Oahu Care Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to meet regulatory requirements for Baseline Care Plans (BCP) for three of three Residents (R)1, R2, and R4. Specifically, R1 did not have a BCP developed within 48 hours of admission, R4's BCP did not include the Stage 2 Pressure Ulcer that was present on admission, and two residents were not provided summaries of the BCP. This deficient practice places residents at risk for not receiving appropriate and timely care, delays the development of care to address resident's immediate health and safety needs, hinders continuity of care, and impedes communication amongst nursing home staff. Findings include: 1) On 03/24/2025 at 10:30 AM, record review of R2s BCP was noted to be blank and not completed. R2 was admitted on [DATE], and comprehensive care plan (CCP) was initiated on 02/28/2025. Further review of R2's electronic medical record (EMR), did not note they were furnished with a copy of their BCP. On 03/24/2025 at 03:00 PM, interview with Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide repositioning, the standard of care for pressure ulcers (PU/ injury to the skin and tissue below the skin due to pressure on the skin for a long time), and as directed in care plans for three Residents (R)1, R2 and R4 out of a sample size of three. This deficient practice puts residents with PU's at risk of worsening the wound, and increases the potential of those at risk to develop one. Findings include: 1) Cross Reference F655 Baseline Care Plan R4 was a [AGE] year old female admitted to the facility for skilled nursing services on 03/19/2025 for short term rehabilitation after being hospitalized for two unwitnessed falls at home. She had a sacral Stage 2 PU present on admission that was not identified on her baseline care plan. Record review revealed no documentation the R4 had been turned or repositioned until after the treatment administration record (TAR) was initatiated on 03/25/2025. 2) Record review of R1's Minimum Data Set (MDS),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop a comprehensive care plan (CCP) for one Resident (R)1 of a sample size of three. Specifically, R1's CCP did not address his safety needs in a timely manner. As a result of this deficiency, R1 may have been at higher risk of falls. The deficient practice of not addressing resident's needs timely in the CCP could affect any resident and be a barrier to meeting their highest potential of physical and mental well-being. Findings include: Record review of R1's electronic medical record (EMR) noted that prior to admission on [DATE], R1 was admitted to a hospital with a subdural hematoma (brain bleed caused by trauma) due to falling at home. R1's baseline care plan (BCP) completed on admission to the facility, noted R1 to be cognitively impaired, marked Yes, for fall(s) in the past three months, level of consciousness marked as disoriented x3 at all times, and functional ability and goals were not assessed. admission progress notes detailed resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure staff use non-expired test strips for their kitchen three compartment sink to test for levels of strength of sanitizer solutions, failed to store clean meal lids on a rack that did not have rusty colored debris and failed to label opened beverages with the opened-on date. Findings Include: 1) Observation on 08/26/24 at 10:40 AM had kitchen staff test the strength of sanitizer in their three compartments sink and found facility was using expired Hydrion test strips with an expiration date of [DATE]. Food Service Worker (FSW) 11 confirmed the test strips were expired and got new test strips and tested the water which was in range. 2) On 08/28/24 at 10:57 AM while observing tray line observed a rack in the kitchen near the stove, which held clean lids for resident meals, had rust colored debris. Inquired with Dietary Manager who confirmed there was rust colored debris and stated, need to change it out. 3) On 08/29/24 at 09:50 AM observed nourishment…

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 implement infection prevention and control measures when providing care for residents on isolation. The facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to residents on transmission-based precautions (TBP). This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: On 08/26/24 at 11:03 AM, observed postings on the door of room [ROOM NUMBER] that stated, Special Droplet/Contact Precautions. The posting also stated that eye protection, gown and gloves are required when entering the room. Registered Nurse (RN)9 confirmed that one of the residents in room [ROOM NUMBER] recently tested positive for COVID-19. On 08/26/24 at 11:39 AM, observed Physical Therapist Assistant (PTA)1 in room [ROOM NUMBER] talking to Resident (R)61. PTA1 was not wearing a gown and did not have a face shield or eye…

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 inform a resident of the risks and benefits of the use of psychotropic drugs and obtain consent for one of five residents (Resident (R)3) sampled for unnecessary medications. As a result of this deficiency, the resident was placed at risk for more than minimal harm. Findings include: R3 was an [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses included but not limited to anxiety disorder, dementia, and major depressive disorder. Ordered medications included mirtazapine and duloxetine (antidepressants). Review of R3's Electronic Health Records (EHR) documented the consents for the use of the psychotropic medications including education on the risks and benefits were not found. On 08/28/24 at 12:34 PM, requested from Director of Nursing (DON) a copy of the consents for the use of antidepressants for R3. DON said he will look in the paper files since R3 was already on the medications before the facility switched over to the EHR. 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, interviews, and record review, the facility failed to ensure a resident's right to be free from physical restraint for staff convenience and not required to treat the resident's medical symptoms for one resident (Resident (R)5) sampled. Positioning wedges were placed under R5's mattress and under the resident's fitted sheet in a manner which could not be removed by the resident, which hindered the resident from freely moving at will. An interview with staff confirmed the positioning wedges were not used to reposition R5 and the resident is capable of independently moving around in bed. As a result of this deficient practice, residents with the ability to move independently are at risk of the potential for more than harm. Findings include: On 08/26/24 at 11:50 AM, 12:30 PM, and 02:05 PM, observed a large black positioning wedge and pillow placed under the bed's mattress. The placement of the positioning wedge and pillow caused the mattress to be concaved and restricted the resident from freely moving around. Inquired with the resident if he was able to move…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide written notification of the bed hold policy to the resident or the resident's representative for two of the five residents (Resident (R)6, and 167) sampled for hospitalization. As a result of this deficient practice, there was a potential for miscommunication. This has the potential to affect all the residents that are transferred to an acute care hospital. Findings include: 1) R6 is a [AGE] year-old resident admitted to the facility on [DATE]. Review of R6's electronic health record (EHR) revealed that she was transferred to an acute care hospital on [DATE] for acute lower GI (gastrointestinal) bleeding. R6's EHR did not contain documentation that R6's representative was provided a written notification of the facility's bed hold policy. On 08/29/24, requested a copy of the written notification of the bed hold policy provided to R6's representative from the Director of Nursing (DON). DON said he will check. On 08/29/24 at 04:14 PM, the Social…

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

Based on interviews and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for one resident (Resident (R)56) sampled. R56's person-centered care plan included an intervention to use alternative communication tools (i.e. interpreter services, available for staff use) for this Korean speaking resident. Staff did not implement the use of interpreter services intervention when conducting the Brief Interview for Mental Status (a tool used to assess the resident's cognition). As a result of this deficient practice, all non-English speaking residents are at risk of the potential for more than minimal harm. Findings include: On 08/27/24 at 12:28 PM, conducted an observation of R56 in the unit's main dining room during lunch. The resident was seated next to another Korean speaking resident and conversed with each other throughout lunch. When R56 was done with her meal, facility staff approached R56 and attempted to have a conversation with the resident in English. R56 waived her hand at the staff then said No, English, then said something…

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 develop a discharge plan for two of 18 residents (Resident (R)61 and R219) sampled. The discharge needs and/or discharge goals for these residents were not identified to ensure the residents are ready for discharge according to their individual needs. As a result of this deficient practice, residents are at risk for more than minimal harm related to an unsafe discharge from the facility and/or a readmission to the facility. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered stated, . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes . c. includes the resident's stated goals upon admission and desired outcomes . 1) R61 is a [AGE] year-old resident admitted to the facility for short-term rehabilitation on 07/24/24. During an interview with R61 on 08/26/24 at 11:48 AM, R61 said he was only at the facility short-term. R61 reported he is from another island and 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 interviews and record review the facility failed to ensure Resident (R)122 is provided appropriate services for communication. As a result of this deficient practice, non-English speaking residents are at potential risk for more than minimal harm. Findings include: On 08/27/24 at 09:10 AM before going into R122's room inquired with Registered Nurse (RN)17 if they use interpreter services with resident and she stated she does not think they are. Administrator overheard and stated they are using interpreter services because she receives the bill and pays it each month. On 08/27/24 at 09:13 AM, attempted to interview R122 and she said, No English. On 08/28/24 at 01:48 PM, conducted an interview with Admissions Staff (AS)2 and she confirmed an admission packet was provided to R122 and she completed R122's admission. Inquired about English as a second language for R122. AS2 stated she would speak slowly for resident and R122 was comfortable with this. AS2 also stated the facility has Korean speaking staff at the facility, the resident ask to use an interpreter, and 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, interviews and record review, the facility failed to ensure the environment remains as free of accident hazards and adequate supervision to prevent accidents for one resident (Resident (R)56) sampled. A nurse's scissor was left unattended in an area accessible to resident and not properly stored. R56 was not adequately supervised, had access to a scissor, and managed to elope from the facility without staff's knowledge. As a result of this deficient practice, residents are at risk of more than minimal harm. Findings include: 1) Observation on 08/26/24 at 11:55 AM, before walking out of a non-COVID room on the second floor observed an N95 mask on the rack that is used to store chux and adult briefs. Inquired with Certified Nurse Assistant (CNA)5 if the N95 mask belongs in the room and he stated he did not know who put it there and said he would throw it away. CNA5 picked up the N95 mask to throw away and behind the N95 mask was a pair of metal scissors on the shelf. On 08/26/24 at 12:15 PM,…

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

Based on interview and record review, the facility also failed to ensure the records for controlled medications were maintained and accurate. As a result of this deficient practice, there is a potential for the diversion of a controlled medication. Findings include: On 08/28/24 at 08:24 AM, an inspection of the medication cart on the second floor was conducted with Registered Nurse (RN)9. While checking the controlled medications logs with RN9, reviewed a log for the administration of morphine sulfate (opioid pain-relieving medication). Observed that a dose was administered on 08/16/24 at 11:01 PM but there was no signature of the staff who gave it to the resident. RN9 confirmed that the staff who administered the medication should have signed the log immediately after giving it. Review of the facility policy titled Controlled Substances stated, . 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record . c. Signature of the nurse administering the dose .

Based on observations, interviews, and record review, the facility failed to properly store physician prescribed topical ointment for one resident (Resident (R)22) and failed to ensure medicated ophthalmic drops were properly labeled with an expiration date for two residents (Resident (R)32 and 52) sampled. As a result of this deficient practice, residents who receive prescribed cream, ointment and medicated ophthalmic drops are at risk for more than minimal harm. Findings include: 1) On 08/28/24 record review of R22's Care Plan (CP) found she has a CP in place for: The resident has bowel/bladder incontinence d/t impaired mobility. At risk for skin breakdown/UTI, or falls. Has potential for constipation. Date Initiated: 06/26/2021 Revision on: 09/04/2021. The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Date Initiated: 06/26/2021 Revision on: 07/09/2024 Target Date: 10/15/2024. Administer Triad paste to groin and perianal area MASD. Date Initiated: 04/26/2024 LPN RN Clean peri-area with each incontinence episode. Date…

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

4. On 10/11/2023 at 03:11 PM, during resident interview, R159 complained of call bell noise during the night, stated It rings 27 times before anyone answers it, I counted it. Complained that it rings so much when she is trying to sleep at night and reported not having a good nights sleep. Observation of the unit found the call light bell speaker is located outside of R159's room on the opposite wall with the speaker facing her room. 5. On 10/11/2023 at 03:21 PM during interview with R161 he reported his roommate (R164) was loud all night and kept him up, he was not able to sleep. R161 stated he was surprised his roommate was so quiet now as he was so loud previously yelling out and moaning. During this time the other resident in question was being assisted by facility staff. R161 said the resident in question will probably soon become loud. 6. On 10/12/2023 at 08:41 AM, during resident interview, R163 reported two days ago (10/10/2023) a resident (R164) in the first bed was yelling and kept him up. Resident reported last night the room was quiet because the resident (R164) in the…

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

Based on observation and staff interview the facility failed to place a Contact Precautions sign and PPE cart outside of R162's room for staff and guest notification and use, failed to clean a shower chair between resident use with noted brown substance on right handrail, failed to have a food services staff (FSS)3 cover a healing burn wound while cooking food, failed to have FSS4 use gloves when unloading clean dishes from the dishwasher, failed to have FSS2 use gloves when performing tray line temperature checks over open food, and failed to deliver a lunch tray that was free from a dirty crumpled up napkin to the second floor. Findings Include: 1. During initial observations of residents, on 10/11/2023 at 10:00 AM, found R162 had contact precautions in place, order read place resident on contact precaution for MRSA [Methicillin-resistant Staphylococcus aureus] at LLE wound. The colored contact precautions sign was placed on a piece of furniture across from the resident's bed inside his room, facing the hallway leading to the resident's room. The cart of PPEs was also located…

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 did not assure that 2 residents out of a sample of 4, Resident (R)38, and R161 was treated with dignity and maintenance of quality of life. Findings Include: 1) An attempt was made to interview R38 on 10/16/23 at 08:40 AM in the hall, across where the nursing station is and elevators. R38 was hard of hearing and distracted. R38 was not able to answer any questions. Surveyor noted that R38's hair was not brushed and hair was oily and messy. On the same day at 08:45, Registered nurse (RN1) put Ketoconazole cream to resident's scalp. RN1 stated that she had itching to her scalp and the cream is placed into her scalp by doctor's order. Inquiry was made regarding her shower schedule and when does she get a hair wash. RN2 stated that clinical assistant #2 (CN)2 does R38's shower. CNA2 does a really good job and blow dries her hair and her shower was yesterday. RN2 further stated that CNA2 was off yesterday and that CNA3 had given R38 a shower. Surveyor questioned if R38 had a shower because her hair did not look clean before…

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 meet the document requirements for resident transfer for two out of two sampled residents (Resident (R) 31, 50). This deficient practice has the potential to negatively affect the continuation of care for the residents. Findings Include: Record review of R31 and R50's Electronic Health Record (EHR) indicated no documentation of R31 and R50's care plans being sent over to the receiving hospital. A review of the facility's document titled, Transfer Information Checklist, indicated that the resident's care plan is not included in the list of documents sent over to the receiving hospital. Interview with the Director of Nursing (DON) was conducted on 10/13/23 at 02:21 PM in the conference room. DON verbalized that the facility does not send over care plan records to the receiving hospital.

Based on record review (RR) and staff interview Resident (R)2 developed a stage two pressure ulcer (PU) on 09/29/2023, it deteriorated and became unstageable on 10/05/2023 which the Minimum Data Set (MDS) coordinator was not made aware of, a significant change was not reported to CMS using the Significant Change in Status Assessment (SCSA) and the Care Area Assessments (CAAs) was not completed within 14 days. Findings Include: During RR on 10/12/2023 noted R2 was being treated for a stage two pressure ulcer that was identified on 09/29/2023. Review of submitted MDS from facility to CMS found there was no SCSA and CAAs completed within 14 days from 09/29/2023. On 10/16/2023 at 12:57 PM met with MDS coordinator and inquired how she would know a resident develops a pressure ulcer. She stated that she is not notified of pressure ulcers, that she's only part-time and facility is trying to hire a full time MDS coordinator. MDS coordinator stated communication was better in the past with nurse managers who would let her know, communication has broken down. Inquired of MDS coordinator if a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review (RR) and staff interview the facility failed to develop and implement a baseline care plan for Resident (R)162's language barrier and R163's diabetes and dialysis. R162's primary language is Chinese and R163's admission diagnosis included Type 2 Diabetes Mellitus (DM) and orders for dialysis on Tuesday, Thursday and Saturday each week. Findings Include: 1.) On 10/11/2023 at 09:45 am while doing rounds with residents on the second floor noted R162 had a language barrier as he told me that he does not speak English when I greeted him. Resident repeated this when I asked how he slept. R162 was not able to communicate with surveyor. RR found R162's primary language is Chinese. RN25, who filled out resident's baseline care plan form, selected unable to determine for Does the resident need or want an interpreter to communicate with a doctor or health care staff? Review of progress notes did not find any documentation that an interpreter service was used to communicate with R162 at any time from…

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

Based on observation, interview and record review, the facility did not assure that 1 resident out of a sample of 4, Resident (R)38, was provided care with hygiene-bathing to maintain activities of daily living. Findings Include: Surveyor noted that R38's hair was not brushed and hair was oily and messy. On the same day at 08:45, Registred nurse (RN1) put Ketoconazole cream to resident's scalp. RN1 stated that she had itching to her scalp and the cream is placed into her scalp by doctor's order. Inquiry was made regarding her shower schedule and when does she get a hair wash. RN2 stated that clinical assistant #2 (CN)2 does R38's shower. CNA2 does a really good job and blow dries her hair and her shower was yesterday. RN2 further stated that CNA2 was off yesterday and that CNA3 had given R38 a shower. Surveyor questioned if R38 had a shower because her hair did not look clean before the cream was applied. RN2 stated that evening shift do showers too. On 10/12/23 at 08:50 AM, an interview was done with CNA3. Surveyor asked CNA3 if he showered R38 yesterday and CNA3 stated Oh I 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 provide treatment and care in accordance with professional standards of practice when the staff did not continue the functional mobility services and therapy as ordered and care planned for 2 of 5 residents sampled (Resident (R)1) and R29. This deficient practice has the potential to harm R1 and R29 by decline in their mobility and worsening of contractures and haults their progress to reach their highest practicable level of health and wellbeing. Findings include: 1) On 10/12/23 at 10:31 AM, R1 was observed in bed. Contractures to left arm and right leg noted. R1 was nonverbal. A review of the Minimum Data Set (MDS) dated [DATE] for R1. In Section I, R1's active diagnosis include but not limited to non-traumatic brain dysfunction, peripheral vascular dysfunction (PVD) and hemiplegia. Section GG shows the resident is dependent with functional abilities and goals. Review of R1's care plan revealed a careplan for a problem for limited…

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, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications. Findings Include: Observation was conducted on 10/13/23 at 11:33 AM on the third floor. Registered Nurse (RN) 1 was observed leaving the medication cart unlocked while administering medications in room [ROOM NUMBER]. The medication cart was left unlocked in the hallway. The hallway had residents and staff members passing by. Interview was conducted with the Director of Nursing (DON) on 10/13/23 at 11:33 AM in the conference room. DON stated that the medication cart should have been locked when RN1 left it unattended. A review of the facility document titled, Medication Administration, was conducted. The document indicated, During administration of medications, the medication cart is kept closed and locked when out 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 of tray line and staff interview the facility failed to correctly plate the prescribed diet for Resident (R) 55 who was ordered a regular chopped diet with nectar liquids. The facility staff prepared a pureed diet for R55. This failed practice puts all the facility residents at risk for receiving a meal that does not meet their health needs. Findings Include: On 10/11/2023 at approximately 11:15 AM while observing food service staff (FSS) plate residents lunches surveyor requested to spot check a tray for accuracy. FSS1, who is temporarily covering as the kitchen manager, pulled a tray that was one of the last trays to be plated and we checked the meal card to what was plated. The tray chosen was for R55 who has a regular chopped diet with nectar liquids ordered. The plated meal appeared to be a pureed diet. Surveyor asked FSS1 and FSS2 if this plated food was the correct meal that should be given to the resident. FSS1 stated no. She was able to have the kitchen staff correct their error and prepare a meal of regular chopped diet for R55. On 10/11/2023 at 11:30…

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 of the kitchen and staff interview the facility failed to store food in accordance with professional standards for food service safety and at the start of temperature taking of the trayline failed to correctly place thermometer in cooked food to register temperature. Findings Include: On 10/11/2023 at 08:30 AM, while doing brief tour of the kitchen, noted there were two separate containers of chopped meat (ham and Portuguese sausage) that were placed in a larger plastic container. Noted the saran wrap that had been placed over the larger plastic container had folded up upon itself when it was placed in the refrigerator that morning. It appears to have caught on the top of the shelf it was placed under. The Food Services Staff (FSS)1, who was covering for the kitchen manger, confirmed the saran wrap should have been covering the chopped meat, explained that the saran wrap was used to do that. On 10/11/2023 at 10:55 AM went to observe the trayline in the kitchen. Kitchen was very busy with food being cooked on the stove and food transferred to metal containers 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 resident interview, record review (RR) and staff interview the facility failed to maintain resident medical records that accurately documented the stage of a pressure ulcer (PU) on the care plan for Resident (R)2, diet order for R55, correct days of the week of dialysis on Occupational Therapy (OT) care plan for R163 and completely fill out communication documents to dialysis center for R163. Findings Include: 1. On 10/12/2023 at 12:52 PM during RR found R2 had developed a stage 2 PU on 09/29/2023. This PU deteriorated and on 10/05/2023 was documented as unstageable. Review of R2's care plan included care for a stage 2 PU. Care plan had been updated on 10/13/2023 with no change made to identify the decline of the pressure ulcer. 2. On 10/12/2023 met with and interviewed R163 who stated he receives dialysis three times a week on Tuesday, Thursday and Saturday. RR found this as accurate with doctors orders for R163 to receive dialysis on Tuesday, Thursday and Saturday. On 10/13/2023 at 09:36 AM met with Physical Therapy (PT) staff who was able to print out a copy of R163's…

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