PALOLO CHINESE HOME
For profit - Corporation
113 Beds
Independent
Data: November 2025
Trust Grade
60/100
#29 of 41 in HI
Photo by Pālolo Chinese Home
Photo by Pālolo Chinese Home
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Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Palolo Chinese Home has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #29 out of 41 facilities in Hawaii, placing it in the bottom half of the state, and #16 out of 26 in Honolulu County, meaning only a few local options are better. Unfortunately, the facility's trend is worsening, with issues increasing from 10 in 2024 to 20 in 2025. Staffing is a strong point, earning 5 out of 5 stars with a turnover rate of 45%, which is average for Hawaii. Notably, the facility has not incurred any fines, indicating compliance with regulations, but it has faced concerns such as failing to ensure proper dish sanitization, which poses a risk of foodborne illness, and not providing residents with adequate information on how to file grievances. Additionally, there were issues with training for contracted nursing assistants, raising concerns about resident safety and care. Overall, while there are strengths in staffing and compliance history, serious weaknesses in operational management must be addressed.
- Trust Score
- C+
- In Hawaii
- #29/41
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Hawaii facilities.
- Skilled Nurses ✓ Good
- Each resident gets 93 minutes of Registered Nurse (RN) attention daily — more than 97% of Hawaii nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Bottom 30%
No red flags
10 → 20 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 20 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Hawaii average (3.4)
Meets federal standards, typical of most facilities
Staff Turnover: 45%
Near Hawaii avg (46%)
Higher turnover may affect care consistency
The Ugly 43 deficiencies on record
May 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation, the facility admission staff accessed one Resident's (R)1 external medical r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation, the facility admission staff accessed one Resident's (R)1 external medical records from an acute care Hospital (H)1 through a portal/link used to facilitate referrals and admissions without R1's consent, after she left the facility against medical advice (AMA). As a result of this deficient practice, R1's rights were violated.
Findings include:
1) R1 was an [AGE] year-old female, who was hospitalized at H1 from 03/23/2025 to 04/02/2025 for acute kidney injury, superimposed on chronic kidney disease. Her medical history includes chronic urinary retention requiring a suprapubic catheter (tube that drains urine from the bladder through the abdomen), recurrent urinary tract infections, bladder cancer and chronic pain. On 04/02/2025 she was discharged to the facility for short-term rehabilitation. On 04/03/2025, R1 left the facility without completing her care. Her daughter signed a Release of Responsibility Against Medical Advice (AMA), and took R1 home.
2) On 05/23/2025 at approximately 02:30 PM, interviewed Registered Nurse (RN5) in the conference room. RN5 worked in the admission office on a temporary basis. She explained that the facility had an Internet portal (H1 Link) with H1, to review medical records of patients that want to come to the facility for care after discharged from the hospital. RN5 explained that once a Resident has chosen the facility for post discharge care, the facility has access to part of their confidential medical records. She explained the admission staff also use the H1 Link to monitor Residents that were transferred to the hospital for a higher level of care and are expected to return to the facility after discharge. RN5 said she was aware that R1 left the facility AMA on 04/03/2025, and would not be returning. She went on to say on 04/04/2025, she accessed part of R1's Emergency Department medical records in H1 Link after she left the facility AMA.
3) On 05/23/2025 at approximately 03:00 PM, accompanied RN5 to admissions office, where she demonstrated the use of H1 Link.
4) Hospital (H)1 had a signed agreement with the facility titled H1's Link Access Agreement. This agreement included:
A. The parties seek to facilitate the use of health information technology in an effort to improve continuity and quality of care through effective communication, ., while also maintaining patient data security and privacy.
6. HIPAA(Health Insurance Portability and Accountability Act (standards protecting health information from disclosure without patients' consents)) and HITECH (Health Information Technology for Economic and Clinical Health) Act. Entity (Facility) agrees to comply with the Health Insurance Portability and Accountability Act of 1996 .Entity assures that his employees and Authorized users are compliant with HITECH and HIPAA, and will monitor all use of H1's Link.
Each authorized user of H1 Link executes a Confidentially and Use Agreement. Reviewed the user agreement titled .Link Confidentiality and Use Agreement Exhibit B, which included: 5. I acknowledge that by accessing the H1 Link, I may obtain confidential patient and clinical information including but not limited to electronic medical records in whole or in part (Confidential Information) and that such Confidential Information constitutes Protected Health Information under Health Insurance Portability and Accountability Act (HIPAA).I agree to access Confidential Information only for those individuals with whom I or the physician(s) for whom I work have an authorized treatment relationship.
5) Reviewed the facility policy titled Confidentiality of Personal and Medical Records Policy, last revised May 2024. The policy included:
2. Keep confidential is defined as safeguarding the content of information including .other computer stored information from unauthorized disclosure without the consent of the individual and/or the individuals' surrogate or representative.
10. Unauthorized persons are permitted to review records only with the signed permission of the resident or legal document allowing such access.
Reviewed the facility policy titled Resident Rights, last revised 04/18/2024. The policy included: i. Be entitled to have their personal and medical records kept confidential and subject to release only as directed by HIPAA regulations.
Reviewed the Admissions Coordinator Job Description last updated 09/22/2021. The essential duties/functions included Treats with confidentiality all information obtained; knowledgeable of all practices and policies concerning confidentiality of information with HIPAA.
6) When R1 left the facility AMA, there was no intent to return back to the facility, so there was no longer a treatment relationship. Any access to R1's medical records through the H1 Link after she left AMA, was a breach of confidentiality.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, document and record review (RR) the facility failed to report to authorities an allegation of potential abu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, document and record review (RR) the facility failed to report to authorities an allegation of potential abuse of one Resident (R)1 of a sample of one. R1 reported she woke up with someone lying next to her in bed. The facility did not identify this incident as potential abuse, and failed to report the allegation to the Office of Healthcare Assurance (OHCA), Adult Protective Services (APS), or the Police. As a result of this deficiency external agencies investigations were delayed and the facility failed to meet their mandated reporting requirements.
Findings include:
1) On 05/19/2025, OHCA received a report from an external agency of an allegation of sexual abuse of an [AGE] year-old female that occurred at the facility by an unknown perpetrator The report included on 04/02/2025 (time not provided), AV (alleged victim) was sleeping and she awoke after she felt AP (alleged perpetrator) laying next to her.
When AP found out that AV was awake, AP slid off AV's bed and left AV's room quietly.AV felt her undergarment and stated it was pulled down.
2) Record review revealed R1 was an [AGE] year-old female, who was hospitalized at hospital (H)1 from 03/23/2025 to 04/02/2025 for acute kidney injury, superimposed on chronic kidney disease. Her medical history includes chronic urinary retention requiring a suprapubic catheter, recurrent urinary tract infections, bladder cancer and chronic pain. On 04/02/2025 she was discharged to the facility for short-term rehabilitation.
3) Reviewed the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised date of 02/26/2024. The policy included:
The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. (See State Agencies to be notified for State Specific requirements).
Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated.
The follow up investigation notes will be submitted .to OHCA within five working days of initial report.
The Director of Nursing, or designee, will promptly report (orally or in writing) the matter to : 1. Department of Health, State Office of Health Care Assurance (OHCA) 2. Adult Protective Services or Child Protective Services 3. Med-[NAME].
State Agencies to be Notified: a) Adult Protective Services (APS) .APS will be called promptly, .
4) On 05/21/2025 at 01:30 PM, interviewed the Social Services Coordinator (SSC) in the conference room. She said when there is an abuse allegation, nursing is responsible to report to the State (OHCA) and Social Service reports to APS. The SCC said if there is concern for the safety of the resident, the police would also be notified. She said she was notified by the ADON (Assistant Director of Nursing) of the incident, and was told R1 said a female staff got in bed with her, pulled down her brief and spooned her for 10 minutes or so and left. SSC said she did not report the incident to APS.
On 05/22/2025 at 09:45 AM, interviewed the ADON in the conference room. At that time asked her what authorities are required to be notified if there is an allegation of sexual abuse. She said if they were aware that a crime was committed, they would notify the police, but that she was not aware of any crime in this incident. The ADON went on to say OHCA would be notified if there was a confirmed allegation. The ADON stated I had no idea that there was an alleged abuse. When asked what R1 told her, she said, In the middle of the night, a female laid next to her. Pulled her brief down and pulled it back up. The ADON said she thought maybe this occurred during patient care, and that R1 didn't say she was touched in anyway. The ADON said the daughter was very concerned, and requested the facility review camera surveillance. Asked the ADON if she offered to call the police, and she said No, I don't think so. When asked why the incident was not reported to external authorities, she said there was no indication there was anything sexual or that she was touched. She went on to say that those words (sexual) were used only after they R1 left the facility. The ADON said she thought the allegation was strange, but it did not make her think it sexual abuse.
On 05/22/2025 at 10:15 AM, interviewed Registered Nurse (RN)1 in the conference room. RN1 said she was a travel nurse and assigned to R1 day shift 04/03/2025. She said that morning R1 used the unit cell phone to call her family, and told her daughter someone got into bed with her. She said the conversation was confusing and she was unable to clarify the timeframe when this occurred. RN1 said R1 denied any other touching. When inquired what her thoughts were regarding the incident based on her training, she said R1 was not oriented to her surroundings, so would not be able to immediately determine how accurate her allegation was, but given the circumstances, and how serious the situation was, it would require a full investigation and reporting to the authorities.
On 05/22/25 at 12:00 PM, conducted an interview with the Administrator in training (ADM) and the Chief Executive Officer (CEO) in the conference room. The ADM said the allegation was being handled as a grievance. He said the next day, he was notified by a detective, requesting the video for evidence, because the daughter reported sexual assault. The ADM said they were aware R1 had been taken to the Emergency Department of two hospitals for examination on 04/03/2025. When inquired why the facility did not notify APS and OHCA, he said because the initial investigation didn't find anything. The CEO said she felt it was the hospitals responsibility to notify APS because the sexual allegation came forward after R1 was discharged from the facility. The CEO said she did not feel this incident was a sexual allegation or potential assault, because what R1 described was nursing care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interviews, observation, record and document review, the facility failed to thoroughly investigate one alleged abuse of a sample of one, reported by Resident (R)1. Specifically, the facility ...
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Based on interviews, observation, record and document review, the facility failed to thoroughly investigate one alleged abuse of a sample of one, reported by Resident (R)1. Specifically, the facility did not; 1) interview R1's roommate, and all staff working, 2) summarize the findings of review of the video surveillance, and 3) document the results of their independent, internal investigation and report them to the Office of Healthcare Assurance. As a result of this deficient practice, there is the potential important information is missing from the investigation, necessary to determine the outcome.
Findings include:
1) Cross Reference F609 Reporting of Alleged violations:
R1 reported to the facility she woke up with someone lying next to her in bed. The facility did not identify this incident as potential abuse, and failed to report the allegation and results of their internal investigation to the Office of Healthcare Assurance (OHCA).
2) Reviewed the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised date of 02/26/2024.
The policy included:
a. Investigation of abuse : .The investigation will include: .iii Resident's roommate statements (if applicable).
3) Reviewed the documentation of the investigation provided by the Administrator in Training (ADM). The individual assigned to lead the investigation was the Assistant Director of Nursing (ADON), who was on duty and notified when R1 made the allegation that someone laid in bed with her. The notes of the investigation were documented electronically in Grievance and Compliant, with entry dates, but no times. The notes were not in sequential order. The document included, but not limited to the following:
04/03/2025 Part 1: Writer (ADON) interviewed resident in her room. She stated the lady jumped in bed. She was sleeping and this lady lied down next to her and pulled down her brief without saying one word. Brief down to her upper thigh and she was exposed. Resident stated that she pulled the brief right back up. Resident denied anything else happened.
04/03/2025 Part 2: .Resident (R1) said she was afraid and did not report it to anyone.Resident was very confident that she could identify the staff. Daughter requested to check the cameras to see who entered the room.
04/03/2025 Part 3: .checked the video clips.
04/03/2025 Part 4: The ADON showed R1 pictures of six staff members, who she did not identify as the person who got in bed with her.
04/03/2025 Part 5: The ADON showed R1 another picture, who she did not identify as the person.
04/04/2025. Reviewed findings with Medical Director. Met with Detective.
04/23/2025: HPD (Honolulu Police Department) Detective coming in today for further investigation .
05/19/2025: Emailed Detective .if there are any further follow up .or if case is closed.
05/20/2025: APS investigation.
This document also included statements from several staff, but did not have a time documented and did not specify if the statement was written or statement made during an interview. Some of the dates on the statement entries were 04/09/2025, which is six days after the allegation was made.
The facility provided on request seven separate handwritten/typed staff statements. Review of the statements revealed two were dated, three did not have dates the statement was written, and two were dated 04/09/2025.
4) On 05/22/2025 at 09:45 AM, interviewed the ADON, who was lead for this investigation, in the conference room. She said she was the nursing leader that was notified that day. The ADON said the nurse had already assessed R1, so when she arrived to the room, she interviewed R1, and stayed with her until her daughter arrived. The ADON said usually they do interviews of staff who worked at the time of the incident, pinpoint the shift or person, but do a wider investigation if needed. The ADON said sometimes they would ask for written statements. She said they would interview other Residents if they witnessed the incident. When inquired if they would interview other residents that an alleged perpetrator had provided care to, she said no. She said that the person who does the interview or gets other pertinent information, documents it in the IR (incident report), which is the running document of the investigation. The ADON said the electronic IR does not automatically time stamp entries and for some reason, it does not show the entries in consecutive order.
On 05/22/2025 at 10:15 AM, interviewed RN1 in the conference room. She said she was assigned to R1 on day shift 04/03/2025. RN1 said when she interviewed R1, she was unable to clarify the timeframe of the alleged incident. RN1 said R1 denied being touched, other than someone laid next to her in bed. She said at that time, she checked R1 and looked for redness, and bruising to her legs, upper arms, and chest. She said she did not see anything. RN1 said she did not look at or assess R1's lower abdomen or pelvic area.
On 05/22/2025 at 12:00 PM, conducted an interview with the ADM and the Chief Executive Officer (CEO) in the conference room. The CEO said they were contacted by a detective the next day. She went on to say what had been described to her was that R1 was confused and someone went into the room and probably changed her brief. The CEO said the conclusion of the investigation was that it was nursing care that was provided. She said she knew the RN tried to do an head to toe assessment after it was reported, but was unable to complete one.
5) The document of the investigation did not include the following:
- An interview with R1's Roommate.
- A written statement or interview with three CNA's (CNA1, CNA2, and CNA9) and RN6, who had been assigned to the unit during that period of time.
- A summary of the findings of the surveillance camera review to include possible correlation with staff statements and interviews.
- The facility's summary and conclusion of the investigation.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Resident's/representatives with the name and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide Resident's/representatives with the name and contact information of the facility grievance official and did not inform them of the right to receive the findings of the investigation and conclusion in writing. In addition, three out of four Resident (R) grievances reviewed, did not include findings, conclusions or if any corrective action was, or would be taken. This deficient practice could affect all Residents because the facility does not provide them the required information for them to file a grievance, and obtain an acceptable resolution.
Findings include:
1) On 05/22/2025 at 02:58 PM, interviewed the Administrator-in-Training (ADM) in the conference room. The ADM confirmed that the grievance official is the Administrator. A concurrent review of the policy, with a revised date of 02/15/2021 stated, 5. The resident or person filing/addressing the grievance .will be informed of the findings .Such report will be made orally by the Administrator or his designee . The ADM stated this was accurate. The policy did not state that the resident or person filing the grievance had the right to obtain a written decision regarding his or her grievance and did not include the name of a grievance official with his/her contact information.
2) On 05/22/2025 at 03:30 PM, the facility's admission Handbook was received and the Grievance Policy in the handbook, with a revised date of 02/2022, was reviewed. The policy stated, 5. The resident or person filing/addressing the grievance .will be informed of the findings .Such report will be made orally by the Administrator or his designee . The policy did not state that the resident or person filing the grievance had the right to obtain a written decision regarding his or her grievance.
3) On 05/22/2025 at 03:45 PM, a walkthrough was done at the facility's Ilima Wing in the [NAME] Building. No posting of the grievance official's name and contact information was located.
4) Reviewed R1's Grievance and Complaint report dated 04/03/2025 at 09:20 AM. The report included: Incident Description heading that .someone in the middle of the night had gotten into the bed with the patient . A review of the report demonstrated that an investigation was conducted by the facility. However, a summary of the internal investigation was not found.
On 05/22/2025 at 12:05 PM, the ADM stated that the investigation was still open because the facility was waiting for the police investigator's conclusion. However, the police investigation is an external investigation and not part of the internal facility investigation. The report also did not include a statement whether the grievance was confirmed or not confirmed, any corrective action to be taken or to be taken by the facility because of the grievance/complaint, and no follow-up provided to the complainant. On 04/03/2025 at 02:41 PM, the Social Services Coordinator (SSC) noted in the progress notes, Daughter .expecting a call back with update.
5) Reviewed R2's Grievance and Complaint report dated 02/10/2025 at 04:34 PM, which included:
Incident Description heading that R2 complained Registered Nurse (RN)4, .didn't respond to the [NAME] (alarm) alert on his [NAME] vest (wearable cardioverter defibrillator) timely and that the LN's (Licensed Nurse's/RN4) behavior is strange like she is on drugs.
On 02/10/2025, the Assistant Director of Nursing (ADON) documented in the report that R2 mentioned Certified Nurse Aide (CNA)7 was lazy and while he was in the dining room, he saw CNA7 walking around the unit 11 times.
On 02/11/2025, the ADON reported R2's concerns to the contracted Nursing Agency that employed RN4 and CNA7. However, a summary of the facility's internal investigation and monitoring of RN4 and CNA7 was not documented.
On 05/03/2025 at 09:15 AM, the ADON stated that if a performance issue is received for an agency staff, the facility will email the Agency regarding the issue. ADON then stated the Director of Nursing (DON), ADON, Infection Preventionist (IP), and Nurse Managers do discuss the issues, but it is not documented. The report also did not include a statement whether the grievance/complaint was confirmed or not confirmed and any corrective action taken or to be taken by the facility because of the grievance/complaint.
6) Reviewed R4's Grievance and Complaint report dated 03/10/2025 at 04:49 PM, which included:
Incident Description heading, Received email from resident's Family Member (FM)1 .newly assigned CNA (CNA8) being too rough and being scared to be alone with her.
On 05/22/2025 at 02:48 PM, the ADM was interviewed. The ADM stated that it was determined it was a transferring issue and the outcome was to not have CNA8 work any further shifts, which was communicated via email to FM1. The report did not include a summary of the investigation, the corrective action taken by the facility, or the communication to FM1 as stated by the ADM.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to provide protections for the health, welfare and rights of each resident residing in the facility by developing and fully implementing poli...
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Based on interviews and record review, the facility failed to provide protections for the health, welfare and rights of each resident residing in the facility by developing and fully implementing policy/procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not (1) include how the facility would ensure contract/agency caregivers who provide care on behalf of the facility would receive the required training elements, and (2) four of a sample size of six contracted Nursing Assistants did not have evidence of the required training. As a result of this deficiency, the facility can not ensure contracted staff have the required knowledge to recognize and prevent abuse, which may result in negative outcomes.
Findings include:
1) Reviewed the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised date of 02/26/2024. The policy included:
a. Employee screening and training .v. All new employees/volunteers will receive training on the abuse policy prior to direct or indirect resident contact. vi. All new employees/volunteers will be oriented to the Abuse Policy and made aware of their responsibility to report any suspected maltreatment as defined and described in this policy. vii. Attendance at a yearly in-service on the Abuse Policy and on Resident Rights is mandatory for all employees/volunteers.
B) Training Components:
It is the policy of this facility to train employees, through orientation and on-going sessions on issues related to abuse and prohibition practices.
Staff and volunteers receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source, exploitation and misappropriation of property upon first employment and annually after that, incorporating the following elements:
- orientation and ongoing programs
- Training on the abuse policies and procedures
- How to deal with aggressive and catastrophic reaction of residents
- How to report abuse without fear of reprisal
- Recognizing the signs of burnout, frustration, and stress
- Training about challenging behaviors and how to intervene
- Communication of reports of resident mistreatment, neglect, and/or abuse. including injuries of unknown source, and misappropriation of property.
- How to identify residents at risk of neglect or abuse.
- Resident [NAME] of Rights
- Review of facility abuse policies and procedures
- Annual notification of covered individuals of their obligation to comply with reporting requirements.
- Immediate Action to an Abuse or Suspected Abuse: Any employee who witnesses potential abusive behavior is required to intervene to end such behavior and protect the health and welfare of the resident.
- (S) Stop the abuse from happening. (P) Protect the resident. (O) Oust /Remove the alleged abuser from the residents out of all resident areas (T) Tell the Charge Nurse/On Call Manager immediately.
Procedure: A. Staff and contracted individuals will be taught the signs and symptoms of staff burnout.
The facility policy does not address the training requirements for contract/agency staff, with the exception of training to identify staff burnout.
2) The Human Resource Director (HRD) reported that the facility supplements staffing with contract/agency staff, and as of 05/23/2025, 22% of the licensed nurses are contract, and 28% of the Nurse Assistant staff are contract.
3) Reviewed a sample of contract profiles for education on abuse. The review revealed the following:
CNA1, employed by Agency (A)6, had documentation of completing Relias training through the agency on 08/21/2024. Further investigation revealed there were five abuse questions, which CNA1 scored only 40%. Two questions were related to Child abuse, and one on Intimate Partner Violence. This would not be an acceptable content/score to validate competency and would not meet the required training elements.
CNA4, employed by A1, agency documents included a Quiz completed by CNA4 on 12/19/2022. The quiz consisted of six true or false questions, which was not corrected/graded. False was circled as the correct answer for the first question; Patients have the right to be free from mental, physical, sexual, and verbal abuse. At the bottom of the quiz, there was a signed statement, that read I have completed the in-service training for Patient Abuse and/or Neglect and understand my responsibility to report any knowledge of abuse, neglect, or exploitation of any patient to the Agency Administrator or Designee. This would not be acceptable validation that training requirements are met.
CNA5, employed by A4 had documentation of an exam titled Core Concepts in Healthcare-Nursing, completed 01/08/2025, which included one question on Elderly Abuse, that CNA5 got correct. There is no other documentation of training on abuse. This would not meet the required training elements.
CNA6, employed by A2 had document of training titled Abuse and Neglect, which included signs of physical abuse, signs of neglect, signs of sexual abuse, and signs of psychological abuse. This training did not cover all the required training elements.
4) On 05/23/2025 at 12:45 PM, interviewed the ADON in the conference room. She discussed the CNA orientation checklist and said all contract CNA's should have a completed checklist in their file. She explained each contract CNA will have a preceptor assigned that is to go over the checklist with them. ADON went on to say the staff will either verbally test the contract CNA or they we will ask them to demonstrate a skill for competency. She said sometimes the preceptor does not have time to sign the checklist, so she will sign it instead of the preceptor. ADON acknowledged she signs for demonstrations which she did not actually observe. Inquired what training they were provided on abuse, and she said they go over STOP, but do not do any other specific training on abuse. The ADON stated the Agency would provide the rest of abuse training. When asked if the Agency included types of abuse, sand signs and symptoms, she stated I don't go over it, maybe its in their agency training.
On 05/22/2025 at 12:00 PM, interviewed the Administrator in Training (ADM) and the Chief Executive Officer (CEO) in the conference room to discuss contract training. The ADM said when they contract with then, they will send over a credential packet that includes training they have completed with the Agency, prior to coming to the facility. He said some of them use the same online educational modules, Relias, that would have similar content. He said they use a lot of agency staff at the facility, so when someone starts, they use an onboarding checklist, as well as they would attend any monthly in-services. The ADM said one of the Agencies (A)1 have new, inexperienced CNA's, so the facility provides them the same orientation as their own staff. At that time, informed the ADM and CEO that some of the contract CNA packets reviewed did not have evidence the Agency provided abuse training that included all the required elements.
On 05/22/2025 at 01:20 PM, interviewed Human Resource Director (HRD), who assists with arranging contract staff. She said when the contract staff packet arrives, they review the packet to ensure the background checks, registry checks and all required documents are there. The HRD said she does not get involved with the details of the Facility agreements with Agencies, and did not know specifics of what each agency included in their abuse education. She said that would be up to Nursing to review.
5) Reviewed seven contracts the facility used for supplemental staffing. The contracts were reviewed for content for any details related to abuse training. The document review revealed the following:
A1 Service Agreement (signed 12/19/2024)
This agreement does not address client (facility) orientation or required training by agency prior to placement.
A2 Staffing Agreement (signed 04/30/2021):
A2 responsibilities: .b. Upon request provide .skills assessments .
Client responsibilities: c. Orient personnel to CLIENT facilities and its rules and regulations, .Allow personnel, on their own time, to attend appropriate facility staff development programs.
A3 Service agreement (signed 04/04/2025):
Customer (facility): Number 8 addresses training to comply with OSHA (Occupational Safety Health Administration), to protect workers from hazards and injuries, and requires the facility to train to their specific policies for compliance. There was nothing in the agreement regarding training for abuse.
A4 Client Services Agreement (signed 06/06/2022)
A4's Responsibilities: 1.shall conduct and supply .skills checklist, application, education, .
Facility responsibilities: 7. Client (Facility) shall orient Personnel to its facility, including its rules, regulations, policies procedures . The length and extent of orientation shall be determined by Client.
A5 Client Staffing Agreement (signed 08/22/2019):
6. Client orientation. Client will provide AGENCY personnel with an orientation to CLIENT specific policies and procedures and processes necessary to equip AGENCY personnel with the knowledge necessary to meet CLIENT expectations for personnel.
A6 Staffing Agreement (signed 12/29/2022):
Client Duties and Responsibilities: (e) .provide Assigned Employees with appropriate orientation, education, training regarding Client's facility, rules, regulation, policies and procedures;
This agreement included a Credentialing Verification and Screening Requirements that included skills checklist.
A7 Professional Contract Agreement (signed 06/25/2020):
The agreement provided does not address any orientation or abuse training.
May 2025
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's right to a dignified existence fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's right to a dignified existence for two (Residents (R) 395 and R18) of three residents sampled for dignity. As a result of this deficient practice, residents dependent on staff are at risk for more than minimal physical and/or psychosocial harm.
Findings include:
1) On 04/28/25 at 08:47 AM, conducted an interview with R394. Inquired if staff provide timely care and respond to call lights in a reasonable time frame. R394 responded, not all the time. R394 explained it depends on who is working, some staff are better than others. R394 reported activating the call light because his/her roommate (R395) needed assistance, and staff took about 25 minutes to respond. R394 stated he/she was worried that his/her call light may not have been working because it took staff a long time to acknowledge the activated call light. R394 activated the call light because R395's legs were dangling off the bed and he/she was concerned the resident was going to fall off the bed.
On 04/28/25 at 01:19 PM, conducted a telephone interview with R395's Resident Representative (RR) 7. RR7 reported two incidents when R395's family members activated the call light for staff assistance with the resident's care needs. RR7 stated the first incident, family waited approximately an hour for staff to respond to the call light and another incident where the family waited approximately 30 minutes for staff to answer the call light. Inquired why the family had activated the call light and RR7 responded the resident's incontinent brief needed to be changed on both occasions. RR7 stated it is difficult to leave R395 knowing that the resident may not be receiving care when needed.
On 04/30/25 at 12:31 PM, conducted an interview with the Director of Nursing (DON) in his office. Informed the DON of reports regarding long waiting timeframes for staff to respond to call lights and helping the residents. DON confirmed 30 minutes is too long for call lights to go unanswered and if staff are unable to immediately answer a call light, staff is trained to, at minimum, verbally check in with the resident and inform them that staff will assist the resident as soon as staff is able to.
2) Resident (R)18 is a [AGE] year-old male re-admitted to the facility on [DATE] for long-term care. R18's admitting diagnoses include, but are not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) left non-dominant side. A review of R18's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/12/25. The assessment indicated R18 had been assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating a determination that he was cognitively intact.
On 04/28/25 at 09:05 AM, observation and concurrent interview was done with R18 at his bedside. R18 stated facility failed to protect and value his private space by not knocking and asking permission before entering, and staff does not close his bathroom door as requested. Observed signage with instruction of, Please . close door all the time. posted on R18's bathroom door. R18 stated that Certified Nurse Aide (CNA)45 let him wait for 30 minutes before assisting him with toileting.
On 04/30/25 at 01:25 PM, interviewed Director of Nursing (DON) in his office. When asked if DON was notified for all R18's complaints and if formal investigation should have been completed, DON confirmed he met with R18 to discuss all his complaints, and formal investigation(s) should have been completed for all of them but had not. DON also stated R18 should be treated with respect and in a dignified manner.
Review of facility's policy and procedure titled, Resident Rights with a revision date of 04/18/24 stated, .[the facility] will treat each resident with respect and dignity . staff will knock, announce themselves, and provide reason for entry before entering . staff will await resident approval prior to entry .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary assistance to help maintain functio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary assistance to help maintain functional mobility and independence on one of two sampled residents (Resident (R)18), for accommodation of needs. This deficient practice has the potential to affect all the residents at the facility.
Findings include:
Resident (R)18 is a [AGE] year-old male re-admitted to the facility on [DATE] for long-term care. R18's admitting diagnoses include, but are not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) left non-dominant side. A review of R18's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/12/25. The assessment indicated R18 had been assessed with a Brief Interview for Mental Status (BIMS) score of 15, indicating a determination that he was cognitively intact.
On 04/28/25 at 09:05 AM, observation and concurrent interview was done with R18 at his bedside. When asked about how often he gets out of his room to participate with any activities, R18 reported that he does not get to participate with activities as often as he wanted to due to his limited mobility. R18 stated staying in his room is not his preference and that on 12/07/24, he had requested the facility provide him with a one-arm-drive wheelchair so that he could safely and independently complete all his Activities of Daily Living (ADLs) including but not limited to grooming, dressing, and toileting throughout the day.
Record review of R18's Electronic Health Record (EHR) revealed a Physical Therapy evaluation dated 03/17/25 documented, .Pt [patient/resident] requires wheelchair for functional mobility due to bilateral amputation .Pt would have maximum independence with functional mobility with a one arm drive wheelchair.
On 04/30/25 at 01:15 PM, concurrent interview and record review was done with the Social Services Coordinator (SS)1 at the dining area. When asked if the resident's request for a one-arm-drive wheelchair for functional mobility had been addressed, SS1 confirmed that the facility was still waiting for an update from the supplier since 12/07/24. Review of the EHR revealed a Social Services note that documented, . resident asked for a manual wheelchair to propel himself. This worker will f/u [follow-up].
On 04/30/25 at 01:25 PM, interviewed Director of Nursing (DON) in his office. DON confirmed that there was no documentation that a timely follow-up had been done.
Review of facility's policy and procedure titled, Resident Rights with a revision date of 04/18/24 stated, . [residents] Have the right to meet with and participate in activities of social . at their own discretion.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the resident's right to choose aspects of the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure the resident's right to choose aspects of the resident's life that are significant to the resident for two (Resident (R) 394 and R395) of two residents sampled. R394 prefers to brush her teeth in the morning, but staff regularly assist the resident in the afternoon. R395 receives hospice service and family reported not wanting the resident up in the wheelchair for more than 15-20 minutes (for meals) to allow the resident to rest in bed. As a result of this deficient practice, residents are at risk for more than minimal negative psychosocial and/or physical outcomes.
Findings include:
1) On 04/28/25 at 08:42 AM, conducted an interview with R394 in the resident's room. R394 reported her preference of brushing her teeth three times a day, when she wakes up and after each meal. However, at the facility, the resident waits long after she wakes up for staff to assist her with brushing her teeth. R394 stated at times she has brushed her teeth around lunch time, well after having breakfast and waking up, which makes the resident feel, Yucky. R394 confirmed brushing her teeth in the morning is important to her.
Review of the facility task, activities of daily living, personal hygiene which included oral hygiene, revealed starting from 04/14/25 (date of admission) to 04/30/25, staff documented the resident brushing her teeth at 10:21 AM, 12:32 PM, 12:40 PM, 12:27 PM, 08:23 AM, 12:25 PM, 12:09 PM, 10:07 AM, 12:46 PM, 12:33 PM, 12:19 PM, 01:42 PM, 08:23 AM, 12:18 PM, 10:21 AM, and 12:31 PM.
On 04/30/25 at 11:53 PM, conducted an interview with the Director of Nursing (DON) regarding the time R394 is assisted with oral hygiene. DON reviewed the oral hygiene task and confirmed staff is assisting the resident in the afternoon most of the time and that is not aligned with R394's preferences.
2) On 04/28/25 at 08:24 AM, entered the [NAME] unit and observed R395 seated in a wheelchair at a table in the unit dining room until 10:40 AM. During this time the resident was observed sleeping periodically in the wheelchair at the table. During lunch observations at 11:15 AM to 11:50 AM, R395 was observed to still be in the wheelchair in the unit's dining room. Mentioned to Unit Clerk (UC)1 that R395 is still out in the wheelchair and UC1 confirmed it. At 01:19 PM, entered the unit and observed R395 in bed with two Family Members, (FM) 10 and FM 54, visiting. FM54 reported R395 had returned to bed about 10 minutes prior. FM54 reported R395 is unable to tolerate sitting in the wheelchair for long periods of time and the family thinks it's important for the resident to be resting in bed and not sleeping in the wheelchair. FM54 stated they told staff to not keep her (R395) in the wheelchair after breakfast, instead take the resident back to bed to rest.
Conducted a telephone interview with R395's Resident Representative (RR) 7 on 04/28/25 at 01:18 PM. RR7 reported R395 is on hospice and has a weakened physical state, and is unable to tolerate sitting in the wheelchair for 20 minutes or longer. RR7 stated that family members have come into the facility and found the resident slumped forward while seated in the wheelchair. As a result of this, RR7 requested that R395 not be left seated in the wheelchair in the common area for more than 15-20 minutes.
On 04/30/25 at 12:05 PM, conducted an interview with DON. Informed DON of the observation of R395 up in the wheelchair for more than 20 minutes and sleeping in the wheelchair, which was not what RR7 and family members wanted for the resident. DON confirmed R395 should have been assisted back to bed when staff was done assisting the resident with her meal and prior to the resident being observed sleeping in the wheelchair.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain a copy of the resident's Advance Health Care Directive (AHCD) and did not inform the resident of his/her right to develop one, provi...
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Based on interview and record review, the facility failed to obtain a copy of the resident's Advance Health Care Directive (AHCD) and did not inform the resident of his/her right to develop one, provide assist in doing so, and/or periodically assess the residents' preference for formulating an AHCD for 2 of 2 residents (Residents (R) 46 and R12) sampled. This deficient practice does not allow residents, when incapacitated, the right to have their health care choices identified and honored.
Findings include:
1) On 04/29/25 at 02:50 PM, review of R46's electronic health record (EHR) revealed a Social Services note dated 09/16/24 at 04:28 PM stating that Social Services to follow-up with hospice provider regarding R46's AHCD. Upon further review of R46's progress notes, no follow-up attempts to obtain the AHCD were documented.
On 04/30/25 at 01:42 PM, interviewed the Social Services Coordinator (SS) 1 in the Social Services office. SS1 confirmed there was no documented follow-up regarding obtaining the AHCD from the hospice provider. SS1 voiced that the Social Worker at the hospice provider is difficult to reach to inquire about the AHCD, but also stated that she could have contacted the visiting Nurse from the hospice provider.
2) On 04/29/25 at 07:51 AM, record review of the R12's Electronic Health Record (EHR) was completed. Advance Health Care Directive (AHCD) could not be found in the EHR.
On 04/30/25 at 01:00 PM, requested AHCD documentation from Director of Nursing (DON). No AHCD documentation was given this day.
On 05/01/25 at 08:16 AM, the facility provided Social Worker (SW)1's progress notes of the AHCD discussion with R12 on 03/05/25. The note details that resident continues to refuse AHCD and is not interested in further discussion. The note was a late entry and created by SW1 on 04/30/25.
On 05/01/25 at 08:31 AM, interview with SW1 completed. SW1 stated she forgot to document her discussion with R12 on 03/05/25 because she went on vacation. SW1 confirmed she was reminded this week from leadership to complete documentation. SW1 agreed that she should have documented after the discussion, or sooner than 04/30/25, but noted that they have been doing their best to keep up.
On 05/01/25 at 09:30 AM, interview with R12 completed. R12 stated that AHCD was discussed with him when he first came to the facility, but did not remember any discussion recently.
On 05/01/25 at 09:45 AM, a follow up interview with SW1, and Social Services Coordinator (SS)1 completed. When SW1 was asked to provide handwritten notes from the discussion with R12 on 03/5/25, SW1 responded, I already shredded it today. SW1 noted she shredded her notes as it was her last day with facility, and she was in the process of cleaning up her work. When both SW1 and SSI were asked how often AHCD documentation should be completed, both stated that it should be done quarterly, and documented timely in the EHR. SW1 and SS1 also agreed that timely documentation in the EHR is extremely important because things can change over time, it is a running record of the resident's care, and it reflects the most updated status of the resident.
Review of the facility's Advance Directive policy, dated 01/30/19, in the On-going Review section, it notes, 1. Quarterly, Social Service Coordinator will review with resident/resident representative regarding Advance Directive as preferences may change over time. For those that don't have an Advance Directive, Social Service Coordinator will discuss again the option for establishing and Advance Directive.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents' environments were clean and homel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents' environments were clean and homelike, as well as, protecting residents' personal property from loss, for two of four residents (Resident (R) 8 and R65) sampled for environment. A staff member did not dispose of soiled and dirty trash items properly, leaving it on top of R8's personal property in her room. This has the potential to cause unpleasant odors and an unsanitary environment. R65's personal lamp was removed from his room without explanation or follow-up. The facility did not exercise reasonable care for the protection of the resident's property from loss.
Findings include:
1) Cross reference to F880, Infection Prevention & Control. The facility failed to ensure R8's soiled incontinence bed pads were properly disposed of to decrease the risk of spreading infectious disease.
Review of R8's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/04/25 found R8 with a score of 15 (cognitively intact) when the Brief Interview for Mental Status (BIMS) was administered.
On 04/29/25 at 08:33 AM, during observation and interview with R8, observed a used wrapped-up incontinence item and used gloves on top of an opened bag that stored incontinence briefs, this was on top of R8's personal belongings (a green bag filled with other bags, arts and craft supplies, and a reusable bowl to microwave food placed inside a plastic bag). A trash bin was observed to be right next to it. Inquired of R8 what the item was and if she put it there, R8 used her reach grabber tool to pick up the item and stated she did not put that there and described the item as her dirty bed pad. R8 proceeded to throw the dirty bed pad into the trash bin and reported she did not know how long it had been there. R8 stated she was last changed this morning but saw the staff member take it out. R8 proceeded to report that agency staff sometimes don't do their job correctly like leave dirty things in her room and wondered where they get their training from.
On 04/30/25 at 11:38 AM, interview with Assistant Director of Nursing (ADON) and Infection Preventionist (IP) were done. IP reported after a staff member provides incontinence care, the dirty supplies should be disposed in a trash bag and if disposing the item in a resident's trash bin in the room it should be taken out of the room to reduce unpleasant smells.
Review of the facility's policy and procedure Safe and Homelike Environment dated 02/28/24 documented General Consideration to Minimize odors by disposing of soiled linens promptly .
2) Resident (R) 65 is a [AGE] year-old male, admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/28/25 noted that R65 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that R65 had intact cognitive function.
On 04/29/25 at 08:31 AM, interviewed R65 who stated that approximately three months ago, he had a personal black floor lamp and the top broke off. Maintenance took it and never brought it back. No replacement was offered, and R65 felt he needed more lighting in the room. R65 also stated he received no explanation by staff if the lamp was going to be fixed or that he could not keep it in his room.
On 04/30/25 at 11:31 AM, interviewed the Maintenance/Housekeeper Manager (MAINT) outside of the facility's Lehua Wing entrance. MAINT stated that he did not recall a floor lamp being removed from R65's room. MAINT stated if any resident's personal property is removed, it is put on the facility TELS work order program and the nursing staff will put a work order in.
On 04/30/25 at 11:38 AM, interviewed Registered Nurse (RN) 6 who stated that she remembered a broken floor lamp and maintenance was told to look at it.
On 04/30/25 at 03:31 PM, a follow-up interview with MAINT was done who confirmed that he could not locate a work order for R65's lamp and the maintenance staff could not recall R65's lamp being removed from his room.
On 05/01/25 at 08:12 AM, interviewed the Assistant Director of Nursing (ADON) in the Activity room. ADON stated that she was made aware that the lamp maybe fell over when staff was providing care. The base and stand were flimsy and had broken. R65 was okay with the lamp being removed but was unsure if his consent for removal and explanation for removal was documented.
On 05/01/25 at 08:29 AM, Interviewed SS1 in the Social Services office. SS1 stated that she was told by the ADON that R65's lamp was in the MDS office and was taken out of his room for safety purposes because it was a tripping hazard, it was shaky, and the facility did not want the electrical outlet to be overloaded.
On 05/01/25 at 08:48 AM, a black lamp was observed in the MDS office, and a picture was taken.
On 05/01/25 at 08:51 AM, R65 confirmed the picture of the black lamp was his personal lamp that was taken out his room.
On 05/01/25 at 11:59 AM, ADON stated that no documentation could be found regarding R65 providing consent for the lamp to be removed from his room or explanation given to R65 for the reason it was being removed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a resident's comprehensive assessment accurately reflected the resident's status at the time the assessment was completed for one of...
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Based on record review and interview, the facility failed to ensure a resident's comprehensive assessment accurately reflected the resident's status at the time the assessment was completed for one of seven residents (Resident (R) 293) reviewed for falls. Staff members were utilizing the bed/chair alarm as an intervention for falls and it was not reflected in the assessment under restraint. This deficient practice put R293 at risk of an inaccurate assessment of the bed/chair alarm and its appropriateness as an intervention.
Findings include:
Cross reference to F689, Accidents. The facility failed to ensure R293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to her left femur (thigh bone) that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to her discharge.
Review of the completed facility report incident (FRI) received by the State Agency (SA) on 08/19/24, documented on 08/12/24 at 06:15 AM, prior to R293's fall with major injury that resulted in fracture to her left femur, the assigned night shift Certified Nurse Aide (CNA) documented, .performed a visual check on resident. Without any restlessness observed, and clip [bed/chair] alarm was in place.
Review of R293's care plan found the intervention for bed/chair alarm was not included in the care plan as an intervention to prevent falls until 10/26/24, after R293's second fall. The care plan documented, The resident uses (SPECIFY: chair/bed) electronic alarm. Ensure the device in in place as needed, initiated on 10/26/24.
Review of R293's progress notes documented the use of a clip or bed alarm after 08/12/24, 10/26/24, and 11/10/24 falls.
Review of R293's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/22/24 under Section P. Restraints, bed alarm and chair alarms were noted to not be in use.
On 05/01/25 at 09:19 AM, an interview and concurrent record review with Director of Nursing (DON) was done. DON reported that there was no task area for staff to document whether clip bed/chair alarms were in place when nursing rounds are done. DON reviewed the MDS Initial Review, by the MDS coordinator, dated 08/19/24 for the quarterly MDS with an ARD of 08/22/24, and during the assessment the bed alarm and chair alarm were not observed to be used. DON stated the MDS coordinator would need to review the progress notes to get an accurate reflection. Upon concurrent review of the progress notes, DON confirmed from 08/16/24 to 08/23/24, during the assessment seven-day look-back, the progress notes documented the clip bed/chair alarms were used. Based on the documentation provided by the progress notes, DON confirmed bed and chair alarm should have been included in the quarterly MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the development and implementation of a comprehe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for two (Residents (R)30 and R56) of 22 sampled residents. As a result of this deficient practice, residents were placed at risk for decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being.
Findings include:
1) On 04/29/25 at 02:31 PM, conducted a record review of R30's Electronic Health Record (EHR). Review of physician orders documented an order for Insulin Glargine- Subcutaneous [under the skin] Solution Pen-injector 100 UNIT/ML [milliliter] Inject as per sliding scale [dose is titrated depending on blood glucose result]: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 600 = 10 units > [if greater than] 400 give 10 units and notify MD [physician] and NP [nurse practitioner], subcutaneously in the morning for DM [diabetes]. Review of R30's comprehensive care plan revealed a care plan was not developed for the use of insulin.
On 04/30/25 at 11:40 PM, conducted a concurrent interview and record review of R30's EHR with the Director of Nursing (DON). DON reviewed R30's physician orders and confirmed R30 has an order to receive a sliding scale dose of Insulin Glargine. DON reviewed R30's comprehensive care plan and confirmed a care plan was not developed for R30's use of insulin.
Review of the facility's policy for baseline, comprehensive, and discharge care plans revealed the following documented: a comprehensive care plan will reflect the resident's stated goals, objectives, and include interventions that address his/her current needs by the nurse observing the needs. The Interdisciplinary team will conduct a care plan meeting to review the comprehensive care plan with the resident/resident representative which should include: Measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
2) On 04/28/25, 04/29/25, and 04/30/25 observed R56 comfortably lying in bed with Oxygen (O2) at 4 liters per minute via nasal cannula.
On 04/30/25 at 01:11 PM, interviewed Licensed Practical Nurse (LPN)1 at the nurse's station. During a concurrent review of R56's comprehensive care plan, when asked if R56's Plan of Care included any respiratory care, LPN1 confirmed it did not include/address any respiratory care evaluation(s), including but not limited to, oxygen administration.
On 04/30/25 at 01:28 PM, concurrent interview and record review with the Director of Nursing (DON) was done in his office. DON reviewed R56's physician orders and confirmed R56 had an order to receive oxygen. When asked if R56's comprehensive care plan was developed to include R56's respiratory care, DON confirmed it was not.
On 04/30/25 at 01:46 PM, conducted a record review of R56's Electronic Health Record (EHR). R56 was admitted to the facility on [DATE] with diagnoses including, but not limited to, vascular dementia, moderate, with other behavioral disturbance. An order was made on 03/04/25 at 01:44 PM, written by the Assistant Director of Nursing (ADON), . Oxygen at 2 Liters/Minute PRN [as needed] via nasal prong [cannula] or 02 mask. Titrate oxygen up to 5 Liters/Minute to keep 02 saturation >93%. Notify MD [physician] if resident is requiring more than 2 Liters/Minute of oxygen and/or is requiring routine oxygen. Review of R56's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/09/25, Section J. Health Conditions, noted, .Other Health Conditions. J1100. Shortness of Breath (dyspnea) documented R56 does not have any shortness of breath or trouble breathing. Review of the R56's comprehensive person-centered care plan with a revision date of 04/15/25, noted it did not include the resident's respiratory care including the administration of oxygen.
The facility's policy titled, Oxygen Administration, with a revised date of 04/09/25, stated, . 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as. b. When to administer, such as continuous or intermittent. c. Equipment setting for the prescribed flow rates. e. Monitoring for complications associated with the use of oxygen.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to revise the comprehensive person-centered care plan f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to revise the comprehensive person-centered care plan for one of seven residents (Resident (R) 293) reviewed for falls, and one of one resident (R12) sampled for urinary catheters. R293's care plan did not include new interventions for falls after sustaining a fall with major injury. As a result, R293 experienced additional falls that may have been avoided. By not revising R12's care plan to include urinary catheter care, R12 was placed at risk for adverse catheter-related issues.
Findings include:
1) Cross reference to F689, Accidents. The facility failed to ensure R293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to left femur (thigh bone) that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to discharge.
Review of the completed facility reported incident (FRI) received by the State Agency (SA) on 08/19/24, documented R293's fall with major injury that resulted in fracture to left femur on 08/12/24. The facility documented under interventions implemented in the report, Upon readmission, resident will continue with current fall interventions: Bed in lowest position, fall mat, clip alarm, and bed sensor alarm in place. Consider positioning alarms out of reach i.e. [for example] head of bed behind headboard as not to be tampered with. Staff to continue frequent checks to anticipate and meet needs.
Review of R293's care plan found bed in lowest position, fall mat, clip alarm, bed sensor alarm in place, and/or positioning alarm out of reach not included in the care plan after readmission on [DATE].
On 05/01/25 at 09:19 AM, an interview and concurrent record review with Director of Nursing (DON) was done. Concurrent review of R293's care plan, DON stated the typical interventions were in place, such as, .call light within reach, ensure wearing appropriate footwear, toilet before and after meals, at bedtime and in the morning . at were in place at admission prior to the incident on 08/12/24. Inquired after readmission, what new interventions were in place, DON confirmed there were no new interventions and the interventions in the care plan were already in place. DON further confirmed the interventions listed in the FRI were not documented in the care plan and new interventions should have been in place after the fall with major injury on 08/12/24.
Review of the progress notes documented R293 had two subsequent falls after 08/12/24, on 10/26/24 and 11/10/24.
Review of the facility's Fall Prevention Policy and Procedure included, if a resident falls, nursing to review and update care plan.
2) On 04/28/25 at 01:05 PM, observed R12 with an indwelling urinary catheter. Concurrent interview with R12 noted that he had the catheter for over a month. Record review noted that resident had the catheter reinserted on 03/16/25. Physician's orders showed catheter care to be done every shift. Review of R12's care plan revealed it was not revised to include goals and interventions for catheter care after it was reinserted on 03/16/25.
On 04/30/25 at 09:00 AM, interview with Registered Nurse (RN)8 completed. RN8 confirmed that care plan was not revised to include catheter care. RN8 also agreed that keeping care plan current is important as it shows what type of care the resident needs.
On 04/30/25 at 10:00 AM, interview with Director of Nursing (DON) confirmed that catheter care should have been included in R12's care plan. DON also agreed that the care plan is important as it reflects the current needs of the resident and to ensure that appropriate interventions are taken.
Review of the facility's Baseline, Comprehensive, and Discharge Care Plan policy, revised on 12/06/24, in the Procedure section, it notes, 10.Changes will be made as necessary, resulting from significant changes in condition or needs .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 10/03/24 at 12:47 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 10/03/24 at 12:47 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11247, documenting a fall with major injury (fracture of the right ankle) for Resident (R)29. On 04/28/25, the SA entered the facility to investigate the incident.
R29 is an [AGE] year-old female admitted to the facility on [DATE] for long-term care. A review of R29's most recent Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/18/25 noted a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reflecting a determination that she is cognitively intact. R29's diagnoses include, but are not limited to, quadriplegia C5-C7 incomplete (weakness or paralysis in both arms), generalized muscle weakness, contracture (a shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, and contracture of muscle of the left hand.
On 04/28/25 at 10:30 AM, an interview was done with R29 at her bedside. When asked about her fall on 10/02/24, R29 stated that Certified Nurse Aide (CNA)33 was transferring her from the bed to a shower chair and she just crumbled. R29 also stated that staff had transferred her many times before with only one person.
On 04/28/25 at 02:42 PM, an interview was done with CNA33 in the staff dining room. When asked about the incident, CNA33 stated, I was not given proper report on this resident [R29]. CNA33 explained that she had never been assigned to R29 before, when her assignment suddenly changed to R29 at the last minute. CNA33 further explained that usually she will receive a verbal report from the previously assigned CNA, but they were both so busy at the time that the only information she received from the off-going CNA was that R29 needed a shower. CNA33 acknowledged that since she was not familiar with R29, she should have checked the Kardex [CNA care plan]. At the time of the incident, CNA33 stated that she knew about the Kardex, but I didn't know how to access it. CNA33 stated R29 started to fall as soon as she got her up off the bed. When asked about the ankle fracture, CNA33 stated I heard a crack [as R29 fell], so she was not surprised to learn that R29 had a major injury.
On 04/30/25 at 09:17 AM, an interview was done with the Director of Nursing (DON) in his office. During a concurrent review of her electronic health record (EHR), DON confirmed that R29 had been a 2-person mechanical lift transfer since 2020, and that this information was reflected in the Kardex. DON also confirmed that CNA33 should have checked the Kardex before transferring a resident she was not familiar with.
Based on interview and record review, the facility failed to ensure two of seven residents (Resident (R) 293 and R29) reviewed for falls were free from accident hazards. R293, whom previously had a fall with major injury (a fracture to the left thigh bone that required surgery), had no new interventions care planned for falls, then had a subsequent fall putting R293 at risk for further injuries. R29 was inappropriately transferred via 1-person manual transfer instead of a 2-person mechanical lift, and as a result suffered a fall with a fracture to her right ankle.
Findings include:
1) R293 was admitted to the facility on [DATE] for skilled nursing with admitting diagnoses of closed distal phalanx (toe) fracture to the right foot, first digit, dementia related to Alzheimer's disease, repeated falls, and osteoarthritis (when the flexible, protective tissue at the ends of bones, called cartilage, wears down) to bilateral knees.
Review of R293's discharge summary from the hospital, prior to admittance to the facility, revealed that in the history and physical section, the resident had been documented with a history of falls and .admitted with a fall with resultant R [right] foot pain found to have fracture of R 1st distal phalanx. Recurrent falls-seem mechanical. She lost her balance - wasn't using her walker and walking on a windy day and fell .There does remain a concern for hypoglycemia [low blood sugar] or hypotension [low blood pressure] since she lives alone and with her memory impairment there is possibility of medications errors leading on to falls.
Review of the completed facility reported incident (FRI) received by the State Agency (SA) on 08/19/24, documented R293's fall with major injury that resulted in fracture to left femur (thigh bone) on 08/12/24. On 08/12/24 at 6:20am [sic] at shift change between Night Shift and Day Shift, CNA [Certified Nurse Aide] .was standing in the hall when he heard a garbage can falling to the floor in resident's room. Upon going to check on resident, CNA observed resident in fetal position on her left side by foot of the bed, not on the fall mat .Resident was admitted .Surgery planned on 08/13/24. The facility documented under interventions implemented in the report, Upon readmission, resident will continue with current fall interventions: Bed in lowest position, fall mat, clip alarm, and bed sensor alarm in place. Consider positioning alarms out of reach i.e. [for example] head of bed behind headboard as not to be tampered with. Staff to continue frequent checks to anticipate and meet needs.
Review of R293's care plan found bed in lowest position, fall mat, clip alarm, bed sensor alarm in place, and/or positioning alarms out of reach not included in the care plan after readmission on [DATE]. (Cross reference to F657, Revision of Care Plan)
Review of the progress notes documented R293 had two subsequent falls after 08/12/24, on 10/26/24 and 11/20/24. On 10/26/24, During medication pass at 05:30AM [sic], CNA alerted this writer that resident was found on the floor next to her bed. This writer rushed to the resident's room and found resident on the floor with head at end of bed. Resident found with brief soiled with fecesand [sic] urine. When asked what happened resident repeated, shee shee, shee shee. Meaning she wanted to use the toilet. This writer performed nursing assessment and took resident's vitals. Resident noted with small bump to L [left] side of head. No other injuries noted. A follow-up entry on 10/26/24 was completed as a late entry, Call light was not on at time of writer entering room Call light was in reach when resident found. Fall mat found against wall - unsure when or who moves fall mat. House keeping moves fall mats - interventions added to care plan to ensure bed alarm and fall mat are in place. On 11/10/24, RN [Registered Nurse] notified by CNA that patient [R293] was found to be sitting on the floor at the End of the patients bed. RN went in to assess patient. Patient sitting on the floor. Bed alarm didn't sound off, patient alarm tested and working, patient clip alarm was off the patient. No head injury noted. Vitals taken, Patient denied pain .Patient stated she tried to go to the bathroom.
On 05/01/25 at 09:19 AM, an interview with Director of Nursing (DON) was done. During a concurrent review of R293's care plan, DON stated the typical interventions were in place, such as, .call light within reach, ensure wearing appropriate footwear, toilet before and after meals, at bedtime and in the morning . that were in place at admission prior to the incident on 08/12/24. Inquired after readmission, what new interventions were added, DON confirmed there were no new interventions and that the interventions in the care plan were already in place. DON further confirmed the interventions listed in the FRI were not documented in the care plan. Although the facility planned to use fall mats, DON confirmed the fall mats were not implemented on 10/26/24 and were only documented in the care plan after the incident. For the incident on 11/10/24, DON confirmed the clip alarm was not on R293 and it was documented she could remove it, DON could not confirm if the intervention listed in the FRI to consider .positioning alarms out of reach . was implemented.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 03/17/25 at 03:44 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tra...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 03/17/25 at 03:44 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11578, documenting a fall with major injury (fracture of a left rib) for Resident (R)28 on 03/14/25. On 04/28/25, the SA entered the facility to investigate the incident. Review of R28's electronic health record (EHR) revealed that R28 had another unwitnessed fall (without injury) on 03/27/25.
Further review of R28's EHR noted the following Fall Risk Evaluations (and their results):
On 03/13/25 at 04:30 PM, prior to the falls, an assessed score of 16, with a Score 10 or higher indicated the resident is at high risk of fall.
On 03/14/25 at 11:00 PM, after the fall with major injury (FMI), an assessed score of 14.
On 03/18/25 at 12:38 PM, after the FMI, an assessed score of 14.
On 03/27/25 at 08:59 AM, after the second fall, an assessed score of 2, indicating a low risk for falls. This Fall Risk Evaluation was marked as completed by Registered Nurse (RN)16.
On 04/30/25 at 09:38 AM an interview was done with the Director of Nursing (DON) in his office. During a concurrent review of R28's Fall Risk Evaluations, DON confirmed that he does expect licensed staff to question when fall risk evaluation scores are vastly different from previous scores, and/or do not match the resident. DON agreed that RN16 should have questioned a fall risk evaluation score of 2 for R28 and that she had completed the form improperly.
On 05/01/25 at 10:15 AM a second interview was done with DON in his office. DON confirmed that RN16's current assignment is as the day shift Charge Nurse, and she should have known how to complete a fall risk evaluation accurately.
Based on interview and record review, the facility failed to ensure staff competency in completing Fall Risk Evaluations accurately for 3 of 7 residents (Residents (R)293, R294, and R28) sampled for falls. This deficient practice placed the affected residents at risk of avoidable adverse outcomes.
Findings include:
1) Cross reference to F689, Accidents. The facility failed to ensure Resident (R)293 was free from accidents and hazards. R293 was admitted to the facility with history of recurrent falls and sustained a fracture to left femur that required surgery due to an unwitnessed fall at the facility. Upon re-admission, post-fall with major injury, new interventions were not developed and R293 had two more unwitnessed falls at the facility prior to discharge.
Review of R293's fall risk assessments instruct a total score of 10 or higher indicates the resident is a high risk of fall. R293's assessments concluded a score of 13 during the admission fall risk assessment on 05/09/24, a score of 11 on 08/11/24, a score of 21 upon readmission on [DATE], and a score of 17 on 10/26/24. On 11/11/24, after the third fall on 11/10/24, the assessment had a score of six, much lower than previous scores. Review of the 11/11/24 assessment was noted to be incomplete in Gait/Balance and Medications and completed by Registered Nurse (RN)4.
On 05/01/25 at 09:19 AM, an interview and concurrent record review with Director of Nursing (DON) was done. DON confirmed the 11/11/24 fall risk assessment was incomplete and did not accurately reflect R293's status.
2) Review of R294's progress notes document he had an unwitnessed fall on 04/05/25. R294 was found at approximately 02:40 AM, on the .left side laying next to his bed with head .facing the end of his bed. Resident reports he was attempting to use restroom. Did not use call light, Denies head injury.
Review of R294's fall risk assessments instruct a total score of 10 or higher indicates the resident is a high risk of fall. R294's admission fall risk assessment concluded a score of 12 on 04/02/24. On 04/05/25, after R294's fall, the assessment had a score of 10, lower than the previous score. A review of the 04/05/25 assessment was noted to be incomplete in Gait/Balance and Medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and review of facility's medication administration policy, the facility failed to keep medications secured for one of twelve residents (Resident (R), 69) observed dur...
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Based on observation, interviews, and review of facility's medication administration policy, the facility failed to keep medications secured for one of twelve residents (Resident (R), 69) observed during medication administration. This deficient practice has the potential to affect all residents in the facility taking medications.
Findings include:
On 04/30/25 at 08:00 AM, observed Registered Nurse (RN)16 during medication administration for R69. RN16 walked out of the room to get correct size glove, leaving multiple medications on R69's bedside table unattended and accessible to anyone who could have entered R69's room. Concurrent interview with RN16 noted that she should not have left medications out of her sight as anyone could have taken the medications and R69 could have taken the wrong dose. RN16 agreed that it is also for safety reasons.
On 4/30/25 at 10:00 AM, interview with Director of Nursing (DON) completed. DON confirmed that RN16 should not have left the medications unattended for safety reasons.
Review of the facility's Medication Administration policy, dated 01/23/07, in the Procedure section, it notes, 10. Administer medication and remain with resident while medication is swallowed. Do not leave medication in a resident's room without orders to do so .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident's menu with selected food choice was followed for one of two residents (Resident (R) 66) sampled for food p...
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Based on observation, interview, and record review, the facility failed to ensure a resident's menu with selected food choice was followed for one of two residents (Resident (R) 66) sampled for food preferences. The facility did not follow-up/communicate with R66's food choice after identifying the selection may have an ingredient he is allergic to, and did not give R66 the opportunity to choose what he wanted to eat. As a result, R66 received a meal that was not listed on the menu provided in advance that he did not want to eat, causing the resident confusion.
Findings include:
On 04/28/25 at 11:17 AM, during lunch dining observation, observed R66 sitting in the dining room with two other residents (R35 and an unidentified resident). R66 had his meal tray on his table and was confused on what was on his plate. The other two residents did not receive their meal tray at this time. He asked R35 what was on his plate for lunch and R35 was observed to take a look at the meal ticket on R66's plate, and stated it was chicken, rice, and cauliflower. R35 explained to R66 that the meal ticket indicated his lunch was supposed to be beef tomato, but it was crossed out and chicken was written on it, and his vegetable was supposed to be bean sprouts, but it was crossed out and cauliflower had been written on instead. R66 stated he did not want chicken and wanted the beef tomato, and that he does not like cauliflower, but likes bean sprouts.
On 04/28/25 at 11:21 AM, inquired of R66 if he had concerns with his lunch provided, R66 reported he did not know why they crossed out beef tomato on his meal ticket and gave him chicken and rice and that he does not like cauliflower but was supposed to have bean sprouts. While explaining his concern, Recreation Aide (RA) 1 suddenly removed R66's meal tray without informing him and R66 asked where he was taking his lunch. RA1 stated he was going to get R66 something else. Registered Dietician (RD) was then observed to approach R66 to find out what was going on and stated she will go ask what happened with the kitchen.
On 04/28/25 at 11:48 AM, observed R66 eating a sandwich. R66 stated they got him a roast beef sandwich and was told by a staff member that they did not serve him the beef tomato because he is allergic to pineapple, and they put pineapple in the sauce. No one had approached R66 prior to lunch to inform him that the beef tomato had pineapple in it, and if he wanted to change his selection. R66 stated I only ordered the chicken once over here and that he was not interested in eating chicken at this time. R66 stated they get a weekly menu and he circles the items he wants to eat ahead of time, and it is posted on his bedroom wall.
Review of the menu posted in R66's room with his circled preference(s) was done for week 04/27/25 to 05/03/25. The lunch menu for 04/28/25 included the options of beef tomato, mediterranean turkey burger with tater tots, roast beef sandwich, or chef salad. The menu further documented the regular entrée items are served with rice or mashed potatoes, bean sprout salad, Italian vegetable mix, and mandarin oranges. R66 had circled beef tomato, rice and mandarin oranges.
On 04/28/25 at 12:01 AM, an interview with RD was done. RD confirmed the kitchen used pineapple in the beef tomato and R66 is allergic. She stated the other choice was turkey burger but R66 is allergic to turkey, so the kitchen staff decided to give him chicken. RD further confirmed that no one approached R66 prior to serving his lunch to inform him that his choice was not available due to his allergies and did not attempt to inform him of other options to choose from.
Review of a progress note dated 04/29/25 documented late entry 4/28/25 1200pm: res [R66] selected the beef tomato for lunch. Res did not receive the beef tomato due to his pineapple allergy which is in the teriyaki sauce used in the beef tomato. The alternative entrée was turkey which res is also allergic to. Res was given chicken instead since res does eat chicken. Writer was notified after investigating ., writer explained to res that due to the allergy, res did not receive the beef tomato. Res stated he preferred to have the roast beef sandwich instead so writer went to the kitchen and brought the roast beef sandwich immediately. Res did eat the sandwich and tolerated well.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide food in the consistency ordered by the physician to meet the needs of 2 of 2 residents (Resident (R) 13 and R69) sampl...
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Based on observation, interview and record review, the facility failed to provide food in the consistency ordered by the physician to meet the needs of 2 of 2 residents (Resident (R) 13 and R69) sampled for appropriate preparation of food. This deficient practice increases the risk of aspiration for residents who have a modified consistency diet order for dysphagia (difficulty swallowing).
Findings include:
1) On 04/28/25 at 11:31 AM, observation of R13's meal ticket noted it stated diet as chopped, regular diet with thin liquids. Observation of the beef tomato entrée on his meal tray noted the tomato was not chopped, and the beef and vegetables were of varying sizes. The Infection Prevention Coordinator (IP) was asked to make a concurrent observation and confirm if the beef tomato entrée was an appropriately chopped consistency. IP responded that it depended on the consistency of the food item and that the tomato was not chopped because it was soft.
On 04/28/24 at 11:43 AM, Certified Nurse Aide (CNA) 31 was asked to make a concurrent observation and confirm if the beef tomato entrée was an appropriately chopped consistency. CNA31 stated that chopped consistency should be less than one inch by one inch in size and confirmed some of the beef and vegetables were bigger than that.
On 04/28/24 at 11:45 AM, Certified Nurse Aide (CNA) 45 stated that chopped consistency is coleslaw size. When asked to make a concurrent observation, CNA45 confirmed that not all the meat and vegetables for R13's beef tomato entrée were appropriately chopped.
On 04/30/25 at 11:12 AM, observation of R13's lunch tray was done, and the bean sprouts were full-sized and not chopped. Interviewed Certified Nurse Aide (CNA) 19 who confirmed that the bean sprouts were not chopped and stated that her reference for a chopped consistency is sugar cube sized, and bigger than minced.
2) On 04/28/25, observation of R69's meal ticket revealed it documented his/her diet as chopped, consistent carbohydrate with thin liquids. The following two observations of food items not appropriately chopped and inconsistent in size were made:
On 04/28/25, observed lunch tray with varying sizes of beef and vegetables for beef tomato entrée.
On 04/30/25, observed breakfast tray with varying sizes of food items. Sausage patty was cut into sugar cube sized pieces, but waffle was cut into silver dollar sized pieces.
On 05/01/25 at 08:02 AM, interviewed the Executive Chef (EC) who stated that the facility's definition for chopped consistency is bite-sized. When asked to define bite-sized, EC stated there is no reference size for chopped consistency because each individual food item will be different.
Review of the Complete IDDSI (International Dysphagia Diet Standardization Initiative) Framework Detailed definitions 2.0 | 2019, found at https://www.iddsi.org/, noted the following definition of bite-sized: Adults, 15 mm = 1.5 cm pieces (no larger than).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to check the refrigerator temperature for one of five refrigerators in the kitchen for two consecutive days on the evening shift. This deficien...
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Based on observation and interviews, the facility failed to check the refrigerator temperature for one of five refrigerators in the kitchen for two consecutive days on the evening shift. This deficient practice puts resident at risk for foodborne illness.
Findings include:
On 04/28/25 at 08:00 AM, initial walkthrough of the kitchen completed. Observed the temperature log for refrigerator #10 was missing PM temperature readings and initials for 04/25/25-4/26/25. Concurrent interview with Executive Chef (EC) noted that he was not sure why it was missed. EC also stated that it might be due to the new system implemented since he started.
On 04/30/25 at 10:00 AM, interview with Director of Nursing (DON) confirmed that refrigerator temperature settings should be checked every day on both the AM and PM shifts to ensure avoiding food spoilage.
On 04/30/25 at 11:30 AM, follow up interview with EC confirmed that temperatures should be checked every day on both AM and PM shifts to prevent any food spoilage and resident illness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record reviews, the facility failed to ensure a resident's (Resident (R) 8) soiled incontinence item and dirty gloves were properly disposed of, and a staff memb...
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Based on observations, interviews, and record reviews, the facility failed to ensure a resident's (Resident (R) 8) soiled incontinence item and dirty gloves were properly disposed of, and a staff member used appropriate personal protective equipment (PPE) for a resident (R84) under enhanced barrier precautions (EBP) for one of four units (Unit W) observed for infection control. These deficient practices increase the risk of the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors.
Findings include:
1) Cross reference to F584, Clean Homelike Environment. The facility failed to ensure a soiled incontinence bed pad was discarded appropriately, the item was placed on R8's personal belongings and visible for visitors to see which had the potential to cause unpleasant odor and an unsanitary environment.
On 04/30/25 at 11:38 AM, interview with Assistant Director of Nursing (ADON) and Infection Preventionist (IP) were done. IP reported after a staff member provides incontinence care the dirty supplies should be disposed in a trash bag and if disposing the item in a resident's trash bin in the room it should be taken out of the room. IP confirmed the incontinence brief bag, gloves, and bed pad would be considered dirty and are infection control concerns when left on and touching a resident's personal items.
Review of the facility's policy and procedure Infectious Waste Management dated 02/22, documented to prevent occupational exposure to infectious waste, Solid disposable diapers and underpads are securely wrapped in a plastic bag and discarded as regular trash.
2) On 04/28/25 at 08:31 AM, during an initial observation of Unit W, observed an EBP sign posted on R84's room door with blue painter's tape, on the top of the sign that specified R84's room number and bed was under precautions. The sign instructed for those providing direct care or close contact to wear a surgical mask, gloves, and gown.
At 08:39 AM, during observation of R84's room, R84 was not in her room but the bathroom door was observed to be closed and the sound of running water from the shower was heard. Certified Nurse Aide (CNA) 16 was observed to come out of the bathroom wearing gloves and a surgical mask but did not have a gown on. Inquired if she was showering R84, CNA16 confirmed she was then proceeded to look at the EBP sign on the door. CNA16 mumbled they said it's okay now .they said its okay . then was observed to walk to Registered Nurse (RN) 13 and then walk back to R84's room, donned instructed PPEs for EBP, and continued to return to R84 in the bathroom.
At 08:46 AM, an interview with RN13 was done. RN13 reported R84 had a skin rash on her arms and on her right upper back. Her arms were cleared by the physician but they were not sure about her right upper back and so she was put on EBP. RN13 confirmed CNA16 should have had a gown on when showering R84.
Review of R84's Electronic Health Record (EHR) found in the dermatologist's physician progress note, R84 was seen on 04/21/25 due to a rash that had been present for three weeks. Upon examination, it was noted R84 had erythematous crusted papules with severe excoriation (redness, raised bumps, and a crusty, often raw appearance, potentially caused by scratching or rubbing) distributed on the right upper arm, left upper arm, and right upper back. Diagnoses included dermatitis unspecified: Drug Eruption vs. [versus] Allergic Contact Dermatitis vs Scabies vs Atopic Dermatitis. Under physician orders, R84 was prescribed Valtrex oral tablet one gram (GM), give one tablet by mouth three times a day for shingles for seven days, started on 04/26/25 and to end on 05/03/25. Review of progress notes documented R84 was monitored and receiving treatment for rash and on 04/26/25 was put on contact isolation for possible shingles. On 04/28/25 at 05:29 AM, a progress note documented Shingles - left arm appears improved, resident denies pain to the arm but states it feels a little itchy. At 07:14 AM, an RN noted, the physician visited the resident and .assessed skin and noted pustules to left forearm were gone .ordered to discontinue Contact/Airborne Precautions. At 09:16 AM the Infection Preventionist (IP) noted the physician .ok to discontinue Contact, EBP, and Airborne precautions due to shingles no longer active.
On 04/30/25 at 11:40 AM, interview with Assistant Director of Nursing (ADON) and Infection Preventionist (IP) were done. IP reported when a resident is under EBP and direct care such as dressing, grooming, and showering, the PPEs, gown, gloves and surgical masks, should be donned. IP further reported when a resident is taken off transmission-based precautions (TBP), housekeeping will first deep clean the room and the resident's status will be discussed prior to taking the sign down.
On 04/30/25 at 11:54 AM, second interview with RN13 was done. RN13 reported on 04/28/25 at approximately 07:00 AM, after she assessed R84's skin to be crusted or scabbed she informed the physician while he was doing his onsite rounds if contact precautions could be discontinued. The physician agreed to discontinue contact precautions, but it was decided to put her on EBP because she still had a rash, to protect R84 and others. Two hours after the physician discontinued contact precautions, another nursing staff called the physician and all precautions were discontinued. Inquired if EBP was activate on 04/28/25 when we first interviewed and observed CNA16 not wearing a gown while showering R84, RN13 confirmed it was still activate.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interviews, and record review, the facility failed to implement interventions in a care plan for one out of three sampled residents (Resident (R) 2). This deficient practice resulted in R2 su...
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Based on interviews, and record review, the facility failed to implement interventions in a care plan for one out of three sampled residents (Resident (R) 2). This deficient practice resulted in R2 sustaining a fall and has the potential to affect all the residents in the facility.
Findings Include:
(Cross reference to F689-Free Of Accident Hazards/Supervision/Devices)
A review of R2's Electronic Health Record (EHR) was conducted on 11/22/24. R2's EHR noted that R2 sustained an unwitnessed fall in the dining room on 10/24/24 at 08:40 PM. Furthermore, R2's current care plan noted the following interventions to prevent her from falling, 6/17/24 Staff to ensure common areas (i.e. dining room) are supervised at all times. Staff to communicate with one another when they have to leave the premises.
A review of the facility's investigative note on R2's fall on 10/24/24 was conducted. The investigative note documented, ROOT CAUSE: .Resident was with family most of the evening and reportedly fell about 5 minutes after family left. Poor communication resulted in staff not supervising the dining room in this 5 minutes window when family left and staff away attending to other residents .
Interview was conducted with the Nurse Manager (NM), with the Administrator present, on 11/22/24 at 10:28 AM. NM stated that after R2's family left, there was a 5-minute window when R2 was left unsupervised in the dining room prior to her fall. NM confirmed that during that time, the interventions in R2's care plan was not being implemented. NM also stated that residents scored as a high risk for falls in the falls risk evaluation would require close supervision.
Interview was conducted with Certified Nurse Assistant (CNA) 3 on 11/22/24 at 10:48 AM via phone call. CNA3 confirmed that R2 was by herself when she found her on the ground in the dining room on 10/24/24.
A review of the facility's policy titled, Baseline, Comprehensive, and Discharge Care Plan, with a last revised date of 04/17/23, was conducted. The policy noted, 12. The facility staff or those acting on behalf of the facility will implement the interventions to assist the resident to achieve care plan goals and objectives.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate supervision to prevent two out of three sampled r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate supervision to prevent two out of three sampled residents (Resident (R) 1 and R2) from falling. Due to this deficient practice R1 sustained a fall that resulted in a laceration to the head. This deficient practice has the potential to affect all the residents who are at risks for falls in the facility.
Findings Include:
(Cross reference to F656-Develop/Implement Comprehensive Care Plan)
1)R1 is a [AGE] year-old male admitted to the facility on [DATE]. R1 has a diagnosis that include, but not limited to, spinal stenosis, mild cognitive impairment, and generalized arthritis. A review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/24, noted that R1's score for Brief Interview for Mental Status (BIMS) was a seven. Which means, R1 has severe cognitive impairment.
A review of the Facility Reported Incident (FRI) document, dated 09/01/24, was conducted. On the FRI, the facility reported that a Certified Nurse Assistant (CNA) 1 had assisted R1 into the outdoor courtyard in his wheelchair. CNA1 then left R1 unsupervised for a few minutes to return to the dining room. Once she returned, CNA1 found R1, on the ground. R1's body was draped over the concrete retainer curb, with face down on rocks.
A review of R1's Electronic Health Record (EHR) was conducted on 11/21/24. R1's EHR contained an assessment for his falls risk, dated 07/05/2024. The falls risk noted a score of 13, which the falls risk tool described, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls.
Interview was conducted on 11/21/24 at 09:08 AM with the Nurse Manager (NM). NM stated that R1 was left unsupervised outdoors for about 5 minutes. NM confirmed that R1 should not have been left unsupervised.
Interview was conducted with CNA2 on 11/21/24 at 12:45 PM. CNA2 stated that R1 loves to go outside, and when he is outside, he is usually supervised by either a rehab nurse aide or a staff from the activities department.
Interview was conducted with Registered Nurse (RN)1 on 11/21/24 at 01:15 PM. RN1 stated that she was working at the time of the incident and called 911 after R1 sustained the fall. When RN1 was asked if residents were ever left unsupervised, RN1 answered, Residents are supposed to be supervised when they are outside.
Interview was conducted with the NM, with the Administrator present, on 11/22/24 at 10:28 AM. NM stated that residents scored as a high risk for falls in the falls risk evaluation would require close supervision.
2)R2 is an [AGE] year-old female admitted to the facility on [DATE]. R2 has medical diagnosis that includes, but not limited to, Alzheimer's disease, parkinsonism, dementia, and anxiety disorder. A review of R2's MDS with an ARD of 10/22/24, noted that R2's score for BIMS was a 0. Which means, R2 had severe cognitive impairment.
A review of R2's EHR was conducted on 11/22/24. R2's EHR contained an assessment for her falls risk, dated 10/17/2024. The falls risk noted a score of 15, which the falls risk tool described, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls.
R2's EHR noted that R2 had sustained an unwitnessed fall in the dining room on 10/24/24 at 08:40 PM. R2 was observed being restless prior to the fall. A review of R2's care plan noted the following intervention to prevent R2 from falling, 6/17/24 Staff to ensure common areas (i.e. dining room) are supervised at all times. Staff to communicate with one another when they have to leave the premises.
Interview was conducted with the Nurse Manager (NM), with the Administrator present, on 11/22/24 at 10:28 AM. NM stated that residents scored as a high risk for falls in the falls risk evaluation would require close supervision.
Jul 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that one of the three sampled residents (Resident (R) 1) rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that one of the three sampled residents (Resident (R) 1) received treatment and care in a timely manner and in accordance with professional standards of practice. This failed practice has the potential to affect all the residents in the facility.
Findings Include:
R1 is a [AGE] year-old female admitted to the facility on [DATE]. R1 has medical diagnosis including but not limited to Moyamoya disease, heart failure, gastrostomy tube (feeding tube), aphasia (communication disorder) following cerebrovascular disease (condition that affects blood flow in the brain).
A review of R1's Electronic Health Record (EHR) was conducted. R1's EHR noted that R1 was diagnosed with a fracture of the left upper arm on 07/12/24.
Interview was conducted with R1's spouse on 07/25/24 at 11:50 AM. R1's spouse stated that he visits R1 every day except on Saturdays. During his visits he would normally perform range of motion exercise involving R1's upper extremities and lower extremities. During his visit on 07/09/24, R1's spouse noticed that R1's left upper extremity was limp. During that time, he did not report it to a staff member. During his visit on 07/10/24, R1's spouse had mentioned to Certified Nurse Aide (CNA) 1 that he had noticed R1's left arm was limp. R1's spouse was not sure if CNA1 had reported the change in R1's status to a licensed nurse. On 07/11/24, R1's spouse mentioned R1's limp left arm to a front desk staff. R1's spouse was not able to recall which front desk staff he had spoken to. On 07/12/24, R1's husband mentioned R1's limp left arm to Registered Nurse (RN) 1.
Interview was conducted with CNA1 on 07/25/24 at 10:48 AM. CNA1 stated that R1's husband had mentioned that R1's arm was limp on 07/10/24. CNA1 did not mention it to a license nurse about the change in R1's condition.
An interview was conducted with RN1 on 07/26/24 at 08:45 AM. RN1 stated that R1's husband had mentioned that her left arm was limp on 07/12/24 at approximately 02:30 PM. Before RN1 could assess R1, RN1 was notified by CNA2 that she observed bruising to R1's left upper extremity during a routine shower. RN1 assessed R1 and notified R1's physician. X-ray was ordered and R1 was diagnosed with a left upper arm fracture. RN1 stated that CNA1 should have reported the change in R1's status on 07/1024, when R1's husband had initially reported it.
Interview was conducted with Director of Nursing (DON) on 07/26/24 at 10:50 AM. DON stated that CNA1 should have reported to a licensed nurse right away after R1's spouse had mentioned her left arm being limp. DON added that a licensed nurse could have assessed R1's left arm earlier.
Review of the facility policy titled, Notification of Resident Change of Condition, dated, 09/25/24 was conducted. The policy noted, Facility staff will report any observed or noticed changes in conditions for a resident to the RN on duty.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview, the facility failed to ensure staff members, including contracted staff, followed the proper use of personal protective equipment (PPE) for a residen...
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Based on observation, record review and interview, the facility failed to ensure staff members, including contracted staff, followed the proper use of personal protective equipment (PPE) for a resident under contact precautions (Resident (R) 1). This deficient practice encourages the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors.
Findings include:
On 07/25/24 at 09:49 AM, observed Radiologist Technologist (RT) in R1's room. Observed the sign Contact Precautions for R1 with donning and doffing instruction on the door. The sign was not easily viewable due to the door being opened. Resident was observed to be lying in bed and RT prepared R1 for X-Rays on her left arm. RT was observed to move R1's blanket and arm to prepare. RT was not wearing a gown. Certified Nurse Aide (CNA) 1 was in the room helping R1's roommate, when RT asked for CNA1's assistance. RT asked if R1's side rail can come down. CNA1 adjusted R1's side rail to come down. CNA1 was not wearing a gown and returned aiding the roommate.
On 07/25/24 at 10:01 AM, interview with Director of Nursing (DON) was done. Inquired if staff members should be wearing proper PPEs when entering a contact precaution's room despite care type, DON confirmed staff should be wearing gowns and gloves when any kind of care to residents under contact precautions.
Review of R1's current care plan documented resident has left ear mastoiditis/left auricular cancer, Enhanced barrier precautions in place.
Review of the facility's policy and procedure Contact Precautions dated 03/2024, documented the purpose To minimize exposure to potentially infectious materials via direct contact. The procedure included Wear a gown whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces or equipment in proximity to the resident. [NAME] gown upon entry into the room or cubicle.
Mar 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide an environment free from any physical restr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, and not required to treat the resident's medical symptoms to one of the sampled residents (Resident (R) 28).
Findings Include:
R28 is a [AGE] year-old-female admitted to the facility on [DATE]. R28 has a medical history not limited to dementia and Alzheimer's.
Observation was conducted on 03/04/24 at 09:18 AM in R28's room. R28 was laying in bed with two wedges tucked underneath the left side of her fitted bed sheet.
Observation was conducted on 03/05/24 at 07:47 AM in R28's room. R28 was positioned with the head of her bed elevated while having breakfast with the assistance of one of the staff. Two wedges were observed tucked under the left side of R28's fitted sheet.
Observation and interview were conducted on 03/06/24 at 08:05 AM in R28's room. R28 was being assisted with feeding by a Certified Nurse's Aide (CNA) 10. Two wedges were tucked on the left side of R28's fitted sheet. CNA10 was queried on the purpose of the two wedges. CNA10 stated that the two wedges were placed underneath R28's fitted sheet to prevent her from getting out of bed and they are placed there every time R28 is in bed. When State Agency (SA) asked if R28 can remove the two wedges on her own, CNA10 stated, no.
Registered Nurse (RN) 10 was interviewed in R28's room on 03/06/24 at 08:23 AM. RN10 stated that she assumed that the two wedges were in place for R28's fall prevention. RN10 reviewed R28's Electronic Health Record (EHR) and confirmed that the two wedges were not an intervention in R28's care plan.
Director of Nursing (DON) was interviewed on 03/06/24 at 03:17 PM in his office. DON stated that the two wedges should not have been placed under R28's bed sheet because the facility does not use wedges to keep residents in bed.
Reviewed the facility's policy titled, Restraint Use-Physical and Chemical, with a revised date of 08/25/21. The policy documented, The resident has the right to be free from any physical or chemical restraint imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observations, record review and interview the facility failed to report an injury of unknown source to resident(R) 22's hands (bruising on top of her hands) to the Director of Nursing which i...
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Based on observations, record review and interview the facility failed to report an injury of unknown source to resident(R) 22's hands (bruising on top of her hands) to the Director of Nursing which impeded the investigation. This injury of unknown source to R22's hands was also not reported within five working days to the State Survey Agency.
Findings Include:
On 03/04/24 at 08:50 AM introduced self to R22 who was laying in her bed. At this time observed R22 had a bruise, which covered the top of her right hand, and appeared to be healing. Inquired if resident knew how she got the bruise and she did not remember how she got it.
On 03/04/24 Record Review (RR) of R22's Electronic Health Record (EHR) found her diagnoses include, but are not limited to,vascular dementia (memory loss) and Paroxysmal Atrial Fibrillation (irregular rapid heart rate) which is treated with medication. R22 takes an anticoagulant (blood thinner), Apixaban. During the RR found a medication order for R22's Apixaban Oral Tablet 2.5 MG give one tablet by mouth two times a day for AFIB (Atrial Fibrillation) which was ordered on 10/27/2023. R22's care plan (CP) included: ANTI-PLATELET MEDICATION: Risk for Bleeding d/t Anti-platelet Therapy which was initiated on 01/30/24. The goal for this problem was Resident Will Show No Signs / Symptoms of Bleeding. Interventions for the problem were Evaluate skin for evidence of impaired coagulation (bruising, petechia, bleeding from orafice). If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. Another problem on R22's CP was ANTICOAGULANT MEDICATION: The resident is on anticoagulant therapy r/t Atrial fibrillation which was initiated on 10/28/23 and revised on 01/30/24. The goal for this problem was The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Interventions listed included Non-Pharm interventions to prevent bleeding include, gerisleeves to bilateral arms, Monitor Bowel Movements to prevent straining, Keep fingernails short, etc. Report any skin abnormalities to the nurse.
On 03/07/24 at 10:52 AM observed R22 in her bed with a bruise covering the top of her right and left hand. Both bruises appeared newer and darker in color. Inquired if R22 knew how she got the bruises to both hands and she could not recall how she got the bruises. Left resident's room to get her assigned nurse. Concurrent interview was conducted with Registered Nurse (RN)2 at this time, at the bedside with R22. Inquired if she knew about bruising to R22's hands. RN2 was not aware of bruising to R22's hands. Surveyor informed RN2 bruising was observed to R22's right hand on 03/04/24 and new bruising today was observed to the top of R22's left hand and both bruising today appeared newer. RN2 assessed resident's hands. RN2 asked R22 if she knew how she got bruising to her hands and R22 could not recall how she got the bruises. Inquired if RN2 found any charting related to bruising in R22's EHR and when it was reported. RN2 was unable to find this in R22's EHR. During this interview R22's assigned Certified Nurse Aide (CNA)5 was also in the room at her bedside.
On 03/07/24 at 11 :00 AM interviewed CNA5 who stated she was endorsed (told about) the bruise to R22's right hand on Tuesday morning from the Monday night shift CNA. Inquired if R22 had any bleeding from her hands and CNA5 denied seeing any bleeding from R22's hands.
On 03/07/24 at 11:34 AM interviewed Director of Nursing (DON) and asked if facility reported injury to R22's hands to the State Survey Agency. DON had not been informed of bruising to top of R22's hands. DON reviewed facility reported incidents (FRIs) and did not find one for bruising to R22's hands. DON stated he would investigate this matter.
On 03/07/24 at 11:37 AM during record review found the last skin assessment for R22 had been done on 3/3/24 with no bruises documented. Review of progress notes in R22's EHR from 02/01/24 to 03/07/24 did not include documentation of bruising to resident's hands.
On 03/07/24 at 11:51 AM interviewed DON who reported he spoke with RN2 who stated she was not notified of bruises to R22's hands. DON confirmed he observed bruising to R22's hands. DON reported he was having RN2 input the event report into Point Click Care and will be submitting the report to the State Survey Agency. DON stated he will complete the investigation by calling the nurses who worked the past week with R22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide assistance for Resident (R) 19 to maintain her ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide assistance for Resident (R) 19 to maintain her personal grooming and oral hygiene and failed to provide proper perineal care (cleaning genital and anus) for R22 putting them at risk for infection. This deficient practice could affect any resident who requires assistance with activities of daily living (ADLs) putting those residents are risk for infection.
Findings Include:
Cross-reference to F880 Infection Control.
1) On 03/05/24 at 10:40 AM entered R19's room and observed her eyes were dirty. R19's eyelashes were covered with a thick clear discharge which made it hard for resident to open her eyes. R19's mouth was dirty and edges of mouth were dry. At this time interviewed Certified Nurse Aide (CNA)5. Inquired if CNA5 had assisted R19 with her morning ADLs and CNA5 stated that she had and then also stated she had gotten busy that morning.
On 03/05/24 Record Review (RR) of R19's Electronic Health Record (EHR) found her diagnoses include, but are not limited to, Alzheimer's Disease, unspecified and functional quadriplegia (unable to move on her own due to severe disability or frailty from a medical condition). Review of R19's Material Data Set (MDS) dated [DATE] found she was coded as 1 for all of her self-care which means she is Dependent- helper does all of the effort. Resident does none of the effort to complete the activity.
Review of R19's Care Plan (CP) found the following problem: ADL's: The resident has an ADL self-care performance deficit r/t neurocognitive deficits, weakness, fatigue, dementia w/functional quadriplegia, Chronic debility w/contracted extremities which was initiated on 10/14/2023. The goal is The resident will be free of complications related to immobility. Interventions on the R19's CP to meet the goal include Personal Hygiene/Oral Care: The resident is totally dependent on 1 staff for personal hygiene and oral care.
2) On 03/05/24 at 11:00 AM observed CNA5 provide perineal care for R22. CNA5 asked another CNA to assist her in holding and turning R22 while she provided care for resident. CNA5 gathered her supplies, curtain was drawn and CNA5 explained to R22 care she was going to provide. CNA5 performed hand hygiene and put on clean gloves. R22's adult brief was opened and CNA5 provided perineal care to R22's front genitalia using wipes and a no rinse foam cleanser. CNA5 used front to back wiping motions. R22 was then turned onto her side so that CNA5 could finish perineal care to residents anus, buttocks and back. At this time CNA5 changed her gloves but did not perform hand hygiene with the glove change. CNA5 was observed using back to front wiping motions once she started wiping R22's back, buttocks and anus. When CNA5 was done wiping R22's anus and back she used the same gloves to apply cream to R22's lower back. CNA5 changed her gloves afterwards, no hand hygiene between glove change and changed R22's adult brief and chux from her bed.
On 03/05/24 Record Review (RR) of R22's Electronic Health Record (EHR) found her diagnoses include, but are not limited to, vascular dementia (memory loss), congestive heart failure (heart does not pump blood well) and above the left leg knee amputation. Review of R22's MDS found for toileting hygiene she was rated a 2 which is substantial/maximal assistance - helper does more than half the effort.
Review of R22's CP found the following problem BLADDER: The resident has bladder incontinence r/t impaired mobility, mild cognitive impairment, and urinary retention initiated on 10/27/2023 that was revised on 01/30/2024. The goal is The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included Clean peri-area with each incontinence episode. Incontinent (no control over bowel movement and urination): Check q2h and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.
An interview was done with the Director of Nursing (DON) on 03/06/24 at 03:18 PM. Inquired if CNA's are provided perineal care training and DON confirmed CNA's are provided with perineal care training during new hire and annually. Reviewed observed care that was provided to R22 today with DON and DON confirmed CNAs are to wipe front to back and perform hand hygiene with each glove change. At this time discussed observation of R19 with poor ADLs. DON confirmed staff are to provide residents with assistance with their ADLs. Requested and was given facility policy on ADLs, hand hygiene, and perineal care.
Review of facility policies found the following for Activities of Daily Living: which was revised on 02/15/24, under Policy: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; . Also under Policy Explanation and Compliance Guidelines: .
3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Review of facility policy Perineal Care revised 02/20/24 states Policy Explanation and Compliance Guidelines .9. a. Cleanse buttocks and anus front to back; vagina to anus in females . 11. Females h. Clean and dry the anal area, starting at the posterior vaginal opening and wiping from front to back.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to prom...
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Based on observation, interviews, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of resident medications.
Findings Include:
Concurrent observation and interview were conducted on 03/05/24 at 10:28 AM. A medication cart was observed left unlocked in the hallway near the dining room. Near the medication cart were four residents and two Certified Nurse's Aide (CNA). Registered Nurse (RN) 11 was observed in one of the resident's rooms. When RN11 returned to the medication cart, she realized she left the cart unlocked and was apologetic. RN11 stated that medication carts should not be unlocked while left unattended.
Interview was conducted with Director of Nursing (DON) over the phone on 03/07/24 at 11:28 AM. DON stated that medication carts should be secured and locked when left unattended.
A review of the facility's document titled, Storage of Medication, dated 01/23 was conducted. The document noted, Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
2) During an observation of a semi-private resident room on 03/09/24 at 09:00AM, there were two different Isolation Precaution warning signs; Contact Isolation and Aerosol Precautions. The two signs d...
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2) During an observation of a semi-private resident room on 03/09/24 at 09:00AM, there were two different Isolation Precaution warning signs; Contact Isolation and Aerosol Precautions. The two signs did not indicate which resident was assigned to which isolation/precaution.
During staff interview on 03/09/24 at 09:10AM, Registered Nurse (RN) 9 acknowledged that the two signs did not specify which resident was assigned to which isolation/precaution. RN9 added that staff, especially new staff, did not know which resident was assigned to which isolation/precaution.
Review of facility policy on Isolation Practices read Contact Precautions Policy, it is the policy of this facility to use category-specific isolation techniques for residents who have infectious or communicable diseases that may necessitate the use of barriers in addition to those used for Standard Precautions. Purpose, to minimize exposure to potentially infectious materials via direct contact . Aerosol generating procedure/treatment policy, HCWs performing an Aerosol Generating Procedure who presents in room during AGP are to wear fit tested N95 respirator for the duration of the procedure. If resident is receiving AGP is not in a private room, pull curtain between residents. Resident in other bed offered to wear a mask. Correct AGP signage is recommended to be placed on the door before starting the AGP (nurse to write time treatment start and time treatment will finish on sign). Blue circle sticker dot will be placed to indicate which resident room requires isolation .
Based on observation, staff interview and review of policy, the facility 1) failed to perform hand hygiene during lunch tray pass and after each glove change while providing peri care (cleaning genital and anus). The deficient practice could affect all residents who require assistance with activities of daily living (ADLs), perineal care and lunch trays putting them at risk for infection. 2) The facility did not distinguish Contact Isolation and Aerosol Precautions between two Residents (R)7, 12.
Findings Include:
Cross-reference to F677 ADL Care Provided for Dependent Residents. Based on observation and interview the facility failed to implement interventions from the comprehensive care plan of Resident (R)19 to meet her personal hygiene and oral care. Failed to perform hand hygiene with each glove change while providing perineal care, and failed to provide proper perineal care for R22.
1) During lunch observation, in the main dining room, on 03/06/24, observed a Certified Nurse Aide (CNA) 6 deliver lunch tray to a resident. CNA6 assisted resident by releasing the resident's wheelchair brakes and moved the resident closer to the table and locked the brakes before leaving the resident. CNA6 picked up another lunch tray and delivered it to another resident who was waiting for their lunch tray. CNA6 did not perform hand hygiene before picking up and delivering the the second resident's lunch tray.
An interview was done with the Director of Nursing (DON) on 03/06/24 at 03:18 PM. Inquired if staff are to perform hand hygiene between resident's meal pass and DON confirmed this.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of policy, the facility failed to remove expired emergency equipment nasal cann...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of policy, the facility failed to remove expired emergency equipment nasal cannula from the Code Crash Cart in the [NAME] Hall.
Findings include:
During an observation of the [NAME] Hall Code Crash Cart, on [DATE] at 08:45AM, there was an expired nasal cannula/oxygen tubing dated [DATE].
Staff interview on [DATE] at 09:00AM, Registered Nurse (RN)9 acknowledged that the nasal cannula/oxygen tubing was expired and removed from the cart.
Review of facility policy on Code Crash Cart read; Policy, It is the policy of this facility to ensure that the facility will maintain at least one emergency cart per patient building . Procedure, 3. Equipment/supplies from the emergency crash cart are used only when emergency care is provided, 4. The emergency crash cart is checked by the Central Supply Clerk and after every use. Missing or expired items are replaced, when applicable.
Mar 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**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 discharge for tw...
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**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 discharge for two residents (R), R92 and R73, out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of the reason for resident's discharge.
Findings include:
1) Cross reference to F625. The facility did not provide written notice of bed-hold policy which was included in the transfer/discharge notification.
Review of the electronic health record (EHR) indicated that R92 was admitted to the hospital on [DATE] for pancreatitis and discharged from the facility. Further review did not show any written notice of discharge to the resident and/or representative.
During staff interview on 03/30/23 at 09:40 AM, Social Services Coordinator (SS1) acknowledged that the facility did not provide written notification of discharge to R92 and/or representative.
During staff interview on 03/30/23 at 10:25 AM, Registered Nurse (RN)1 reviewed the Facility Notification of Transfer or Discharge form for R92 and said the family was verbally notified by phone of discharge but there was no written notification given.
Review of facility policy titled Discharge Notice Policy revised on 03/01/18, read the following: Purpose, [facility] will provide proper and timely notice to a resident who will be discharged as required by regulations and laws. The facility will work with the physician to obtain adequate documentation about the reason to discharge the resident. The facility will provide preparation and orientation to the resident, family and receiving facility prior to discharge . B. Timing of the notice a. The transfer/discharge notice will be issued with a discharge date at least 30 days before the resident is transferred or discharged . i. The notice will be in a language and manner that the resident can understand. ii. If the transfer/discharge was an emergency, the notice will be issued as soon as practicable when: . 4. An immediate transfer or discharge is required by the resident's urgent medical condition . C. Contents of the notice Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language in which is understood .
2) Cross Reference to F625. The facility did not provide written notice of bed-hold policy which was included in the transfer/discharge notification.
On 03/28/23 at 10:50 AM interviewed R73. R73 reported following admission to the facility he was hospitalized . R73 was unable to recall when, however, reported an ambulance came and took him to the hospital. R73 further reported he was not sure why he was being transferred to the hospital. Inquired if the facility provided written notice of transfer or bed-hold policy (ability to return to the facility). R73 responded that this information was not provided. R73 stated the acute hospital provided discharge locations and he chose to return to the facility.
Record review found R73's original admission date was 06/06/22. On 12/16/22, R73 was readmitted from the hospital. Further review found a document titled, Facility Notification of Transfer or Discharge with an admit date of 12/16/22. The form was not completed. Information regarding date of transfer/discharge; location; reason for transfer/discharge, signature of the responsible party being notified; and signature of charge nurse/facility representative were blank. The document included protection and advocacy contact phone numbers, bed hold policy, grievance procedure rights, and Medicaid insurance rights. A review of the census information documents the resident was readmitted to the facility on [DATE] from the hospital.
On 03/31/23 at 08:30 AM interviewed SS1. Requested to review the notification to the State Long Term Care Ombudsman and written notification to the resident regarding the transfer. SS1 returned at 08:48 AM to report they have copy of notification to the Ombudsman. Requested SS1 to follow-up on written notification of transfer.
On 03/31/23 at 1:45 PM, the Administrator provided a copy of the Facility Notification of Transfer or Discharge and explained when residents are sent to the hospital in an emergency, the facility does not provide the form to the resident. The facility will obtain the resident's signature upon their return to the facility. The Administrator confirmed written notification of transfer was not provided as soon as practicable or upon the resident's return to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**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 ...
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**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), R92 and R73, out of four residents sampled. As a result of this deficiency, there was a potential for miscommunication and/or misunderstanding of the facility's bed-hold policy.
Findings include:
1) Cross Reference to F623. R92 was transferred to a hospital. The facility did not provide R92 with a written notification of the transfer.
Review of the electronic health record (EHR) indicated that R92 was transferred to the hospital on [DATE] for pancreatitis. Further review did not show any written notice that specifies the duration of bed-hold policy to the resident and/or representative.
During staff interview on 03/30/23 at 09:40 AM, Social Services Coordinator (SS1) acknowledged that the facility did not provide written notification of bed-hold policy to R92 and/or representative.
During staff interview on 03/30/23 at 10:25 AM, Registered Nurse (RN)1 reviewed the Facility Notification of Transfer or Discharge form for R92 and said the family was verbally notified by phone but there was no written notification given.
Review of facility policy titled Bed Hold Prior to Transfer with no date, read the following: Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave . Notice before Transfer 1. The facility will have a process in place to ensure residents and/or their representatives are made aware the facility's bed-hold and reserve bed payment policy well in advance of being transferred to the hospital or when taking therapeutic leave of absence from the facility. 2. The facility will have policies that address holding the resident's bed during periods of absence, such as during hospitalizations or therapeutic leave. 3. The facility will provide written information about these policies to residents and/or resident representatives prior to and upon transfer for such absences.
2) Cross Reference to F623. R73 was transferred to a hospital. The facility did not provide R73 with a written notification of the transfer.
On 03/28/23 at 10:50 AM, R73 reported he was transferred to an acute hospital. Inquired whether the facility provided a written notification of the bed-hold policy. R73 responded that the facility did not provide bed-hold information. R73 clarified, the acute hospital provided choices of discharge locations and he chose to return to the facility.
On 03/31/23 at 08:19 AM interviewed Registered Nurse (RN)1. Inquired whether R73 was provided with bed-hold information. RN1 reported the nurses will attempt to follow-up with residents' family or call the resident. RN1 reported bed-hold information is discussed at admission. RN1 deferred to social services. On 03/31/23 at 08:48 AM, SS1 reported the nursing department provides bed-hold information.
A review of document titled; Facility Notification of Transfer of Discharge includes the facility's bed-hold policy. On 03/31/23 at 01:45 PM, Administrator confirmed, R73 was not provided written notice of the transfer which would include information on the facility's bed-hold policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R91's electronic health record (EHR) was reviewed. Read R91's discharge Minimum Data Set (MDS) assessment with Assessment Ref...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R91's electronic health record (EHR) was reviewed. Read R91's discharge Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 02/09/23. It revealed that R91 was admitted to the facility on [DATE] from the hospital for encephalopathy (damage or disease that affects the brain). R91 received speech, language, and pathology (SLP), occupational therapy (OT), and physical therapy (PT) services. The discharge MDS further revealed that R91 was discharged to 03. Acute hospital. Under Progress Notes, read Social Services Note documented on 02/01/23 at 14:12 (2:12) PM. It stated, . confirmed a pickup time for resident of 2PM on 2/9/23 and indicated he [son] would be brining [sic] resident to her home and staying with her and providing care for now .
On 03/30/23 at 2:50 PM, a phone interview with the Director of Nursing (DON) was conducted. The DON concurrently reviewed R91's discharge MDS in the EHR. DON confirmed that R91 was coded as being discharged to the hospital. After reviewing R91's discharge progress notes, DON stated that R91's discharge MDS was coded in error as she was discharged home and not to the hospital. DON stated that they were auditing three MDS assessments a month up until November 2022 and stopped. DON further stated that they will resume auditing MDS assessments once a month starting in April.
Based on record review and interview with staff members, the facility did not assure assessments accurately reflected the residents' status for two (Residents 19 and 91) out of eighteen assessments reviewed. The facility inaccurately coded Resident (R)19 with a facility-acquired Stage III pressure ulcer and R91 as being discharged to the hospital, instead of to the community. This deficient practice has the potential to affect the development of a person-centered care plan, resulting in not meeting the needs of the residents.
Findings include:
1) On 03/28/23, the facility provided a copy of the Resident Matrix (identifies pertinent care categories for: newly admitted residents in the last 30 days who are still residing in the facility, and all other residents). Resident (R)19 was identified with a Stage III pressure ulcer which was facility acquired.
R19 was admitted to the facility on [DATE]. Diagnoses include displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing; unspecified fall; and dementia, unspecified severity, without behavioral disturbance.
A review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/07/23 noted in Section M. Skin Conditions, R19 was not coded with an unhealed pressure ulcer. R19 also noted with a surgical wound and skin tear. Subsequent MDS for a significant change with an ARD of 03/06/23 documented one unhealed Stage III pressure ulcer that was not present upon admission/reentry to the facility. The facility developed a care plan for the healing of the pressure ulcer.
R19's acute hospital discharge summary (discharge date of 02/01/23) noted the resident presented at the hospital due to an unwitnessed fall at home resulting in a left intertrochanteric femur fracture. R19 was admitted for operative fixation.
Further review found the wound consultant's report. The report of 02/23/23 noted R19 had a wound located on the left lateral leg. The wound occurred by pressure mechanism after being found on the ground prior to admission. The consultant assessed the wound and made treatment recommendations. The impression was a pressure ulcer of left leg, stage III.
On 03/30/23 at 2:46 PM a telephone interview was conducted with the Director of Nursing (DON). The DON reported R19 was admitted with the wound. The facility's wound consultant assessed, and indicated it was a Stage III pressure ulcer. Based on the consultant's report, the MDS coordinator coded it as a new wound acquired in the facility. The DON reported the assessment was inaccurate as the wound was present on admission. The DON stated corrections will be made.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 03/25/23 at 12:23 PM, R86 was observed to have a urinary catheter with a tubing and bag system.
On 03/29/23 at 09:21 AM, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) On 03/25/23 at 12:23 PM, R86 was observed to have a urinary catheter with a tubing and bag system.
On 03/29/23 at 09:21 AM, R86 was interviewed in her room. R86 had a urinary catheter tubing and bag system because of her diagnosis of retention of urine and hoped to have it taken out before she was discharged home soon.
On 03/31/23 at 08:25 AM, R86 and Registered Nurse (RN)3 were interviewed in R86's room. R86 stated that the staff provided her education about caring for her urinary catheter with tubing and bag system. R86 was taught to clean the catheter insertion/exit site with a wet, soapy cloth and to keep catheter tubing and bag system clean. RN3 confirmed that education for care of her urinary catheter with tubing and bag system was provided to R86 and that R86 mostly does her own catheter insertion/exit site care, but at times may need assistance.
Reviewed R86's electronic health record (EHR). admission Record revealed that R86 was a [AGE] year old resident admitted on [DATE]. Care plan for R86's .Indwelling catheter (urinary catheter with a tubing and bag system) . revealed that it was placed on 02/28/23. Care plan did not include any personalized interventions to identify that she was able to receive and was provided education for caring for her urinary catheter with tubing and bag system, the need for follow up after education was given to her, and that R86 may need assistance at times with proper catheter insertion/exit site care.
On 03/31/23 at 12:22 PM, a phone interview was conducted with the Director of Nursing (DON). The DON confirmed that R86's care plan should be personalized according to her needs and capabilities.
Reviewed the policy, CARE PLANS - BASELINE, COMPREHENSIVE, AND DISCHARGE, last revised on 08/25/21. It stated, PURPOSE: Comprehensive Care Plan The purpose of the Comprehensive Care Plan policy is so that each resident will have a person-centered comprehensive care plan developed and implemented to meet his or hers other preferences, goals, and address the resident's medical, physical, mental, and psychosocial needs.
Based on observation, record review and interviews, the facility failed to develop person-centered care plans for 3 residents (R) (R35, R52, and R86) of 18 residents which addressed: 1) the risks for bruising and bleeding with the use of anticoagulants; 2) non-pharmacological interventions were developed for a resident on sleep medication for insomnia; 3) non-pharmacological interventions were not developed for a resident receiving routine and prn (as needed) pain medication and 4) education for the care of a urinary catheter tubing and bag system. This deficient practice has the potential to result in not meeting residents' needs and affect residents' ability to meet their highest physical, mental, and psychosocial needs.
Findings include:
1) R35 was admitted to the facility on [DATE]. R35 has a physician's order for routine administration of Eliquis (an oral anticoagulant that is used to prevent and treat certain types of blood clots), 5 mg (miligrams), two times a day and aspirin tablet, 81 mg, one time a day for blood clots and atrial fibrillation.
A review of the annual Minimum Data Set (MDS) with assessment reference date (ARD) of 12/08/22 documents in Section N. Medications, R35 received an anticoagulant seven days in the last seven days. The resident's care plan did not identify the use of an anticoagulant with interventions to monitor for adverse effects (bleeding, bruising, nose bleeds or bleeding of gums) and providing care to address resident at risk for bruising and bleeding.
On 03/31/23 at 08:07 AM an interview and concurrent record review was done with Registered Nurse (RN)1 at the nurse's station. RN1 confirmed the interdisciplinary team did not include the use of an anticoagulant in the resident's plan of care. RN1 reported the licensed nurses are monitoring R35 for bleeding and bruising in the Treatment Administration Record (TAR). RN1 checked the [NAME] (resident care instructions for certified nurse aides) to inform certified nurse aides R35 is at risk for bruising and bleeding due to the use of an anticoagulant. RN1 confirmed the [NAME] did not provide care instructions for the certified nurse aides. RN1 was asked whether the interdisciplinary team develops a plan of care to address the use of an anticoagulant. RN1 responded yes.
On 03/31/23 at 12:41 PM an interview was conducted with Certified Nurse Aide (CNA)8. CNA8 was asked if there are special instructions for providing care to R35. CNA8 responded R35 will get upset if you use too much pressure during peri care. Inquired if CNAs observe for bruises or bleeding during care (i.e., shower) to the nurse. CNA8 again responded R35 gets upset when you use pressure during peri care and at times will refuse to change personal brief.
On 03/31/23 at 3:30 PM, the Minimum Data Set Coordinator (MDSC) was asked whether the interdisciplinary develops a care plan for residents receiving an anticoagulant. MDSC responded the team will usually create care plan for use of anticoagulant.
2) Cross Reference to F757. R35 receives routine and prn medications for pain related to brachial plexus disorder. The interdisciplinary team did not develop non-pharmacological interventions to address R35's pain.
The facility provided a policy and procedure for care plans (last revision date of 08/25/21). The purpose of the policy is so that each resident will have a person-centered comprehensive care plan developed and implemented to meet his or hers preferences, goals, and address the resident's medical, physical, mental, and psychosocial needs. The procedure includes the interdisciplinary team will complete assessments/evaluations to obtain information pertinent to the development of the comprehensive care plan, identifying resident-specific problems, goals, and interventions. The comprehensive care plan will identify resident's needs, choices, and preferences.
3) R52 was admitted to the facility on [DATE]. Diagnoses include but not limited to Alzheimer's disease, unspecified; vascular dementia, unspecified severity with mood disturbance; adjustment disorder with mixed disturbance of emotions and conduct; constipation; and insomnia.
Review of the physician order for March 2023 include Trazodone HCI tablet (antidepressant and sedative), 175 mg by mouth at bedtime for insomnia and Melatonin tablet, give 8 mg by mouth at bedtime for insomnia (family supplies). Review of R52's annual MDS with an ARD of 02/10/23 documents in Section N. Medications, R52 received an antidepressant seven days of the last seven days. A review of the care plan found no non-pharmacological interventions for insomnia. For example, sleep hygiene interventions (behavioral and environmental practice to help with insomnia).
On 03/30/23 at 09:44 AM an interview and concurrent record review was conducted with Registered Nurse (RN)1 at the nurse's station. Reviewed R52's care plan for the use of Trazodone to treat insomnia. RN1 found a plan for the use of an antidepressant medication related to insomnia. The goal was for R52 to be free from discomfort or adverse reactions related to antidepressant therapy through the next review date.
The interventions included:
1) Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift; and
2) Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; insomnia; and appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyes.
RN1 was asked if nursing documents R52's number of hours of sleep at night or whether a goal for how many hours of sleep R52 needs. RN1 reviewed the Medication Administration Record (MAR) and reported licensed nurses document interventions implemented and monitor behavior related to the use of Trazodone. Nurses are documenting every shift in the MAR for no behaviors, unable to sleep, and restlessness. RN1 confirmed non-pharmacological interventions to address R52's insomnia were not developed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F756 - Drug Regimen Review, Report Irregular, Act On - facility failed to draw laboratory tests recommende...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F756 - Drug Regimen Review, Report Irregular, Act On - facility failed to draw laboratory tests recommended by consultant pharmacist.
Review of electronic health record (EHR) for R2 was done. Medication Regimen Review (MRR) dated 05/31/22 revealed that the consultant pharmacist recommended the laboratory testing for A1C (average blood sugar level the past 3 months) and BMP (Basic Metabolic panel - test to check fluid balance and level of electrolytes) be considered. Review of laboratory results in the EHR done and was unable to find A1C and BMP results for June and July 2022.
Concurrent record review and interview with the Administrator done on 03/31/23 at 11:05 AM in her office. Reviewed MRR dated 05/31/22 scanned into EHR. Asked if A1C and BMP were checked as recommended by the consultant pharmacist, she said she will look into it. Further review of the EHR under Results revealed that there was a completed lab order on 06/07/22 for A1C and BMP. At 3:00 PM, phone interview with Administrative Assistant (AA) confirmed that the facility's contracted laboratory services provider did not receive any specimen from R42 for A1C and BMP testing and there was no documentation that the attending physician agreed or disagreed with the consulting pharmacist's recommendation.
Concurrent interview and record review conducted with Registered Nurse (RN)2 on 03/31/23 at 3:55 PM in the conference room. Asked RN2 why the A1C and BMP testing ordered on 06/07/22 was noted as completed in the EHR but the contracted laboratory services provider said they did not receive any specimen. RN2 replied that the order was inputted into the EHR incorrectly and because of this, it did not show in the MAR (Medication Administration Record). If it does not show in the MAR, the secretary would not create a requisition for the lab (laboratory test).
Based on observations, record review and interviews, the facility failed to follow bowel regimen protocol in accordance with the physician orders for one of one resident (R), R52, sampled with constipation. The facility also failed to have a lab drawn and follow up on the results for R42's blood sugar management. These deficient practices have the potential to result in adverse consequences in residents needing bowel or blood sugar management.
Findings include:
1) On the morning of 03/28/23, R52 was observed lying in bed. The resident was grimacing. R52 was asked if he had pain. The resident responded he had stomach problems. R52 was asked whether medication was provided to facilitate bowel movement. R52 confirmed medication was successful, however, had a sandwich last night and not feeling well. A follow-up visit with R52 at 2:36 PM, R52 still expressed presence of a sore stomach and tried to eat some lunch.
Record review noted R52 was admitted to the facility on [DATE]. Diagnoses include constipation, unspecified; Alzheimer's disease, unspecified; vascular dementia, unspecified severity, with mood disturbance; and insomnia, unspecified.
The physician orders included, MiraLax Powder 17 gm (grams)/scoop by mouth one time a day for constipation; MiraLax Powder 17 gm/scoop by mouth as needed for constipation; Lactulose Solution, 10 gm/15 ml, give 30 ml by mouth as needed for no BM (bowel movement) for two days; Bisac-Evac Suppository, 10 mg, insert one suppository rectally as needed for no BM for three days; and Enema Ready-To-Use, insert one dose rectally as needed for diagnosis of no BM x3 days and suppository not effective.
A review of the annual Minimum Data Set with an assessment reference date of 02/10/23 documents R52 was always incontinent of bowel and bladder. R52 also coded to require extensive assist with one-person physical assist for toilet use.
R52 has a care plan for bowel incontinence and risk of constipation (date initiated 02/03/22 and revised on 02/14/22). The goal is for R52 to have normal BM at least every 2-3 days. Interventions include administer bowel regimen as ordered; check resident every two hours and assist with incontinent care as needed; and provide loose fitting, easy to remove clothing. Also noted, R52 receives an antidepressant (Trazodone for insomnia) with a side effect of constipation.
On 03/30/23 at 09:44 AM an interview and concurrent record review was done with Registered Nurse (RN)1 at the nurses' station. RN1 reviewed the physician orders for the bowel protocol, confirmed orders: Lactulose if no BM for two days, suppository for no BM for three days, and enema for no BM for three days and suppository ineffective. RN1 assisted with the review of the Medication Administration Record (MAR) and documentation of R52's BM history. RN1 noted R52's last bowel movement was on 03/17/23. There was no bowel movement from 03/18/23 through 03/21/23 (four days). Lactulose was administered on 03/19/23 at 05:56 PM (second day). The medication was documented as ineffective. On 03/21/23 at 10:15 PM a suppository was provided. Suppository was noted to be ineffective. R52 had two bowel movements on 03/22/23. After the review, RN1 confirmed R52's bowel protocol was not followed, the suppository was administered on the fourth day, it should have been administered on 03/20/23 (third day of no bowel movement).
Further review noted R52's last bowel movement was on 03/22/23. There was no bowel movement for two days (03/23/23 and 03/24/23). There was no documentation Lactulose was provided on the second day of no bowel movement. The MAR documented a suppository was administered on 03/25/23 at 11:02 PM (third day of no bowel movement). This administration was documented as ineffective, and a suppository was administered on 03/26/23 at 07:35 AM with effective results. RN1 reported Lactulose should have been administered on 03/24/23, the second day of no BM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to draw laboratory tests for one resident (R), R2, as recommende...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to draw laboratory tests for one resident (R), R2, as recommended by the consultant pharmacist. This deficient practice has the potential to cause adverse consequences for residents where the consultant pharmacist has recommended actions to be taken for medication management.
Finding includes:
Cross reference to F684 Quality of Care - laboratory order was not properly entered in the electronic health record (EHR) and there was no laboratory requisition generated.
Reviewed electronic health record (EHR) for R2. R2 was admitted on [DATE] for hospice care. Diagnoses include but not limited to diabetes (high level of sugar in the blood), long term use of insulin, chronic kidney disease, and congestive heart failure (condition where the heart does not pump blood efficiently causing fluid buildup in the feet, arms and lungs). Ordered medications include insulin (regulates blood sugar levels) and furosemide (water pill).
Review of a Medication Regimen Review (MRR) dated 05/31/22 revealed that the consultant pharmacist recommended the laboratory testing for A1C (average blood sugar level the past 3 months) and BMP (Basic Metabolic panel - test to check fluid balance and level of electrolytes) be considered. Review of laboratory results in the EHR was done and unable to find A1C and BMP results for June and July 2022.
On 03/31/23 at 09:40 AM, asked Administrator for a copy of the A1C and BMP results that were drawn for the R42 as recommended by the pharmacist. At 10:50 AM, Administrative Assistant (AA) provided a copy of the Nurse Practitioner's visit note dated 02/06/23. Documented in the note were BMP results from 10/24/22 and A1C results from 03/14/22.
Concurrent record review and interview with the Administrator done on 03/31/23 at 11:05 AM in her office. Asked what the facility's process was for reviewing the monthly MRRs. Administrator replied that the consultant pharmacist sends the MRRs to the Director of Nursing (DON). The DON then distributed the MRRs to the nurses' stations and the nurse assigned to that unit reviews them. For any MRRs that had recommendations from the pharmacist, the MRR is placed in the physician's inbox at the nurses' station. When the attending physicians make rounds, they note on the MRR if they agree or disagree with the recommendations and return them to the nurses for review. Any physician's orders are then inputted into the EHR. The MRRs are then scanned into the EHR by the unit secretaries. Administrator then showed the MRR for R42 dated 05/31/22 that was in a binder in her office. Asked if A1C and BMP were checked as recommended by the consultant pharmacist, she said she will look into it. At 03:00 PM, phone interview with AA confirmed that the facility's contracted laboratory services provider did not receive any specimen from R42 for A1C and BMP testing and there was no documentation that the attending physician agreed or disagreed with the consulting pharmacist's recommendation.
Reviewed facility's policy Medication Regimen Review and Reporting with an effective date of September 2018. Page two stated, 8. Recommendations shall be acted upon within 30 calendar days. the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to assure pain medication was provided with adequat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with staff members, the facility failed to assure pain medication was provided with adequate indication for its use for one resident (R), R35, of five residents sampled for medication review. The prn (as needed) medications for pain did not indicate the parameters for its use or include non-pharmacological interventions to relieve pain. This deficient practice has the potential to ensure the resident attains the highest practicable mental, physical, and psychosocial well-being.
Findings include:
R35 was admitted to the facility on [DATE]. Diagnoses include but not limited to brachial plexus disorder (injury caused by damage to those nerves, typically from trauma, tumors, inflammation, pressure, athletic injuries, or being stretched too far); chronic systolic (congestive) heart failure; ischemic cardiomyopathy; basal cell carcinoma of skin or other parts of face; constipation; Type 2 diabetes mellitus with other skin complications; and venous insufficiency.
On 03/29/23 at 08:06 AM an interview was conducted with R35. R35 reported having pain in the right arm which is managed by medication.
A review of the physician's order for management of pain includes the following routine and prn (as needed) medications:
1) gabapentin capsule, 300 mg (miligram), give by mouth two times a day for pain;
2) methadone HCI, 10 mg, give three tablets by mouth every 8 hours for chronic right arm pain;
3) monitor for pain every shift;
4) acetaminophen tablet, 325 mg, give two tablets by mouth every four hours as needed for pain; and
5) morphine sulfate tablet, 30 mg, give 180 mg by mouth every 4 hours as needed for pain-severe.
A review of the Medication Administration Record (MAR) for March 2023 documents no prn of acetaminophen was administered. R35 was received prn of morphine sulfate on 18 of 31 days with two administrations of prn medications on 03/15/23 and 03/20/23. The pain level ranged from 5 to 10. The pharmacy medication review from September 2022 to March 2023 does not address R35's pharmacological pain regimen.
Review of the annual Minimum Data Set (MDS) with an assessment reference date of 12/08/22 notes R35 was on a scheduled pain medication regimen, prn pain medications, and no non-medication intervention for pain in the last five days. R35 reported having pain constantly which affected ability to sleep at night and limited day-to-day activities. R35 numerically rated pain as 10 (highest on the pain scale).
A care plan was developed to address R35's pain related to brachial plexus disorders. Interventions included:
1) The resident's pain is aggravated by movement.
2) The resident's pain is alleviated/relieved by PRN morphine and scheduled methadone.
3) Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.
4) Evaluate the effectiveness of pain interventions.
5) Identify and record previous pain history and management of that pain and impact on function to identify previous response to analgesia including pain relief, side effects and impact on function.
6) Monitor/document for side effects of pain medication (constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness, and falls).
7) Monitor/record pain characteristics every shift (severity scale, anatomical location, onset, duration, aggravating factors, and relieving factors).
8) Monitor/record/report to Nurse resident complaints of pain or requests for pain treatments; and
9) The resident is able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain.
On 03/31/23 at 08:07 AM an interview and concurrent record review was conducted with Registered Nurse (RN)1 at the nurses' station. RN1 confirmed the orders to manage R35's pain. Inquired what are the parameters for administering morphine. RN1 reviewed the MAR and responded morphine was administered for numeric pain levels between 5 and 10, mostly 9. Further inquired when acetaminophen is administered. RN1 confirmed the physician orders does not differentiate the use of morphine and acetaminophen. RN1 noted orders indicate morphine to be provided for severe pain (no numeric value) and the order does not include numeric pain levels for administration of acetaminophen. RN1 reviewed R35's care plan for pain and confirmed the interdisciplinary team did not develop non-pharmacological interventions to alleviate the resident's pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility did not ensure that medication error rate was below five percent (%). Tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility did not ensure that medication error rate was below five percent (%). Two administration errors to resident (R)243 out of a sample of 5 residents, were observed out of 32 opportunities, resulting in a 6.25% medication error rate. This deficient practice has the potential for inadequate administration of medications and/or adverse effects to residents.
Finding includes:
On 03/30/23 at 08:42 AM, observed Registered Nurse (RN) 8 perform medication administration at the Lehua section of the facility. Observed RN8 administer fluticasone propionate nose spray and Trelegy inhaler to resident (R) 243. RN8 notified R243 that she will be giving her nose spay and inhaler. RN8 was holding the base of the nasal applicator between her index and middle fingers with her thumb on the bottom of the bottle. RN8 inserted the nasal applicator into R243's left nostril and pressed the bottom of the bottle twice. RN8 then inserted the applicator in the left nostril, administered 2 sprays then replaced the cover for the applicator. RN8 then got a cup of water and told the R243 to use it to rinse her mouth after administration on the inhaler. RN8 told R243 to take a deep breath, but the inhaler was not yet on R243's lips. R243 took a deep breath through her nose. RN8 then told R243 to breath normally through her mouth as she placed the inhaler on R243's lips. R243 took a short and quick [NAME] through her mouth with her lips around the mouthpiece of the inhaler. RN8 then asked R243 to rinse her mouth and use the cup to spit out the water. RN8 then went back to the medication cart to document the medications administered in the computer.
At 1:30 PM, conducted an interview with RN8 at the seating area outside of a resident's room. Asked RN8 to talk us though how to administer a nasal spray and an inhaler. RN8 replied: I would read the directions given by the doctor on the label of the medication, if it has to be given to both nostrils, let the resident know what is about to be done, uncap the nasal spray and spray into nostril, give resident time to breath it in then do the same for the other nostril. When asked if she should cover the other nostril while giving the nasal spray, RN8 said: the directions do not say to cover the other nostril. Asked what the resident needs to do before being given the nasal spray, RN8 said if the nose is dirty, clean it. Her breathing was okay, so I went ahead and administered the spray. When asked about the administration of the inhaler, RN8 said, read the directions, uncap the inhaler, have a cup of water ready to rinse the mouth, have the resident take a deep breath when the inhaler is on the lips then exhale. Asked RN8 if medication administration was part of the orientation program when she was in training. She replied that part of the orientation was on medication administration, and there was a checklist they had to complete. Asked RN8 if we could review the package insert for the nasal spray and inhaler, she said she will get them from the medication cart. Package insert for the nasal spray stated: Step 1. Blow your nose to clear your nostril. Step 2. Close one nostril. Tilt head forward slightly. insert the nasal applicator into the other nostril. Step 3. Start to breath in through your nose and WHILE BREATHING IN press firmly and quickly down on the applicator. Step 4. Breath out through your mouth. Package insert for the inhaler stated: . Step 2. While holding inhaler away from your mouth, breath out (exhale) fully. Step 3. Inhale your medicine. Put mouthpiece between your lips. Take one long, steady, deep breath in through your mouth. hold your breath for about 3 to 4 seconds. Step 4. Breathe out slowly and gently. Asked RN8 what would she have done differently after reading the package inserts for the nasal spray and inhaler. RN8 responded that for the nasal spray, she would have asked R243 to blow her nose first, closed one nostril, tilted her head forward, told resident to inhale through nose then exhale through her mouth, and clean the tip of the applicator after use. For the inhaler, RN8 said she would make sure the resident exhaled first, instructed her to take a long and deep breath through her mouth when her mouth was sealed around inhaler mouthpiece, kept fingers off the vent and told the resident to hold her breath after. When asked what the concern would be if the package insert instructions were not followed when administering nasal sprays and inhalers, RN8 responded the residents would not get the full dose the medication, and they would not be effective. RN8 also stated that: I'll need to start reading the package inserts of meds (medications).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure hand hygiene procedures were followed by staff between...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure hand hygiene procedures were followed by staff between glove change during a dressing change for one resident (R), R45, and failed to ensure droplet precautions were maintained for another resident, R35, receiving aerosolized medication out of a total sample of 14 residents. These deficient practices encourages the development and transmission of communicable diseases and infections which may affect the health and safety of residents, staff, and visitors.
Findings include:
1) On 03/29/23 at 10:15 AM, observed Registered Nurse (RN) 8 while providing care for resident (R)45. RN8 told R45 that she will be giving her morning medications through her gastrostomy tube (GT - tube inserted though the belly directly into the stomach) and will also be changing the dressing. RN8 washed her hands in the bathroom sink and donned gloves prior to administering the medications and flushing the GT with water. After flushing the GT, RN8 changed her gloves and removed old dressing to R45's GT site. RN8 changed her gloves again and proceeded to clean the GT site, applied a clear cream to the site and covered it with a new dressing. RN8 did not perform hand hygiene between glove changes. Asked RN8 after she was done if she was supposed to perform hand hygiene after removing gloves and before donning new gloves, RN8 replied, I'm guessing, yes?
On 03/31/230 at 09:10 AM, interview conducted with the Administrator who also functions as the infection preventionist (IP), and Administrative Assistant (AA) in the conference room. Administrator confirmed that staff were educated to perform hand hygiene between glove changes.
2) On the morning of 03/28/23 during the screening of residents, observed signs posted on the wall next to the doors titled, Aerosol Contact Precautions. The posting instructed staff and visitors to clean hands when entering and leaving the room, use a NIOSH-approved N95 (respirator), wear eye protection, gown, and glove at door, and keep door closed during procedure. The sign also had an area to document the start time and end time. There was also a posting of two more signs, one with instructions for sequence for putting on PPE and the second for removing PPE. Interviewed Registered Nurse (RN)2 regarding the reason for aerosol contact precautions and instructions for use of PPEs when visiting residents with aerosol contact precautions. RN2 explained residents with these signs are on hospice and receive duoneb (treatment to open the airways of the lungs, making it easier to breathe) through a nebulizer (machines that change liquid medication into a breathable mist). RN2 explained PPE is required while residents are receiving treatment. RN2 instructed to check for documentation of the start and end time of treatment and if residents are receiving treatment to use PPEs.
On 03/31/23 at 12:38 PM requested to interview the Certified Nurse Aide (CNA) that provides care for Resident (R)35. Staff member assisted in finding CNA8. The staff member located CNA8 in room [ROOM NUMBER] and called her to come out. CNA8 was observed through the opened door to walk out from behind the privacy curtain of bed A (closest to the window). CNA8 was wearing a procedural mask, not an N95. Observed the aerosol contact precautions sign with documentation of start time of 12:25 PM and end time of 12:40 PM. CNA8 reported she was providing care for R54. CNA8 was asked if she should be wearing a PPE as R18 in bed B (closest to the door) was receiving aerosol treatment. CNA8 responded she does not have to wear PPE as the curtains are closed and was not providing care to the resident receiving treatment.
RN2 came to room [ROOM NUMBER]. RN2 confirmed R18 was receiving aerosol treatment (via nebulizer) and was coming to discontinue the treatment. The engine of the nebulizer machine could be heard running. RN2 was asked whether CNA8 should don PPE as directed by the signage. RN2 reported it was not necessary for CNA8 to wear PPE because the curtain is drawn. Concurrent observation with RN2 found the privacy curtains were drawn to the left and right of R18 with the front opened. CNA8 had to walk past R18's bed to exit the room. RN2 acknowledged the gap in the privacy curtain to the front and commented it is confusing.
On 03/31/23 at 1:31 PM an interview was conducted with the Director of Nursing (DON) via telephone. The DON reported when providing aerosol treatment, staff are to document the start and end time of the procedure and follow the guidelines for use of PPE. DON stated the door is closed before the procedure and the curtains are completely drawn around the resident that is receiving treatment. Inquired whether staff members entering the room during treatment should don PPEs. DON responded that he didn't think so .PPEs are indicated only for the side where treatment is being provided. DON confirmed the door to the room should be closed during treatment and the curtain completely drawn around the resident's bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected 1 resident
Based on observations, interview, and record review, the facility failed to conduct COVID-19 testing correctly on staff being screened during a COVID-19 outbreak. This deficient practice has the poten...
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Based on observations, interview, and record review, the facility failed to conduct COVID-19 testing correctly on staff being screened during a COVID-19 outbreak. This deficient practice has the potential to transmit the COVID-19 virus affecting the health and safety of residents, staff, and visitors.
Finding includes:
On 03/28/23 at 1:02 PM, observations were made of Registered Nurse (RN)1 conducting staff COVID-19 testing to manage an outbreak at the facility. RN1 wore a gown, gloves, face shield, and mask. Staff (S)1 wore a face mask, took off her mask, and did not hand hygiene after touching her mask. S1 swabbed both nostrils, and placed the swab unto the COVID-19 testing card and closed it. S1 did not hand hygiene after touching the COVID-19 testing card. S2 wore a face mask, pulled down her face mask by touching the front and pulling it down to her chin. S2 did not perform hand hygiene after touching her mask. S2 swabbed both nostrils, and placed the swab unto the COVID-19 testing card and sealed it closed. S2 did not hand hygiene after touching the COVID-19 testing card and repositioned her eyeglasses on her face as she walked away from the table where she conducted her COVID-19 self-test. S3 sat down at a table, removed her mask, and did not hand hygiene after touching her mask. S3 swabbed both nostrils, placed the swab on the COVID-19 testing card and closed the card. S3 did not hand hygiene before leaving the testing area.
On 03/28/23 at 1:30 PM, RN1 was asked if she instructed the staff to hand hygiene before and after performing their self-test and she stated, No.
Reviewed the BinaxNOW COVID-19 Ag [antigen] CARD obtained from the box of BinaxNOW COVID-19 test kits. Under PRECAUTIONS, it stated, . 16 .patient samples, controls, and test cards should be handled as though they could transmit disease. Observe established precautions against microbial hazards during use and disposal. Under SPECIMEN COLLECTION and HANDLING, it stated, . Refer to the CDC [Centers for Disease Control and Prevention] Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html.
Reviewed the CDC's How to Collect an Anterior Nasal Swab Specimen for COVID-19 Testing poster from the aforementioned link leading from . Key Points . Guidance for self-collection of specimens can be found here . It stated, Set up 1. Disinfect the surface where you will open the collection kit. Remove and lay out contents of kit. Read instructions before starting specimen collection. 2. Wash hands with soap and water. If soap and water are not available, use hand sanitizer. Under . Preparation of specimen for return . 8. Place the swab in the sterile tube . 9. Wash hands or re-apply hand sanitizer. Under . Returning the specimen and clean-up . 12. Throw away the remaining specimen collection kit items. 13. Wash hands or re-apply hand sanitizer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
Based on staff interview, the facility failed to inform all residents, their representatives, and families of those residing in the facility by 5:00 PM the next calendar day of confirmed cases of COVI...
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Based on staff interview, the facility failed to inform all residents, their representatives, and families of those residing in the facility by 5:00 PM the next calendar day of confirmed cases of COVID-19. This deficient practice fails to appropriately notify the residents and/or their representatives and families of an ongoing COVID-19 virus transmission in the facility.
Finding includes:
On 03/30/23 at 07:30 AM, Administrator notified the state agency (SA) that on the evening of 03/29/23, two residents and two employees tested positive for the COVID-19 virus. The facility also reported that one employee tested positive for the COVID-19 virus on 03/26/23.
An interview was conducted with the Administrator on 03/31/23 at 09:15 AM in the conference room. Asked if residents and their families or representatives are notified of the COVID-19 cases in the facility. Administrator responded that they only notified the families and representatives of the residents that tested positive for COVID-19, the ones that came in contact with the COVID-19 positive employees and those that are identified as high risk. Notifications were done the same day. Another weekly notification is sent out for all the residents and their families or representatives every Friday. A second interview was done at 1:34 PM with Administrator in the conference room. Asked if all residents and their families of representatives were notified of the positive cases on 03/26/23 and 03/29/23. Administrator confirmed that only the affected residents' families or representatives were notified and not all residents and their families or representatives were notified by 5:00 PM the next calendar day.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews with staff, and record review, the facility failed to assure a system was established to ensure the dish machine sanitization process was in proper working order and ...
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Based on observations, interviews with staff, and record review, the facility failed to assure a system was established to ensure the dish machine sanitization process was in proper working order and failed to ensure labeling of food items. This deficient practice has the potential to result in foodborne illnesses.
Findings include:
1) On 03/29/23 at 10:45 AM observed the [NAME] washing dishes. Inquired whether dishes are sanitized by heat or chemicals. The cook responded that the dish machine is supposed to sanitize dishes by heat, however, for a prolonged period, the water temperature did not reach 180 degrees Fahrenheit. The cook reported there is a problem with the heater, so it does not reach the appropriate temperature. Further queried what is being done to sanitize the dishes. The cook explained that initially the dish machine will start okay but over a period, the machine does not meet the temperature. The cook responded that the dishes were immersed in quaternary solution to ensure sanitization. [NAME] ran the dish machine, observed the water temperature of the wash cycle was 160 degrees Fahrenheit and the rinse cycle was 150 degrees Fahrenheit.
On 03/29/23 at 11:20 AM the Food Service Manager (FSM) was interviewed. FSM clarified the dish machine did not meet the required temperature so was converted to a low temperature dishwasher. Inquired whether the sanitizing solution is chlorine or quaternary. FSM responded chlorine is not used to sanitize dishware. Requested to review the manufacturer's direction for use (MDFU). FSM was agreeable to contact their contractor for directions and get the MDFU.
On 03/30/23 at 12:50 PM, FSM reported the sanitizing solution is chlorine. Inquired when did they identify problems with the dish machine, FSM responded July/August. The dish machine was switched to a low temperature with sanitizing solution on 12/07/22. Requested operator's manual for the dish machine, FSM was agreeable to follow-up with the contractor.
On 03/31/23 at 06:50 AM, FSM reported the contractor has provided the facility with strips to test the chlorine-based sanitizing solution. The staff are testing the sanitizing solution at every meal service. Inquired whether staff are documenting the results of the tests. FSM responded this is an ongoing process and currently staff are not documenting the results of chlorine testing.
On 03/31/23 at 12:15 PM, requested staff demonstrate the testing of the dish machine's sanitizing chemical. The FSM had the test strips in the office and brought it to the dish machine. The dishwasher tore a strip of the paper, dipped the strip into remnants of clear fluid in a cup, and the color of the strip was matched to the color chart on the container. The dishwasher stated the solution was 100 ppm (parts per million). Queried how many ppm is okay, the FSM was observed standing behind the dishwasher and heard whispering 50 to 100 ppm.
The FSM reported the sanitizing solution is checked at meal service, three times a day. FSM confirmed the test results of the sanitizing solution was not documented, they just moved to sanitizing solution. FSM reported in December the dish machine was converted to low temperature with chemical sanitization. FSM reported the contractor came on 03/29/23. FSM reported previously water temperatures were being documented. Requested to review the logs of the dish machine temperatures prior to the conversion to low temperature. FSM was agreeable to provide.
On 03/31/23 at 1:25 PM, FSM reported the requested temperature logs for the dish machine was destroyed, it is beyond recognition. FSM provided one-page directions titled, Chlorine Sanitizer Test Procedures for Low-Temperature Dish machines from the contractor. A review of the instructions found the dishwasher did not follow the directions for testing the chlorine sanitizer. Step 4 directs tester, After dipping, let sit for at least 5 seconds but not more than 10 seconds before reading the strip, the dishwasher matched the test strip to the color chart as soon as the strip was removed from the liquid. The instructions did not indicate the designate the acceptable range of the test results. Inquired what are acceptable parameters for the chlorine solution. FSM provided the Product Specification Document which noted the final rinse water should be at a concentration of 100 ppm, not to exceed 200 ppm. Also, noted to ensure the concentrations does not fall below 50 ppm.
2) On 03/28/23 at 08:30 AM an initial brief tour of the kitchen was done with assistance from the FSM. Observed in the #2 Walk-in Freezer a sealed white plastic bag with no label. The FSM was asked what was contained in the bag. FSM responded it may be chicken cordon bleu, then said, it's probably a turnover. FSM commented that the item had expired. The date printed on the bag was 02/16/23.
Observation of the #7 Line Reefer found a tray with food items (bowls of fruit, pureed bread, pudding). FSM reported he thinks the food items on the tray were from today's breakfast. There was no label on the individual food items and no label on the tray to indicate the food items were from today's breakfast service. Observed there was another tray with food items that was labeled with a date. Asked FSM whether the tray is supposed to be labeled with a date. FSM responded yes.
Observation of the ice machine found brown and gray substances on the white plastic plate above the bin where the ice was stored. The FSM was asked what is that? FSM responded the staff has scrubbed the part and commented they need to replace that part.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interview with residents and staff members, the facility failed to assure a resident that was hit on the face by another resident was monitored to ensure the ...
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Based on observations, record review, and interview with residents and staff members, the facility failed to assure a resident that was hit on the face by another resident was monitored to ensure the victim received care to maintain the resident's highest practicable physical and psychosocial well-being.
Findings include:
The facility submitted a facility reported incident regarding resident-to-resident abuse on 09/24/22. The facility reported on 09/24/22, Registered Nurse (RN)8 heard a commotion in the Pikake dining room around 15:15. Resident (R)15 reportedly punched R12 in the face. Another resident, R42 stated R15 hit R12 on the right side of her face. RN8 assessed R12 and noted redness to her right cheek, no bruising or swelling. R15 was moved out of the Pikake unit and provided with 1:1 supervision.
On 12/01/22 at 09:25 AM observation found R12 asleep in her room. Asked R12 how she was doing today, she responded, so-so. When asked questions to elaborate, she was unable to respond.
On 12/01/22 at 09:30 AM observed R15 lying in bed, wearing glasses. Asked him how he was doing, he responded very softly and unable to make out what he was saying.
On 12/01/22 at 09:25 AM interviewed R42, the witness to the incident. R42 was asked about the incident, she responded she does not remember the incident and only heard about it. Asked how she heard about it, she replied from staff. Informed her that a resident hit R12, R42 responded, she thought R12 hit R15. Again, she stated that she does not remember.
A review of R12's record following the incident found no progress notes to assess how and whether R12 was affected by the incident. There were no social work notes indicating R12's psychosocial status was assessed and monitoring whether there was a change of behavior or signs of distress. There were no nursing notes to monitor whether R12's redness to the cheek subsided or assessed if there was subsequent bruising/swelling or pain to the site where she was hit.
The facility referred R12 for a facial x-ray. The progress note (09/26/22 at 12:58) documents the x-ray was done on 09/25/22. No acute fracture or dislocation seen.
On 12/01/22 at 11:55 AM an interview was conducted with the Director of Nursing (DON) and Social Services (SS). The DON was asked what happens following an incident regarding an allegation of abuse. DON replied, he believes staff would visit resident and communicate with the family. These visits and communication with the family would be documented in the progress notes.
Requested DON and SS review R12's progress notes which documents the facility's follow-up with the resident. DON responded notes would be included in the progress notes under alert charting. DON reported the social services staff member assigned to R12 no longer works at the facility. DON reviewed the subsequent social services progress notes (post incident) and confirmed there were three entries. First dated 09/27/22 at 1319 that family members were called to notify facility on 03/18/23 they would like to escort resident to wedding. Second dated 09/27/22 at 1321 documented family member's contact number. Third contact 10/23/22 at 2267, social services interviewed resident for quarterly mood assessment. The DON confirmed there were no entries to monitor the resident's mood following the incident.
The DON was asked whether nursing would monitor R12 for further injury or pain. DON responded nursing would document daily, every shift for approximately a week to note whether resident has pain or residual injury from incident. Requested staff review the resident's progress notes for any follow-up by nursing. DON confirmed there is no documentation of nursing monitoring the resident for any residual injuries.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Hawaii facilities.
Concerns
- • 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Palolo Chinese Home's CMS Rating?
CMS assigns PALOLO CHINESE HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Hawaii, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Palolo Chinese Home Staffed?
CMS rates PALOLO CHINESE HOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 45%, compared to the Hawaii average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Palolo Chinese Home?
State health inspectors documented 43 deficiencies at PALOLO CHINESE HOME during 2022 to 2025. These included: 43 with potential for harm.
Who Owns and Operates Palolo Chinese Home?
PALOLO CHINESE HOME is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 113 certified beds and approximately 90 residents (about 80% occupancy), it is a mid-sized facility located in HONOLULU, Hawaii.
How Does Palolo Chinese Home Compare to Other Hawaii Nursing Homes?
Compared to the 100 nursing homes in Hawaii, PALOLO CHINESE HOME's overall rating (3 stars) is below the state average of 3.4, staff turnover (45%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Palolo Chinese Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Palolo Chinese Home Safe?
Based on CMS inspection data, PALOLO CHINESE HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Hawaii. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Palolo Chinese Home Stick Around?
PALOLO CHINESE HOME has a staff turnover rate of 45%, which is about average for Hawaii nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Palolo Chinese Home Ever Fined?
PALOLO CHINESE HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Palolo Chinese Home on Any Federal Watch List?
PALOLO CHINESE HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.