Life Care Center Of Kona

Based on interview and record review, the facility failed to ensure an account of all controlled drugs is maintained. Reconciliation of the controlled medication reconciliation sheet and the medication documented a discrepancy between the count of the medication and the number of actual pills. As a result of this deficient practice, there is the potential for more than minimal harm. Findings include: On 09/24/24 at 09:57 AM, conducted an inspection of a medication cart with Licensed Practical Nurse (LPN)13. Review of R41's-controlled medication reconciliation sheet for Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) documented 38 tablets. Counted the actual pills stored in the locked compartment with LPN13 which documented only 37 pills. Reviewed R41's Medication Administration Record (MAR) with LPN13. R41's MAR did not contain documentation the medication was administered to the resident. LPN13 reported R41 was administered Oxycodone HCl 5 mg at 07:30 AM for the resident's complaint of a pain level, 5 out of 10. LPN13 confirmed she should have updated the Controlled Medication…

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 assure two residents reviewed, of the 18 sampled, had accurate information placed in their Electronic Health Record (EHR). Review of R20's Advanced Health Care Directive (AHCD) found it was signed by the agent the resident had selected to be his decision maker and not by the resident. R2's physician documented resident as [AGE] years old over a three-year span, identified the resident as full code when he is a Do Not Resuscitate (DNR) and documented resident did not have any allergies when he is allergic to Clindamycin. The deficient practice puts all residents at risk if the resident's AHCD is not filled out correctly prior to it being utilized by the facility and resident's health status is not accurately documented by the physician. Findings Include: 1) On 09/23/24 during record review of R20's EHR found there is a copy of his AHCD which shows his agent, the person named as the one making healthcare decisions for R20 signed the form where R20 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 observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents on isolation. The facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to Resident (R)1, who was on Enhanced Barrier Precautions (EBP), and performing hand hygiene between glove changes. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings include: On 09/22/24 at 10:43 AM, observed a sign by the entrance of R1's room that stated, Enhanced Barrier Precautions . Everyone Must: . Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing . Transferring . Wound Care: any skin opening requiring a dressing . On 09/23/24 at 11:00 AM, observed RN (registered nurse) Care Manger (CM) and Certified Nursing Assistant (CNA)23 change the dressing to R1's open wounds to his back and buttocks. CM and CNA23 entered R1's room without wearing a gown. CM placed the supplies 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 record review and staff interviews, the facility failed to ensure pneumococcal vaccine was offered to one of the five residents (Resident (R)1) in the sample. This deficient practice placed the resident at risk for acquiring, transmitting, and developing possible complications from pneumococcal disease. Findings include: Review of the Electronic Health Record (EHR) of R1 was conducted. Vaccination tab of the EHR had the records of all vaccines administered to the R1 including vaccines not given at the facility. Review of the vaccination records revealed that R1 has not received the pneumococcal vaccine. On 09/24/24 at 02:09 PM, a concurrent interview and record review was conducted with the Infection Preventionist (IP) in her office. Asked IP if there were any records or scanned documents in the EHR to show if R1 was given the pneumonia vaccine or if he declined the vaccine. IP was not able to find a consent or declination in the EHR and said will ask Administrator if there was one paper in the paper chart. On 09/24/24 at 03:29 PM, Administrator confirmed that R1 was 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 observations and staff interviews, the facility failed to follow safe food storage requirements. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for food-borne illnesses. Findings include: 1) On 09/17/23 at 10:14 AM, initial tour of the kitchen area was conducted. Observed a wall-mounted fan next to the entrance that was turned on and directed at the food preparation area. A thick layer of dust was observed on both front and back screens of the fan. On 09/19/23 at 11:02 AM, concurrent observation and interview conducted with Food Services Director (FSD). Showed FSD the wall-mounted fan that still had a thick layer of dust on both front and back screens. FSD acknowledged that the fan was dusty and needed to be cleaned. FSD also said that it was installed a few months ago and was not put on the assignment log yet to remind the kitchen staff to clean it every month. FSD added that she will have the staff clean the fan after they are done with the lunch service. 2) On 09/17/23 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.

Based on interviews and record review, the facility failed to set priorities for its performance improvement activity that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in that area, and affect health outcomes, and resident safety. Findings include: Prior to conducting the facility's Quality Assurance Performance Improvement (QAPI) program, the facility's matrix (printed 09/17/23 at 02:34 PM) and new admission matrix (printed 09/17/23 at 12:00 PM) were reviewed. Both matrix's reviewed excluded Resident (R)6 and the resident is not included following data. The mode of information provided on the matrix is quantified from either a resident's most recent Minimum Data Set (MDS) submission with no distinction between annual, quarterly, or significant change submissions. Both matrixes identified the following areas: Falls- 19 residents Infections- 7 residents Significant weight loss/gain- 5 residents Indwelling catheter- 4 residents Intravenous therapy (IV)-3 residents Pressure ulcers (PU)-1 resident Hemodialysis…

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 review of the Staffing Report from the Centers for Medicare and Medicaid Services (CMS), the facility failed to have sufficient nursing staff to provide 24-hour nursing care. As a result of this deficiency, the call bell response was delayed for one Resident (R)13 out of four residents sampled and the CMS Staffing Report identified this facility for having low staffing. Findings include: During resident interview on 09/17/23 at 11:00AM, R13 stated sometimes it would take up to thirty minutes or more for staff to answer the call bell and that the facility could use more nursing staff. Staff interview 09/17/23 at 01:00PM, Administrator said that the facility was currently short on staffing and that they were working on various efforts to increase their staffing numbers. Review of CMS Staffing Report showed there was low staffing for this facility.

Based on staff interview, the facility failed to designate an individual as the Infection Preventionist (IP) that works at least part-time at the facility. The individual designated as the IP is also working full-time as the Director of Nursing (DON). Findings include: During the entrance conference on 09/17/23 at 10:34 AM, inquired as to who was the IP for the facility. The Administrator confirmed the IP position is currently open and the DON and a unit supervisor have been covering the position. On 09/20/23 at 09:15 AM, an interview was conducted with the DON in her office. Asked DON how long has she been covering as the IP for the facility. The DON said that she has been covering for the position since January 2023 when the facility's designated IP resigned. Asked DON if there was anyone else in the facility trained to perform the responsibilities of the IP. The DON said another RN is currently in training but will only be the backup once she has completed her training. DON also added that the facility is actively looking for a qualified applicant to fill the position permanently…

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 notify the resident's physician or inform the resident's representative of a serious medical incident for two Residents (R)23 and R40 sampled. The deficient practice placed the residents at risk of harm. Findings include: 1) The State Agency (SA) received a Facility Reported Incident (FRI) #10454 documented on 07/20/23, R20 got upset with R23 for yelling and poured hand sanitizer on R23's head. Residents were separated and R23's eyes were flushed with normal saline. On 09/18/23 at 09:05 AM, conducted a review of R23 Electronic Health Record (EHR), documented the resident is an [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnosis which include Dementia, Alzheimer's, and routine healing of fractures. Review of the R23's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/23, Section C. Cognition, Brief Interview for Mental Status (BIMS) score was 4, indicating…

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 notification of transfer and/or discharge to the resident, resident's representative, and/or to the Office of the State Long-Term Care Ombudsman (LTCO) for two residents (Resident (R)55 and R4) sampled. Findings include: (Cross Reference to F625: Notice of Bed Hold Policy Before/Upon Transfer) 1) R55 was admitted to the facility on [DATE] for long term placement. Review of the Electronic Health Record (EHR) documented R55 was transferred to an acute care hospital on [DATE] after an unwitnessed fall. Progress note documented that the emergency department, attending physician, R55's family and on-call supervisor were made aware of the transfer. On 06/10/23, it was documented in the progress notes that R55 was admitted to the acute care hospital. It was not noted if the LTCO was notified. Unable to locate documentation of LTCO notification in the EHR. Requested a copy of the LTCO notification of discharge for R55 from the Administrator on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide a written bed-hold notice at the time of transfer of a resident to hospitalization to the resident and the resident representative which specifies the duration of the bed-hold policy for two Residents (R)4 and R55 sampled. This deficient practice has the potential to affect all residents. Findings include: (Cross Reference to F623 Notice Requirements Before Transfer/Discharge) 1) The State Agency (SA) received a Facility Reported Incident (FRI) #10338 documented on 06/05/23, R4 had an unwitnessed fall in the resident's bathroom, assessed with significant pain to the right hip, and was transferred to an acute hospital for further evaluation and treatment. The acute hospital reported to the facility that R4 had sustained a right hip fracture and would be admitted to the acute hospital. During the review of R4's EHR, on 09/19/23 at 10:08 AM, this surveyor was unable to find documentation a written bed-hold notification was provided 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 record review, staff interview and review of Minimum Data Set (MDS) instruction, the facility failed to properly transmit the discharge MDS to the Centers for Medicare and Medicaid Services (CMS) System, for three Residents (R)33, R42, R43 out of three residents sampled. As a result of this deficiency, there was inaccurate data in the CMS System. Findings include: On 09/18/23 at 02:35 PM, Record review showed the following discharges: R33 discharged from the facility on 05/14/23, R42 discharged from the facility on 05/13/23, R43 discharged from the facility on 05/30/23. The Long-Term Care Survey Process (LTCSP) triggered that the MDS Record for these residents were over 120 days old. During staff interview on 09/18/23 at 03:20 PM, the MDS Coordinator acknowledged that the three MDS records, previously mentioned, were not transmitted the CMS System. Review of the MDS instruction read Discharge Assessments, generally completed when Medicare Part A stay ends . or the resident is physically discharged on the same day or within one day of the end of the Medicare Part A stay. 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 interviews and record reviews, the facility failed to ensure the comprehensive person-centered care plans were implemented for one Resident (R)8 in the sample. R8 was left alone in the bathroom and had an unwitnessed fall. As a result of the fall, R8 was injured and sustained a hematoma on the forehead. There were signs in R8's bathroom to not leave the resident alone and the resident's care plan documented an intervention to not leave the resident alone in the bathroom. As a result of this deficient practice, R8 was physically harmed and is at risk for a decline in their quality of life. There is the potential for all residents to not attaining their highest practicable physical, mental, and psychosocial well-being if the resident's comprehensive person-centered care plan is not implemented. Findings include: (Cross Reference to F689 Free of Accident Hazards) On 09/17/23 at 11:17 AM, observed R8 in her room sitting up in her wheelchair. R8 had a dressing on the right side of her forehead. When asked…

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 revise a resident's comprehensive person-centered care plan for one Resident (R)4 sampled. The deficient practice places all residents at risk of harm, with the potential to not reach their highest quality of life, and/or the highest physical, mental, and psychosocial well-being. Findings include: On 09/18/23 at 11:07 AM, observed R4 wheel herself down the hallway and into R1's room. Observed R4 seated in the wheelchair at R1's bedside (only R4's feet and the lower one-fourth of the wheelchair was visible), the privacy curtain was drawn, and the residents were unsupervised. Concluded observation of the resident's at 12:46 PM, due to R4 leaving the room. From 11:15 AM to 12:46 PM, R4 and R1 were unsupervised and not visible from the doorway so staff walking past the room would not be able to tell what was happening behind the curtain. During that time, no staff entered the room to ensure the residents were safe and/or interacting appropriately. On 09/18/23 at 09:15 AM, conducted a review of R4'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.

Based on observations, interviews, and record review, the facility failed to ensure a resident receives the necessary services to maintain grooming for one Resident (R)29 sampled. Findings include: On 09/18/23 at 08:50 AM, conducted an observation and interview with R29. Observed R29's skin was dry, cracking and the resident's toenails were thick, yellow, and growing over the front of his toes. The greater toenail was so long, that it grew over the front of the toe and appeared to be in contact with the ground. Asked the resident if he was able to cut his toenails. R29 confirmed he is unable to cut his own toenails. The resident stated his nails are too thick and cannot be cut with a regular nail clipper. Observation of R29's toenails confirmed it was too thick to fit in a nail clipper and needs to see a podiatrist for proper care. Inquired if he would like to have his toenails trimmed and lotion on his feet, the resident stated Yes, I would like that, because I cannot do it myself, or I would. On 09/19/23, requested a copy of any documentation of a podiatry appointment or…

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 staff interview, the facility failed to provide annual in-service education for one Certified Nursing Assistant (CNA)18 out of eleven staff sampled. As a result of this deficiency, the facility failed to conduct in-service education at least once every twelve months as required. Findings include: Record review on 09/21/23 at 11:00AM, In-Service Record for CNA18 showed the following: last in-service on Hazmat 06/02/22, last in-service on Infection Control 06/03/22, last in-service on Fire and Safety 06/02/22, last in-service on Accident Prevention 07/06/22, last in-service on Patient Rights 06/03/22. Staff interview on 09/21/23 at 12:30PM, Administrator acknowledged that the in-service education for CNA18 was out of the twelve-month requirement period

Based on observation, interview, and record review, the facility failed to ensure a resident's own medication stored in the medication cart was properly labeled in accordance with professional standards, including the expiration date and cautionary instruction. As a result of this deficient practice, residents are at a potential risk of harm. Findings include: On 09/19/23 at 08:50 AM, conducted an inspection of a medication storage cart. In the bottom drawer of the medication cart, observed a bottle of Acetaminophen 325 milligrams (mg) with no label and R34's last name written on the top of the cap with a sharpie pen. Review of R34's Physician's Orders documented an order for Acetaminophen 650 mg by mouth every four hours as needed for pain or temperature above 100.8 degrees Fahrenheit, not to exceed 3 grams in 24-hours. The physician's ordered cautionary instruction to not exceed 3 grams in 24 hours due to the potential for serious liver damage. Shared observations with the Director of Nursing (DON) who stated the bottle of Acetaminophen 325 mg was R34's own medication, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed facility protocols for standard and transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE), wearing PPE appropriately, and failing to dispose of trash from an active COVID-19 room properly. In addition, the facility failed to provide care for residents with COVID-19 in alignment with the Centers for Disease Control and Prevention's (CDC) guidelines. 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: Cross-reference to F886 COVID-19 Testing. The facility failed to ensure staff conducting point-of-care (POC) COVID-19 outbreak testing on themselves conducted the testing in a manner consistent with current…

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 Comprehensive Care Plan (CP) for five residents (R) (R11, R46, R19, R48, and R13) in a sample of 18 residents, 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) Cross Reference to F684. R11 was with moisture-associated skin damage (MASD) for approximately one month and eventual development of a Stage 2 pressure ulcer. R11 was admitted to the facility on [DATE]. Diagnoses includes but not limited to personal history of transient ischemic attach and cerebral infarction without residual deficits, fistula of vagina to large intestine, dementia with behavioral disturbance, and history of urinary…

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 staff conducting point-of-care (POC) COVID-19 outbreak testing on themselves conducted the testing in a manner consistent with current standards of practice for conducting COVID-19 tests. As a result of this deficient practice, the facility placed the residents and staff at an increased risk of COVID transmission. This deficient practice has the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: On 06/08/22 at 12:21 PM, an interview was done with the Infection Preventionist (IP) in the conference room. The IP stated that the facility was currently in outbreak testing since 05/21/22. Residents were being tested for COVID-19 twice a week until 05/30/22, then decreased to once a week. Staff remained on twice a week testing. On 06/09/22 at 06:55 AM, arrived at the facility and observed Occupational Therapist (OT)2 and Staff Member (SM)1 standing outside the staff entrance after just swabbing themselves for COVID-19.…

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 ensure that one resident (R)27, out of a sample of 18 residents, was able to use his call light appropriately to alert staff for assistance. The facility did not ensure that R27's call light was within reach for his use and did not assess if R27's current call light was still appropriate for his use and mentation. This deficient practice has the potential to affect all residents suffering from Alzheimer's disease in the facility and who rely on staff for assistance. Finding includes: On 06/06/22 at 11:12 AM, an initial observation of R27 was done. R27 was lying in bed and his call light control was not nearby. R27 was queried as to how he would call for assistance and he stated, I don't know how to communicate (with staff). On 06/07/22 at 08:21 AM, R27 was lying in bed with his call light clipped to the bedsheet to the right of him. His roommate, R32, stated that R27 forgets that he has his call light. R27 stated, No one told me that I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure that a transfer summary detailing R50's medical history was completed by his physician and sent to the local area hospital he was transferred to. This deficient practice failed to communicate important information about R50's acute illness that may have hindered continuity of his care. This has the potential to affect all residents who transfer to a hospital for treatment. Findings include: On 06/07/22 at 2:32 PM, R50's EHR was reviewed. R50 is a [AGE] year-old resident that was initially admitted to the facility on [DATE] for complicated diabetes and chronic obstructed pulmonary disease (an inflammatory lung disease that causes obstructed airflow from the lungs). A physician encounter with date of service 05/17/22 was read. It stated that R50 was transferred to a local area hospital on [DATE] for difficulty breathing and decreasing oxygen levels in his blood. Given his rapid decline and his expressed desire to be fully treated, it was felt…

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 ensure that the appropriate notifications were done when R34 was transferred to a hospital for emergent care, a facility-initiated transfer. This deficient practice fails to protect residents from involuntary discharge and has the potential to affect all residents in the facility. Finding includes: On 06/07/22 at 1:32 PM, R34's EHR was reviewed. The Progress Notes from 04/07/22 to 04/13/22 were read. On 04/08/22, R34 had medical changes that included right sided facial drooping, incontinence of urine that was new, and low blood pressure. R34 was transferred to a hospital for evaluation and was admitted to the hospital. There was no documentation that a written notification of R34's facility-initiated transfer was sent to his family and to the Ombudsman. The hospital discharge summary was reviewed, and R34 was admitted to the facility on [DATE] for a heart condition and discharged back to the facility on [DATE]. On 06/09/22 at 09:00 AM, the DON 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 record review and interview with staff members, the facility failed to ensure a discharge summary with an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another was done. The discharge summary may help reduce or eliminate confusion for the continuum of care. Findings include: Record review done on 06/07/22 at 2:24 PM noted R54 was admitted to the facility on [DATE] and discharged on 05/14/22. A review of the progress note dated 05/14/22 documents the family decided to take resident home today due to financial issue. The physician was notified. The family signed form for discharge against medical advice. Medications were released to the family. R54 was discharged with her family with recommendation to see her primary community physician as soon as possible. Further review found no documentation of a discharge summary. Requested a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff members, the facility failed to monitor, and evaluate Resident (R)11's response to interventions, and/or revise the interventions as appropriate to facilitate the healing of moisture-associated skin damage (moisture-associated skin damage is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). This deficient practice compromised R11's skin and possibly a contributory factor to the development of a Stage 2 pressure injury. Findings include: Cross Reference to F657. The facility failed to revise care plan interventions to treat moisture-associated skin damage (MASD). Cross Reference to F686. Resident (R)11 had compromised skin and developed a Stage 2 pressure injury. R11 was admitted to the facility on [DATE]. Diagnoses includes but not limited to personal history of transient ischemic attack and cerebral infarction without residual deficits, fistula 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, record review and interview with staff members, facility failed to prevent the formation of pressure ulcers [localized damage to the skin and/or underlying soft tissue usually over a bony prominence) for one, R11, of two residents sampled. A resident assessed at mild risk for developing a pressure ulcer developed a Stage 2 pressure ulcer and this deficient practice has the potential to affect all residents dependent on staff for care. Findings include: Cross Reference F684. Resident (R)11 with compromised skin, moisture-associated skin damage to the groin and coccyx for approximately one month with no change in interventions/treatment possibly contributed to the development of a Stage 2 pressure ulcer to the coccyx/sacrum. R11 was admitted to the facility on [DATE]. Diagnoses includes but not limited to personal history of transient ischemic attack and cerebral infarction without residual deficits, fistula of vagina to large intestine, history of falling, anxiety disorder, dementia with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that two residents, R46 and R19, in the sample were free from accident hazards by thoroughly assessing and developing interventions consistent with their needs. As a result of this deficient practice, R46 and R19 were placed at risk of an avoidable accident and/or injury. This deficient practice has the potential to affect all the residents at the facility who are at a high risk for falls or display exit-seeking behavior. Findings include: 1) Cross Reference to F657. Based on the root cause analysis, the facility did not revise the resident's care plan to include factors contributing to the resident's fall. Resident (R)46 was admitted to the facility on [DATE] with diagnoses including but not limited to anxiety disorder; displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing; unspecified nondisplaced fracture of first cervical vertebra, subsequent encounter for fracture…

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 reviews, the facility failed to ensure that medically related social services were provided to one resident (R)32, out of a sample of two residents. This deficient practice failed to provide emotional support to R32 and ensure the highest practicable mental and psychosocial well-being is maintained. The deficient practice has the potential to affect all residents in the facility who suffer from depression. Finding includes: On 06/07/22 at 08:30 AM, an initial observation and query was done with R32. R32's bed was by the window, and he was watching television. R32 had a depressed affect. R32 stated that there was no social worker (SW) in the facility, that the staff are too busy to talk to him, and that State Agency (SA) had been the only one to come into his room to converse. On 06/07/22 at 12:24 PM, R32's electronic health record (EHR) was reviewed. R32's PHQ-9 (Patient Health Questionnaire; a nine-question survey to assess for the presence and severity of depression) dated 01/17/22 was scored at zero or minimal depression. PHQ-9…

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 record review, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two medication errors observed out of twenty-eight opportunities for errors, for an error rate of 7.14%. Safe medication administration practices are essential for the health and well-being of the residents. As a result of this deficient practice, two residents received the wrong medication. This deficient practice has the potential to affect all residents in the facility. Findings include: On 06/08/22 at 08:23 AM, during medication administration, observed Registered Nurse (RN)1 prepare and administer to Resident (R)48 one tablet of Senna Plus 50/8.6mg [milligrams]. Senna Plus is senna and docusate sodium, a laxative with stool softener compound. At 09:56 AM while reviewing R48's electronic health record (EHR), it was noted that the medication order was for senna 8.6mg (the laxative) alone. On 06/08/22 at 08:31 AM, during medication administration, observed RN1 prepare and administer to R41 one tablet of Calcium 600mg. At 10:00 AM while reviewing R41'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 observation and interview, the facility failed to ensure all medications used in the facility were securely stored in locked compartments, and that floor stock medications were not used past the manufacturer expiration dates. Proper storage and labeling of medications is necessary to promote safe administration practices, and to decrease the risk of medication errors and diversion of resident medications. This deficient practice has the potential to affect all residents in the facility. Findings include: On 06/07/22 at 09:10 AM, while walking through the unit, observed an unlocked and unmonitored medication cart outside a resident room, blocking the doorway. There was no staff in sight. The resident's room had no resident in Bed A, closest to the door, and Bed B, near the window, had its privacy curtain pulled closed. State Agency (SA) sat in hallway across from the resident's room and the unsecured medication cart to continue observations. Observed two residents and one staff member walk past the cart. At 09:14 AM, observed Licensed Practical Nurse (LPN)4 come from behind…

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.