Aloha Nursing & Rehab Centre

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record and document review, the facility failed to make timely revisions to the comprehensive person-centered care plan of four residents (R)1, R2, R3 and R4, of six residents sampled. Findings include: 1) R1 was a male admitted to the facility on [DATE] for pneumonia, due to Coronavirus. He required one person assist for all activities of daily living. On 09/09/2024, a family member (FM)1 made a complaint regarding nursing care, and specifically requested that R1's clothes be changed daily, and that he would be up for all meals. Review of the complaint/grievance form included the follow up .(Director of Nursing/DON) to f/u w/CNA's (follow up with Certified Nurse Assistants) about standard of care-specifically changing Res' (R1's) clothes daily. Res will be up for all meals. The document indicated the issue was resolved. Review of Nursing Progress notes dated 09/25/2024 at 10:57 AM revealed the following entry: .Requires 1x person mod (moderate) assist with ADL's and transfers.Requires 1:1…

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 identify and plan in advance for the situation where one Resident (R)4, of one sampled, would have a predictable condition decline, in which health care decision-making would be needed to provide guidance to the direct care staff. Specifically, when R4 had a significant change of condition, clinical interventions where implemented, the Power of Attorney (POA) was notified in a timely manner for direction, but staff failed to immediately consult with the physician about the condition change. As a result of the lack of planning, there may have been a delay in transfer to a higher level of care. Findings include: 1) R4 was a [AGE] year old male, who was a long term resident at the facility with a history of Parkinson's Disease, dementia, severe dysphagia (difficulty swallowing), coronary artery disease, chronic obstructive pulmonary disease, asthma, hypertension, and congestive heart failure. On 03/03/2025, R4 was sent to the hospital due to shortness of…

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

Based on interviews and record review, the facility failed to ensure a resident's right to be informed in advance of the risks and benefits of proposed care for two of three residents (R) (R4 and R11) sampled. The facility did not have documentation that the resident or resident representative was informed, in advance, of the risk and benefits of psychotropic medication therapy. As a result of this deficient practice, resident's receiving psychotropic medication are at risk for more than minimal harm. Findings include: 1) On 01/03/25 at 02:13 PM, conducted a review of R4's Electronic Health Record (EHR). Review of physician orders documented an order for scheduled Lexapro (ordered on 12/03/24) and Ativan as needed (PRN) (ordered 11/29/24). R4's EHR did not contain documentation for the use of Lexapro and Ativan and documentation of education regarding the risk versus benefit for both medications. On 01/03/25 at 03:40 PM, conducted a concurrent interview and record review of R4's EHR with the Director of Nursing (DON). DON navigated R4's EHR and confirmed the facility did not inform…

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 review of the policy, the facility failed to store food in a safe manner and maintain a sanitary cooking area. Two nourishment refrigerators on the first and second floors internal temperatures were not kept at or below 41 degrees. Perishable foods in the refrigerators were found to be at temperatures that were at 49.5 and 51 degrees. One pantry refrigerator in the main kitchen was found with an internal temperature at 43 degrees. Opened foods were not labeled with an indication of when staff should dispose of the food in the pantry, dry storage, and cooking areas. The deficient practice places residents in the facility at risk for foodborne illness. Findings include: Observation in the Kitchen on 08/06/24 at 08:40 AM in the pantry refrigerator, observed an open package of shredded [NAME] mozzarella cheese with no label or date. There was no internal thermometer found inside the unit. The external digital temperature reading was 48 degrees. The surveyor asked the kitchen…

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

Based on record review and interview, the facility failed to include in the facility assessment the staffing resources required to meet the needs of their resident population. This deficient practice has the potential to affect all the facility's resident's ability to maintain or attain their highest practicable physical, functional mental and psychosocial well-being. Findings include: The facility assessment stated the facility is licensed for 141 beds with an average daily census of 95 residents based on the resident population profile from 06/05/23 to 06/04/24. Review of the facility assessment found documentation that describes the facility's resident population and acuity levels, however, there was no documentation of the staffing levels required to meet the residents' needs. On 08/09/24 at 10:04 AM, a concurrent interview and record review was conducted with the Administrator and the Director of Nursing (DON) in the education room. Asked Administrator and DON how staffing levels are determined. DON said it is based on the census and acuity. Asked if the required staffing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the resident's right to formulate an Advanced Health Care Directive (AHCD) for three of six Residents [(R)151, R87, and R97] sampled. Findings include: R151 is an [AGE] year-old male, admitted to the facility on [DATE], after a hospitalization for metabolic encephalopathy (brain dysfunction caused by an underlying illness), and has full code status per his medical record face sheet. R151's Electronic Health Record (EHR) reviewed. No AHCD found. No supporting documentation about formulating or obtaining an AHCD was found in the progress notes or Care Plan (CP) dated 07/24/24. Copy of the AHCD and/or supporting documentation for R151 requested from the Administrator on 08/07/24 at 11:40 AM. Social services progress note dated 08/07/24 at 12:35 PM reviewed that documented the following: Previously inquired about AHCD? POLST and spouse said that they have a will which she believes includes that, requested she bring in a copy. Reminded spouse today…

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 electronically transmit and complete the Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) system within 14 days for one Resident [(R)87] sampled. Findings include: On 08/07/24 at 02:49 PM, conducted an interview and concurrent record review of R87's Electronic Health Record with the Minimum Data Set Coordinator (MDSC)1. Reviewing R87's Minimum Data Set (MDS) documented there was a late warning for the submission of the admissions MDS, R87 returned from the hospital on [DATE]. The MDS had not yet been submitted. MDSC1 confirmed R87's MDS was late and should have been submitted to the CMS system but was not. During an interview with the Director of Nursing (DON) and the Administrator on 08/07/24 at 03:25 PM, requested the MDS 3.0 Final Validation Report. DON provided the MDS 3.0 Final Validation Report on 08/09/24 at 09:58 AM which documented R87's target date was 07/23/24 Assessment Completed Late: Z0500B (assessment…

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, staff interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and/or implemented for three residents (Resident (R)300, R250 and R52) in the sample. Specifically, a care plan was not developed to monitor for adverse effects of taking a blood thinner for R300. No care plan was developed for the care of R250's Peripherally Inserted Central Catheter (PICC) line (tube inserted into a vein in the upper arm and threaded into a large vein above the heart to provide intravenous treatments), The facility did not develop a care plan to address R52's skin condition. As a result of these deficient practices, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. These deficient practices have the potential to affect all the residents at the facility. Findings include: 1) R250 is a [AGE] year-old resident, admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the resident's comprehensive person-centered care plan was revised for one Resident (R)87 of 22 residents in the sample. Findings include: Review of R87's Electronic Health Record (EHR) documented R87 was discharged to a hospital on [DATE] and returned to the facility on [DATE]. On 08/07/24 at 02:38 PM, inquired with Social Services Manager (SSM)8 if R87 had a care plan meeting since the resident returned from the hospital. SSM8 confirmed R87 has not had a care plan meeting since the resident returned from the hospital (07/17/24) and was not currently on the facility's calendar to have a care plan meeting. SSM8 reported when the Minimum Data Set (MDS) is submitted, it triggers facility to schedule a care plan meeting on their calendar. (Cross reference with F640: Encoding/transmitting/Resident Assessment) During a concurrent record review and interview with MSDC1, it was confirmed the facility had not yet submitted R87's MDS to the Centers for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident (R)150 of 22 in the sample, was free of accidents during her stay in the facility and failed to develop a discharge plan that would ensure the resident was safely discharged . R150 had multiple falls during her stay in the facility. The deficient practice increased the resident's risk for injury and has the potential to affect residents who are discharged home. Findings include: Aspen Complaint Tracking System (ACTS) intake #10993 dated 05/30/24 documented, R150 had several falls while in the facility and was discharged home from the facility on 05/25/24, without home supervision, and without family support due to an unsafe environment. Telephone call to R150's Family Member (FM) and Power of Attorney on 08/08/24 at 5:06 PM. FM stated the day before she was going to be discharged , R150 had a fall, and that she had at least four while in the facility. I worked with the Social Services Assistant (SSA)2 and told her that R150 isn't…

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

Based on observation, interview and record review, the facility failed to provide appropriate services to prevent urinary tract infections for one resident (Resident (R) 52) sampled. The deficient practice exposed the resident to contaminants that may cause preventable urinary tract infections. This has the potential to affect all residents with a urinary catheter. Findings include: On 08/06/24 at 11:58 AM, observed R52 in a wheelchair being assisted out of the elevator on the second floor. R52 had a urinary catheter tubing connected to a collection bag placed in a privacy cover hung under the wheelchair seat. While R52 was being pushed from the elevator to the dining area table, the catheter tubing was dragging on the floor. Review of the Electronic Health Record (EHR) for R52 revealed that he has a suprapubic catheter (tube inserted into the bladder through a cut in the abdomen to drain urine) and went out on 08/06/24 to see his doctor to have it changed. On 08/08/24 at 01:33 PM, an interview with the Infection Preventionist (IP) was conducted, IP confirmed that the 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, interviews, and record review, the facility failed to ensure that staff implemented specific competencies necessary for resident safety. This deficient practice has the potential for harm. Findings include: 1) Review of Resident (R)34's Electronic Health Record (EHR) documented on the most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/24, Section C. Cognitive Patterns, R34 scored a seven (7) on the Brief Interview for Mental Status (BIMS), indicating R34's cognition is severely impaired. On 08/06/24 at 10:29 AM, conducted an observation of R34 is the resident's room, seated in a wheelchair, with a bedside table in front of the wheelchair, with ten (10) medications tablets on the table, and no staff present in the room or in the line of sight of the resident. Inquired with R34 about the pills on the bedside table and if he took any, he reported those were his medications and could not remember if he took any of the medications. On 08/06/24 at 11:05 AM, conducted a concurrent interview and record review with Registered…

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 records review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and reconciled. This deficient practice increases the risk for diversion of residents' medications. Findings include: Concurrent observation, record review, and interview was conducted during a medication cart check on 08/08/24 at 08:20 AM. The facility document titled, Verification of Controlled Substance Count, dated August 2024, contained a blank spot for the oncoming day shift nurse signature for 08/08/24. Registered Nurse (RN)7 was informed of the missing signature. RN7 was observed placing his signature in the blank space. RN7 stated that he had forgotten to sign his name after he counted the medications with the outgoing night shift nurse. RN7 confirmed that signing the form together with the outgoing shift is the correct process. Interview was conducted with the Director of Nursing (DON) on 08/08/24 at 10:22 AM. DON stated that outgoing and incoming nurses will both go to the medication cart and go…

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

Based on interview and record review, the facility failed to review and act upon a pharmacist's recommendation on a monthly Medication Regimen Review (MRR) for one of five sampled residents (Resident (R) 79). This deficient practice has the potential to negatively affect R79's overall health and well-being. Findings Include: A review of R79's Electronic Health Record (EHR) was conducted. R79's EHR documented a MRR dated 05/31/24. The MRR noted a recommendation by the pharmacist, This resident continues to receive an atypical antipsychotic. Please consider, lipid panel [measurement of cholesterol and triglyceride in the blood], LFT [Liver Function Test], A1C [measurement of the average amount of sugar in the blood in the past few months]. Further review of R79's EHR, did not contain lab results for lipid panel, LFTs, and A1c. An interview with the Director of Nursing (DON) was conducted on 08/08/24 at 01:55 PM, near the conference room. DON confirmed that R79's MRR, dated 05/31/24, was not reviewed by the physician. Therefore, the recommendations for the lab work were not completed.…

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 accommodate a diet preference for one of 25 sampled residents (Resident (R)300). This deficient practice has the potential to affect R300's overall well-being. Findings include: R300 is a [AGE] year-old male admitted to the facility on [DATE]. Interview was conducted with R300 on 08/06/24 at 09:25 AM in R300's room. R300 stated that a dietician and cook had taken notes on his diet/food preference, and he often does not receive what he had requested. When asked what was listed on his preference, R300 stated he was a vegetarian. R300 continued to add that on multiple occasions he was served food that contained meat. R300 stated that he was served spaghetti with meat sauce at one point. He also mentioned two occasions when the kitchen had served him potato chips, when he specifically asked for fries. Interview was conducted with R300 on 08/07/24 at 12:35 PM. R300 was observed eating spaghetti with tomato sauce. R300 stated that the kitchen had originally…

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. While providing care for Resident (R)250, the facility staff was not wearing applicable Personal Protective Equipment (PPE), did not perform hand hygiene between glove change, and did not follow guidelines to prevent possible cross-contamination of clean supplies. These deficient practices placed the resident at risk for developing preventable infections and other adverse health complications. Findings include: Review of R250's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] for short-term rehabilitation and long-term intravenous (IV) antibiotics administration. R250 has a Peripherally Inserted Central Catheter (PICC) line (tube inserted into a vein in the upper arm and threaded into a large vein above the heart to provide intravenous treatments) for the administration of prescribed IV antibiotics. On 08/08/24 at 08:11 AM, observed…

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/document review, out of a sample of three residents (R), the nursing staff failed to immediately consult one Resident's (R)1 physician when there was a change in condition. In addition, the resident's family was not notified of the change of condition and subsequent transfer to a hospital. As a result of this deficiency, the MD was not aware of the condition change from baseline and was not able to implement interventions which may have prevented further decline. This deficient practice has the potential to affect any resident with a change of condition and may result in harm or death. Findings include: 1) R1 was a [AGE] year old female that was at the facility for short term rehabilitation. Diagnosis included, but not limited to exacerbation of bronchiectasis (chronic lung condition from inflammation and infection), COPD (chronic obstructive pulmonary disease, progressive respiratory disorder) with Pseudomonas (bacteria), MAC (uncommon lung disease caused by a specific group 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 reviews, and interview, the facility failed to provide respiratory care that is in accordance with professional standards of practice for two Residents (R)1 and R2, out of a sample size of three. The physician order for R1's oxygen therapy did not include the type of delivery system, when to administer or discontinue the oxygen, and prescribed oxygen flow rates, and R2's oxygen administration was outside the parameters of the physician order. In addition, the facility Oxygen Therapy Protocol does not meet the requirements of a complete order/standing order. These deficient practices could potentially cause harm to any residents who is administered oxygen. Findings Include: 1) R1 was a [AGE] year old female that was transferred to the facility from acute care on 07/19/23 for short term rehabilitation. She had been hospitalized for respiratory failure, and weight loss. Diagnosis included, but not limited to, hypercapnic respiratory failure (usually caused by COPD (chronic obstructive…

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 , medical record and document review, the facility failed to ensure a physician (MD)1 responded when staff attempted to contact him regarding a resident's (R)1 change of condition, on 08/17/2023. As a result of this deficiency, no provider was made aware of R1's status and there were no interventions implemented, that may have prevented further decline of R1's condition. In addition, the facility policy to provide/arrange for provision of physician services 24 hours a day in case of emergency directs staff to contact the medical director if unable to reach the provider, but does not provide arrangements if the medical director does not respond. This deficiency puts all residents at risk of decline which may result in harm or death, if there is not a system in place to reach a physician 24/7 for emergencies. Findings include: 1) On 08/17/2023 at approximately 10:45 PM, Registered Nurse (RN)1 attempted to notify Resident (R)1's physician (MD)1, regarding a change of condition. RN1's progress note read, Writer alerted MD and on-call managers around 2245 (10:45 PM)…

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

Based on observations, interview, and record review, the facility failed to completely screen visitors, guest, vendors for signs and symptoms of COVID-19. As a result of this deficiency, residents, staff, and visitors were at increased risk for contracting the COVID-19 virus. Findings Include: Observation on 08/21/23 at 07:50 AM, there was a passive screening station for COVID-19 at the entrance to the facility. The station prompted visitors, guest, vendors to complete a screening questionnaire related to COVID-19. There was no staff in the immediate vicinity to monitor the station. Upon completion of the questionnaire, there was nothing provided to verify that the screening questionnaire was completed. The visitor, guest, vendor could enter the facility and there was no visual validation to show that the screening for COVID-19 was completed. On 08/21/23 at 08:07 AM, conducted the initial brief tour of the kitchen. Observed outside contractor for pest control walk into the kitchen area from the dining room without a mask. Asked outside contractor if he was supposed to be wearing 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, interview, and record review, the facility failed to treat one resident (R), R46, out of two residents sampled, with dignity and respect. This deficient practice has a negative effect on maintaining and enhancing R46's self-esteem and self-worth. The deficient practice has the potential to cause psychosocial harm to R46. Findings Include: R46 is a [AGE] year-old male admitted to the facility on [DATE]. R46 has a diagnosis that include but is not limited to Parkinson's Disease. A review of his most recent Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/23/23 revealed that R46 was determined to have a Brief Interview for Mental Status (BIMS) score of 14, meaning he was found to be cognitively intact. Observation was conducted on 08/21/23 at 11:18 AM in R46's room. R46 was in the middle of eating a meal. A staff member was in the room handing him a drink. R46 was observed without pants or shorts on. R46 only had a shirt and his incontinence brief. He 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 observation, record review, and interviews, the facility failed to document an interdisciplinary (IDT, includes but not limited to, the physician, social worker, dietitian, and nurse) assessment and care plan regarding a resident's self-administration of medication. The lack of this process failed to ensure that resident (R), R56, out of a sample of one, was assessed appropriately for having the capability to self-administer his medication safely and correctly. There also was no process to follow-up with R56 to ensure that he retained the capability to self-administer medication. This deficient practice could potentially harm residents who want to self-administer their medication(s). Findings Include: On 08/23/23 at 08:30 AM, conducted a concurrent observation and interview with Registered Nurse (RN)11 while administering R56's medications in R56's room. RN11 stated that R56 was able to administer his own medicated eye drops (Dorzolamide Hcl (Hydrochloride) - Timolol Mal Solution 22.8 - 6.8 mg (milligrams)/ml (milliliter) to treat his glaucoma). RN11 stated that there 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 reviews and interview, the facility failed to ensure a safe and effective transition of care for three of five residents (R), (R64, R82 and R12) in the sample. The facility did not provide a copy of the comprehensive care plan goals to the receiving provider. This deficient practice does not provide an accurate picture of the resident and of his/her needs which will result in poor continuity of care. Findings Include: 1) During an interview on 08/22/23 at 09:01 AM, R64 stated he was recently hospitalized for low blood pressure and pneumonia (lung infection). Review of Electronic Health Record (EHR) revealed that R64 is a [AGE] year-old resident admitted on [DATE]. R64 was transferred to an acute care hospital on [DATE] for non-ST-elevation myocardial infarction (less severe form of heart attack), respiratory failure, and pneumonia. Documented in the Progress Notes on 07/01/23 at 04:06 PM, . Report including recent labs (laboratory results), AHCD (advanced health care directives), face 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 observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for three of 22 residents (R)26, R34,and R64 in the sample. Care plans and interventions were not personalized to the needs of the residents. As a result of this deficient practice, the residents are at risk of not reaching their highest practicable physical and psychosocial well-being. Findings Include: 1) Cross Reference F692 Nutrition/Hydration Status Maintenance On 08/21/23 at 01:27 PM, observed R26 in her room with the main entree of her lunch not eaten. The whole broccoli pieces were not eaten and were two inches in length. The meal ticket on R26's tray indicated a regular diet with chopped texture. On 08/22/23 at 12:18 PM, observed R26 in her room with her lunch tray on her bedside table pushed to the left side of her bed. R26's entree of chicken and noodles were not eaten. The chicken piece was approximately 4.5 inches in length and 3 inches wide and not chopped.…

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 reviews, and interviews, the facility failed to maintain the nutrition status of one Resident (R)26 out of a sample of four residents. R26's diet texture was not provided to her according to the physician's order, which could potentially impact her dietary intake. This deficient practice rendered R26 under nourished and does not allow R26 to live at her highest practicable physical and psychosocial well-being. Findings Include: Cross Reference to F656 Develop/implement Comprehensive Care Plan On 08/21/23 at 01:27 PM, observed R26 in her room with the main entree of her lunch not eaten. The whole broccoli pieces were not eaten and were two inches in length. The meal ticket on R26's tray indicated a regular diet with chopped texture. Record review of R26's electronic health record (EHR). Orders revealed a diet order for Regular diet, Chopped texture, regular/Thin consistency with a start date of 08/08/22. Review of R26's latest care plan for the Focus for Resident is at risk for fluid and nutritional deficit r/t [related to]: variable intake, underwt…

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 reviews, and interview, the facility failed to provide respiratory care that is in accordance with professional standards of practice for one Resident (R)64, out of one resident in the sample. The physician order for the use of oxygen did not include the type of delivery system, when to administer or discontinue the oxygen, and prescribed oxygen flow rates. This deficient practice could potentially cause harm to residents due to the lack of physician direction. Findings Include: On 08/21/23 at 09:59 AM, observed R64 sitting up in bed watching television. R64 had a nasal cannula (plastic tubing placed into the nares) connected to an oxygen concentrator set at 2.5 liter per minute. R64 said he was going out for his hemodialysis treatment and will not be back until later that afternoon. Review of the electronic health records (EHR) revealed that R64 was admitted on [DATE]. Diagnoses includes but not limited to end stage renal disease (kidneys are not functioning) with dependence 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 record reviews and staff interview, the facility failed to communicate two medication recommendations, between the pharmacist and the attending physician, for one resident(R), R51, out of five residents sampled. As a result of this deficiency, the facility put R51 at risk for complications related to medications. Findings Include: Review of the electronic health record (EHR) showed R51 was admitted to the facility on [DATE] with diagnosis including Dementia, Diabetes, Post-Traumatic Stress Disorder, Hypothyroidism, and Depression. Review of the Medication Regimen Review (MRR) document completed by the Pharmacist dated 02/23/23 read . Will recommend clarification on diagnosis of Sertraline [antidepressant medication] . There was no documentation that this was communicated to the attending physician. Another review of the MRR completed by the Pharmacist dated 05/31/23 read .Will recommend possibility of discontinuing evening supplements to reduce pill burdens at bedtime . There was no documentation 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 observations, interview, and record review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications. Findings Include: Concurrent observation and interview were conducted on 08/24/23 at 08:11 AM in the first-floor hallway. A medication cart was observed unlocked in the hallway with staff members, residents, and visitors walking by. This surveyor and Director of Nursing (DON) were present when Licensed Practical Nurse (LPN) 1 was interviewed. LPN1 stated, I thought I locked it. He also added that medication carts should always be locked. A review of the facility's policy titled, Medications: Storage, with a revision date of 01/11/23 was conducted. The document indicated, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

Based on observations and interview, the facility failed to label food items with the dates they were opened to ensure they were not served after the expiration date. As a result of this deficiency, residents, visitors, and staff were put at risk for contracting a foodborne illness. Findings Include: On 08/21/23 at 08:07 AM, conducted the initial brief tour of the kitchen. Observed two thickener containers by the food preparation area that were opened. Both containers did not have a label to indicate when they were initially opened, and both were nearly empty. Observed an open bottle of cranberry juice on another counter that was half full and without a label indicating when it was opened. Interviewed Kitchen Manager (KM) in the kitchen at the end of the intial brief tour conducted on 08/21/23. Queried KM if the thickener and cranberry juice were supposed to be labeled and KM stated staff are supposed to put a sticker on the item with the open date and use-by date written on it. KM asked one of the kitchen staff to put a label with their respective dates on the containers.