Palolo Chinese Home

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 right to a dignified existence for two (Residents (R) 395 and R18) of three residents sampled for dignity. As a result of this deficient practice, residents dependent on staff are at risk for more than minimal physical and/or psychosocial harm. Findings include: 1) On 04/28/25 at 08:47 AM, conducted an interview with R394. Inquired if staff provide timely care and respond to call lights in a reasonable time frame. R394 responded, not all the time. R394 explained it depends on who is working, some staff are better than others. R394 reported activating the call light because his/her roommate (R395) needed assistance, and staff took about 25 minutes to respond. R394 stated he/she was worried that his/her call light may not have been working because it took staff a long time to acknowledge the activated call light. R394 activated the call light because R395's legs were dangling off the bed and he/she was concerned 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 provide necessary assistance to help maintain functional mobility and independence on one of two sampled residents (Resident (R)18), for accommodation of needs. This deficient practice has the potential to affect all the residents at the facility. Findings include: Resident (R)18 is a [AGE] year-old male re-admitted to the facility on [DATE] for long-term care. R18's admitting diagnoses include, but are not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) left non-dominant side. A review of R18's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/12/25. The assessment indicated R18 had been assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating a determination that he was cognitively intact. On 04/28/25 at 09:05 AM, observation and concurrent interview was done with R18 at his…

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 choose aspects of the resident's life that are significant to the resident for two (Resident (R) 394 and R395) of two residents sampled. R394 prefers to brush her teeth in the morning, but staff regularly assist the resident in the afternoon. R395 receives hospice service and family reported not wanting the resident up in the wheelchair for more than 15-20 minutes (for meals) to allow the resident to rest in bed. As a result of this deficient practice, residents are at risk for more than minimal negative psychosocial and/or physical outcomes. Findings include: 1) On 04/28/25 at 08:42 AM, conducted an interview with R394 in the resident's room. R394 reported her preference of brushing her teeth three times a day, when she wakes up and after each meal. However, at the facility, the resident waits long after she wakes up for staff to assist her with brushing her teeth. R394 stated at times she has brushed her…

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

Based on interview and record review, the facility failed to obtain a copy of the resident's Advance Health Care Directive (AHCD) and did not inform the resident of his/her right to develop one, provide assist in doing so, and/or periodically assess the residents' preference for formulating an AHCD for 2 of 2 residents (Residents (R) 46 and R12) sampled. This deficient practice does not allow residents, when incapacitated, the right to have their health care choices identified and honored. Findings include: 1) On 04/29/25 at 02:50 PM, review of R46's electronic health record (EHR) revealed a Social Services note dated 09/16/24 at 04:28 PM stating that Social Services to follow-up with hospice provider regarding R46's AHCD. Upon further review of R46's progress notes, no follow-up attempts to obtain the AHCD were documented. On 04/30/25 at 01:42 PM, interviewed the Social Services Coordinator (SS) 1 in the Social Services office. SS1 confirmed there was no documented follow-up regarding obtaining the AHCD from the hospice provider. SS1 voiced that the Social Worker at the hospice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents' environments were clean and homelike, as well as, protecting residents' personal property from loss, for two of four residents (Resident (R) 8 and R65) sampled for environment. A staff member did not dispose of soiled and dirty trash items properly, leaving it on top of R8's personal property in her room. This has the potential to cause unpleasant odors and an unsanitary environment. R65's personal lamp was removed from his room without explanation or follow-up. The facility did not exercise reasonable care for the protection of the resident's property from loss. Findings include: 1) Cross reference to F880, Infection Prevention & Control. The facility failed to ensure R8's soiled incontinence bed pads were properly disposed of to decrease the risk of spreading infectious disease. Review of R8's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/04/25 found R8 with a score of 15 (cognitively…

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

Based on record review and interview, the facility failed to ensure a resident's comprehensive assessment accurately reflected the resident's status at the time the assessment was completed for one of seven residents (Resident (R) 293) reviewed for falls. Staff members were utilizing the bed/chair alarm as an intervention for falls and it was not reflected in the assessment under restraint. This deficient practice put R293 at risk of an inaccurate assessment of the bed/chair alarm and its appropriateness as an intervention. Findings include: Cross reference to F689, Accidents. The facility failed to ensure R293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to her left femur (thigh bone) that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to her discharge. Review of the completed facility report incident (FRI) received by the State Agency (SA)…

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 did not ensure the development and implementation of a comprehensive person-centered care plan for two (Residents (R)30 and R56) of 22 sampled residents. As a result of this deficient practice, residents were placed at risk for decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. Findings include: 1) On 04/29/25 at 02:31 PM, conducted a record review of R30's Electronic Health Record (EHR). Review of physician orders documented an order for Insulin Glargine- Subcutaneous [under the skin] Solution Pen-injector 100 UNIT/ML [milliliter] Inject as per sliding scale [dose is titrated depending on blood glucose result]: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 600 = 10 units > [if greater than] 400 give 10 units and notify MD [physician] and NP [nurse practitioner], subcutaneously in the morning for DM [diabetes].…

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 revise the comprehensive person-centered care plan for one of seven residents (Resident (R) 293) reviewed for falls, and one of one resident (R12) sampled for urinary catheters. R293's care plan did not include new interventions for falls after sustaining a fall with major injury. As a result, R293 experienced additional falls that may have been avoided. By not revising R12's care plan to include urinary catheter care, R12 was placed at risk for adverse catheter-related issues. Findings include: 1) Cross reference to F689, Accidents. The facility failed to ensure R293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to left femur (thigh bone) that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two of seven residents (Resident (R) 293 and R29) reviewed for falls were free from accident hazards. R293, whom previously had a fall with major injury (a fracture to the left thigh bone that required surgery), had no new interventions care planned for falls, then had a subsequent fall putting R293 at risk for further injuries. R29 was inappropriately transferred via 1-person manual transfer instead of a 2-person mechanical lift, and as a result suffered a fall with a fracture to her right ankle. Findings include: 1) R293 was admitted to the facility on [DATE] for skilled nursing with admitting diagnoses of closed distal phalanx (toe) fracture to the right foot, first digit, dementia related to Alzheimer's disease, repeated falls, and osteoarthritis (when the flexible, protective tissue at the ends of bones, called cartilage, wears down) to bilateral knees. Review of R293's discharge summary from the hospital, prior to admittance to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff competency in completing Fall Risk Evaluations accurately for 3 of 7 residents (Residents (R)293, R294, and R28) sampled for falls. This deficient practice placed the affected residents at risk of avoidable adverse outcomes. Findings include: 1) Cross reference to F689, Accidents. The facility failed to ensure Resident (R)293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to left femur that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to discharge. Review of R293's fall risk assessments instruct a total score of 10 or higher indicates the resident is a high risk of fall. R293's assessments concluded a score of 13 during the admission fall risk assessment on 05/09/24, a score of 11 on 08/11/24, 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.

Based on observation, interviews, and review of facility's medication administration policy, the facility failed to keep medications secured for one of twelve residents (Resident (R), 69) observed during medication administration. This deficient practice has the potential to affect all residents in the facility taking medications. Findings include: On 04/30/25 at 08:00 AM, observed Registered Nurse (RN)16 during medication administration for R69. RN16 walked out of the room to get correct size glove, leaving multiple medications on R69's bedside table unattended and accessible to anyone who could have entered R69's room. Concurrent interview with RN16 noted that she should not have left medications out of her sight as anyone could have taken the medications and R69 could have taken the wrong dose. RN16 agreed that it is also for safety reasons. On 4/30/25 at 10:00 AM, interview with Director of Nursing (DON) completed. DON confirmed that RN16 should not have left the medications unattended for safety reasons. Review of the facility's Medication Administration policy, dated 01/23/07,…

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 a resident's menu with selected food choice was followed for one of two residents (Resident (R) 66) sampled for food preferences. The facility did not follow-up/communicate with R66's food choice after identifying the selection may have an ingredient he is allergic to, and did not give R66 the opportunity to choose what he wanted to eat. As a result, R66 received a meal that was not listed on the menu provided in advance that he did not want to eat, causing the resident confusion. Findings include: On 04/28/25 at 11:17 AM, during lunch dining observation, observed R66 sitting in the dining room with two other residents (R35 and an unidentified resident). R66 had his meal tray on his table and was confused on what was on his plate. The other two residents did not receive their meal tray at this time. He asked R35 what was on his plate for lunch and R35 was observed to take a look at the meal ticket on R66's plate, and stated it was chicken, rice, and cauliflower. R35 explained to R66 that the meal…

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

Based on observation, interview and record review, the facility failed to provide food in the consistency ordered by the physician to meet the needs of 2 of 2 residents (Resident (R) 13 and R69) sampled for appropriate preparation of food. This deficient practice increases the risk of aspiration for residents who have a modified consistency diet order for dysphagia (difficulty swallowing). Findings include: 1) On 04/28/25 at 11:31 AM, observation of R13's meal ticket noted it stated diet as chopped, regular diet with thin liquids. Observation of the beef tomato entrée on his meal tray noted the tomato was not chopped, and the beef and vegetables were of varying sizes. The Infection Prevention Coordinator (IP) was asked to make a concurrent observation and confirm if the beef tomato entrée was an appropriately chopped consistency. IP responded that it depended on the consistency of the food item and that the tomato was not chopped because it was soft. On 04/28/24 at 11:43 AM, Certified Nurse Aide (CNA) 31 was asked to make a concurrent observation and confirm if the beef tomato…

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

Based on observation and interviews, the facility failed to check the refrigerator temperature for one of five refrigerators in the kitchen for two consecutive days on the evening shift. This deficient practice puts resident at risk for foodborne illness. Findings include: On 04/28/25 at 08:00 AM, initial walkthrough of the kitchen completed. Observed the temperature log for refrigerator #10 was missing PM temperature readings and initials for 04/25/25-4/26/25. Concurrent interview with Executive Chef (EC) noted that he was not sure why it was missed. EC also stated that it might be due to the new system implemented since he started. On 04/30/25 at 10:00 AM, interview with Director of Nursing (DON) confirmed that refrigerator temperature settings should be checked every day on both the AM and PM shifts to ensure avoiding food spoilage. On 04/30/25 at 11:30 AM, follow up interview with EC confirmed that temperatures should be checked every day on both AM and PM shifts to prevent any food spoilage and resident illness.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's (Resident (R) 8) soiled incontinence item and dirty gloves were properly disposed of, and a staff member used appropriate personal protective equipment (PPE) for a resident (R84) under enhanced barrier precautions (EBP) for one of four units (Unit W) observed for infection control. These deficient practices increase the risk of the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors. Findings include: 1) Cross reference to F584, Clean Homelike Environment. The facility failed to ensure a soiled incontinence bed pad was discarded appropriately, the item was placed on R8's personal belongings and visible for visitors to see which had the potential to cause unpleasant odor and an unsanitary environment. On 04/30/25 at 11:38 AM, interview with Assistant Director of Nursing (ADON) and Infection Preventionist (IP) were done. IP reported after a staff member provides incontinence care the dirty supplies…

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 implement interventions in a care plan for one out of three sampled residents (Resident (R) 2). This deficient practice resulted in R2 sustaining a fall and has the potential to affect all the residents in the facility. Findings Include: (Cross reference to F689-Free Of Accident Hazards/Supervision/Devices) A review of R2's Electronic Health Record (EHR) was conducted on 11/22/24. R2's EHR noted that R2 sustained an unwitnessed fall in the dining room on 10/24/24 at 08:40 PM. Furthermore, R2's current care plan noted the following interventions to prevent her from falling, 6/17/24 Staff to ensure common areas (i.e. dining room) are supervised at all times. Staff to communicate with one another when they have to leave the premises. A review of the facility's investigative note on R2's fall on 10/24/24 was conducted. The investigative note documented, ROOT CAUSE: .Resident was with family most of the evening and reportedly fell about 5 minutes after family left. Poor communication resulted in staff not supervising 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 interviews and record review, the facility failed to provide adequate supervision to prevent two out of three sampled residents (Resident (R) 1 and R2) from falling. Due to this deficient practice R1 sustained a fall that resulted in a laceration to the head. This deficient practice has the potential to affect all the residents who are at risks for falls in the facility. Findings Include: (Cross reference to F656-Develop/Implement Comprehensive Care Plan) 1)R1 is a [AGE] year-old male admitted to the facility on [DATE]. R1 has a diagnosis that include, but not limited to, spinal stenosis, mild cognitive impairment, and generalized arthritis. A review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/24, noted that R1's score for Brief Interview for Mental Status (BIMS) was a seven. Which means, R1 has severe cognitive impairment. A review of the Facility Reported Incident (FRI) document, dated 09/01/24, was conducted. On the FRI, the facility reported that a Certified Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure that one of the three sampled residents (Resident (R) 1) received treatment and care in a timely manner and in accordance with professional standards of practice. This failed practice has the potential to affect all the residents in the facility. Findings Include: R1 is a [AGE] year-old female admitted to the facility on [DATE]. R1 has medical diagnosis including but not limited to Moyamoya disease, heart failure, gastrostomy tube (feeding tube), aphasia (communication disorder) following cerebrovascular disease (condition that affects blood flow in the brain). A review of R1's Electronic Health Record (EHR) was conducted. R1's EHR noted that R1 was diagnosed with a fracture of the left upper arm on 07/12/24. Interview was conducted with R1's spouse on 07/25/24 at 11:50 AM. R1's spouse stated that he visits R1 every day except on Saturdays. During his visits he would normally perform range of motion exercise involving R1's upper extremities and…

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

Based on observation, record review and interview, the facility failed to ensure staff members, including contracted staff, followed the proper use of personal protective equipment (PPE) for a resident under contact precautions (Resident (R) 1). This deficient practice encourages the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors. Findings include: On 07/25/24 at 09:49 AM, observed Radiologist Technologist (RT) in R1's room. Observed the sign Contact Precautions for R1 with donning and doffing instruction on the door. The sign was not easily viewable due to the door being opened. Resident was observed to be lying in bed and RT prepared R1 for X-Rays on her left arm. RT was observed to move R1's blanket and arm to prepare. RT was not wearing a gown. Certified Nurse Aide (CNA) 1 was in the room helping R1's roommate, when RT asked for CNA1's assistance. RT asked if R1's side rail can come down. CNA1 adjusted R1's side rail to come down. CNA1 was not wearing a gown and returned aiding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, and not required to treat the resident's medical symptoms to one of the sampled residents (Resident (R) 28). Findings Include: R28 is a [AGE] year-old-female admitted to the facility on [DATE]. R28 has a medical history not limited to dementia and Alzheimer's. Observation was conducted on 03/04/24 at 09:18 AM in R28's room. R28 was laying in bed with two wedges tucked underneath the left side of her fitted bed sheet. Observation was conducted on 03/05/24 at 07:47 AM in R28's room. R28 was positioned with the head of her bed elevated while having breakfast with the assistance of one of the staff. Two wedges were observed tucked under the left side of R28's fitted sheet. Observation and interview were conducted on 03/06/24 at 08:05 AM in R28's room. R28 was being assisted with feeding by a Certified Nurse's Aide (CNA) 10. Two wedges were tucked 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, record review and interview the facility failed to report an injury of unknown source to resident(R) 22's hands (bruising on top of her hands) to the Director of Nursing which impeded the investigation. This injury of unknown source to R22's hands was also not reported within five working days to the State Survey Agency. Findings Include: On 03/04/24 at 08:50 AM introduced self to R22 who was laying in her bed. At this time observed R22 had a bruise, which covered the top of her right hand, and appeared to be healing. Inquired if resident knew how she got the bruise and she did not remember how she got it. On 03/04/24 Record Review (RR) of R22's Electronic Health Record (EHR) found her diagnoses include, but are not limited to,vascular dementia (memory loss) and Paroxysmal Atrial Fibrillation (irregular rapid heart rate) which is treated with medication. R22 takes an anticoagulant (blood thinner), Apixaban. During the RR found a medication order for R22's Apixaban Oral Tablet 2.5 MG give one tablet by mouth two times a day for AFIB (Atrial Fibrillation) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide assistance for Resident (R) 19 to maintain her personal grooming and oral hygiene and failed to provide proper perineal care (cleaning genital and anus) for R22 putting them at risk for infection. This deficient practice could affect any resident who requires assistance with activities of daily living (ADLs) putting those residents are risk for infection. Findings Include: Cross-reference to F880 Infection Control. 1) On 03/05/24 at 10:40 AM entered R19's room and observed her eyes were dirty. R19's eyelashes were covered with a thick clear discharge which made it hard for resident to open her eyes. R19's mouth was dirty and edges of mouth were dry. At this time interviewed Certified Nurse Aide (CNA)5. Inquired if CNA5 had assisted R19 with her morning ADLs and CNA5 stated that she had and then also stated she had gotten busy that morning. On 03/05/24 Record Review (RR) of R19's Electronic Health Record (EHR) found her diagnoses…

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, interviews, 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: Concurrent observation and interview were conducted on 03/05/24 at 10:28 AM. A medication cart was observed left unlocked in the hallway near the dining room. Near the medication cart were four residents and two Certified Nurse's Aide (CNA). Registered Nurse (RN) 11 was observed in one of the resident's rooms. When RN11 returned to the medication cart, she realized she left the cart unlocked and was apologetic. RN11 stated that medication carts should not be unlocked while left unattended. Interview was conducted with Director of Nursing (DON) over the phone on 03/07/24 at 11:28 AM. DON stated that medication carts should be secured and locked when left unattended. A review of the facility's document titled, Storage of Medication, dated 01/23 was conducted. The document…

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

2) During an observation of a semi-private resident room on 03/09/24 at 09:00AM, there were two different Isolation Precaution warning signs; Contact Isolation and Aerosol Precautions. The two signs did not indicate which resident was assigned to which isolation/precaution. During staff interview on 03/09/24 at 09:10AM, Registered Nurse (RN) 9 acknowledged that the two signs did not specify which resident was assigned to which isolation/precaution. RN9 added that staff, especially new staff, did not know which resident was assigned to which isolation/precaution. Review of facility policy on Isolation Practices read Contact Precautions Policy, it is the policy of this facility to use category-specific isolation techniques for residents who have infectious or communicable diseases that may necessitate the use of barriers in addition to those used for Standard Precautions. Purpose, to minimize exposure to potentially infectious materials via direct contact . Aerosol generating procedure/treatment policy, HCWs performing an Aerosol Generating Procedure who presents in room during AGP…

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, staff interview and review of policy, the facility failed to remove expired emergency equipment nasal cannula from the Code Crash Cart in the [NAME] Hall. Findings include: During an observation of the [NAME] Hall Code Crash Cart, on [DATE] at 08:45AM, there was an expired nasal cannula/oxygen tubing dated [DATE]. Staff interview on [DATE] at 09:00AM, Registered Nurse (RN)9 acknowledged that the nasal cannula/oxygen tubing was expired and removed from the cart. Review of facility policy on Code Crash Cart read; Policy, It is the policy of this facility to ensure that the facility will maintain at least one emergency cart per patient building . Procedure, 3. Equipment/supplies from the emergency crash cart are used only when emergency care is provided, 4. The emergency crash cart is checked by the Central Supply Clerk and after every use. Missing or expired items are replaced, when applicable.

Based on observations, interviews with staff, and record review, the facility failed to assure a system was established to ensure the dish machine sanitization process was in proper working order and failed to ensure labeling of food items. This deficient practice has the potential to result in foodborne illnesses. Findings include: 1) On 03/29/23 at 10:45 AM observed the [NAME] washing dishes. Inquired whether dishes are sanitized by heat or chemicals. The cook responded that the dish machine is supposed to sanitize dishes by heat, however, for a prolonged period, the water temperature did not reach 180 degrees Fahrenheit. The cook reported there is a problem with the heater, so it does not reach the appropriate temperature. Further queried what is being done to sanitize the dishes. The cook explained that initially the dish machine will start okay but over a period, the machine does not meet the temperature. The cook responded that the dishes were immersed in quaternary solution to ensure sanitization. [NAME] ran the dish machine, observed the water temperature of the wash cycle…

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 staff interview, the facility failed to inform all residents, their representatives, and families of those residing in the facility by 5:00 PM the next calendar day of confirmed cases of COVID-19. This deficient practice fails to appropriately notify the residents and/or their representatives and families of an ongoing COVID-19 virus transmission in the facility. Finding includes: On 03/30/23 at 07:30 AM, Administrator notified the state agency (SA) that on the evening of 03/29/23, two residents and two employees tested positive for the COVID-19 virus. The facility also reported that one employee tested positive for the COVID-19 virus on 03/26/23. An interview was conducted with the Administrator on 03/31/23 at 09:15 AM in the conference room. Asked if residents and their families or representatives are notified of the COVID-19 cases in the facility. Administrator responded that they only notified the families and representatives of the residents that tested positive for COVID-19, the ones that came in contact with the COVID-19 positive employees and those that are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for two residents (R), R92 and R73, out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of the reason for resident's discharge. Findings include: 1) Cross reference to F625. The facility did not provide written notice of bed-hold policy which was included in the transfer/discharge notification. Review of the electronic health record (EHR) indicated that R92 was admitted to the hospital on [DATE] for pancreatitis and discharged from the facility. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 03/30/23 at 09:40 AM, Social Services Coordinator (SS1) acknowledged that the facility did not provide written notification of discharge to R92 and/or representative. During staff interview on 03/30/23 at 10:25 AM, Registered Nurse (RN)1 reviewed 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 record review, staff interview, and review of policy, the facility failed to provide written notice of bed-hold policy for two residents (R), R92 and R73, out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of the facility's bed-hold policy. Findings include: 1) Cross Reference to F623. R92 was transferred to a hospital. The facility did not provide R92 with a written notification of the transfer. Review of the electronic health record (EHR) indicated that R92 was transferred to the hospital on [DATE] for pancreatitis. Further review did not show any written notice that specifies the duration of bed-hold policy to the resident and/or representative. During staff interview on 03/30/23 at 09:40 AM, Social Services Coordinator (SS1) acknowledged that the facility did not provide written notification of bed-hold policy to R92 and/or representative. During staff interview on 03/30/23 at 10:25 AM, Registered Nurse (RN)1 reviewed 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 record review and interview with staff members, the facility did not assure assessments accurately reflected the residents' status for two (Residents 19 and 91) out of eighteen assessments reviewed. The facility inaccurately coded Resident (R)19 with a facility-acquired Stage III pressure ulcer and R91 as being discharged to the hospital, instead of to the community. This deficient practice has the potential to affect the development of a person-centered care plan, resulting in not meeting the needs of the residents. Findings include: 1) On 03/28/23, the facility provided a copy of the Resident Matrix (identifies pertinent care categories for: newly admitted residents in the last 30 days who are still residing in the facility, and all other residents). Resident (R)19 was identified with a Stage III pressure ulcer which was facility acquired. R19 was admitted to the facility on [DATE]. Diagnoses include displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4) On 03/25/23 at 12:23 PM, R86 was observed to have a urinary catheter with a tubing and bag system. On 03/29/23 at 09:21 AM, R86 was interviewed in her room. R86 had a urinary catheter tubing and bag system because of her diagnosis of retention of urine and hoped to have it taken out before she was discharged home soon. On 03/31/23 at 08:25 AM, R86 and Registered Nurse (RN)3 were interviewed in R86's room. R86 stated that the staff provided her education about caring for her urinary catheter with tubing and bag system. R86 was taught to clean the catheter insertion/exit site with a wet, soapy cloth and to keep catheter tubing and bag system clean. RN3 confirmed that education for care of her urinary catheter with tubing and bag system was provided to R86 and that R86 mostly does her own catheter insertion/exit site care, but at times may need assistance. Reviewed R86's electronic health record (EHR). admission Record revealed that R86 was a [AGE] year old resident admitted on [DATE]. Care plan for R86's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to follow bowel regimen protocol in accordance with the physician orders for one of one resident (R), R52, sampled with constipation. The facility also failed to have a lab drawn and follow up on the results for R42's blood sugar management. These deficient practices have the potential to result in adverse consequences in residents needing bowel or blood sugar management. Findings include: 1) On the morning of 03/28/23, R52 was observed lying in bed. The resident was grimacing. R52 was asked if he had pain. The resident responded he had stomach problems. R52 was asked whether medication was provided to facilitate bowel movement. R52 confirmed medication was successful, however, had a sandwich last night and not feeling well. A follow-up visit with R52 at 2:36 PM, R52 still expressed presence of a sore stomach and tried to eat some lunch. Record review noted R52 was admitted to the facility on [DATE]. Diagnoses include constipation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to draw laboratory tests for one resident (R), R2, as recommended by the consultant pharmacist. This deficient practice has the potential to cause adverse consequences for residents where the consultant pharmacist has recommended actions to be taken for medication management. Finding includes: Cross reference to F684 Quality of Care - laboratory order was not properly entered in the electronic health record (EHR) and there was no laboratory requisition generated. Reviewed electronic health record (EHR) for R2. R2 was admitted on [DATE] for hospice care. Diagnoses include but not limited to diabetes (high level of sugar in the blood), long term use of insulin, chronic kidney disease, and congestive heart failure (condition where the heart does not pump blood efficiently causing fluid buildup in the feet, arms and lungs). Ordered medications include insulin (regulates blood sugar levels) and furosemide (water pill). Review of a Medication Regimen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff members, the facility failed to assure pain medication was provided with adequate indication for its use for one resident (R), R35, of five residents sampled for medication review. The prn (as needed) medications for pain did not indicate the parameters for its use or include non-pharmacological interventions to relieve pain. This deficient practice has the potential to ensure the resident attains the highest practicable mental, physical, and psychosocial well-being. Findings include: R35 was admitted to the facility on [DATE]. Diagnoses include but not limited to brachial plexus disorder (injury caused by damage to those nerves, typically from trauma, tumors, inflammation, pressure, athletic injuries, or being stretched too far); chronic systolic (congestive) heart failure; ischemic cardiomyopathy; basal cell carcinoma of skin or other parts of face; constipation; Type 2 diabetes mellitus with other skin complications; and venous insufficiency. On 03/29/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility did not ensure that medication error rate was below five percent (%). Two administration errors to resident (R)243 out of a sample of 5 residents, were observed out of 32 opportunities, resulting in a 6.25% medication error rate. This deficient practice has the potential for inadequate administration of medications and/or adverse effects to residents. Finding includes: On 03/30/23 at 08:42 AM, observed Registered Nurse (RN) 8 perform medication administration at the Lehua section of the facility. Observed RN8 administer fluticasone propionate nose spray and Trelegy inhaler to resident (R) 243. RN8 notified R243 that she will be giving her nose spay and inhaler. RN8 was holding the base of the nasal applicator between her index and middle fingers with her thumb on the bottom of the bottle. RN8 inserted the nasal applicator into R243's left nostril and pressed the bottom of the bottle twice. RN8 then inserted the applicator in the left nostril, administered 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to ensure hand hygiene procedures were followed by staff between glove change during a dressing change for one resident (R), R45, and failed to ensure droplet precautions were maintained for another resident, R35, receiving aerosolized medication out of a total sample of 14 residents. These deficient practices encourages the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors. Findings include: 1) On 03/29/23 at 10:15 AM, observed Registered Nurse (RN) 8 while providing care for resident (R)45. RN8 told R45 that she will be giving her morning medications through her gastrostomy tube (GT - tube inserted though the belly directly into the stomach) and will also be changing the dressing. RN8 washed her hands in the bathroom sink and donned gloves prior to administering the medications and flushing the GT with water. After flushing the GT, RN8 changed her gloves…

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

Based on observations, interview, and record review, the facility failed to conduct COVID-19 testing correctly on staff being screened during a COVID-19 outbreak. This deficient practice has the potential to transmit the COVID-19 virus affecting the health and safety of residents, staff, and visitors. Finding includes: On 03/28/23 at 1:02 PM, observations were made of Registered Nurse (RN)1 conducting staff COVID-19 testing to manage an outbreak at the facility. RN1 wore a gown, gloves, face shield, and mask. Staff (S)1 wore a face mask, took off her mask, and did not hand hygiene after touching her mask. S1 swabbed both nostrils, and placed the swab unto the COVID-19 testing card and closed it. S1 did not hand hygiene after touching the COVID-19 testing card. S2 wore a face mask, pulled down her face mask by touching the front and pulling it down to her chin. S2 did not perform hand hygiene after touching her mask. S2 swabbed both nostrils, and placed the swab unto the COVID-19 testing card and sealed it closed. S2 did not hand hygiene after touching the COVID-19 testing card 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.