Hale Makua - Kahului

Based on observations, interviews and review of policy, the facility failed to treat one Anonymous Resident (ARes1) and Resident (R)499 of six residents sampled, with respect and dignity. As a result of this deficiency ARes1 was not promoted the right to the maintenance of enhancement of their quality of life. The facility also left R499 in her soiled diaper for more than 40 minutes, putting R499 at risk for urinary tract infection (UTI) and perineum skin breakdown. Findings include: 1) During Resident interview on 04/10/25 at 03:00 PM, ARes1 relayed the following concerns: 1. Staff took a long time (sometimes up to forty minutes) to answer the call light. Staff would consistently say that they're not assigned to that room and pass the room without helping. ARes1 felt ignored because of this. 2. Staff did not maintain resident privacy after receiving a bath. ARes1 said the privacy curtains would be left wide open and felt exposed without wearing any clothing. 3. Staff did not wash hands before feeding. ARes1 said staff would have to be reminded to wash their hands before feeding…

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 interview with staff members, the facility failed to implemented residents' care plans to eliminate risk of an accident related to wandering and elopement and monitor the effectiveness of interventions as necessary for 3 of 4 (Residents 1, 2, and 3) residents sampled. 1) Resident (R)1 had an actual elopement, the facility failed to revise the resident's care plan to develop person centered interventions, direct care staff were unaware of approaches/interventions to employ for R1's wandering behavior and the wandering and exit seeking behaviors were not accurately monitored resulting in no baseline data to determine the efficacy of the interventions. 2) The facility failed to develop a care plan to prevent elopement for R2 with wandering behaviors prior to the start of the survey. The facility also did not implement or accurately document care plan approaches for monitoring the function of WanderGuard once a day and the targeted behaviors (wandering and refusal 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 observation and interview with staff members, the facility did not execute a resident's right to reside in a clean home environment. Findings include: On 01/13/25 at 02:11 PM, observed Resident (R)1 in a wheelchair, self-propelling on her unit. At 02:17 PM, observed R1 enter room [ROOM NUMBER]. R1 transferred herself from the wheelchair onto Bed A and laid down. At 02:30 PM observed staff members enter room [ROOM NUMBER], stood by the foot of Bed A, then exit the room. At 02:35 AM, observed Certified Nurse Aide (CNA)1 enter room [ROOM NUMBER], close the privacy curtain and assisted R1 back to the wheelchair. CNA1 wheeled R1 back to her room. Observed room [ROOM NUMBER] with signage for Enhanced Barrier Precautions (EBP - set of infection control practices that involve wearing gowns and gloves during high-contact care for residents at risk of infection, i.e. indwelling medical devices, wounds). CNA2 reported the reason for EBP is R6 receives dialysis treatment. Observation from 02:40 PM to 02:50 PM, 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, record review, and interview with staff members, the facility failed to develop a person-centered comprehensive care plan for 1 (Resident 2) of 4 residents reviewed for wandering/elopement behavior. This deficient practice has the potential to place resident at risk for accidents (i.e., falls, resident to resident altercations) and affect the resident's ability to achieve and maintain her highest medical, mental, and psychosocial needs and to cause adverse effects related to falls and resident to resident altercations. Findings include: Cross Reference to F689. Resident (R)2 has been identified for being at risk for elopement with a history of wandering behavior. The facility failed to conduct annual and quarterly elopement risk assessments, and implement care plan for wandering behavior. On 01/13/25 from 12:00 PM to 01:00 PM intermittent observations found R2 wandering on her unit, sometimes stopping to talk to other residents and at times would follow staff around the unit. A review of the quarterly Minimum Data Set (MDS) with an assessment reference date…

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

Based on observations, record review, and interviews with staff members, the facility did not ensure a person-centered comprehensive care plan was reviewed and revised following an actual incident of elopement for 1 (Resident 1) of 4 residents in the sample. Findings include: Cross Reference to F689. Resident (R)1 had an actual elopement on 12/06/24 and wandering behavior that places R1 at risk for falls, resident to resident altercations, and elopement. Review of R1's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 10/21/24 notes R1 yielded a score of 3 (severe cognitive impairment) when the Brief Interview for Mental Status was administered. R1 was also coded for wandering, occurring one to three days during the observation period. R1 requires supervision or touching assistance for walking 10 feet, walking 50 feet with two turns, and walking 150 feet. A review of R1's progress notes from 11/29/24 to 01/12/25 found entries of R1 wandering into other residents' rooms: 11/29/24 at 02:41 PM, R1 wandered into another resident's room at night; 12/08/24, R1…

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, record review, narcotic count sheet review and policy review the facility failed to: 1) Label open on dates for five of six blood glucose test strips stored in two medication carts, have a nurse sign the narcotic count sheet when the count was done, store unopened insulin in a refrigerator per manufacture instructions and discard expired medication by the discard by date, 2) Ensure all medications used in the facility were stored in accordance with manufacturer recommendations in 3 of 16 medication carts and 3) Discard an expired medication stored on the storage cart. The deficient practice could affect residents having their blood glucose tested if the strip is expired, affect a resident receiving narcotic pain medication if the count has to be reconciled, affect a resident who is ordered insulin but cannot receive what is on hand due to it being stored incorrectly, affect a resident receiving an expired medication. Proper storage of medications is necessary to promote safe…

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 the resident's right to be informed in advance, of the risk and benefits of the use of a psychotropic medication, and consent to treatment for two of five (Resident (R)134 and R141) sampled. R134's Resident Representative (RR)4 was not aware that the resident was receiving duplicate antidepressant therapy. RR4 confirmed the risk/benefits, education was not provided to RR4 regarding duplicate antidepressant therapy and did not sign a consent form. Requested a consent form from the facility and the facility confirmed a consent form was not obtained from RR4. As a result of this deficient practice, residents are at risk for more than minimal harm. Findings include: 1) On 10/16/24 at 10:13 AM, conducted an interview with R134's Resident Representative (RR)4. During the interview, inquired about the three large bandages on R134's head. RR4 reported R134 frequently scratching and picking at his skin, on his head. Asked RR4 what interventions are the facility implementing for R134's scratching/picking behavior. RR4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) R67 is an [AGE] year-old female admitted to the facility on [DATE]. R67 has a medical history that includes, but not limited to, chronic obstructive pulmonary disease, dependence on supplemental oxygen, acquired absence of eye, and anxiety disorder. R67 had an annual assessment on 08/14/2024. During the assessment R67 had a Brief Interview for Mental Status (BIMS) score of 15, which means R67 is cognitively intact. Concurrent observation and interview were conducted on 10/15/24 at 10:27 AM in R67's room. R67 was laying in bed. R67's call light was laying on a chair that was against a wall. R67 was not able to reach her call button. R67 asked State Agency (SA) if he/she can hand her the call light. R67 stated that she can call for help, but frequently the call light is not nearby for her to use. Observation was conducted on 10/17/24 at 09:08 AM in R67's room. R67 was laying in bed and asked SA if he/she has seen her call light. SA observed R67's call light laying on the floor. Interview was conducted with 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 implement a person-centered Comprehensive Care Plan (CP) for one resident in the sample (Resident 98). Despite identifying Resident (R)98 as an accident/safety hazards risk due to his smoking and behaviors, and after multiple documented incidents related to his smoking and behaviors surrounding his smoking, R98's smoking CP was not implemented consistently. As a result of this deficient practice, R98 was placed at risk for additional altercations related to his behaviors surrounding smoking. Findings include: On 04/05/24 the state agency (SA) received a facility-reported incident (FRI) ACTS #10878, describing a physical altercation between Resident (R)98 and R448 related to both residents smoking behaviors. An investigation into the FRI during the recertification survey conducted on 10/15/24 - 10/18/24 found deficient practices related to the incident. On 10/15/24 at 03:15 PM, observed R98 sitting in the designated smoking area alone with no staff present. On 10/16/24 at 10:01 AM, observation was done of R98…

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 revise the care plan for one Resident (R)32 to provide the support needed when he leaned over in his wheelchair. Findings include: Cross reference to F684. R32 is an [AGE] year-old male admitted to the facility on [DATE]. Primary diagnosis includes Parkinson's disease and unspecified dementia per review of the facesheet. Random observations on the East dining/ activity area on the following dates, 10/15/24 at 09:16 AM; 10/16/24 at 10:30 AM; 10/16/24 at 2:19 PM; 10/17/24 at 10:14 AM; and 10/17/24 at 2:04 PM. Observed R32 sitting in a high back wheelchair, his neck bent to the right side leaning over and sleeping. Care plan reviewed. Approach start date 09/19/2024. I have a tendency to lean over in my wheelchair (WC) or have my head to the side sleeping in my WC. Assist me to upright position and use my cushion to support as I allow .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide one resident with support of the head and neck while sitting in his wheelchair. The resident sleeping in his wheelchair slumped over to the right side throughout the day. The deficient practice affected one resident in the sample's quality of care. Findings include: Cross reference to F657 R32 is an [AGE] year-old male admitted to the facility on [DATE]. Primary diagnosis includes Parkinson's disease and unspecified dementia. Random observations on the East dining/ activity area on the following dates, 10/15/24 at 09:16 AM; 10/16/24 at 10:30 AM; 10/16/24 at 2:19 PM; 10/17/24 at 10:14 AM; and 10/17/24 at 2:04 PM. Observed R32 sitting in a high back wheelchair, his neck bent to the right side leaning over and sleeping. Interview with Licensed Nurse (LN) 35 on 10/18/24 at 11:35 AM to discuss the care plan for R32. LN35 stated that we don't have care planned interventions for support when he leans over in his chair, but he has a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment to prevent urinary tract infections. R180's catheter tubing was observed to have sediment and blackish growth on the sediment throughout the entire length of the tubing. Review of R180's Electronic Health Record (EHR) did not contain an order for treatment of sediment and blackish growth in the catheter tubing. As a result of this deficient practice, residents with catheters are at risk for more than minimal harm. Findings include: On 10/15/24 at 01:20 PM, conducted an observation and interview with R180 in the resident's room. While conducting the interview, observed R180's catheter tubing with copious amount of sediment and blackish growth throughout the catheter tubing. Resident stated the last time his catheter was changed was 3 weeks ago and prior to that, he had the same catheter and tubing for 3 months. Inquired if staff said anything to the resident…

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

Based on observation, interview, and record review, the facility failed to implement a thorough process to assure accurate reconciliation and accounting for all controlled medications, for 1 of 16 medication carts, in order to promptly identify loss or potential diversion. Findings include: On 10/17/24 at 08:55 AM, an inspection of the North Team 2 medication cart was done with Registered Nurse (RN)3. During a review of the Narcotic Signature Sheet, noted that the oncoming day shift nurse, RN3, had not signed or initialed it yet to attest and verify that the narcotic count was correct. RN3 confirmed that the narcotic count is done at the start of every shift, completed by both the off-going and on-coming nurse, and signed by both. RN3 verified that the off-going nurse had signed it, but she had not. At first, RN3 stated that she usually sign it before the end of my shift. After further questioning however, RN3 confirmed that she should have signed it as soon as the count was done, and agreed that with only one initial, it makes it appear as if the off-going nurse did the count by…

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 manage and monitor the medication regimen for one Resident of five in the sample by implementing a gradual dose reduction (GDR) for use of an antipsychotic or provide the clinical rationale from the physician that it was not recommended. The deficient practice failed to promote the residents highest practicable mental, physical, and psychosocial well-being. Findings include: Resident (R) 32 is an [AGE] year-old male admitted to the facility on [DATE]. Primary diagnosis includes Parkinson's disease and unspecified dementia per record review of the annual Minimum Data Set (MDS). Random observations of R32 on the East dining/ activity area on the following dates, 10/15/24 at 09:16 AM; 10/16/24 at 10:30 AM; 10/16/24 at 2:19 PM; 10/17/24 at 10:14 AM; and 10/17/24 at 2:04 PM. Observed R32 sitting in his wheelchair at the table sleeping or sitting quietly. No aggressive behavior observed. Record review dated 09/18/24. R32 takes the following…

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 store cutting boards and resident plate lids on racks that did not have rust colored debris. This deficient practice could affect all residents who are provided meals from the kitchen, putting them at risk for foodborne illness. Findings Include: On 10/15/24 at 10:04 AM during initial tour of kitchen, a concurrent interview and observation was done. Observation of one rack that had cutting boards stored also had rust colored debris. The Acting Nutritious Services Director stated she would move the (cutting boards) to a different area. On 10/17/24 at 10:50 AM while in the kitchen, to observe the tray line, noticed a rack with rust colored debris that stored the lids for the residents plates. Acting Nutritious Services Director confirmed the rust colored debris and stated she is in the process of replacing both racks.

Based on observation, interviews, and record review, the facility failed to ensure proper cleaning procedures for shared equipment were followed by a staff member. This deficient practice promotes the development and transmission of communicable diseases and infections and has the potential to affect the residents in one of the facility units. Findings include: Observation was conducted on 10/18/24 at 09:30 AM. Licensed Practical Nurse (LPN) 2 was seen rolling a vital signs machine into one of the rooms. LPN2 was not observed cleaning the blood pressure cuff with wipes prior to using it on Resident (R) 143. Once LPN2 was done taking R143's blood pressure and other vital signs, LPN2 rolled the vital signs machine towards R181's bed. LPN2 was observed taking R181's blood pressure. LPN2 did not clean the blood pressure cuff in between the two residents. LPN2 then placed the vital signs machine in the hallway. LPN2 did not wipe down the machine and/or attachments prior to parking it in the hallway. Interview was conducted with LPN2 on 10/18/24 at 09:46 AM. LPN2 stated that she should…

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

Based on observation and staff interview, the facility failed to secure a storage room containing Germicidal Bleach Wipes, Surface Disinfectant Wipes and Hand Sanitizing Wipes. As a result of this deficiency, the facility put the safety and well-being of the residents at risk for accident hazards. Findings include: On 10/16/24 at 02:00 PM, the Storage Room near the Ilima Nurse Station was not secured and no staff was in the immediate vicinity to stop anyone from entering the room. A keypad lock was installed on the door, but the door could be opened by just pulling it. The room contained several containers of Germicidal Bleach Wipes, Surface Disinfectant Wipes and Hand Sanitizing Wipes. Staff interview on 10/16/24 at 02:25 PM, Director of Nursing was queried about the previous observation and acknowledged that the Storage Room should have been secured to prevent any unauthorized entry and accident hazards.

Based on interview and record review, the facility failed to honor the right of Resident (R)3 to receive visitors of her choosing at the time of her choosing, for both visits and telephone calls. As a result of this deficient practice, R3 was denied the opportunity to speak with her son when he called on the phone and denied the choice of receiving visits from her husband. This placed R3 at risk for a decline in her quality of life and prevented her from attaining her highest practicable well-being. The facility corrected the deficient practice prior to the abbreviated survey to investigate a complaint filed on her behalf. Findings include: On 07/29/2024, the State Agency (SA) received a complaint forwarded from the Long-Term Care Ombudsman (LTCO) and a complaint from the attorney of Resident (R)3's family member (FM)1, both detailing how the facility had denied visits/access to R3 from all family members except for her power-of-attorney (POA), as well as the LTCO. On 08/05/24, the state agency received an e-mailed complaint from FM1 detailing several concerns about her care. Among…

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, document and record review (RR), the facility failed to ensure that two Resident's (R)1 and R2 of a sample of four had their comprehensive care plans (CP) reviewed and revised in a timely manner to include high risk behaviors that needed to be closely monitored. R1 had exit seeking behavior, which was not added to the CP in a timely manner, and R2 was not swallowing his medications at the time of administration, which was not added to the CP. As a result of this deficient practice, there was increased risk the behavior would reoccur and may result in a negative outcome. This deficient practice has a potential to affect all residents. Findings include: 1) R1 is [AGE] year old male admitted to the facility on [DATE] after being hospitalized for delirium tremors, alcohol withdrawal, chronic alcoholism and lactic acidosis (build-up of lactic acid in bloodstream). He lived alone and completely independent prior to his admission. His medical history includes severe alcohol use disorder. alcoholic…

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 necessary care and services to maintain the activities of daily living, including personal hygiene for one of three residents sampled. As a result of this deficient practice, Resident (R)3 was hindered from attaining her highest practicable well-being. This deficient practice has the potential to affect all residents at the facility. Findings include: Resident (R)3 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her diagnoses include, but are not limited to, a history of cerebral infarction (stroke), chronic kidney disease, diabetes with diabetic peripheral angiopathy without gangrene (changes in blood vessels that contribute to the formation of plaques in the arteries of the limbs, particularly the feet and legs), and other nail disorders. On 08/05/2024, the state agency received an e-mailed complaint from R3's family member (FM)1 detailing how when he had visited R3 from July 24 to July 28,…

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 adequate diabetic foot care for Resident (R)3. As a result of this deficient practice, the facility placed R3 at risk for avoidable injuries. This deficient practice has the potential to affect all residents in need of diabetic foot care. Findings include: Resident (R)3 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. Her diagnoses include, but are not limited to, a history of cerebral infarction (stroke), chronic kidney disease, diabetes with diabetic peripheral angiopathy without gangrene (changes in blood vessels that contribute to the formation of plaques in the arteries of the limbs, particularly the feet and legs), and other nail disorders. On 08/05/2024, the state agency received an e-mailed complaint from R3's family member (FM)1 detailing how when he had visited R3 from July 24, 2024 to July 28, 2024 he had made several observations that were concerning to him regarding her care. Among…

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 (RR) and interviews, the facility failed to provide incontinence care, in accordance with professional standards of practice and individual care plans (CP) for two resident's (R)1 and R2, of a sample size of seven. As a result of this deficient practice, the residents were at increased risk of adverse outcomes related to incontinence that included comfort, skin breakdown and infection. This could affect their ability to meet their highest potential of physical and mental well-being. The deficient practice had been corrected prior to the survey, and met the criteria for past noncompliance. Findings include: 1) The Office of Healthcare Assurance (OHCA) received a completed facility incident report on 02/29/2024 regarding incontinence care. On the evening of 02/24/2024, a CNA (Certified Nurse Assistant)1 reported two residents (R1 and R2) were allegedly not provided incontinent care by CNA2, scheduled on the day shift. R1 is a [AGE] year old female admitted to facility 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 resident interview, the facility failed to ensure residents were furnished with the information for contacting the State Survey Agency to file a complaint. This deficient practice has the potential to impede a resident(s) ability to exercise their right to file a complaint. Findings include: On 10/12/23 at 09:20 AM an interview was conducted with resident council representatives. The representatives were asked if they have been informed of their right (and provided information on how) to formally complain to the State Survey Agency (SA) about the care they are receiving. The representatives were not aware they could submit a complaint to the SA. Also, the representatives were not aware of whether this information is posted.

Based on observations, interviews, and record reviews, the facility failed to uphold a resident's right to privacy of one resident (R), R367, out of two residents in the sample. A certified nursing assistant (CNA) did not provide the necessary privacy of R367 during his shower. This deficient practice violates the resident's right to privacy and could potentially cause psychosocial harm to the resident. Findings include: On 10/11/23 at 08:26 AM, observations were made on one nursing unit. In R367's room, observed a CNA bathing a resident in the shower. The door to the bathroom was opened, the curtain in the room to cover the large window pane was open, and the room door to the hallway was opened. The resident was naked sitting on a shower chair and the whole left side of his body was able to be visualized from the hallway. Record review of the West Neighborhood Roster updated on 10/08/23 showed that R367 was the sole occupant of that room where the observation of a CNA showering a resident in the bathroom occurred. On 10/12/23 at 09:20 AM, conducted an interview with Certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a comfortable, homelike environment for residents at the facility, as evidenced by hot, uncomfortable temperatures in the resident rooms, especially when the room door was closed for personal care, poor pest control, dusty electric fans that were widely used throughout the facility, and walls in resident room(s) in need of repair. As a result of this deficient practice, the residents unnecessarily experienced an uncomfortable environment that was not homelike, with the potential to cause psychosocial harm. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)165 is a [AGE] year-old female admitted to the facility on [DATE]. Her current diagnoses include, but are not limited to, persistent vegetative state, hemiplegia (muscle weakness or partial paralysis on one side of the body) affecting both sides of the body, and aphasia (loss of ability to understand or express…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2) During an interview with Resident (R)154 on October 10, 2023, they expressed an increase in their anxiety recently, due to the recent Lahaina Fire. The spouse escaped the Lahaina fire with car, family dog and themselves only. The home and all its contents was lost in the fire. Although R154 was not physically present when this occurred, she was traumatized by the news of how her immediate family had escaped, and the loss of the family home and belongings including important documents. Record review of R154's Electronic Heath Record (EHR), and interview with Neighborhood Supervisor (NS)3 and Social Services Assistant (SSA)3 confirmed there was no psychosocial assessment or comprehensive care plan completed for R154 after this traumatic event for trauma informed care. The facility failed to assess, develop, and implement a comprehensive care plan for trauma informed care for R154 following this traumatic event to provide psychological support, services, and treatment. 3) R212 tested positive for COVID on July…

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 review and revise the Resident's Comprehensive Care Plan (CP) for 3 of 36 residents (R) in the sample (Residents 149, 75, and 147), to effectively address their status, condition, and needs. As a result of this deficient practice, staff did not have the information necessary to adequately care for these residents so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)149 is a [AGE] year-old female admitted to the facility on [DATE]. Her admitting diagnoses include, but are not limited to, unspecified trochanteric fracture of left femur (fracture of upper left thigh bone/hip), Alzheimer's disease, dementia, and anxiety disorder. On 09/26/23, the State Agency (SA) received a facility-reported incident (FRI) through e-mail. The FRI (ACTS #10564) detailed an incident where R186 reached out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to: 1) Implement 2 (Residents 147 and 263) of 3 residents' bowel protocol. The facility failed to accurately document 147's bowel activity resulting in unnecessary invasive treatment (suppository and two enemas). This deficient practice has the potential to result in residents experiencing discomfort, fecal impaction, or receiving unnecessary treatment. 2) Assure a root cause analysis for 1 (Resident 75) of 5 residents investigated for skin conditions was done. The facility did not identify contributing factors of skin breakdown. This deficient practice has the potential to result in further skin breakdowns, lack of healing of existing wounds, and/or further wound infections. 3) Inform Resident (R)463 of a schedule change for an appointment with the cardiologist. In addition, the facility did not assure R463's medications were available, to avoid missing doses. This deficient practice has the potential to result in the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. Facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP) and while handling potentially contaminated items, performed hand hygiene after removing gloves, and maintained shower chairs in sanitary and good repair. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: 1) On 10/10/23 at 10:42 AM, observed Registered Nurse (RN)15 wearing a gown, gloves and face mask while providing care to a resident in room [ROOM NUMBER]. RN15 said she was giving medications through the gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) and a gown was required because the resident is on enhanced barrier precautions. There was a sign by the door that…

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

Based on interviews, the facility failed to assure residents of the facility were treated with respect and dignity and provided care in an environment that enhances their quality of life. This deficient practice has the potential to result in residents not attaining or maintaining their highest practicable physical and psychosocial well-being. Findings include: On 10/12/23 at 09:20 AM an interview was conducted with resident council representatives in the Gardenia neighborhood. A resident reported sometimes the facility is short-handed and staff must work doubles. The resident further shared that she/he feels for the staff and most of them are very nice but sometimes they have an attitude, maybe they had a bad day. A resident also reported that staff will call female residents mama or grandma and expressed concern for females who are single and don't have children or grandchildren. The resident also shared, maybe these residents may not want to be called mama or grandma. A resident reported experiences of activating the call light, staff respond and turn off the call light. 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 and interview, the facility failed to accommodate the needs of 1 of 2 residents (R) sampled by not ensuring that her call light was always placed within her reach, or positioned so that she could activate it. As a result of this deficient practice, R65 was placed at risk of not having her emergent needs met in a timely manner and was prevented from achieving independent functioning with regards to calling for help. This deficient practice has the potential to affect all the residents at the facility who can activate a call light. Findings include: Resident (R)65 is a [AGE] year-old female admitted to the facility on [DATE]. R65's current diagnoses include but are not limited to osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time) of both hands, chronic pain, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and dementia. On 10/10/23 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, interviews and record review, the facility failed to identify and ensure the resident's right to make choices about aspects of his life that are significant to him was supported for 1 of 6 residents (Resident (R) 110) in the sample. The facility did not identify and accommodate R110's choice to smoke more than twice daily. As a result of this deficient practice, the resident was at risk of potential negative psychosocial outcomes. Findings include: On 10/10/23 at 11:24 AM, initial interview with R110 conducted in his room. R110 said he is a smoker and was only allowed to smoke twice a day. R110 also said that he has terminal cancer and would like to smoke at least four times a day. When asked if he had brought this up with the staff, he responded that he has but the staff do not listen to him. He feels that he does not have a choice and can only go out to smoke when the staff are able to take him. On 10/11/23 at 10:44 AM, observed R110 up in a non-motorized wheelchair being pushed by…

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

Based on observations, interviews, and record review, the facility failed to ensure one of the 36 residents (Resident (R) 8) in the sample was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. R8 had her bed positioned against the wall and a pillow was placed under the fitted bed sheet. As a result of this deficient practice, R8 was not able to get out of bed on her own. Findings include: On 10/10/23 at 10:26 AM, observed R8 lying in bed with a pillow on her left side placed under the fitted bed sheets. Her bed was also positioned against the wall on her right ride. At 01:33 PM, R8 was observed in bed with left arm leaning on the pillow on her left side that was still under the bed sheet. Asked R8 if she needed to get out of bed but she did not verbally respond. On 10/11/23 at 08:04 AM, observed R8 lying in bed with eyes closed. A pillow was placed under the fitted bed sheet on her left side. On 10/12/23 at 09:27 AM, observed R8 lying in bed with eyes closed. A pillow was placed under the fitted bed sheet…

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 written notice of transfer or discharge for one of three residents (Resident (R) 14) sampled for hospitalization, and failed to send a notice of discharge to the Office of the State Long-Term Care Ombudsman (LTCO). Findings include: R14 was admitted to the facility on [DATE]. On 10/11/23 at 11:07 AM, a review of the Electronic Health Record (EHR) for R14 revealed that she was transferred and admitted to a local acute care hospital on [DATE] for pneumonia, and on 09/10/23 for a leaking gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). A document titled, Notice of Resident Discharge/Transfer and Bed Hold Policy dated 09/13/23 was scanned into the EHR. The document noted that R14's family and the LTCO were notified of the discharge to the hospital on [DATE]. However, no document was found for R14's hospitalization on 07/07/23. On 10/18/23 at 09:27 AM, a concurrent interview and record review was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Resident 2 and Resident 165) sampled received the appropriate treatment, equipment, and services to increase or prevent further decrease in range of motion (ROM). As a result of this deficient practice, both residents have been placed at risk of worsening contractures and hindered from reaching their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits. Findings include: 1) Resident (R)165 is a [AGE] year-old female admitted to the facility on [DATE]. Her current diagnoses include, but are not limited to, persistent vegetative state, hemiplegia (muscle weakness or partial paralysis on one side of the body) affecting both sides of the body, and aphasia (loss of ability to understand or express speech, caused by brain damage). In addition, R165 has a gastrostomy tube (an opening into the stomach from the abdominal wall, made…

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) R134 had an indwelling urinary catheter. It was observed by this writer that on October 10, 11, 12, 17 and 18, 2023, the catheter bag had a privacy cover over it, and was attached to the side of the bed. However, on each observed occasion, the bag with the privacy cover was sitting on the floor, allowing easy access for any bugs or insects crawling on the floor to enter into the privacy cover, providing a risk of contamination that may lead to a urinary track infection for R134. The facility failed to ensure safe and adequate catheter care was being conducted. Based on observations and interviews, the facility failed to ensure that 2 of 2 residents (Resident (R) 179 and R134) sampled for indwelling urinary catheters received the appropriate treatment and services to prevent urinary tract infections. This deficient practice has the potential to expose both residents to contaminants that may cause preventable urinary tract infections. Findings include: 1) On 10/12/23 at 04:00 PM, observed Registered Nurse (RN)25 and a nursing student in R179's room without wearing a gown. R179 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with staff members, the facility failed to assure resident's enteral formula was labeled with resident's name, date and time of preparation, rate of feeding and the resident's room number on the label for 1 (Resident 75) of 1 resident sampled. This deficient practice has the potential to result in administration to the wrong resident, over/underfeeding, or using expired formula. Findings include: Resident (R)75 was admitted to the facility on [DATE]. Diagnoses include but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side; other paralytic syndrome following non traumatic intracerebral hemorrhage; quadriplegia (form of paralysis that affects all four limbs, plus the torso), unspecified; aphasia (language disorder that affects a person's ability to communicate); and dysphagia (difficulty swallowing foods or liquids). On 10/11/23 at 08:06 AM observed R75 lying in bed. There was a bag of Diabetisource formula…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to ensure 2 of 6 residents (R) sampled for respiratory services (Residents 2 and 165) received care consistent with professional standards of practice or facility protocol. As a result of this deficient practice, the residents' safety was compromised, and they were placed at an increased risk of avoidable injuries and/or adverse outcomes in the event of a respiratory emergency. This deficient practice has the potential to affect all residents at the facility with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs). Findings include: 1) R2 is an [AGE] year-old female admitted to the facility on [DATE]. Her current diagnoses include, but are not limited to, primary lateral sclerosis (a neuromuscular…

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

Based on resident interview, record review and staff interviews, the facility failed to identify a recent trauma and any triggers that may further traumatize the resident for one of the residents in the sample. Findings include: During an interview with Resident #154 (R154) on the afternoon of October 10, 2023, they expressed feelings of increased anxiety. The resident's spouse was present and informed surveyor of her escape from the recent Lahaina fire, escaping with only themselves, the family pet dog and the car. The house and all belongings were lost in the fire. Although the resident was not physically present during the fire, the news of the fire and its direct impact on her spouse, their family home, and family pet dog was traumatizing for her to learn about, and increased her level of anxiety that she already suffered with. A document of a Trauma-Informed Care Observation dated 08/15/2023 provided by the facility post-survey, asked the question Have you ever experienced, witnessed, learned about a natural disaster (e.g. flood, tornado, hurricane, earthquake etc.)? R154…

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 with staff member, the facility failed to competently provide nursing services for administration of medication as evidenced by the nursing staff not following standard procedure and best practice for administering medications. In addition, the nurse administered the medications approximately 2 hours after the scheduled time, as per the provider orders. Findings include: On 10/12/23 at 10:14 AM observed Resident (R)140 seated at a table in the breezeway with another resident, R54, with no visible staff around. R140 was ingesting a pudding-like substance from a small plastic cup. Inquired if she was taking her medicine, R54 nodded her head yes. Neighborhood Supervisor (NS)2 was called over and a concurrent observation was done. NS2 confirmed the small plastic cup contained R140's crushed medication mixed in pudding. Inquired whether R140 was assessed to self-administer her medication. NS2 responded R140 receives crushed medication and can scoop and ingest 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 ensure all medications used in the facility were labeled in accordance with professional standards, including accurate expiration dates. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. In addition, the facility failed to clearly label a multidose vial (MDV, medication vial that is accessed multiple times to deliver doses to different residents) in one medication room out of three rooms sampled. The opening date of a multidose vial (MDV) of tuberculin (TB) purified protein derivative (PPD) was not clearly written on the vial. This medication is injected under the skin of residents to check for the presence of tuberculosis (disease where a specified type of bacteria infects the lungs and/or other organs). This deficient practice could potentially cause an infection in residents receiving a medication that is accessed multiple times from the MDV. These…

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 one resident (Resident 186) that were accurately documented, in accordance with accepted professional standards and practices. This deficient practice has the potential to affect all the residents at the facility. Findings include: On 10/12/23 at 09:18 AM, during a review of Resident (R)186's comprehensive care plan, it was noted that no revisions were made to his Behavioral Symptoms care plan following an incident on 09/26/23 where he spontaneously grabbed R149 by the forearm and left a bruise. On 10/12/23 at 09:30 AM, requested a printed copy of R186's comprehensive care plan from the Administrator. At 11:18 AM, the care plan was received from the Administrative Assistant (AA). Under the care plan for Behavioral Symptoms was the following intervention documented with a start date of 09/29/23: I have a tendency to grab someone if you are close to me, and I do not realize my own strength. Try to keep other residents at a safe distance from me. At 11:31 AM, a review of a Care Plan History Report revealed that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure pneumococcal vaccination was offered to one of the five residents (Resident (R) 179) in the sample. This deficient practice placed the resident at risk for acquiring, transmitting, and developing possible complications from pneumococcal disease. Findings include: On 10/17/23 at 03:30 PM, review of R179's Electronic Health Record (EHR) conducted. R179 is an [AGE] year-old resident admitted to the facility on [DATE] for long-term care. Review of vaccination records revealed that R179 did not receive the pneumococcal vaccine. On 10/18/23 at 09:53 AM, concurrent interview and record review conducted with Registered Nurse (RN)15 in the nurses' station. RN15 confirmed that R179 did not receive the pneumococcal vaccine after checking the EHR. RN15 also said that there was an order to offer the vaccine but does not know if the vaccine was offered since there was no signed consent or declination form in the EHR. RN15 said she will follow up 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.