Ka Punawai Ola

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and record review, the facility failed to maintain a functioning clock for one Resident (R)143 out of three residents sampled. As a result of this deficiency, R143 did not know the time of day when referring to that non-functioning clock. Findings include: Review of Electronic Health Record (EHR) showed R143 was admitted on [DATE] with diagnosis including Stroke, Aphasia (language disorder that affects the ability to communicate), Urinary Tract Infection. During observation of R143's room on 04/01/25 at 10:30 AM, a wall clock showed the time as 08:25 and was not functioning. Observation of R143's room wall clock on 04/02/25 at 08:45 AM showed the same time 08:25 as previously mentioned and still not functioning. Resident interview on 04/02/25 at 08:50 AM, R143 said he wished the wall clock worked because it was located on the wall right in front of him. R143 said he told the staff about the clock not working a day ago. Staff interview on 04/03/25 at 09:15…

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 store food in accordance with professional standards for food service safety. Findings include: On 04/23/24 at 08:06 AM, during the initial tour of the facility's kitchen with Food Service Director (FSD), inquired with FSD if the facility labels food items when the arrive at the facility, FSD reported they label food items when they arrive and when they open them. Observed in the small prep-refrigerator, juice refills of apple juice, orange juice, cranberry juice, and passion orange guava juice for a juice dispenser without a label when the juice arrived. Inquired if the juice had a use-by date, FSD was not able to locate the date on the juice refills. Further observed three boxes of fudge brownie mix, with no use-by-date or date when the facility received the items. Review of the facility's policy and procedure, Food Safety revised on 04/26/23 documented The First In, First Out (FIFO) method is used in food storage or according to state regulations .Food is labeled with the date received if not already…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the resident's choices, for 5 of 21 Residents (R32, R231, R22, R2, and R47) sampled. As a result of this deficient practice, the residents were placed at an increased risk for avoidable declines and/or injuries. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation (rehab) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/11/24…

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 support and honor the food preferences of one resident (R) in the sample, and one unsampled resident. This deficient practice has the potential to impact all the residents at the facility with food preferences. Findings include: 1) Resident (R)33 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (rehab) following a left hip fracture. R33's admitting diagnoses include, but are not limited to, congestive heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD). Review of R33's Minimum Data Set (MDS) initial 5-day assessment with an Assessment Reference Date (ARD) of 04/01/24 noted that R33 was evaluated as having a score of 13 out of 15 for her Brief Interview for Mental Status (BIMS) exam, reflecting a determination of cognitively intact. On 04/23/24 at 11:25 AM, an interview was done with R33 at her bedside. When asked about unintended weight…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures to prevent the transmission of communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE) and performing the proper form of hand hygiene at all appropriate times while caring for Resident (R)33. In addition, the facility failed to assure staff performed hand hygiene between glove changes while performing perineal care (cleaning genital and anus area) for R131. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) Resident (R)33 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (rehab) following a left hip fracture. R33's admitting diagnoses include, but are not limited 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 observation, interview, and record review, the facility failed to identify, support, and honor one Resident's (Resident 32) preference to be informed of a time range that rehabilitation therapy services would occur. As a result of this deficient practice, R32 did not have her needs met and was placed at risk of not attaining her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility receiving therapy services. Findings include: Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (therapy) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as…

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 follow-up and ensure residents were informed of their right to develop an advance health care directive (AHCD); or periodically reassessed in his/her decision-making capacity to do such according to State Law, for four of ten residents sampled (Resident (R) 2, R16. R40 and R7). As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. Findings include: 1) On 04/24/24 at 09:55 AM during record review of R2's Electronic Health Record (EHR), R2's advanced health care directive was not found. R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. Review of R2's Care Plan (CP) found she has a Focus identified as DISCHARGE PLAN: Resident's Name wishes to discharge home after therapy is completed. Code Status: DNR (Do Not Resuscitate), Comfort measures only, No artificial nutrition by tube. Advanced Directives: Resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a clean, comfortable and homelike environment, as evidenced by uncomfortable temperatures in Resident (R) 283's and R284's room(s), and splatters on the kitchen ceiling. In addition, the facility failed to exercise reasonable care for the protection of one resident's clothing from loss, as evidenced by Resident (R)32's complaint that so many of her clothing pieces were not returned to her from laundry that she now had her family doing her laundry. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 04/23/24 at 09:39 AM, made observation of R283 and R284 in their room. R283 was observed to have at least four blankets covering her with a blanket covering her head. R284 was observed sleeping covered with two blankets up to her neck. The blow of the cold air conditioner could be felt when entering the room. The thermostat read 71 degrees Fahrenheit (F). On 04/23/24 at 12:43…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure written notification of discharge was provided to the resident or resident representative as soon as practicable before transferred or discharged and send a copy of that notice to a representative of the Office of the State Long-Term Care Ombudsman for three Residents ((R)25, R7, and R29) sampled. Findings include: 1) Conducted a review of R25's EHR on 04/23/24 at 10:28 AM which documented R25 was transferred and admitted to an acute hospital, twice, on 01/01/24 to 02/21/24 and 02/24/24 to 03/05/24. Review of the R25's EHR did not contain documentation of a written notification. Requested the Administrator provide documentation of the written notification to R25's resident representative and the Office of the State Long-Term Care Ombudsman for both times R25 was transferred to an acute hospital. On 04/25/24 at 04:15 PM, the Administrator provided an email which documented an email was sent to R25's resident representative on 02/26/24, two days…

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 written notification of the facility's bed hold policy was provided to one of four residents sampled (Resident (R) 7) and their representative. Findings include: R7 was transferred and admitted to the hospital twice on 03/04/24 to 03/06/24 and 03/21/24 to 03/25/24 with diagnosis of stroke. A review of R7's Electronic Health Record (EHR) found no documentation that a written notification regarding the facility's bed hold policy was provided to R7 or her representative for hospitalization from 03/21/24 to 03/25/24. On 04/26/24 at 10:47 AM, an interview with Administrator was done. Administrator reported the facility did not give written notification regarding the facility's bed hold policy to R7 or her representative for hospitalization from 03/21/24 to 03/25/24. Review of the facility's policy and procedure Bed-Hold Policy reviewed on 08/09/23, documented The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes 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 review and interview, the facility failed to ensure that the Discharge Assessment for Resident (R)80 accurately reflected the resident's discharge status. Findings include: Record review done on 04/25/24 at 02:59 PM noted Resident (R)80 was admitted to the facility on [DATE] and discharged to home on [DATE]. Review of Minimum Data Set (MDS) Discharge Assessment with an Assessment Reference Date (ARD) of 02/17/24 noted R80 was incorrectly documented as discharged to Short-Term General Hospital (acute hospitals, IPPS [inpatient prospective payment system]). On 04/26/24 at 10:31 AM, an interview was done with MDS Coordinator (MDSC)3 in her office. MDSC3 confirmed that R80's Discharge Assessment had been incorrectly documented and transmitted. MDSC3 stated that R80 had been discharged home with home health services.

Based on observations, interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for one resident (Resident 6) sampled. Resident (R)6 is totally dependent on staff for all care, was observed lying in bed with no activities implemented. As a result of this deficient practice, dependent residents are at risk of a lack of sensory stimulation. Findings include: On 04/24/24 at 03:03 PM, conducted a review of R6's EHR which documented R6 was admitted to the facility with diagnosis of an intracranial hemorrhage, convulsions, quadriplegia, aphasia (loss of the ability to understand or express speech related to brain damage), with bilateral stiffness and contractures of the shoulders, hands, and knees. Review of R6's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date of 03/14/24, Section GG. Functional Abilities and Goal, documented R6 has impairment of the upper and lower extremities and is dependent on staff for all care. Review of R6's activities care plan documented R6 is dependent on staff for meeting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a resident's medical record was accurate for one resident (R)6 sampled. R6's hard medical record chart located in the nursing station contained a Physician Orders for Life Sustaining Treatment (POLST) which documented in the event of a medical emergency, R6 should receive cardiopulmonary resuscitation. However, a POLST located in the unit's POLST binder contained a POLST which documented R6 as Do Not Attempt Resuscitation (DNAR). Findings include: On [DATE] at 10:08 AM, conducted a review of R6's electronic health record (EHR). Review of R6's physician's orders documented an order to Do Not Attempt Resuscitate- Full Treatment (ordered on [DATE]). Review of an acute hospital's hospitalist discharge summary ([DATE]) documented .Given patient's multiple medical comorbidities, discussed that if an event were to occur where the patient (R6) would need to need CPR, prognosis would be poor. [Family Member (FM)1] in agreement, patient to be DNAR, okay…

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 with staff, and review of the facility's infection control policy, procedures, and protocols 1) the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were implemented, 2) the facility failed to ensure measure to prevent the spread and transmission of communicable diseases were followed. Facility staff did not perform hand hygiene between glove use and did not disinfect shared equipment after use. This deficient practice has the potential to affect all residents, staff and visitors at the facility. Findings include: (Cross-Reference to F713 Availability of Physicians for Emergency Care) 1) On 05/02/23 at 09:18 AM, observed Resident(R)37 with an indwelling urinary catheter. No Enhanced Barrier Precaution (EBP) or other transmission-based precautions (TBP) sign was posted at the door of the room and appropriate EBP/TBP personal protective equipment (PPE) supplies were not located outside of R37's room. 2) On 05/02/23 at 09:46 AM, observed R342. No enhanced-barrier…

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

Based on observations, interviews, and record review, the facility failed to ensure a resident (Resident (R)50) received a therapeutic diet as prescribed. As a result of this deficiency, R50 could have experienced harm due to aspiration had this surveyor not intervened prior to staff administering water that was not nectar thickened. Findings include: On 05/03/23 at 11:14 AM, this surveyor was seated outside of R50's room. R50 was coughing and one of the resident's visitors (V)1 approached this surveyor and requested a cup of water for the resident. V1 was encouraged to activate R50's call light as no staff were visible in the hallway. V1 activated the call light and Licensed Nurse (LN)22 answered the call light at 11:17 AM and was informed that R50 was coughing and needed some water. At 11:22 AM, LN22 approached R50's room with a cup of water and proceeded to don Personal Protective Equipment (PPEs) and this surveyor observed the water in the cup did not appear to be nectar thickened and stopped LN22 from giving R50 the water. Had this surveyor not intervened at this time, R50…

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

Based on observations and staff interview, the facility failed ensure that all foods were stored in a closed container and provide a clean area to prepared food. As a result of this deficient practice, there is an increased potential for a food-borne illness that could affect all residents, staff and visitors that the facility kitchen serves meals to. Findings Include: 1) On 05/02/23 at 08:02 AM, initial tour and observation was done in the kitchen with the Food Services Director (FSD). Observed an uncovered plastic container filled with a white powdered substance by the juice dispenser. Next to the container was a clear plastic cover that was of the same size. Asked FSD what the clear cover was for, he said it was for the uncovered container next to it that was filled with the powdered thickener they use to thicken liquids. FSD then proceeded to cover the open container of powdered thickener. Interview with FSD conducted on 05/04/23 at 09:34 AM in his office. Asked FSD if the container of powdered thickener observed on 05/02/23 was supposed to be covered. FSD stated that all…

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, the facility failed to ensure the resident's right to self-determination through support of a resident's choice was facilitated for one of seven (Resident (R)189) residents sampled. R189 had previously selected to have miso soup with lunch and did not receive the item. As a result of this deficient practice, there is the potential for psychosocial harm. Finding include: On 05/02/23 at 12:49 PM, conducted an observation of Resident (R)189 during lunch. Review of R189's lunch ticket located on the resident's tray, documented R189 had circled and selected to have miso soup with lunch. Observation of the food items on the resident's tray revealed there was no miso soup. Inquired with R189 about the missing miso soup. R189 confirmed the circled miso soup on his/her lunch ticket indicated that the resident wanted it for lunch, but the item was not on his/her lunch tray. The resident stated that staff did not check or notice the miso soup was not his/her lunch tray. R189 stated I usually have soup with all of my meals at home, so I was really looking…

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 failed to provide written transfer/discharge notice upon hospitalization for one of three (Resident(R)88) residents sampled. Findings include: (Cross-Reference to F625 - Notice of Bed Hold Policy and Return) On 05/04/23 at 02:20 PM, conducted RR of R88's electronic health record (EHR) of hospitalization. Nursing progress notes documented R88 transferred to hospital on [DATE], but review of EHR progress notes, miscellaneous documentation, and social services notes, did not find documentation of facility providing written notice of transfer or discharge to R88 or resident's representative. On 05/04/23 at 04:16 PM, conducted an interview and concurrent RR with Administrator. The Administrator stated following R88's transfer to the hospital on [DATE], the facility informed the resident's representative by telephone but did not provide written notice of R88's transfer or discharge.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of policy, the facility failed to provide written notice of bed-hold policy for two Residents (R): 1) R139 of four residents sampled, 2) R88. As a result of this deficiency, there was potential for miscommunication. Findings include: 1) Review of the Electronic Health Record indicated that R139 was transferred to the hospital on [DATE] for a fall, hip fracture. Further review did not show any written notice of bed-hold policy to the resident and/or representative. During staff interview on 05/05/23 at 09:20 AM, Admissions Assistant (Admit1) acknowledged that the facility did not provide written notification of bed-hold policy to R139 and/or representative. Admit1 also said that the facility recently started a new process to provide written notification of bed-hold policy to resident and/or representative. Review of facility policy on Discharge Process and Bed Holds read the following: Bed-hold, holding or reserving a resident's bed while the resident is absent…

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 (RR), the facility failed to develop and implement a baseline care plan to provide effective and person-centered care of the resident that meets professional standards of quality care for one Resident (R)340. Findings include: (Cross-Reference to F697 - Pain Management) On 05/02/23 at 10:15 AM, interviewed R340. R340 underwent right knee surgery and was admitted to the facility on [DATE]. Observation of R340 confirmed swelling to the right knee and right lower leg. Regarding pain, R340 stated that staff have been providing pain medication every 4-6 hours based on resident's reported pain level but resident prefers to minimize opioid use and has been attempting to decrease amount of opioid medication taken. R340 denied being advised by care provider or facility staff of non-pharmacological or non-opioid interventions for treating pain or edema. On 05/04/23 at 10:42 AM, RR of R340's medical orders in resident's electronic health record (EHR) documented: Attempt…

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 comprehensive person-centered care plans were developed/implemented for two residents (Resident (R)191 and R4) sampled. R191 wandered unsupervised out of the facility on 04/15/23 and the facility did not develop a care plan until 05/02/23. Review of monitoring sheets documented staff did not implement 30-minute checks of R191 for wandering behavior in accordance with the resident's interventions listed on the care plan. R4 was not being monitored for side effects of prescribed psychotropic (drugs affecting behavior, mood, thoughts, or perception) medications. This deficient practice has the potential to affect all residents with wandering behavior or those psychotropic medications and has the potential to result in harm. Findings Include: (Cross reference to F689 Accident Hazard) 1) R191 was admitted to the facility on [DATE] with diagnosis that include congestive heart failure, hemiplegia and hemiparesis following a cerebral infarction…

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 adequate supervision to prevent an elopement for a resident (Resident (R)191) with wandering behavior. R191 exited the facility unsupervised and without staff's knowledge and only became aware of the resident's absences after another resident alerted staff. As a result of this deficient practice, there was the potential for serious harm to the resident. Findings include: (Cross reference to F656 Develop/Implement a Comprehensive Care Plan) R191 was admitted to the facility on [DATE] with diagnosis that include congestive heart failure, hemiplegia and hemiparesis following a cerebral infarction affecting the dominant right side, pneumonitis due to inhalation of food and vomit, glaucoma, atrial fibrillation, and memory deficit following cerebrovascular disease. On 05/03/23 at 1:07 PM, conducted a review of R191 Electronic Health Record (EHR). A progress notes on 04/15/23 at 2:24 PM documented, Received update from unit manager that resident 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 observations, interviews, and record reviews (RR), the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two (Resident (R)71 and R340) residents sampled. Findings include: (Cross-Reference to F655 - Baseline Care Plan) 1) On 05/02/23 at 10:15 AM, interviewed R340. R340 underwent right knee surgery and was admitted to the facility on [DATE]. Observation of R340 confirmed swelling to the right knee and right lower leg. Regarding pain, R340 stated that staff have been providing pain medication every 4-6 hours based on resident's reported pain level but resident prefers to minimize opioid use and has been attempting to decrease amount of opioid medication taken. R340 denied being advised by care provider or facility staff of non-pharmacological or non-opioid interventions for treating pain or edema. On 05/04/23…

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

Based on observations, interviews, and record reviews (RR), the facility failed to provide or arrange for the provision of physician services 24-hours a day, in case of emergency for one of two residents (Resident (R)342) sampled. As a result of this deficient practice, the facility failed to adequately assess a resident for a potentially contagious condition. Findings include: (Cross-Reference to F880 - Infection Prevention and Control) On 05/02/23 at 09:46 AM, observed R342. No enhanced-barrier precautions (EBP) or other transmission-based precautions (TBP) sign was posted at resident's room. R342 had diffuse red rash covering both legs and was being evaluated by resident's Advance Practice Registered Nurse (APRN)1. Upon completing the evaluation, APRN1 stated that the resident was the one who identified the rash to her, and this was the first time APRN1 was informed of R342's condition. On 05/02/23 at 01:09 PM, interviewed R342. R342 stated that she identified the rash to the nurse last week. On 05/04/23 at 12:32 PM, conducted a RR of R342's Electronic Health Record (EHR).…

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

Based on record review and staff interview, facility failed to provide adequate monitoring for one of the residents (R) sampled. R4 was not being monitored for side effects of prescribed psychotropic (drug effecting behavior, mood, thoughts or perception) medication. As a result of this deficient practice, there is a potential for negative impact on R4's quality of life. This deficient practice has the potential to affect all residents on psychotropic medications. Findings Include: Cross reference to F656 (Develop/Implement Comprehensive Care Plan). Facility failed to implement intervention to monitor resident for side effects of antidepressant. Review of electronic health record (EHR) revealed that R4 was prescribed duloxetine HCL (antidepressant medication) 30 mg (milligrams) once a day for depression. Common side effects for the medication include blurred vision, feeling dizzy, difficulty sleeping, dry mouth, headache, constipation and nausea or vomiting. Surveyor was not able to locate documentation in the EHR if the staff were monitoring R4 for side effects of the…

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

Based on observation, staff interview, record review, and review of equipment service manual, the facility failed to ensure routine maintenance cleaning of the cabinet filter, based on the manufacturer's recommendation, for one out of three oxygen concentrators reviewed. This deficient practice put Resident (R) 44 at risk for the development and transmission of communicable diseases and infections. Findings include: During resident observation, on 05/03/23 at 09:00 AM, R44 was receiving oxygen via a Perfecto2 V Oxygen Concentrator. The cabinet filter of that oxygen concentrator appeared to have dirt and/or dust on the cabinet filter. A review of Electronic Health Record showed that R44 was admitted with a diagnosis of Dementia, Stroke, Hypertension, Atrial Fibrillation, Hypothyroidism, Hyperlipidemia, Anxiety, Encephalopathy, Palliative Care. R44 had a doctor's order to use oxygen as needed for shortness of breath. During staff query on 05/03/23 at 10:30 AM, Director of Nursing (DON) acknowledged that the cabinet filter was dirty and that there was no routine maintenance cleaning.…

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.