know R47 was diabetic until she was hospitalized prior to her admission at the facility. When asked how her blood sugar levels are, FM responded, Sometimes it goes up, sometimes it goes down. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure three of the five residents (Resident (R) 5, R9 and R29) sampled for medication review were free from unnecessary medications. The PRN (as needed) order for a psychotropic medication (drugs affecting behavior, mood, thoughts or perception) for R9 and R29 was not limited to 14 days and there was no documented rationale for continuance. Also, the facility failed to ensure Gradual Dose Reductions (GDR) for the psychotropic medications for R5, R9 and R29 were done as recommended by the pharmacist. As a result of this deficient practice, the facility failed to promote or maintain the highest practicable mental, physical and psychosocial well-being of these three residents. This has the potential to affect all residents in the facility that are prescribed psychotropic medications. Findings include: Cross reference to F756 (Drug Regimen Review, Report Irregular, Act On). Facility did not ensure the attending physician responded to the recommendations…

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 ensure the medical records were accurately documented for one of the three residents (Resident (R) 222) sampled for closed records review. Statements from staff interviews did not match what was documented in the Electronic Health Record (EHR). This deficient practice has the potential to affect the care provided to all the residents in the facility. Findings include: Cross reference to F689 (Free of Accident Hazards/Supervision/Devices). The failed to prevent a resident from exiting the building without authorization. Complaint document retrieved from Aspen Complaints/Incidents Tracking (ACTS) 10728 was submitted by Adult Protective Services (APS) on 01/11/24. Complainant stated that on 11/07/23 between 01:00 AM and 04:00 AM, R222 was found outside of the building. When complainant read the written report on the incident, and it stated that R222 was found Trying to get outside the door. Review of R222's EHR conducted. Under Progress Notes, Registered Nurse (RN) 4 documented on 11/07/23 at 07:26 AM, At 0040 Alarm was…

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

Based on observation and staff interview, the facility failed to maintain resident (R)34's bed cord control, that raises and lowers the bed, in safe operating condition. The bed cord was frayed in multiple places putting the resident and staff at risk for electrocution. Findings Include: Upon entry to facility on 01/22/24, went to second floor to observe residents. Residents had already eaten their breakfast and some were still in their beds. During this time observed R34 in her bed with a bed cord which is used to raise and lower her bed that had multiple areas that were frayed exposing the colored cords underneath the protective covering. On 01/23/024 at 08:10 AM, went to R34's room to observe if her bed cord was fixed. The same frayed bed cord remained on her bed and was attached near the resident on her bedrail giving her access to the control. At this time interviewed Licensed Practical Nurse (LPN) 2, who was assigned to R34, and asked if the cord was safe and if staff had reported it to maintenance to be fixed. LPN2 stated she did not notice the frayed bed cord and she said…

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.