Pu'uwai 'o Makaha

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4) R60 was a [AGE] year old female with a medical history that included acute respiratory failure due to acute on chronic heart failure. RR revealed the following: Physician written order start date [DATE]: Code Status: Do Not Attempt Resuscitation/No artificial nutrition by tube. Provider Orders for Life-Sustaining Treatment (POLST) Document dated [DATE]: Do Not Attempt Resuscitation/DNAR (allow natural death) signed by R60. Social Service (SS) Progress note dated [DATE] at 10:44 AM.She does not wish to fill out an advance directive nor did she want educational pamphlet explaining it. Full code status . The SS progress note was inaccurate. 3) R32 is a [AGE] year-old male resident with a diagnosis that included Dementia with other behavioral disturbances. R32's cognitive status is severely impaired (per RR of his Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE]. During an observation on the unit on [DATE] at 1:15 PM observed R32 had a fall alarm clipped to his gown. RR of CP for Falls…

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 (RR) and interview, the facility failed to: 1. Include an accurate assessment of resident's psychological state in the quarterly Minimum Data Set (MDS) for one Resident (R32) and; 2. Failed to identify that a bed alarm was in place. The deficient practice failed to accurately assess the resident's psychosocial wellbeing. The residents in the facility with psychological needs are affected. Findings include: Cross reference to F741 Behavioral health services. Electronic Medical Record (EMR) reviewed 06/17/24. Mood and behavior were not coded on the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) 06/17/24 with any indicators of psychosis and the bed alarm was not coded as being used. The bed alarm is documented throughout the nursing notes as being in place for R32. Interview on 07/25/24 at 2:51 PM with the Director of Nursing (DON) and Social Services Director (SSD). The surveyor asked why the mood and behavior assessments didn't include an accurate description of the resident's documented behaviors. The SSD replied that the behaviors may not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review (RR) the facility failed to revise one Resident's (R35) care plan (CP) timely to reflect the status/treatment of her fractured leg after a fall. As a result of this deficiency, staff may not have been aware of the treatment plan required monitoring and interventions needed. This deficient practice could affect any resident. Findings include: R35 is a [AGE] year-old who had lived at the facility since 03/02/21. She had cognitive communication deficit, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance. R35 has muscle weakness, difficulty walking and uses a wheelchair for mobility. She is moderately impaired with a Brief interview for Mental Status (BIMS) score of 8. On 05/24/24 R34 fell and injured her left lower leg. She was transferred to the emergency room for care, where she was diagnosed with fracture of the tibia/fibula. She returned to the facility on 5/25/24 with an orthopedic boot splint on her leg. 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 observation, interviews, and record review (RR), the facility failed to make arrangements for one Resident (R35) to be transported to an appointment with a consultant. As a result of this deficiency, there was a delay taking her cast off. This deficient practice could affect any resident with outside appointments and may prevent them from meeting their highest potential of psychosocial and medical well-being. Findings included: R35 is a [AGE] year-old who had lived at the facility since 03/02/21. Diagnoses included cognitive communication deficit, major depressive disorder, severe psychotic symptoms, and dementia with behavioral disturbance. R35 has muscle weakness, difficulty walking and uses a wheelchair for mobility. She is moderately impaired with a Brief interview for Mental Status (BIMS) score of 8. On 05/24/24 R34 fell and injured her left lower leg (LLE). She was transferred to the emergency room for care, where she was diagnosed with fracture of the tibia/fibula. She returned to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review RR), the facility failed to provide supervision of one Resident (R) 3 to ensure the safety of female residents. Specifically, the facility investigated an allegation that R3 inappropriately touched a female resident (R6). As a result of that investigation R3 was to be supervised when in the presence of vulnerable females to ensure their safety. R3 was observed to be alone in the dining area with a female resident (R39) on 07/24/24, which put her safety at risk. If R3 is not supervised, it puts all female residents at risk of a similar occurrence, which could result in psychological or physical harm. Findings include: The Office of Healthcare Assurance (OHCA) received a facility incident report, (FRI) intake 11041 regarding an alleged resident to resident abuse. The report documented on 06/29/24 a Certified Nurse Assistant (CNA) observed R3 seeming to touch resident's (R6) private area over her clothing. Nursing attempted to find out more about the situation…

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 (RR) the facility failed to: 1. Ensure it provided an environment to promote the mental and psychosocial wellbeing for one resident in the sample Resident (R) 32 was agitated and distressed evidenced by loud yelling and acting out while isolated in his room. 2. The nursing staff did not monitor R32's behaviors or; 3. Report changes to the physician for four days and; 4. Implement non-pharmacological interventions in his plan of care. The deficient practice resulted in the resident having poor psychological and emotional health and self-inflicted injuries that occurred as a result of his behavioral outbursts. Residents in the facility with psychological and emotional health needs are at risk. Findings include: R32 is a [AGE] year-old male resident admitted to the facility on [DATE]. His Diagnoses included cerebral infarction (stroke) with left sided weakness; vascular dementia with behavioral disturbances; aphasia (unable to speak) and severe anxiety. His…

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 assist Resident (R) 13 in scheduling a dental appointment that he missed on 11/28/23 (per Dental clinic) and 12/05/23 (per resident's Care Plan) for a cleaning. The deficient practice could affect all residents in the facility who require assistance in scheduling dental appointments. Findings Include: On 07/23/24 at 10:48 AM during Record Review (RR) of R13's Electronic Health Record (EHR) found resident has a Care Plan (CP) in place for at risk for mouth or facial pain related to decaying (cavity) and/ or broken natural teeth 10/19/23 oral thrush. Dental appointment made for 12/05/23 for cleaning. During this record review of R13's progress notes found a nurse had documented on 12/5/23 R13 left the facility to go to an appointment but the facility nurse did not state what the appointment was for. Another progress note dated later in the day on 12/5/23 was written by another facility nurse who documented R13 returned to the facility at 4 PM but did not state where he returned from. On 07/25/24 at 12:20 PM interview 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 interviews and record review, the facility failed to update one resident's (R)1 care plan (CP) timely to include interventions to address her aggressive behavior and mood, when she verbalized feelings staff did not like her or want to care for care because she was transgender. Due to this deficiency, R1's CP was not comprehensive and did not include person centered care approaches to meet her individual needs. This deficiency has the potential to affect all residents if the CP is not comprehensive, so residents can achieve their highest potential of physical and emotional well-being. Findings include: 1) R1 was admitted to the facility on [DATE] following a stroke affecting the right dominant side. Past pertinent medical history included dysarthria (difficulty speaking) following a stroke, psychoactive substance abuse (harmful use of psychoactive substances, including alcohol and illicit drugs), conversion disorder (mental health condition that disrupts how your brain works) with seizures 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 interviews, and record review, the facility failed to make a referral that was part of one resident's (R)1 behavioral health care plan (CP). Specifically, R1 was to have a referral made to a local Health Care Center (HCC) for a psychologist consult as soon as possible. The referral was not made. As a result of this deficiency, R1 did not get the behavioral health services needed to meet her highest level of psychological well-being. This deficiency has the potential to affect any resident with an outside consult. Findings include: 1) R1 was admitted to the facility on [DATE] following a stroke affecting the right dominant side. Past pertinent medical history included dysarthria (difficulty speaking) following nontraumatic intracerebral hemorrhage, psychoactive substance abuse (harmful use of psychoactive substances, including alcohol and illicit drugs), conversion disorder (mental health condition that disrupts how your brain works) with seizures or convulsions, hypertension, major depressive disorder,…

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 QAPI program made a good faith attempt to analyze the data collected to identify performance indicators of the corrective actions implemented to determine if the facility is sustaining corrections. The facility conducted audits related to deficient practices identified by the survey team during a recertification survey. The data from the audits was not analyzed to determine if the corrective actions were sustained, or if revisions are necessary. Findings include: (Cross Reference to F882 Infection Preventionist Qualification/Role) On 10/16/23 at 11:11 AM, conducted an interview with the Director of Nursing, (DON), Administrator, and the Regional Nurse Supervisor (RNS) regarding the facility's Plan of Correction (POC) for the recertification survey completed on 07/28/23. Requested to review the Quality Assurance Performance Improvement (QAPI) meeting minutes. Review of the QAPI meeting minutes conducted on 10/03/23 documented the Agenda Item related to the recertification survey findings were marked as Action 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 observations and interviews, the facility failed to ensure the resident's right to a dignified existence for four residents (Resident(R)65, Anonymous Resident (AR)1, AR2, and AR3). R65 reported staff did not respond to the resident's activated call light or assess/acknowledge the resident if staff could not immediately assist the resident for 30-45 minutes while on isolation precautions. Observations and/or interviews with AR1, AR2, and AR3 confirmed call lights were not being addressed in a timely manner despite the presence of staff. As a result of this deficient practice, the residents are at risk for potential physical and psychosocial harm. Findings include: On 07/28/23 at 08:52 AM reviewed the intake number (#)10399 from the Aspen Complaints Tracking System (ACTS). Complaint received to the Office of Healthcare Assurance (OHCA) on 07/03/23 via telephone. R65 reported that on admission the resident in isolation for 10 days due to being positive for COVID-19 and during that time, the resident had to wait 30-45 minutes for staff to respond and address the 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.

Based on observations and interview, the facility failed to ensure the most recent survey results and plan of correction post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. Finding includes: On 07/27/23 at 12:15 PM, while on the lower unit this surveyor was unable to locate the facility's posting of the most recent survey results. At 12:19 PM, conducted an interview and observation of the most recent survey results with the Director of Nursing (DON). Informed the DON that this surveyor was unable to locate the most recent survey results. The DON escorted this surveyor into the main dining room (lower unit) and showed this surveyor the survey results binder which was in a corner of the dining room near the entrance to the rehab room. Only residents and family in that corner of the dining room would be able to visibly see the results binder. There was no clear indicator on the bulletin board (where the results were located) to highlight the presence of the results. Also, when residents are assisted to the dining…

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 provide a homelike environment for a resident (Resident(R)49) in hospice care, staff interrupting resident meals to administer medication, and residents receiving meals in the shared dining areas. R49's is a hospice resident and the resident's room walls were bare, no pictures, calendars, or any personal items, to ensure a homelike environment and equipment (not in-use) was being stored in the room. Resident's meals were left on trays while dining in the main dining room on both units (Unit 1 and Unit 2) throughout the survey. As a result of this deficient practice the residents are potentially at risk of psychosocial harm. Findings include: 1) Observations of the same five residents having lunch in the Unit 2 dining room on 07/25/23 at 12:17 PM; 07/26/23 at 12:15 PM; and 07/27/23 at 12:15 PM confirmed on the first two days 4 of 5 residents meals and beverages remained on trays and on the last day, all resident meals remained 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 observations, record reviews, and interviews, the facility failed to appropriately address out of range temperature for one of its two medication refrigerators and discard expired glucose testing supplies. This deficient practice has the potential to negatively affect the efficacy and integrity of medications that require to be stored at proper temperatures and placed all residents that need glucose testing at risk for potential harm as their medical care is dependent on precise glucose test results. Findings Include: On [DATE] at 09:07 AM, observation of the medication refrigerator was done with Resident Care Manager (RCM) 1 in the medication storage room. The refrigerator contained insulin, suppositories, and vaccines. A document titled Medication Refrigerator Temperature Record was placed in a plastic protective sleeve on the door of the refrigerator. RCM1 said the nurses check and log the temperature daily. Review of the document showed that under Standard, the temperature range was noted as 36-46…

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

Based on observations and staff interviews, the facility failed to follow food safety requirements. The temperature for the refrigerator used for food storage was out of range and a container of juice was found in a refreshment refrigerator that was over one month from the date it was opened. This deficient practice has the potential to affect all residents, visitors and staff who have meals served by the facility, placing them at risk for food-borne illnesses. Findings include: On 07/27/23 at 10:32 AM while checking on the nourishment refrigerator in Unit 2, an opened container of prune juice was found that was half full. The date written on the cap was 06/14/23. Asked Registered Nurse (RN) 18 how long the container of prune juice is good for once opened. RN18 said she was not sure but will ask kitchen staff. RN18 then called the kitchen and spoke to one of the staff. After RN18 hung up the phone, she confirmed the prune juice was only good for 7 days after it has been opened. RN18 apologized and proceeded to empty the bottle in the sink. Asked RN18 if there were any residents 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 observation, interview and record review, the facility failed to accurately assess one Resident (R)16 for functional limitations of the bilateral upper extremities (BUE). The deficient practice affected R16's range of motion (ROM) due to not receiving the care and treatment needed to maintain or improve his functional status. As a result, the care plan was not implemented, and the restorative care not provided. Findings include: During observations of R16 on 07/27/23 at 10:41 AM, R16 stated to the surveyor I need to get these fixed while holding up both hands showing the surveyor and the nurse. Both of R16's hands appeared to be contracted. R16 expressed wanting to call the doctor, but he/she did not have a personal phone and the phone facility provided phone does not work well. Surveyor inquired with the Registered Nurse (RN)38 if any referrals were made to the doctor to evaluate R16's contracted hands (cross reference to F688 Increase/ prevent a decrease in range of motion/mobility). On 07/27/23 at 11:07 AM, reviewed R16's Electronic Health Record (EHR). The reviewed…

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 update the care plan with new interventions to address two Resident's (R)14 and R16 of two residents in the sample had been refusing restorative care. The deficient practice negatively impacts the resident's functional capacity to prevent decline and maintain range of motion and mobility. Findings include: (Cross Reference to F688 Increase/Prevent Decrease in Range of Motion/Mobility) On 07/25/23 at 3:10 PM, observed R14 in her bed with bilateral upper extremities (BUE) (hands) and bilateral lower extremities (BLE) were contracted. Noted a long red roll on the nightstand and two booties on the bedside table. On 07/27/23 at 4:48 PM, observed R14 with bilateral hands fisted. Noted carrot on the nightstand and the boots on the bedside table. At 05:05 PM asked Registered Nurse (RN)15 if R14 participates in any range of motion exercises. RN15 Stated, we try, but she refuses, when we try to clean her hands, she gets mad. On 07/28/23 at 09:09 AM, observed R14 lying in bed with bilateral fists tightly closed. knuckles…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide the resident (R)14 and R16 with the care and services to maintain and prevent the further decline in the Range Of Motion (ROM) in both residents hands and legs. The deficient practice affects the resident's psychosocial well-being and mobility. Findings include: (Cross reference to F657 Care Plan Timing and Revision) 1) Observation of R14 on 07/25/23 at 3:10 PM in bed with contracted bilateral upper extremities (BUE) (hands) and bilateral lower extremities (BLE). Noted a long red roll on the nightstand and two booties on the bedside table. Review of R14's Electronic Health Record (EHR) on 07/27/23 at 04:26 PM. Review of R14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/12/2023, documented in Section C: Brief Interview for Mental Status (BIMS) score was an 8 indicating the resident has moderately low cognitive functioning and the resident's active diagnosis is hemiplegia, the resident is unable to move…

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

Based on observations, record review and staff interviews, the facility failed to ensure professional standards of practice were implemented for a resident (Resident (R) 47) using a suction machine. As a result of this deficient practice, resident was placed at risk for potential of harm related to respiratory infection. This deficient practice has the potential to affect all residents that require suctioning. Findings Include: On 07/25/23 at 10:03 AM, observed R47 lying in his bed with his eyes closed. R47 had a suction machine on his bedside table and the suction tip wrapped in a paper towel on his bed. The cannister was filled with a frothy, clear to whitish fluid and was halfway full. Date written on the cannister was 07/09/23. Record review revealed that R47's diagnoses included lung cancer and he is taking guaifenesin (cough medicine) four times a day to help clear mucus or phlegm in his lungs. At 01:03 PM, interview conducted with R47 in his room. Observed R47 coughing and able to spit out whitish phlegm into a basin that was lined with a plastic bag. Asked resident if he…

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 staff demonstrated competency relating to medication administration. As a result of this deficient practice, all residents are at risk for more than minimal harm. Findings include: During the revisit survey, on 10/12/23 at 12:28 PM, an observation was made of Nursing Staff (NS)5 entering an Anonymous resident's (AR)3's room with a medication cup and left the room shortly after. This surveyor entered AR3's immediately after NS5 left the room and observed two medication tablets on a napkin which was located on the resident's meal tray and one tablet in the resident's mouth, indicating NS5 did not stay and ensure AR3 took the medication as ordered by the physician. Inquired with AR3 if the facility conducted an assessment for self-administration of medications. AR3 confirmed he/she did not partake in an assessment to assess the resident's readiness to self-administer medications. AR3 also stated that one of the medications can upset his/her stomach and usually takes it after lunch; AR3's lunch was located on 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 and interview, the facility failed to ensure the daily nurse staffing information was in a prominent area. Finding includes: On 07/27/23 at 12:19 PM, while on Unit 1 this surveyor was unable to locate the daily nurse staffing information. At 12:20 PM, conducted an interview and observation regarding posting the daily nurse staffing information with the Director of Nursing (DON)1. The DON1 stated that the daily nursing information is written daily on the whiteboard behind the nursing station. Review of the whiteboard with the DON1 documented the role of the staff (licensed nurse or Certified Nursing Aide (CNA)) was not identified. This surveyor observed a single sheet of paper with the appropriate information, but it was difficult to distinguish it from the multiple other white papers posted on the bulletin board. The daily nurse staffing information blended in with other papers and the DON1 did not identify that it was posted, and this surveyor pointed it out. The DON1 confirmed the daily nurse staffing information was not posted in a distinguished 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 interviews and record review, the facility failed to ensure the drug regime of each resident is reviewed at least once a month by a licensed pharmacist for 1 of 6 residents (Resident (R)8) sampled. Review of R8's Electronic Health Record (EHR) documented the pharmacist did not conduct a monthly drug regime review for May 2023 and June 2023 until 07/27/23, after surveyor requested documentation of May 2023 and June 2023 Drug Regime Review (DRR). As a result of this deficient practice, the residents are at potential physical harm. Findings include: On 07/27/23 at 09:15 AM, conducted a review of R8's EHR. Review of the EHR documented R8 had an order for Bupropion HCl extended-release tablet 150 milligrams (mg) twice a day (BID) ordered on 04/21/23 and Sertraline 100 mg tablet, once a day was ordered on 04/21/23. This surveyor was unable to locate the DRR for R8 and requested the facility to provide the documentation. On 07/28/23 at 08:08 AM, received the requested documentation of R8's DRR. For May 2023, an observation date for May 2023 the Pharmacist Drug Regime Review was…

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

Based on interviews and record review, the facility failed to designate an individual as the Infection Preventionist (IP) which works at least part-time in the facility and/or completed specialized training in infection prevention and control. The individual designated as the IP is also working full-time as the Director of Nursing (DON). The facility recently hired Nursing Staff (NS)33 as the IP, however, NS33 did not complete specialized training in infection prevention and control. As a result of this deficient practice all residents are potentially at risk for harm. Findings include: (Cross Reference to F862: QAPI Program) During the entrance conference on 10/12/23 at 09:46 AM, inquired with the Administrator regarding the IP position. The Administrator stated the DON is primarily responsible for overseeing the infection control program as the IP and receives assistance with aspect of the Infection Control Prevention (ICP) program with the assistance from the Administrator, Minimum Data Set (MDS) nurse, and other staff while a floor nurse transitions into the position. 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 staff interview, the facility failed to ensure one of five residents (Resident (R) 47) sampled for immunization was provided the influenza vaccine. This deficient practice placed the resident at risk of acquiring, transmitting or experiencing complications from seasonal influenza. Findings Include: Review of Electronic Health Records (EHR) revealed that R47 is a [AGE] year-old resident admitted on [DATE] as a lateral transfer from another long term care facility. Diagnoses include diabetes (high blood sugar levels) and lung cancer. Immunization records from previous facility showed his last influenza vaccine was administered on 12/16/20. Review of scanned documents under Consent Forms revealed that R47 signed a consent to receive the influenza vaccine on 02/02/23, however, there was no record in the EHR showing the vaccine was administered. On 07/28/23 at 01:45 PM, concurrent interview and record review was conducted with Director of Nursing (DON) in his office. Asked DON if 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 and interview, the facility failed to provide an adequate call system so the resident could communicate with the nursing staff. The deficient practice places the resident at an increased risk of harm. One Resident (R)36 had a touch pad call light that was placed out of reach. Resident was not able to demonstrate how to use it to call the nurse. Findings include: During an observation on 07/26/23 at 09:38 AM noted the touch pad (call light) for R36 was found on the upper left corner of the mattress out of his reach. Asked the resident if he knew how to call for help? He shook his head no. Surveyor tested the touch pad, and the call light came on. R36 stated I never knew that's how to call for help. A certified nurse aide (CNA) came in to answer the call light and the resident said he wanted something to eat. Surveyor asked the CNA if he knows how to use the call light. The CNA said that he should, but the aide probably forgot to put it back after she repositioned him.