The Care Center Of Honolulu

Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for one [Resident (R) 6] of one resident sampled for restraints, The deficient practice could affect all residents at the facility who are using bedrails. Findings Include: On 09/03/25 at 12:13 PM observed R6 in bed with bilateral 1/2 upper bedrails up on her bed. R6 was observed holding onto the rails as she lay in her bed. On 09/04/25 at 02:30 PM requested the Director of Nursing (DON) provide a copy of R6's consent for bedrail use and she stated it is in the resident's restraint physical assessment that was filled out on 07/27/25. The DON also stated the nurse wrote a progress note regarding the conversation with the Resident's daughter giving verbal consent for bedrail use. On 09/04/25 record review of R6's Electronic Health Record (EHR) revealed an assessment to use the 1/2 upper bedrails was completed on 07/27/25. Reviewed R6's Care Plan (CP) and found the use of bedrails was not included in the care plan. On 09/05/25 at 03:52 PM, interviewed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the care plan for one of two residents investigated for care planning, [Resident (R) 1] was revised by the interdisciplinary team to include interventions to prevent recurring hospitalizations. The resident has had multiple re-hospitalizations within the recent months and was not reflected in his care plan. The deficient practice may impact the resident's quality of life and the right to a dignified existence. Findings Include:Observation on 09/03/2025 at 02:08 PM in R1s room. R1 was lying in his bed and didn't answer make eye contact or speak when asked questions. R1 had a trachea collar that was connected to the mechanical ventilator. Noted a Gastric (G-tube) feeding pump at the bedside and an intravenous (IV) infusion pump on the other side of the bed. R1 was resting with his eyes open. Review of the Electronic Medical Record (EMR) on 09/04/25. R1 is an [AGE] year-old male resident admitted to the facility on [DATE] (most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide the following for one [Resident (R) 15] of one resident sampled for quality of care: A homelike environment with a comfortable room temperature; provision of adequate personal care of hair, skin and nails; and provision of a water pitcher for hydration between meals. The deficient practice impacted the resident's quality of end-of-life care with a comfortable and dignified existence in the facility. Findings include:Observation and interview with R15 on 09/03/2025 at 10:34 AM in his room. R15 was in an isolation room on transmission-based precautions for a respiratory infection. R15's skin on his arms, hands, legs and feet were dry, scaly and flaky. R15's hair was tousled, and his mustache was over his lip which made him appear disheveled. The nails on his hands were 3/4 inch long, yellow, and thick. Asked if the staff ever trim his hair, shave him or offered to trim his nails. He said he can't shave himself and the nurse said she…

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

Based on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one of one resident's sampled for nutrition/hydration, [Resident (R) 74]. This deficient practice affects residents who rely on staff to provide fluids to maintain proper hydration and health.Findings Include: On 09/02/25 at 10:29 AM, concurrent observation and interview was done. Observed no water pitcher at R74's bedside. Subsequent observation was done at 11:35 AM, and no water pitcher was observed at resident's bedside. An interview was done at 11:37 AM with R74, when asked if she needed water pitcher at her bedside, R74 stated, Yes, I would like to have my own water pitcher. R74 also explained that she feels thirsty at times and has dry lips but was not provided a water pitcher. An interview was done at 11:40 AM with Certified Nurse Aide (CNA)103 inside resident's room. Asked if R74 requires a water pitcher in her room and confirmed that the resident is able to pour water from a pitcher without assistance and should have a water pitcher at her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promptly, within three days, refer a resident with lost dentures for dental services for one [Resident (R) 150] of two residents sampled for dental services. As a result, R150 did not obtain the option or consult of denture replacement, and her dietary order was downgraded.Findings Include: On 09/02/25 at 09:22 AM, an observation and interview were conducted with R150. R150 reported that her dentures were stolen and needs a new pair. She could not recall how long her dentures have been missing, only that it has been a while. She stated she had informed the facility about the loss and was told the dentist comes to the facility. She has been waiting for a dentist to come for a replacement. R150 explained the missing denture has been affecting her ability to chew while eating. An observation of her room and R150 confirmed the absence of her upper denture.Review of R150 inventory list confirmed R150 had upper dentures upon admission 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.

Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff was wearing applicable personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and improper hand hygiene and glove changes between a dirty and clean task. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.Findings include:1) On 09/04/25 at 08:14 AM, observed Registered Nurse (RN)27 administer medications to Resident (R)5 through her gastrostomy tube. RN27 was wearing a mask and gloves as she administered the medications to R5 but did not wear a gown. On 09/05/25 at 12:53 PM, an interview with the Infection Preventionist (IP) was conducted in her office. The IP confirmed that staff are to wear a gown, gloves and mask when administering medications through a gastrostomy tube for a Resident who is on enhanced barrier precautions.Review of facility policy titled…

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 homelike environment. The facility did not remove any of the resident meal trays (an institutional characteristic) after serving residents in the dining room. This deficient practice affects all residents dining in the dining areas. Findings include: On 08/12/24 at 11:55 AM, conducted a dining observation of twelve (12) residents eating lunch in the main dining room on the 1st floor. All 12 residents' meals remained on the meal trays. Inquired with Resident (R)138 and the resident's Family Member (FM)1 if it was their preference for the resident's meal to remain directly on the tray for the entirety of the meal. FM1 reported that they were not given the option to have the food taken off the cafeteria style trays, staff just always leave it on the trays. Inquired with Dining Staff (DS)3 regarding residents' meals being served and remaining on the cafeteria style tray throughout the meal service. DS3 confirmed all the residents dining in the 1st floor dining room have their meals on the tray. Asked if…

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 interviews, the facility failed to ensure posted nurse staffing information was in clear and in an identifiable and prominent place. As a result of this deficient practice, residents and resident representatives are not informed of the number of staff available for resident care. Findings include: 1) On 08/13/24 at 10:55 AM, conducted observations of daily staff posting at the entrance of the building and on all four (4) units. Near the entrance of the building, after the screener's station, Daily Staff Posting is posted on a bulletin board along with the employee clock in/out system, a Stay up to Date with your Covid Vaccine poster, Cover your Cough poster, August 2024 Employee Calendar, Mandatory CNA (Certified Nurse Aide) Meeting, and a list of employees who need to see the Director of Nursing (DON) prior to starting the shift. The 24-hour-Daily Staff Posting form was printed on what appeared to be an 11-inch (in) x 13 in paper. The print was small, and this surveyor was unable 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 observations, interview, and record review, the facility failed to store and serve food in accordance with professional standard for food service safety. This deficient practice has the potential to place facility residents at risk for food-borne illness. Findings include: 1) A concurrent observation and interview were conducted on 08/12/24 at 08:27 AM in the facility kitchen. One of the refrigerators contained a container of rice porridge with a discard date of 08/11/24. Dietary Director (DD) stated that it should have been discarded since the kitchen staff performs audits twice a day. Review of the facility policy titled, Food Receiving and Storage, with a revised date of 10/2017, was conducted. The facility policy documented, Food shall be received and stored in a manner that complies with safe food handling practices. 2) Concurrent observation and interview were conducted with the Dietary Aide (DA) 1 on 08/12/24 at 08:53 AM. DA1 was observed checking the dishwasher sanitizer with a quality assurance strip. When asked if she logs the results, DA1 stated that kitchen…

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 privacy for one of the sampled residents (Resident (R) 415). This failed practice had a negative affect on R415's psychosocial well being and has the potential to affect all the residents in the facility. Findings include: Interview was conducted with R415 on 08/12/24 at 09:22 AM in R415's room. R415 stated that on multiple occasions, the staff would pull the privacy curtains from around her bed while providing personal care to her roommate. R415 stated that pulling the curtain from her side to provide privacy to her roommate ends up exposing her to individuals passing in the hallway. Interview was conducted with R415 on 08/13/24 at 09:04 AM in R415's room. R415 stated that on 08/12/24, she was exposed to the other resident in the room as well as individuals passing in the hallway. Observation was made on 08/13/24 at 09:16 AM in R415's room. While R415 was talking to State Agency (SA), Certified Nurse Aide (CNA) 62 was observed pulling one of the privacy curtains near the entrance of the room/R415'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 interview and record review, the facility failed to ensure the resident's right to be free from verbal abuse for one resident (Resident (R)31) sampled. After filing a complaint with the facility regarding the Alleged Perpetrator's (AP) treatment of R31, AP was informed not to have any form of contact with the resident. Following this instruction, R31 reported to the Assistant Administrator (AADM) that AP had verbally confronted and intimidated him while he was alone in his room. AADM confirmed that he did not identify AP's confrontation and intimidation of R31 as potential abuse, and did not initiate an investigation into the incident. As a result of AP confronting R31 about the initial complaint, R31 reported feeling unsafe, fearful of additional retaliation from AP, increased anxiousness, hypervigilance with loss of sleep, and violent nightmares of having to defend himself from AP. As a result of this deficient practice, the resident was not kept safe while allegations were thoroughly investigated.…

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 report an allegation of potential abuse to the Administrator of the facility, the State Agency (SA), and Adult Protective Services in accordance with State law through established procedures. R31 reported to the Assistant Administrator (AADM) that a staff member [alleged perpetrator (AP)] confronted him about an initial complaint he had made about AP. AADM confirmed the incident was not identified as potential abuse, and because of not identifying it as possible abuse, it was not reported accordingly. Findings include: (Cross reference to F585, F600, F610) R31 is a [AGE] year-old resident, who was admitted to the facility on [DATE] for physical and occupational therapy to improve his level of functioning. R31's diagnoses include sepsis, cellulitis (skin infection that appears red and swollen) of upper limb, hypertension, a history of falling, and a need for assistance with personal care, weakness, and unsteadiness on feet. Review of R31's Electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to thoroughly investigate an allegation of potential abuse for one resident (Resident (R)31) sampled. R31 reported to the Assistant Administrator (AADM) that a staff member confronted and intimidated him about a complaint he made about the staff member. AADM confirmed the incident was not identified as potential abuse and an investigation into the incident was not initiated. Findings include: (Cross reference to F585, F600, F609) R31 is a [AGE] year-old resident, who was admitted to the facility on [DATE] for physical and occupational therapy to improve the resident's level of functioning. R31's diagnoses include sepsis, cellulitis (skin infection that appears red and swollen) of upper limb, hypertension, a history of falling, and a need for assistance with personal care, weakness, and unsteadiness on feet. Review of R31's Electronic Health Records (EHR) documented a Minimum Data Set (MDS) admission assessment with an Assessment Refence Date (ARD) 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 review and interview, the facility failed to correctly document the presence of a stage three pressure ulcer in the Resident Assessment Instrument (RAI) for one Resident (R) 56 of 32 in the sample. As a result of this deficient practice, R56 was not properly coded which could affect the resident's care plan and potential outcomes. All residents have the potential to be affected. Findings include: R56 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses that include anoxic brain damage, muscle weakness, contractures of left and right forearm muscle, stage three pressure injury to the sacrum . per record review (RR) of face sheet. RR of a skin & wound evaluation, dated 08/12/2024, noted the following documentation: Stage three to sacrum. present on admission. 0.3 centimeters (cm) long 0.2 cm wide no undermining or depth. No tunneling. Wound healing is slow or stalled but stable, little/no deterioration. Generic wound cleanser with foam dressing . 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 observation and record review, the facility failed to implement the care plan for two Residents, (R)126 and R218, of 32 residents in the sample. R126 was not repositioned at least every two hours to promote healing of his pressure ulcer and R218 was not routinely repositioned or transferred to a wheelchair. The deficient practice placed the residents at risk for a decline in their functional and physical health status. All residents who are dependent on staff have the potential to be affected. Findings include: Cross reference to F686. R126 is a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis that includes heart failure; septicemia; wound infection and an unhealed stage four pressure ulcer of the sacral region, per Record Review (RR) of the face sheet. During random observations of Resident (R)126 in his room on the following days and times: 08/12/24 at 09:07 AM and 2:00 PM; 08/13/24 at 09:15 AM; 11:30 AM; 2:00 PM and 3:45 PM; 08/14/24 at 08:45 AM, 11:38 AM, 1:45 PM, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide treatment consistent with professional standards of practice to promote the healing and prevent infection of an existing stage four pressure ulcer for one Resident (R) 126. R126 required maximum assistance and was not repositioned off of the wound at least every two hours. The deficient practice places placed the resident at risk of worsening a stage four pressure injury. All residents who require maximum assistance from staff have the potential to be affected. Findings include: R126 is a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis that includes heart failure; septicemia; wound infection and an unhealed stage four pressure ulcer of the sacral region, per Record Review (RR) of the face sheet. Observation and interview with R126 in his room on 08/12/24 at 09:04 AM. R126 was in his bed on his back with the head of bed up 45 degrees. R126 said that he used to walk pretty well before but now I'm in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide the care to maintain or improve the highest level of range of motion and mobility for one Resident (R) 218 of 32 in the sample. The resident was not routinely repositioned and placed up in the chair daily as ordered by the physician. The deficient practice placed the resident at an increase risk of a decline in functional status. Findings include: R218 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis that includes depression, hemiplegia, and hemiparesis (weakness) per Record Review (RR) of face sheet. Observation of R218 in her room on 08/12/24 at 10:15 AM. R218's laying on her back with her bed flat, her right leg started shaking. Facial grimacing noted and an adhesive patch on her left knee. Observation of R218 on 08/12/24 at 2:33 PM. The resident was observed on her back in bed, with a contracture of her left arm, non-verbal, moaning and grimacing, and when asked if she was having pain, she moaned…

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

Based on observation and interview, the facility failed to ensure that staff implemented specific competencies necessary for resident safety. This deficient practice has the potential for harm. Findings include: On 08/14/24 at 09:00 AM, while waiting to check a medication cart on Unit 4, observed Registered Nurse (RN)10 dispose of a medication tablet in the trash bin (unlocked, unsecure) located on the side of the medication cart. The medication landed on the top of other trash which was visible and accessible to anyone passing the medication cart. Inquired if it was okay to dispose of the medication tablet in the trash bin at the side of the medication cart which was unsecured and unable to be locked. RN10 stated she would have to check on how she was supposed to dispose of that medication. RN10 confirmed she disposed of a tablet of Aspirin 81 mg (milligrams) on the side of the medication cart and remained unsure of how to properly dispose of the medication. As RN10 and this surveyor were discussing RN10 disposing of the medication in an unsecure/unlocked trash bin, 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.

Based on observation, interview, and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled on 1 of 4 units in the facility. This deficient practice increases the risk for diversion of resident medications. Findings include: Observation was conducted on 08/14/24 at 07:38 AM at the nurses' station on the second floor. Registered Nurse (RN)24 was observed preparing medications for a resident. The medication cart she was using was unlocked and RN24 was accessing the medications contained in the medication cart. A review of the facility's document titled, Controlled Item Checklist, dated August, was conducted on 08/14/24 at 07:49 AM. The sheet did not contain the outgoing night shift nurse and the incoming day shift nurses' signatures for August 14, 2024, in the 07:00 AM boxes. RN24 was informed of the missing signatures. RN24 stated that it should have been signed earlier with the outgoing night shift nurse. On 08/14/24 at 07:57 AM, RN24 and RN20 were both observed signing the facility'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.

Based on record review and interview, the facility failed to ensure the physician, the facility's medical director, and/or director of nursing acted upon irregularities the pharmacist reported during the monthly medication regimen review (MRR) for two of five residents sampled (Resident (R) 67 and R110). The attending physician did not document in the medical record that the identified irregularities had been reviewed, nor did he/she document the rationale for the no change in medications. Findings include: Review of the facility's policy and procedure Medication Regimen Reviews, revised in May 2019, documented The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. 1) During review of R67's Electronic Health Record (EHR), under the pharmacist note in progress notes, the pharmacist documented for MRR 07/31/24 to see report. Review of documented MRRs uploaded in the…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's food preference/request was followed for one of four residents sampled (Resident (R) 106). R106 requested white bread for every meal and did not get white bread for every meal. Findings include: On 08/12/24 at 10:45 AM, during an interview with R106 at the bedside, resident reported she spoke with the facility's dietician and requested to have milk every morning and plain white bread every meal but has not been getting her request. R106 did not understand why she needed to ask for milk and white bread every day. On 08/12/24 at 12:36 PM, observed R106's lunch tray to not have plain white bread. R106 stated no bread again and brought out a half a slice of white bread from the top of her nightstand kept in a cup that she saved from the morning and said, good thing I kept one. Reviewed R106's meal card for lunch on her meal tray which documented + 2 SLICES BREAD DAILY (untoasted). On 08/13/24 at 08:24 AM and 08/14/24 at 08:44 AM, observed R106 eating breakfast with bread and milk on her plate,…

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 maintain medical records on 1 of 32 residents sampled, that were accurately documented. As a result of this deficient practice, Resident (R)313 was placed at risk for a decrease in quality and competency of care. In addition, based on observation, interview, and record review, the facility failed to keep a resident's Electronic Health Record (EHR) confidential. This deficient practice places residents' EHRs at risk for violations of the Health Insurance Portability and Accountability Act (HIPAA). Findings include: 1) Resident (R)313 is a [AGE] year-old male admitted to the facility on [DATE] for short-term rehabilitation. R313's admitting diagnoses include, but are not limited to, acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), epilepsy, and esophageal (tube that runs from the throat to the stomach) obstruction. As a result of his admitting diagnoses, R313 was admitted with a tracheostomy…

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 the Binding Arbitration Agreements ([NAME]) they asked the residents (or their representatives) to enter into, were explained in a form and manner that they could understand. This is evidenced by 1 of 3 residents or resident representatives (of Resident 63) sampled stating she did not have the BAA explained to her in a way that she understood what it meant. Findings include: On 08/13/24 at 12:00 PM, an interview was done with the resident representative/family member (FM3) for Resident (R)63 at his bedside. During a concurrent review of a copy of the signed BAA and being asked if she recognized it, FM3 reported that she believed it was a form in a bunch of forms that had been sent to her to sign once when R63 was being re-admitted from the acute care hospital. FM3 also reported that she could not recall the form being explained to her and stated that she wasn't sure what it was for. After the state agency (SA) explained the BAA form to her, FM3…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections for two of six residents sampled for infection control (Resident (R) 126 and R85). R85's humidifier bottle was not properly secured to the oxygen concentrator. During R126 sacral wound dressing change, the nurse didn't sanitize hands after removing dirty gloves and before putting on clean gloves. This failure could place the resident at risk for infection. Findings include: 1) On 08/12/24 at 08:38 AM, during an observation of R85's room, observed R85 on oxygen, oxygen contractor running, and the humidifier bottle had broken off tape around it and was taped on the bottom sticking to the ground. The rubber band that secured the humidifier bottle to the concentrator was broken and there was tape around the concentrator. R85 reported the humidifier bottle was taped to the concentrator this morning but it fell off and he…

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 maintain a medical record that was accurately documented for one of three residents in the sample. Two entries documented in the electronic medical record stated the resident's fractured shoulder was the right shoulder when the injury occurred in the left shoulder. A third entry documented the resident was transferred to the wrong acute care hospital. The deficient practice has the potential to affect all residents residing in the facility. Findings include: Electronic medical record (EMR) reviewed for Resident (R)1. admission note: 12/20/2023 at 22:28 .Left arm swollen. With elastic bandage and sling in place. Skilled nursing note: Registered Nurse (RN)10. 12/23/2023 14:18. Patient (Pt.) alert oriented x3 verbalizing appropriately .right arm swelling noted, brace and sling in place, placed pillow under to have extremity elevated . Skilled Nursing note: RN25. 12/24/2023 at 18:25 .pt. alert and oriented x 3. Verbalizing appropriately, .Right arm swelling, and discoloration noted. Pulses noted arm warm to touch . General…

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 policy review, the facility failed to protect and promote quality of life for 4 of 5 residents sampled (Residents (R)29, 52, 75, and 1) by making sure that they were treated with respect and dignity. Specifically, the facility failed to ensure that English was consistently spoken in all resident care areas, exposing R1 to frustrating situations. R29 handling R29 roughly while providing care despite resident's request to be gentle. R52 and R75 both reported having to wait 30 minutes to 1 hour for staff to respond and/or acknowledge the resident after activating their call light. This deficient practice has the potential to affect all residents in the facility. Findings include: 1) On 08/07/23 at 11:43 AM, conducted an interview with R29 regarding staff treating the resident with respect and dignity. R29 reported there are some staff that are rough when they clean her down there (providing peri care). R29 explained that she had surgery down there and I have to remind the staff more than once to be gentle. R29 reported that it is not very respectful when you…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review (RR), the facility failed to accommodate the needs of 3 of 5 residents sampled (Residents (R)1, 74, and 100) by ensuring that their call lights were always placed within reach. As a result of this deficient practice, the residents were placed at risk of not having their needs identified and met in a timely manner. This deficient practice has the potential to affect all the residents at the facility who can activate a call light, or have it activated on their behalf. Findings include: 1) Resident (R)1 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R1's active diagnoses include but are not limited to quadriplegia (a form of paralysis that affects all four limbs, plus the torso), respiratory failure, and dependence on a respirator (ventilator) for breathing. A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/25/23 revealed that R1 was determined to have a Brief Interview for…

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

Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications. Findings include: On 08/09/23 at 08:49 AM, an inspection of the Ventilator Care Unit (VCU) medication cart #3 was done with licensed practical nurse (LPN)1. Observed in the 3rd drawer of the cart were the following unlabeled bottles of over-the-counter (OTC) vitamins/supplements: 1 open bottle of Tangy Tangerine Tablets 2.0 1 open bottle Z-Stack vitamin 1 closed bottle Z-Stack vitamin Interview done with LPN1 revealed the unlabeled bottles were medications (with accompanying physician orders) for Resident (R)9. LPN1 stated that R9's family brings the medications in from the outside, and that the facility holds and administers them from the medication cart. LPN1 confirmed that 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 and interviews, the facility failed to ensure food was stored and prepared in accordance with standards for food safety. As a result of this deficient practice, all resident have the potential to be affected and experience harm. Findings include: 1) On 08/07/23 at 08:44 AM, during the initial brief tour of the kitchen, observed an open box of [NAME] Beef Patty and an open bag of diced potatoes (in an unlabeled box) in the freezer. The beef patties and diced potatoes were both open to the freezer air and appeared to have freezer burn. The Dietary Director (DD)1 was present and confirmed the open bags of beef patties and diced potatoes should have been sealed properly, but was not, and both items were freezer burnt. DD1 removed the beef patties and diced potatoes from the freezer. 2) On 08/09/23 at 11:37 AM, during a follow-up visit to the kitchen, observed staff plating resident's lunches. Observed a pot on the stove that contained cooked chicken (alternative/special request) which 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 observations and staff interview, the facility failed to secure an electrical panel on Nursing Unit 4. As a result of this deficient practice, the facility put the safety and well-being of the residents as well as the public at risk for accident hazards. Findings include: During an observation of Nursing Unit 4 on 10/07/23 at 10:00 AM, the electrical panel was not secured. The panel contained electrical circuit switches numbered one to thirty five. No staff members were in the immediate vicinity to prevent any residents and/or visitors from accessing the electrical panel. Second observation of Nursing Unit 4 on 10/08/23 at 11:00 AM showed the same electrical panel was not secured. Again, no staff members were in the immediate vicinity to prevent any residents and/or visitors from accessing the electrical panel. During staff inquiry on 10/09/23 at 08:30 AM, the Administrator acknowledged that the electrical panel should have been secured. Administrator stated that they would immediately have the electrical panel secured/locked.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review (RR), the facility failed to identify and support 2 of 2 residents sampled (Residents (R)1 and 65) preference to be gotten up out of bed daily. As a result of this deficient practice, these residents did not have their needs met and were placed at risk of not attaining their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)1 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R1's active diagnoses include but are not limited to quadriplegia (a form of paralysis that affects all four limbs, plus the torso), respiratory failure, and dependence on a respirator (ventilator) for breathing. A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/25/23 revealed that R1 was determined to have a Brief Interview for Mental Status (BIMS) score of 14, meaning he was found to be cognitively intact. During an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide a safe, homelike environment for one out of 49 residents sampled (Resident (R) 88). This deficient practice has a negative effect on resident's quality of life and places her at risk for psychosocial harm. Findings Include: R88 is a [AGE] year-old female admitted to the facility on [DATE]. Observation and interview were conducted on 08/07/23 at 02:11 PM. R88 stated, My neighbor's snacks are all over the place. I don't like seeing it all! The curtains need to be washed. It has not been washed since I have been here. It smells bad. An observation was made on a tear in the curtain that created a 5inch-by-5inch hole. To the right of R88's television are shelves, tables, large plastic storage bins, and stackable trays. These items contained food, packing boxes, plants, pillows, blankets, paper goods, and drinks. The items are stacked on top of one another creating a 5-foot-high pile. Some of the bins are overflowing with items that could potentially…

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 document ongoing re-evaluation of the need for restraints for one out of four residents sampled (Resident (R) 429). This deficient practice places the resident at risk for psychosocial harm. Findings Include: R429 is a [AGE] year-old male admitted to the facility on [DATE]. Observations were conducted at various times between the dates 08/07/23-08/10/23. R429 had his mitten restraint on throughout the four-day span. Interview was conducted with Registered Nurse (RN) 25 on 08/09/23 at 01:34 PM near the nurse's station. RN25 stated that R429's mitten is supposed to be released every two hours. RN also mentioned that she only completes the flowsheet and has not charted in the progress notes regarding R429's restraint use. Interview was conducted with Unit Manager (UM) 3 on 08/09/24 at 02:58 PM. UM3 stated that charting in the progress notes should be done every shift especially regarding restraints. After reviewing R429's Electronic Health…

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

Based on interviews and document review, the facility failed to report one reportable event of suspected resident (Resident (R)52) abuse event to the State Agency (SA) and Adult Protective Services (APS) within 2 hours of the incident if serious bodily injury is present, as mandated by state law. On 03/28/23 it was reported to the facility that R52 had an injury to the right shoulder which was red, swollen, and could not move his/her arm. R52 was allegedly abuse by Facility Staff (FS)4. As a result of this deficient practice the SA did not have information to determine if an investigation by their agency was needed, and there is the potential incidents are not thoroughly investigated, putting all residents of potential abuse at risk. Findings include: (Cross Reference to F600 Allegation of Abuse; F610 Conducting a Thorough Investigation; and F676 Maintain Abilities) The definition of Willful as defined at 485.5 in the definition of abuse and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The definition 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 interviews and record review, the facility failed to ensure further potential for abuse was prevented and a completed report was submitted to the State Agency (SA) within 5 days of the incident. Facility Staff (FS)7 partially dislocated Resident (R)52's right (R) shoulder while attempting to reposition the resident. Applying the federal and state definitions of willful and abuse, the SA found the facility to not be in compliance with regulations and identified the incident as abuse. The facility did not identify the incident as abuse and therefore did not remove the staff from providing care and submitted the completed report 6 days after the incident. Findings include: (Cross Reference to F609 Reporting an Allegation on Abuse/Neglect/Misappropriation; F610 Conducting a Thorough Investigation; and F676 Maintain Abilities) The definition of Willful as defined at 485.5 in the definition of abuse and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The definition of Abuse as defined at 483.5 as the willful…

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 properly document a transfer summary to be received by an acute care provider for one resident (R), R378, out of a sample of two residents. This deficient practice fails to inform the receiving acute care provider of the care needed by the resident and does not allow R378 a smooth transfer to the acute care provider from the facility. Finding includes: Record review of R378's electronic health record (EHR). Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/05/22 revealed that R378 was admitted to the facility on [DATE] from a hospital. R378 had the following medical diagnoses: irregular heart rate, heart failure (a weakened heart that cannot supply the body with enough oxygen), an active cancer of a type of white blood cells (WBCs) that produce antibodies to help the body fight off infections, an anemia (low blood cell count) where the bone marrow cannot produce new WBCs, red blood cells (RBCs, provides oxygen to all cells in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the timely review and revision of the Resident's Comprehensive Care Plan (CP) included his family representative/healthcare surrogate for 1 of 3 residents (Resident (R)84) in the sample. As a result of this deficient practice, staff did not have all the information necessary to effectively address the resident's status, condition, and/or needs adequately so that he could meet his highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: Resident (R)84 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R84's active diagnoses include but are not limited to a personal history of traumatic brain injury, chronic respiratory failure, and functional quadriplegia (a form of paralysis that affects all four limbs, plus the torso). R84 does not speak and is incapable of voluntary movement of his limbs or head. In addition,…

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 provide the necessary care and services to ensure two residents' abilities in activities of daily living are not diminished. Facility Staff (FS)7 repositioned R52 by pulling the resident's arm resulting in a subluxation (partial dislocation) of the resident's right (R) shoulder. Prior to the incident, R52 could walk approximately 100 feet with minimal assistance and was in the process of finding appropriate discharge placement after the incident the resident is unable to walk and is not receiving restorative services to help maintain his/her strength to walk. As a result of this deficient practice, all residents needing restorative services are at a for potential risk of harm. Findings include: (Cross Reference to F600 Allegation of Abuse; F609 Reporting an Allegation on Abuse/Neglect/Misappropriation; and F610 Conducting a Thorough Investigation) The facility's completed report for ACT#10193 was reported to the SA via email on 04/04/23 documented, On 3/28/23 Resident was being repositioned in bed by staff…

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 staff interview, the facility failed to provide appropriate services to prevent urinary tract infection for one out of four residents (Resident (R) 43) sampled. This deficient practice exposes the resident to possible infection causing contaminants and has the potential to affect all residents with urinary catheters. Findings Include: On 08/07/23 at 09:58 AM, during initial observations, R43 was lying supine in bed with head elevated watching television. Observed R43 had a urinary catheter draining light yellow urine into a covered drainage bag that was on the floor. After initial observation of all 47 residents in the unit was completed, noted the drainage bag was still on the floor at the following times: 11:12 AM, 11:44 AM, 12:29 AM, 01:33 PM and 2:42 PM. On 08/08/23 at 08:20 AM, observed urinary catheter drainage bag was on the floor. Record review revealed that a urine analysis (urine test to check for infections) was done on 08/08/23. Further review revealed that R43 already had a urinary tract infection in June 2023. On 08/09/23 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 observation, interview, and record review, the facility failed to provide the appropriate treatment and services to assess an identified complication, and prevent further potential complications related to enteral tube-feedings (TF) for 1 of 3 residents sampled (Resident (R)84). As a result of this deficient practice, the facility placed the resident at risk for continued avoidable complications. This deficient practice has the potential to affect all residents at the facility receiving enteral feedings. Findings include: Resident (R)84 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R84's active diagnoses include but are not limited to a personal history of traumatic brain injury, chronic respiratory failure, and functional quadriplegia (a form of paralysis that affects all four limbs, plus the torso). R84 does not speak and is incapable of voluntary movement of his limbs or head, and is dependent on enteral tube-feedings (TF) for all nutrition. In addition, R84 does not…

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

Based on observation, interview, and record review (RR), the facility failed to ensure nurse competency in medication administration as evidenced by an extended release tablet being crushed and administered to a resident. This deficient practice places the residents at risk for avoidable declines in health status and decreased quality of care and has the potential to affect all the residents at the facility receiving crushed medications. Findings include: On 08/09/23 at 07:51 AM, medication pass observations were done with licensed practical nurse (LPN)1 as she prepared and administered medications for Resident (R)25. Observed LPN1 remove a potassium chloride ER (extended release) 10mEq (milliequivalent) tablet from the blister pack and place it into a medication cup. The blister pack had a bold pharmacy label prominently placed that read Do not crush . A minute later, after LPN1 had prepared the other 6 medications for R25, LPN1 proceeded to crush the potassium chloride ER tablet. At 08:01 AM, the crushed potassium chloride was administered via a gastric tube to R25. At 08:18 AM,…

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

Based on interviews and record review, the facility failed to ensure that records for controlled medications are in order and that an accurate account is maintained and reconciled. The staff did not document the actual amount of medication in the container and signed off on medications not yet administered. As a result of this deficiency, there is a potential for the diversion of controlled medications. Findings include: 1) On 08/09/23 at 08:20 AM, conducted an inspection of a medication cart with Nursing Staff (NS)34. Review of the Controlled Medication Sign-Off sheet documented NS34 had pre-signed the sheet of the count that is to be preformed with the on-coming evening shift nurse later in the day. NS34 confirmed the sheet controlled medications sheet was pre-signed and should not have been, it should have been signed in the presence of and witnessed by the on-coming shift immediately after the count was verified as accurate. The purpose of the on-coming and off-going nurses conducting and verifying the controlled medication count serves as part of the facility's system 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 that medication regimen irregularities were identified, reported, and addressed for 1 of 5 residents sampled (Resident (R)74). As a result of this deficient practice, the resident was placed at risk of avoidable complications related to his documented medication allergies. This deficient practice has the potential to affect all residents at the facility receiving medications. Findings include: Resident (R)74 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. R74's active diagnoses include but are not limited to chronic respiratory failure, and dependence on a respirator (ventilator) for breathing. On 08/09/23 at 10:33 AM, during a record review of his electronic health record (EHR), the following orders were noted: 05/11/23 Trazodone HCl [hydrochloride] Oral Tablet 50 MG [milligrams] (Trazodone HCl) Give 0.5 tablet by mouth as needed for Sleep. For 6 months at bedtime. Hold for sedation. 06/23/23 AVOID trazodone 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 record review, the facility failed to maintain medical records on 1 of 36 residents sampled (Resident (R)25) that were complete and accurately documented. As a result of this deficient practice, the medication administration record (MAR) for R25 was incorrect until the state agency (SA) pointed out the discrepancy. Timely and accurate medical record documentation, especially of medications administered, is essential for the care of any resident. This deficient practice has the potential to affect all the residents at the facility. Findings include: On 08/09/23 at 07:51 AM, medication pass observations were done with licensed practical nurse (LPN)1 as she prepared and administered medications for Resident (R)25. Observed LPN1 administer and/or attempt to administer 7 medications to R25. 6 medications were given via her gastric tube. The seventh medication was a mouth rinse that LPN1 tried to administer, however R25 did not tolerate even the small amount attempted via a disposable oral swab, so LPN1 wasted most of it. At 09:30 AM, while attempting to verify if LPN1 had…

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

Based on observations, interviews, and record review, the facility failed to perform proper hand hygiene and follow infection control processes. This deficient practice places the residents and visitors at risk for the development and transmission of communicable disease and infections. Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), as well as follow standard precautions by performing hand hygiene in between glove changes. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) Observation was conducted on 08/07/23 at 08:14 AM near the front entrance on the first floor. Infection Preventionist (IP) was performing rapid Covid testing to facility visitors. IP swabbed the first surveyor…

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.