Ann Pearl Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that medication regimen irregularities/recommendations were addressed by the physician for one of five residents (Resident (R) 7) sampled for unnecessary medications. As a result of this deficient practice, R7 was placed at risk of avoidable complications related to continuing an as needed psychotropic (a drug taken to exert an effect on the chemical makeup of the brain and nervous system) past 14 days without a clinical rationale. Findings include: R7 is a [AGE] year-old female admitted to the facility on [DATE] for long-term care. A review of R7's Minimum Data Set (MDS) Quarterly Review Assessment with an Assessment Reference Date (ARD) of 12/03/24 noted that her diagnoses include, but are not limited to, dementia with behavioral disturbance-aggression, and left-sided weakness and paralysis following a stroke. A review of R7's electronic health record (EHR) noted the following open-ended physician order on 08/26/24: Lorazepam 0.5 mg…

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 implement the facility's infection prevention and control measures for one of two residents (Resident (R) 35) sampled for Transmission Based Precautions (TBP). The facility did not ensure nursing staff hand hygiene between glove use while providing wound care for R35. This deficient practice has the potential to put residents at risk of spreading infections and communicable diseases. Findings include: R35 was admitted to the facility on [DATE] with diagnoses of acute osteomyelitis on right ankle and foot, stage 4 pressure ulcer of right heel, non-pressure chronic ulcer of right lower left with fat layer exposure and left lower left limited to breakdown of skin, local infection of the skin and subcutaneous tissue, and pseudomonas. Review of R35's Electronic Health Record (EHR) found R35 started contact precautions on 02/22/25 due to lab results of methicillin-resistant Staphylococcus aureus (MRSA) infection (a bacteria that's become…

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 provide one Resident (R)1 the right to equal access of quality care. Specifically, R1's primary language was Korean and the facility did not have an effective process in place to access interpreters. Due to this deficiency, staff were unable to communicate and understand R1's needs to provide her the quality of care she had the right to. This deficiency has the potential to affect any resident whose primary language is not English. Without appropriate communication, the resident's may not meet their highest level of physical and psychosocial well-being. Findings include: 1) R1 was an 85 year female admitted to the facility on [DATE], for short term physical and occupational therapy after a brief hospitalization for generalized weakness. Her primary language was Korean, she used hearing aides, and had mild cognitive impairment. R1's medical history included but not limited to anemia, chronic kidney disease, and Type 2 Diabetes 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, document review and medical record review (RR), the facility failed to ensure a person-centered comprehensive care plan (CP) was developed to address one resident's (R)1 needs of a sample size of three. R1 had significant hearing impairment, but the CP did not include this barrier to communication. As a result of this deficiency, the care team may not have been aware of her hearing impairment when interacting with her. There is a potential any resident may not reach their highest practical physical and psychosocial potential if their needs are not identified and addressed in the CP. Findings include: 1) R1 was an 85 year female admitted to the facility on [DATE], for short term physical and occupational therapy after a brief hospitalization for generalized weakness. Her primary language was Korean, she used hearing aides, and had mild cognitive impairment. On 05/16/2024, R1 was transferred to the Emergency Department for psychiatric evaluation after she attempted self harm. She 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 maintain the dignity of one of the 14 residents (R) in the sample. The urinary catheter bag for R101 was not covered and visible from the hallway, revealing his medical condition to other residents and visitors to the facility. This deficient practice has the potential to affect all residents in the facility with an indwelling urinary catheter. Findings include: R101 is an [AGE] year-old resident admitted to the facility on [DATE] for short-term rehabilitation and wound care. R101 had an indwelling urinary catheter (flexible tube placed in the body to drain and collect urine from the bladder) to prevent getting the wounds to groin area wet. On 03/19/24 at 08:47 AM, observed R101 lying in bed in his room watching videos on his tablet. R101's bed was positioned closest to the door and is visible from the hallway. The collection bag for his indwelling urinary catheter was hung on the right side of his bed facing the door. There was no cover…

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 ensure an injury of unknown origin was thoroughly investigated for one resident sampled. On 02/25/24, the facility submitted a completed event report for resident (R)12 who sustained a left hip fracture, origin of the injury was not known. The investigation report did not include documentation of R12's incident during physical therapy that was reported to nursing staff. Interview of staff responsible for completing the investigation confirmed the facility was unaware of the resident's report and the incident during PT could have potentially been the source of R12's injury. The investigation was initiated by the facility after becoming aware of R12's left hip fracture. As a result of this deficient practice, the Resident experienced a delay in the diagnosis and treatment of a left hip fracture. Findings include: Cross reference F580- notification of physician. Conducted a review of R12's electronic health record (EHR). Initial x-ray results take on 02/03/24 documented No obvious displaced or impacted fracture noted at this…

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 review of the facility's policy and procedure, the facility failed to ensure the controlled drug records were reconciled between shifts. The deficient practice potentially places the facility at risk for the diversion of controlled medications. Findings include: On 03/21/24 at 09:08 AM, while conducting medication administration observations with registered nurse (RN)19, staff proceeded to initial the controlled medication reconciliation count sheet, for the off-going (11 PM- 7 AM) shift and the on-coming (3 PM-11 PM) shift. Inquired with RN19 what the facility's procedure is for verifying the count of the controlled medications between shifts is. RN19 stated the off-going shift and the on-coming shift nurses do the count together and sign the sheet once the count is completed and correct. RN19 stated, I probably shouldn't have done this in front of you, then confirmed he/she did not sign the controlled medication reconciliation sheet in the presence of the off-going nurse and pre-signed the form for the on-coming shift and by doing so there is…

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 label medications in accordance with acceptable professional standards. Proper labeling of medications is necessary for safe administration practices and to decrease the risk of medication errors. This deficient practice has the potential to affect all the residents in the facility. Findings include: On 03/20/24 at 08:03 AM, observed Licensed Practical Nurse (LPN)23 during the morning medication pass. While LPN23 was preparing the medications for Resident (R)252, observed the box for the inhaler (device used to deliver medicine into the lungs) with no open and discard dates. On 03/20/24 at 09:41 AM during a concurrent interview with LPN23 and inspection of the medication cart for the Ilima wing, LPN23 confirmed that the inhaler for R252 was supposed to be labeled with the open and discard dates. Review of the facility policy titled Medication Storage stated, . 10. Medications, . need to be labeled when opened. It [sic] using a label tag that requires open and discard dates, these should be filled in…

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

Based on observation, interview and record review, the facility failed to implement the facility's infection prevention and control measures. The facility did not ensure the staff were wearing applicable personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP). This deficient practice placed all the residents at risk for the potential spread of infections and communicable diseases. Findings include: On 03/19/24 at 08:11 AM, observed a sign by the entrance of Resident (R)101's room that stated he was on EBP and to check with the nurse before entering the room. Asked Licensed Practical Nurse (LPN)23 if a gown was needed prior to entering the room. LPN23 said a gown is only needed when providing high contact care like bathing, dressing, transferring to wheelchair, wound dressing change or catheter care. LPN23 added that a gown is not needed if staff are going in just to talk to the resident, giving oral medications or serving meals. When asked why R101 was on EBP, LPN23 said it was because he had an indwelling urinary catheter and open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to provide services by sufficient numbers of nursing staff evidenced by long call light waiting times by the residents in the facility. The deficient practice has the potential to result in an increased risk for an adverse event for the residents residing in the facility. Findings include: Interview with Licensed Nurse (LN)10 on 01/17/2024, at 8:25 AM. When asked if they have four Certified Nurse Aides, (CNA's) and one float, said yes, but it's not enough, I had a resident who needed to be changed and my CNA was feeding another resident, so I took over the feeding so she could change my resident. I could have passed four meds, but what can you do. It's not enough, we had three CNA's and recently went down to two because our census dropped. Even with three it wasn't enough. Observation on 01/17/2024 at 09:27 AM. Resident R35 was laying in her bed in a room at the other end of the corridor away from the nurses station. Her family member (FM)2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to implement its performance improvement project for a problem prone area when the untimely call response times were identified. The deficient practice has the potential to adversely affect the residents residing in the facility. Findings include: 01/18/2024 at 09:00 AM reviewed the Resident council minutes dated 10/02/2023 on Old business discussed: Call light concerns. No information provided. New Business: Call light and staff concerns. Residents report a long waiting time for them to go back to bed or to get help using the bathroom. Vague minutes, no details provided. Resident Council minutes dated 07/10/2023 minutes. Old business discussed: Call light concerns. Residents suggesting call/ bell some kind of noise alarm for when they use the light. New business: Call light and staff concerns (cross reference to F725 Sufficient Nursing Staff). 01/19/2023, at 1:20 PM, reviewed the call light logs for July and December 2023. The December report: weekly averages for [DATE] on Ilima 441 total…

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 update the care plans (CP) for three dependent residents with a diagnosis of dementia in the sample, who had multiple falls. Resident's (R)10, 12, and 14. The deficient practice placed the residents at an increased risk for injury. In addition, the facility did not revise R1's CP to include notifying the provider if her systolic blood pressure (SBP) was over 160. This increased the risk that the provider would not be notified R1's BP was outside desired parameters. Findings include: 1) R1 is a [AGE] year old female admitted to the facility for IV (intravenous) therapy and short term rehabilitation on 10/10/2023 following a fall at home that resulted in a compression fracture T11-T12 (thoracic vertebrae). Her diagnosis also included but not limited to resistant hypertension. R1 was alert and oriented and had a BIMS of 15 (cognizant). During her stay at the facility, her medication was changed several times in effort to control her high…

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 (RR), the facility nursing staff did not display the competencies and necessary skill set when monitoring one resident's (R)1 blood pressure to meet the residents needs safely. Specifically the staff did not notify the provider as ordered when her systolic blood pressure was out of parameters. This put R1 at higher risk that her hypertension would not be managed effectively. Findings include: 1) R1 is a [AGE] year old female admitted to the facility for IV (intravenous) therapy and short term rehabilitation on 10/10/2023 following a fall at home that resulted in a compression fracture T11-T12 (thoracic vertebrae). Her diagnosis also included but not limited to resistant hypertension. R1 was alert and oriented and had a BIMS of 15 (cognizant). During her stay at the facility, her medication was changed several times in effort to control her high blood pressure. On 12/08/2023 R1's physician (MD)1 wrote the order Blood pressure check.-Notify Provider if SBP is frequently over…

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 Medical Director (MD) was responsible for coordination of medical care in the facility, including the oversight of other practitioner practicing in the facility. Findings include: (Cross-Reference to F710 Resident's Care Supervised by Physician) On 03/03/23 at 12:15 PM, during a surveyor meeting, the team became aware that R24's attending physician had not adequately addressed the resident's significant weight loss. (Cross Reference to F710 - Resident's Care Supervised by a Physician.) On 03/03/23 at 12:17 PM, conducted an interview with the MD with all surveyors present. Inquired how the MD coordinates and provides oversight for other practitioners providing care for residents in the facility. MD stated he was not aware that there were other physicians providing care in the facility and was unaware of his responsibility to provide oversight of other practitioners in the facility. Informed MD of R24's significant weight loss and R24's attending physician did not address or document any plan of care or pain 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 observations and interviews with staff member, the facility failed to provide a homelike environment for residents. The facility failed to remove trays when passing meals to residents. The facility failed to repair water damage due to water leakage from the roof in three residents (Resident (R) 9, R2, and R61) in one nursing unit As a result of this deficiency, resident is at risk of a negative psychosocial outcome. Findings include: 1) On 02/28/23 at 12:35 PM, observed 8 residents in the main dining area of the facility for lunch. Of the 8 residents in the dining room, 7 of the resident's meals remained on their trays throughout the entire meal. Inquired with the anonymous resident regarding why his/her lunch was not on a tray like the other residents observed. The anonymous resident stated that he/she did not want to get staff in trouble, but staff only take the meals off the trays if you ask them, because it's easier to clean if we make a mess. 2) During lunch dining observation on 02/28/23 at 12:06 PM in the facility's locked memory unit, observed nine of 10 residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of the COVID-19 Risk Mitigation Plan, the facility failed to provide COVID-19 vaccine education for two Residents (R) 25, R42 of the five residents sampled. As a result of this deficiency, the facility did not meet the regulation for providing education regarding benefits and potential risks associated with the vaccination. Findings include: Review of Electronic Health Record (EHR) revealed that R25 was admitted on [DATE]. Further review showed R25 refusal of the COVID-19 vaccination on 02/02/23. There was no documentation of education regarding the benefits and potential risks associated with vaccine. Review of Electronic Health Record (EHR) revealed that R42 was admitted on [DATE]. Further review showed R42 refusal of the COVID-19 vaccination on 12/31/22. There was no documentation of education regarding the benefits and potential risks associated with vaccine. During staff interview on 03/03/23 at 12:25 PM, Infection Preventionist (IP) acknowledged that there…

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, policy review, record review, the facility failed to ensure three of 22 sampled residents (Resident (R) 48, R36, and R3) were treated with respect and dignity. Findings include: 1) Review of the Facility Reported Incident (FRI), ACTS #9900, read the following: on 11/09/22, certified nurse aide (CNA) had attitude, was rude, mean and documented the CNA threw a napkin in her face . During an interview with R48 on 03/01/23 at 11:00 AM, R48 was alert and oriented and could answer all questions appropriately. R48 recalled the incident previously mentioned and revealed that it made her feel like she was not treated with respect and dignity. Review of Electronic Health Record (EHR) showed that R48 was admitted on [DATE] with diagnoses including Congestive Heart Failure, Hypoxemia, Iron Deficiency Anemia, Hypertension, Neuralgia, Diabetes, Anxiety . R48's Brief Interview for Mental Status (BIMS) evaluation done on 08/29/22 showed a score of 14/15 which meant that R48 was…

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

Based on observation and interviews, the facility failed to ensure that required notices in the facility were easily readable for residents. This deficient practice affects residents who can visualize the postings in the facility. Findings include: On 02/28/23 at 08:16 AM, started initial observations in the facility. Observed postings of the RESIDENTS' RIGHT GRIEVANCE PROCEDURE in various areas of the facility. This document contained contact information of agencies residents can call, printed on an 8 ½ inch by 11 inch paper which was laminated. On 03/01/23 at 10:00 AM, a resident council meeting was held in an unused resident room. Five of nine residents voiced a concern about not being able to read the posting of agencies and their phone numbers. They stated, The print on the posters are too small. On 03/03/23 at 11:00 AM, a concurrent observation and interview were done with the Social Services Associate (SSA). SSA was shown the RESIDENTS' RIGHT GRIEVANCE PROCEDURE document posted in a nursing unit. The magnification glass to enable residents to read it did not reach the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff member, the facility failed to assure one of four residents (R)46 sampled exercised their right to formulate an advanced health care directive (AHCD). This deficient practice has the potential to cause harm to residents when they are provided medical care that is not in accordance with their wishes. Findings include: R46 was admitted to the facility on [DATE]. On 02/28/23 at 02:20 PM reviewed R46's Electronic Health Record (EHR) for documentation of an AHCD. AHCD was not found. Review of R46's Declaration of Authority to Act as Surrogate for Patient form documented R46's family member as an Appointed (Non-Designated) Surrogate. The form includes a standard statement of I, (Name of Surrogate), under penalty of false swearing, provide the following statement of facts and circumstances establishing my authority to act as surrogate for (Name of Patient) who has been determined by the primary physician to lack capacity to make healthcare decisions and no agent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to protect one of 22 residents sampled from abuse. Resident (R) 20 sustained second degree burns from a heating pad, an item not allowed in the facility, left on her calves by a certified nurse aide (CNA). Finding Includes: Cross Reference to F609 (Reporting of Alleged Violations). The facility failed to report suspected neglect to the Stage Agency. F610 (Investigate/Prevent/Correct Alleged Violation). The facility failed to investigate and prevent further potential neglect after R20 sustained second-degree burns from the use of a heating pad. F689 (Free of Accident Hazards). The facility failed to ensure R20 was free from accident hazards from the use of an electric heating pad, sustain second-degree burns to both left and right calf areas. Centers for Medicare & Medicaid Services (CMS) defined abuse as the willful infliction of injury .with resulting physical harm, pain or mental anguish . Willful, as defined in the definition of abuse…

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, record and policy review, the facility failed to report suspected abuse to the State Agency (SA) for resident (R) 20. As a result of this deficient practice the SA did not have information to determine if an investigation by the agency was needed, and there is the potential that incidents that are poorly investigated put all residents at risk for neglect. Findings include: Cross Reference to F600 (Free from Abuse and Neglect). The facility failed to protect one of 22 residents sampled from abuse. Resident (R) 20 sustained second degree burns from a heating pad, an item not allowed in the facility, left on her calves by a certified nurse aide (CNA). Cross Reference to F689 (Free of Accident Hazards). The facility failed to ensure R20 was free from accident hazards from the use of an electric heating pad, sustain second-degree burns to both left and right calf areas. R20 is a [AGE] year-old resident admitted to the facility on [DATE]. Diagnoses include paraplegia (paralysis affecting lower…

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 records review, the facility failed to thoroughly investigate and prevent further potential neglect after R20 sustained second-degree burns from the use of a heating pad. The lack of a thorough investigation and prevention could lead to a corrective action that is ineffective and would continue to put the residents at risk for preventable harm. Finding Includes: Cross Reference to F600 (Free from Abuse and Neglect). The facility failed to protect one of 22 residents sampled from abuse. Resident (R) 20 sustained second degree burns from a heating pad, an item not allowed in the facility, left on her calves by a certified nurse aide (CNA). Cross Reference to F609 (Reporting of Alleged Violations). The facility failed to report suspected neglect to the Stage Agency. Cross Reference to F689 (Free of Accident Hazards). The facility failed to ensure R20 was free from accident hazards from the use of an electric heating pad, sustain second-degree burns to both left and right calf areas. R20 is 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's (Resident (R)8) comprehensive person-centered care plan was implemented. R8 has difficulty swallowing and requires staff supervision during meals for aspiration precaution, observations were made of R8 eating meals in his/her room with no staff present. As a result of this deficiency, the resident is at risk of harm from aspirating during meal(s). Findings include: On 02/28/23 at 08:50 AM, conducted an observation of R8 in his room seated upright in bed, bedside table across his lap, eating breakfast by himself. Interviewed the resident and observed the resident coughing periodically throughout the meal. The resident's cough was wet and it sounded as if the resident was coughing to clear his throat. At 08:57 AM, R8 coughed excessively, and certified nurse aide (CNA) 40 came into the room, checked on R8, then CNA40 left the room, and R8 continued eating his breakfast unsupervised. On 02/28/23 during lunch, observed R8…

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 review and revise the comprehensive plan of care for three of 22 residents sampled (Resident (R) 7, R41 and R49). This deficient practice failed to effectively address the residents' status, condition, and needs, and therefore not assisting these residents attain their highest practicable physical and psychosocial well-being. Findings include: 1) Review of Electronic Health Record (EHR), showed that R7 was admitted on [DATE] with diagnoses including End Stage Renal Disease, Dialysis, Alzheimer's Disease, Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease . Medications include Clopidogrel which is used to prevent heart attacks, stroke, prevents blood clots and recommends implementing bleeding precautions. Review of R7's current Comprehensive Care Plan (CP) did not include any precautions for bleeding. During staff interview on 03/02/23 at 12:00 PM, the Director of Nursing (DON) acknowledged that there was no…

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 professional standards of practice were implemented for a resident (Resident(R)32) receiving supplemental oxygen. As a result of this deficient practice, residents on supplemental oxygen are at a potential of harm related to respiratory infection. Findings include: Multiple observations (02/28/236 at 09:12 AM; 03/01/23 at 08:53 AM; and 03/02/23 at 08:52 AM) were made of R32's oxygen concentrator, mask/tubing, and reusable container (holds humidifying solution) and the equipment was not labeled with a date or time. On 03/02/23 at 10:20 AM, conducted a review of R32's Electronic Health Record (EHR). Review of physician orders documented R32 receives oxygen 1-4 Liter per minute (LPM) vis nasal cannula for shortness of breath (SOB) or oxygen levels below 90%. On 03/02/23 at 02:35 PM, conducted an interview with an anonymous nursing staff (NS) 8 regarding the labeling of tubing and humidifier concentrator container. NS8 stated the tubing and reusable reservoir should have been labeled with the date and…

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

Based on observations, interviews, and record review (RR), the facility failed to ensure physician services adequately addressed the needs of one of 22 residents sampled (Resident (R) 24). Physicians are required to supervise medical care of residents by prescribing medications and therapy, participating in resident assessment and care planning, monitoring changes in resident's medical status, and providing consultation or treatment when contacted by the facility. Findings include: (Cross-Reference to F841 Responsibilities of Medical Director) On 02/28/23, conducted a RR of Resident (R) 24's Electronic Health Record (EHR). Review of R24's vitals documented on 08/04/2022, R24 weighed 96 lbs. On 02/22/2023, R24 weighed 86.4 pounds which is a -10.00 % loss. On 01/04/2023, R24 weighed 103 lbs. On 02/22/2023, the resident weighed 86.4 pounds which is a -16.12 % loss. On 02/28/23 at 02:05 PM, conducted a telephone interview with R24's guardian (GG). GG stated that she comes to the facility daily during mealtimes to assist R24 with eating. However, she had recently undergone surgery and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide behavioral health care to one of 22 residents (R) sampled. R62 was not monitored for adverse effects or effectiveness of prescribed psychotropic (drugs affecting behavior, mood, thoughts, or perception) medications. This deficient practice has the potential to affect all residents on psychotropic medications. Findings include: R62 is a [AGE] year-old resident admitted on [DATE] for short term rehab after a hospitalization due to a fall at home. Diagnoses include lung cancer, anxiety disorder, and depression. On 02/28/23 at 12:56 PM, observed R62 sitting on wheelchair holding an emesis basin and was drooling. She said she just threw up. Licensed Practical Nurse (LPN) 2 came in the room to check on her and later helped R62 to her bed. LPN2 was observed administering R62 her medication by mouth. After LPN2 left, asked R62 if she felt well enough to talk, she responded Yes. Asked R62 what happened, she responded she had an anxiety…

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 that an accurate account of controlled drugs is maintained and periodically reconciled. As a result of this deficiency, there is the potential for the of diversion of controlled drugs. Findings include: 1) On 03/02/23 at 09:14 AM, conducted an inspection of a medication cart on 1 of 3 units. Review of the Controlled Medication & Shortened Expiration/Unlabeled Medication Sign Off log (accounts for counted and ensuring the accurate reconciliation of controlled drugs between shifts) documented 4 incidents (03/23/23 at 14:00 (02:00 PM) on-coming staff; 03/2/22 at 22:00 (10:00 PM) on-coming and off-going 03/02/23 at 06:00 AM off-going shift) when staff did not complete the form. Also, on 03/02/23 the 14:00 (02:00 PM) off-going was signed in advance. Reviewed the form with Registered Nurse (RN)1 and he/she confirmed the log was not properly signed by staff and staff should not have pre-signed the log. On 03/02/23 at 09:29 AM, conducted an interview with the Director of Nursing (DON) and the Regional Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interview, the facility failed to adequately monitor medication for one resident (R), R37, of five residents sampled for unnecessary medications. As a result of this deficient practice, R37 was put at risk for adverse side effects of a psychotropic medication. Findings include: R37 is a [AGE] year-old and was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease. major depressive disorder, insomnia, unsteadiness on feet, repeated falls, muscle weakness, cerebral infraction, and vascular dementia with other behavioral disturbance. During review of R37's monthly medication regimen review (MRR) from the consultant pharmacist to the attending physician, the MRR for the month of November 2022 documented the following recommendation from the pharmacist This resident is receiving citalopram (Celexa) 30 mg {milligrams]/ day. Citalopram has a maximum recommended dose of 20mg daily in geriatric patients due to increased exposure and risk of QT prolongation…

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

Based on observation, interview, and record review, the facility failed to ensure all medications used in the facility were securely stored in locked compartments. Proper storage is necessary to decrease the risk of diversion of resident medications. This deficient practice has the potential to affect all residents in the facility. Findings include: On 02/28/23 at 08:36 AM during an initial observation of residents, observed a resident walk up to a medication cart in the activity room and lean on to the side of the medication cart. Observed two residents in wheelchairs independently move to the front of the activity room toward the medication cart, a total of nine resident were in the activity room. Upon close observation of the medication cart observed it to be unlocked and unattended. Registered Nurse (RN) 3 assigned to the medication cart was administering medication to a resident in the activity room with her back facing the medication cart. Interview with RN3 confirmed the medication cart should have been locked. Review of the facility's policy and procedure section 4.1 STORAGE…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assist Resident (R) 41 obtain routine dental care, including making an appointment, arrange for transportation to and from the dental service location, and if eligible, apply for reimbursement of dental services as incurred medical expense under the State plan. Findings include: R41 is a Medicaid resident and was admitted to the facility on [DATE]. On 02/28/23 at 11:05 AM interview with R41's resident representative, Family Member (FM) 14, was done. FM14 reported R41 was admitted to the facility with dentures that she can longer use. FM14 stated R41 has not seen a dentist since admission to the facility and would love for her to get her dentures fixed or have new dentures. FM14 reported the facility knew R41's had dentures and they no longer fit her. Review of R41's Electronic Health Record (EHR) documents in the nursing notes R41 looking for her dentures and document the dentures not being used due to it not fitting well on 12/06/20 and 12/08/20. The…

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

Based on observations, interviews, and record review, the facility failed to ensure food was stored in in accordance with professional standards for food service safety. Finding include: On 02/28/23 at 08:14 AM, conducted an inspection of walk-in refrigerator. Observed unsealed container of ricotta cheese that was not labeled with date/time opened or a discard date. The ricotta cheese container was shown to the Dietary Manager (DM) and inquired about the facility's procedure for labeling and determining how long food products are kept after opening. DM stated that the opened container of ricotta cheese should have been labeled with the date and time it was opened and the ricotta cheese was not labelled in accordance with the facility's procedure. Received and reviewed the facility's Food Storage policy and procedure (last updated 10/15/17) on 03/02/23. The policy and procedure documented, food storage containers shall be labeled when container is first opened and date when product will be consumed, sold, or discarded.

Based on documentation, the facility failed to ensure a single resident bedroom measured at least one hundred square feet of usable space and ensure a multi-resident room provides a minimum space of eighty square feet per bed of unusable space, excluding closets, bathrooms, alcoves and entryways. Findings include: 1) Room HH1 on the Hale Ho'olu unit accommodates one resident. HH1 does not measure at least one hundred square feet of usable space and is short by five feet three inches of the 100 square feet requirement for this room. 2) Room HH3 on the Hale Ho'olu unit houses multiple residents and does not meet the requirement of eighty square feet per bed of usable space and is short five feet eight inches of the 240 square feet requirement.