How many inspection deficiencies does GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER have?

GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER has 38 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER?

GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER has a four-star staffing rating from CMS with 1.50 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER

Name: GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER
Address: 3-3420 KUHIO HIGHWAY, SUITE 300, LIHUE, HI, 96766, US
Telephone: (808) 245-1802
Rating: 4.0

3-3420 KUHIO HIGHWAY, SUITE 300, LIHUE, HI 96766 · (808) 245-1802

For profit - Corporation 110 Beds OHANA PACIFIC MANAGEMENT CO. Data: November 2025

Trust Grade

73/100

#15 of 41 in HI

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GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER nursing home in LIHUE, HI

Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Garden Isle Healthcare and Rehabilitation Center has a Trust Grade of B, indicating it is a good choice for care, though not without some concerns. It ranks #15 out of 41 facilities in Hawaii, placing it in the top half statewide, and #2 out of 5 in Kauai County, meaning only one local option is better. However, the facility is experiencing a worsening trend, with issues increasing from 9 in 2024 to 11 in 2025. Staffing is a strength, with a 4/5 star rating and a turnover rate of 27%, which is lower than the state average, suggesting that staff are familiar with residents. While there have been no fines, which is positive, some specific incidents raised concerns: food safety practices were inadequate, with items not properly labeled, and residents reported waiting over an hour for assistance after activating call lights, indicating potential staffing shortages during busy times. Overall, while there are strengths, families should also be aware of these weaknesses when considering this facility.

Trust Score: B
In Hawaii: #15/41
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 27% annual turnover. Excellent stability, 21 points below Hawaii's 48% average. Staff who stay learn residents' needs.
Penalties: No fines on record. Clean compliance history, better than most Hawaii facilities.
Skilled Nurses: Each resident gets 90 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: 38 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 9 issues

2025: 11 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (27%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (27%)
21 points below Hawaii average of 48%

Facility shows strength in staffing levels, quality measures, staff retention, fire safety.

The Bad

Chain: OHANA PACIFIC MANAGEMENT CO.

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 38 deficiencies on record

Feb 2025 11 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

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Based on observation and staff interview the facility failed to promote the dignity and self-esteem for one of nine residents sampled for dining observation. During lunch observation, Resident (R)57 was seen with staff who stood over him as they assisted him to eat. The deficient practice does not promote the resident's self-esteem and put him at risk for weight loss. Findings include: On 02/18/25 at 12:30 PM during lunch, observed Certified Nurse Aide (CNA)11 assist R57 with his meal. R57 was sitting up in his bed, and CNA11 was observed standing over R57 as she assisted him with his meal. During this time surveyor observed there was an empty chair nearby in resident's room. Inquired of CNA11 how she is to position self when feeding resident and she stated she can stand or sit when she feeds the resident. Inquired if CNA11 had training regarding feeding residents their meals and she confirmed she had training on this. During record review of R57's Electronic Health Record (EHR) found he had a three pound weight loss over the past month but has had an overall gradual increase of weight since admission. On 02/20/25 at 02:52 PM, interviewed Director of Nursing (DON) and inquired how CNAs are to position themselves when assisting resident's with their meals. DON confirmed the CNAs are expected to assist the resident with their meals at eye level for dignity and staff are educated on this upon hire and annually. Requested facility policy on assisting residents with meals which she provided. Review of facility policy titled Assistance with meals with original effective date 07/2017 stated, . Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents Requiring Full Assistance 1. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals; .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to accommodate one of one Resident (R)12 in the sample with the assistance needed to put her hearing aids on during personal care. The deficient practice caused discomfort and frustration for the resident who had to wait for a trained staff that was available to assist her. This deficient practice has the potential to affect all residents that use a hearing aid. Findings include: Observation and interview with R12 on 02/19/25 at 09:29 AM in her room. When the surveyor approached R12 asking her if she has time for a few questions, she cupped her ear and motioned the surveyor to come close and speak loudly. R12 said they haven't come in to help her with her hearing aids yet. During the interview, the surveyor asked her if she is able to get the help she needs from the staff. R12 said, The availability of staff who have experience is an issue, for example putting my hearing aids in. The younger staff don't know what to do with them. If they've never used them or had a resident who wears them, they don't know how. A staff came in to answer the call light and asked R12 if she needed something. The surveyor asked her if she could help with R12s hearing aids. The staff said, I can't do that, I'm not trained yet. I'll get the nurse to help. At 09:52 AM, speech therapist and the Registered Nurse (RN)35 came in to help R12 with her hearing aids. Minimum Data Set (MDS) admission assessment dated [DATE] reviewed. R12 had a brief interview of mental status summary score of 13, cognitively intact. Hearing is coded, With moderate difficulty; the speaker has to increase volume and speak distinctly. She was not coded as having a hearing aid or other appliance used. Care plan dated 01/21/25 reviewed. No sensory problems that include the use of a hearing aid documented on R12s care plan. Observation on 02/20/25 at 08:45 AM in R12's room. The Speech Therapist (ST)15 was assisting R12 to insert her hearing aids. ST15 said, I'm having a little trouble with the right hearing aid. The surveyor confirmed that ST15 was assisting R12 to insert the hearing aids. At 09:00 AM, the surveyor spoke to ST15 in the hallway outside R12's room. The surveyor asked ST15 if she was able to insert the hearing aids for R12, she stated, Yes, we were successful, R12 is very helpful. The surveyor asked her if the Nurses are trained to insert the hearing aids for the residents. ST15 stated that all of the nurses are trained to insert the hearing aids. Interviewed the Director of Nursing (DON) on 02/21/25 at 10:09 AM. Asked when are residents with hearing aids assisted to put them in and who are trained to assist them with their hearing aids. The DON said, Our CNA's [Certified Nurse Aide] have been trained on how to insert the hearing aids and we have a policy that we follow. We try to assess the resident upon admission for self-administering of their own hearing aids. The surveyor asked the DON what time of the day the resident should have their hearing aids inserted. DON responded, I think they should upon rising in the morning, when they wake up to toilet. We put glasses and hearing aids on in the morning and remove them at night, which is the standard. DON added that it should be as soon as possible, so that they can get started on their day. Review of policy titled, Hearing aid, use and care of dated 06/19/23 stated, Purpose: To assist the resident with use and care of a hearing aid for maximum effectiveness . To enhance psychosocial well-being .

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Cross-reference to F695 Respiratory/tracheostomy Care and Suctioning for R4. Despite identifying that R4 was at risk for complications with his tracheostomy, the facility failed to develop and implement a tracheostomy care plan that included life saving interventions for an unplanned extubation. On 02/20/25 at 02:34 PM reviewed R4's care plan with Director of Nursing (DON) who confirmed there are no interventions regarding emergency care for resident if his tracheostomy became dislodged. 4) Cross-reference to F700 Bedrails for R27. Despite reviewing the facility consent form for Enabler & Restraint Rationale/Consent form with R27 and having him sign it the facility failed to completly fill out the form and develop and implement a care plan for the use of bedrails. On 02/21/25 at 09:51 AM, an interview with DON confirmed that R27 did not have a care plan for the use of the bedrails. Based on observations, record reviews and interviews, the facility did not ensure that a comprehensive person-centered care plan was developed and/or implemented for four of 21 residents (Resident (R)14, R43, R4 and R27) in the active patient sample. The facility failed to develop a comprehensive care plan for the use of bedrails and special mattress for R27, R43 and R14, and emergency care for a tracheostomy (surgically crated opening through the neck into the windpipe) for R4. As a result of this deficient practice, the residents were placed at risk for unmet care needs, decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. Findings Include: 1) R14 is a [AGE] year-old resident admitted to the facility on [DATE] for long-term placement. Diagnoses included but not limited to hemiplegia and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke), vascular dementia with behavioral disturbance, and aphasia. On 02/18/25 at 10:47 AM during the initial screening of the residents, observed R14's bed had a concave mattress on his bed. R14 was sitting up in his wheelchair in the activities/dining area. On 02/19/25 at 08:49 AM, observed R14 in bed with head elevated and watching television. R14 was using a concave mattress and had both upper side rails up. At 09:58 AM, an interview was done with Certified Nurse Aide (CNA)23 in R14's room. Asked CNA23 what was the purpose of the concave mattress and side rails. CNA23 said the side rails are used as an enabler since he is able to turn and reposition himself in bed by pulling on them with his left arm. For the concave mattress, CNA23 said it was to prevent R14 from dangling his legs when lying in bed. On 02/19/25 at 10:46 AM, a phone interview was conducted with the R14's family member (FM)4. Asked FM4 if she participates in the care plan conferences for R14. FM4 said, Yes, the last one was in December. When FM4 was asked how long has R14 been using the concave mattress, FM4 said she was not aware they were using a concave mattress. FM4 said she knew about the side rails since they had to call her to get consent but did not know about the concave mattress. On 02/20/25, review of R14's Electronic Health Record (EHR) was conducted. Consent and assessment for the use of the side rails were scanned into the EHR. Review of care plan dated 01/17/24 revealed that the there was no intervention documented for the use of both the side rails and the concave mattress. On 02/20/25 at 02:23 PM, a concurrent interview and record review was conducted with the Director of Nursing (DON) in her office. Asked DON what was the purpose of the concave mattress for R14. DON said, It is used as a perimeter or lip for when he (R14) sits on the edge of the bed when he's eating his meals at bedside. It's like a guide so he knows where the edge of the bed is. Asked DON if R14 is able to transfer from his bed to the wheelchair by himself. DON said he requires extensive assistance and is totally dependent on staff for transfer from bed as stated in the care plan. Asked DON if there was any care plan developed for the use of the concave bed and side rails. DON reviewed the latest care plan dated 01/17/24 and acknowledged that there was no mention of the use of a concave bed and side rails. DON added that they should be included in the care plan. 2) R43 is an [AGE] year-old resident admitted to the facility on [DATE] for long-term care placement. Diagnoses included but not limited to dementia with other behavioral disturbances, aphasia (loss of ability to understand or express speech) following cerebral infarction, restlessness and agitation, and history of falls. On 02/18/24 at 10:50 AM, observed R43 in her bed that was set at its lowest position, pushed up against the wall on the right side with a fall mat on the left side, and padded side rails were in use for the upper half of the bed. On 02/20/25, review of R43's EHR was conducted. Assessment, consent and order for the use of the side rails as an enabler were found in the EHR. Review of care plan with a revision date on 01/30/25 revealed that there were no interventions documented for the use the side rails. On 02/21/25 at 09:22 AM, a concurrent interview and record review was conducted with the DON in her office. Asked DON if there was any documentation in the comprehensive care plan on the use of the side rails for R43. DON stated that they are used as an enabler when the resident is in bed. DON was not able to find a care plan for the use of the side rail in the EHR. DON confirmed that there should be a care plan developed for the use of the side rails.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide services to ensure one of two residents (R)52 sampled for ADL (activities of daily living) decline, maintained a level of function and the range of motion of his upper and lower extremities. The deficient practice resulted in the resident's lack of movement to get out of bed. Findings Include: Cross reference to F697 - Pain Management. On 02/18/25 at 11:10 AM, observed R52 in his bed with his eyes closed. Noted he was wearing a knee brace on his right leg. R52 is an [AGE] year-old male admitted to the facility on [DATE] for skilled nursing following a stroke. Diagnosis includes Parkinson's disease, Type two diabetes, Lewy body dementia (a vascular disease in the brain) and communication deficit. Telephone interview waS conducted with R52s family member (FM)10 on 02/19/25 at 09:10 AM. The surveyor asked if R52 has had a decline in his ability to get out of bed or exercise in the past few months. FM10 said, I think he needs more exercise. He was walking before and was able to use his walker when he first got there. After the insurance stopped paying for him to have therapy he started to decline. They restarted his therapy and worked with him for a while, but it's been a long time, and he stays in bed and now his muscles are not working. He was able to get up with a walker, but now they need to use a lift to get him out of bed. He's declining both due to his medical condition and because he's not getting any exercise. Asked if R52 is getting any restorative care and are staff doing any range of motion with him. FM10 said, Now he's so stiff that he it's really hard to move his legs, he says he's having a lot of pain when he moves his legs. Inter-Disciplinary Team (IDT) care plan dated 11/25/24 reviewed. Occupational Therapy (OT) Toolkit with exercises. Passive Range of motion (ROM) right side weakness shoulder. Elbow, forearm and wrist. Certified Nurse Aide (CNA) will perform passive ROM to bilateral lower extremities (BLE) daily as tolerated. Nursing to don (put on) right ankle splint for up to 6 hours two times per day as tolerated. Review of the attendance form documented the licensed nursing staff were present. Minimum Data Set (MDS) annual assessment dated [DATE] reviewed. R52 has a brief interview for mental status summary score of 01 and is severely cognitively impaired. He is dependent on staff for his activities of daily living (ADL) and mobility. Interview with the Director of Rehab Services (DOR) on 02/21/25 at 9:00 AM. The surveyor asked if there is a restorative nursing program and if not, how do residents receive restorative care. DOR said, After we discharge the resident from skilled nursing, we educate the resident, family members and nursing staff on the follow up exercises. We also add it to the care plan. I send the care plan to the nurses, and we put a copy inside the room on the inside of the closet door. On the care plan it will say complete the home exercise program, (HEP) and list's the exercises to be completed. The surveyor asked the DOR where the exercises are being documented when they complete them. DOR said, she wasn't sure where nursing is documenting the range of motion exercises. The surveyor shared the telephone conversation with FM10 and the concerns about R52s decline in range his range of motion. DOR said, it was brought up during the IDT meeting. DOR said she received an email from the MDS coordinator (MDSC) on 02/19/25 that F10 is concerned that the resident is not getting enough exercise. DOR said she addressed it with the Director of Nursing (DON). The surveyor asked the DOR how they will follow up on the concerns. An IDT screening referral form will be filled out by the DOR to request for an ADL evaluation, then submitted for approval. Received and reviewed the email communication on 02/21/25 at 10:00 AM from the MDSC to the DOR dated 02/18/2024 at 11:51 AM. Documented that during the care conference dated 01/30/25, FM10 was concerned about the decline in transfers and strength after R52 got sick previously this month. DOR agreed to do the evaluation. Interview with Registered Nurse (RN)45 on 02/21/25 at 11:00 AM on the third floor. The surveyor asked when R52 is getting range of motion exercises, how often and who provides it. RN45 said usually, it is the CNAs who do the ROM when they provide the morning care, or in the afternoon. Sometimes the nurses will do it but usually it's the CNAs. Interview with CNA28 on 02/21/25 at 11:13 AM. The surveyor asked CNA28 what ROM exercises is she doing with R52 and how often? CNA28 said, I usually do his legs, in the morning when we're providing his care. Putting the lotion on then stretching his leg and bending at the knees. We stretch his arms too. When he does get up to the chair, he scoots down, he has pain to his butt. He's very stiff and complains when sitting too long. He doesn't get up to go to activities often. Observation in R52's room on 02/21/25 at his bedside. The surveyor opened his closet and viewed the exercises posted on the door. R52 was lying on the bed with his eyes closed. He was wearing a brace on his right knee. Review of facility policy titled Activities of Daily Living dated 05/01/21 stated, . The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate .Care and services will be provided for the following activities of daily living; . 2. Transfer and ambulation; Policy Explanation and compliance Guidelines: . 2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview the facility failed to assure one of one resident (R)4 sampled for respiratory/tracheostomy (surgically created opening through the neck into the windpipe) care had a care plan with interventions for an unplanned extubation and failed to assure the new tracheostomy tube was placed at bedside for such an emergency situation. The deficient practice could put R4 in a situation that could impede his breathing, causing a preventable life threatening situation. Findings Include: Cross reference to F656 Develop/Implement Comprehensive Care Plan for R4. Despite identifying R4's need for tracheostomy care and need to have a new replacement tracheostomy at his bedside the facility failed to include life saving emergency interventions in R4's care plan for an unplanned extubation. On 02/19/25 at 12:33 PM observed R4 in his room lying in his bed. R4 was observed with a tracheostomy. R4 did not appear in any distress and could be heard breathing with the use of his tracheostomy. During review of R4's Electronic Health Record (EHR), found resident had a care plan for tracheostomy care but the plan did not include interventions for emergency situations such as if/when the tracheostomy tube becomes dislodged. On 02/20/25 at 09:18 AM, interviewed Registered Nurse (RN)10 who was assigned to take care of R4 that day. Interview was conducted with RN10 in R4's room at the bedside. Inquired about emergency equipment that is kept in R4's room at the bedside. RN10 was able to show all emergency equipment needed for R4 except a new replacement tracheostomy tube. Inquired of RN10 where the new tracheostomy tube is supposed to be in his room and she pointed to the shelf below the ambu bag (a medical tool which forces air into the lungs) that is on the wall near R4's bed. The shelf was empty, no new tracheostomy tube was seen in R4's room. Inquired if RN10 knew if there was a new replacement tracheostomy tube available for R4 and she stated it is in her med cart. Asked if it is supposed to be in the med cart and not in the room. RN10 confirmed it is supposed to be left at the bedside on the shelf and she stated I will get it. and brought it and left it in the room on the shelf underneath the ambu bag. On 02/20/25 at 02:34 PM reviewed R4's care plan with Director of Nursing (DON) who confirmed there were no interventions regarding emergency care for resident if his tracheostomy became dislodged. DON confirmed the emergency tracheostomy is supposed to be in R4's room at bedside. DON stated she had holders attached to the wall where it (new replacement tracheostomy tube) can be placed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to identify, anticipate and effectively manage pain for one of two residents (R)52 sampled for pain. The deficient practice resulted in the resident's intolerance to attend activities and participate in exercises to prevent a decline in his Activities of Daily Living (ADLs). Findings Include: Cross reference to F676. Telephone interview with R52s family member (FM)10 on 02/19/25 at 09:10 AM. F10 stated that R52 isn't participating in therapy or exercises because he has pain. He used to get up and go to activities, but now he stays in bed. When they try to move his legs and get him up, he goes ow, ow, ow. His legs are really stiff. Record review of the face sheet on 02/19/25. R52 is an [AGE] year-old male who was admitted to the facility on [DATE] for skilled nursing services. Minimum Data Set (MDS) annual assessment dated [DATE] reviewed on 02/19/25. R52 is dependent on staff for his ADLs and mobility and was coded as not having pain during the pain assessment interview. Care plan reviewed on 02/19/25. Pain. Resident is at risk for alteration of comfort due to [d/t] disease process. Resident will verbalize reduction of pain.Approach start date 06/01/23. Goal target Date: 04/30/25. Administer medications: per MAR [Medication Administration Record]. Monitor and record any non-verbal signs of pain. Interview with Certified Nurse Aide (CNA)28 on 02/21/25 at 11:13 AM. The surveyor asked CNA28 if R52 is able to participate in the Range of Motion (ROM) exercises and if he has pain. CNA28 said, Yes, he says ow, ow, and has pain with every little movement. If we can get him up to the chair, he scoots down, he has pain to his butt. He's very stiff and complains when sitting too long. He doesn't get up to go to activities often. Interview with Registered Nurse (RN)45 on 02/21/25 at 11:38 AM. The surveyor asked RN45 if R52 is having a lot of pain and if so what type of pain control is he getting. RN45 confirmed that he is having pain with movement, he says ow, ow, ow, and said, He's on Gabapentin (pain medication) 200 milligrams (mg) three times per day (TID) for leg pain. R52 also has acetaminophen (Tylenol) as needed (PRN), and acetaminophen with codeine PRN. Gabapentin is scheduled, the other two are PRN's. The surveyor asked RN45 if R52 is being given the PRN medication every day to address the pain with movement. After reviewing the medication administration record (MAR), she said, It doesn't look like he's been getting the PRNs regularly, not very much in the last month. MAR for February 2025 reviewed. Pain Monitor every (Q) shift. R52s pain level was documented zero on the following dates: 02/01/25 to 02/16/25; five on 02/17/25; zero on 02/18/25 to 02/20/25. Tylenol #3 (300 mg acetaminophen 30 mg codeine (controlled pain medication) tab. Take 1 tab Q 6 hours PRN pain 6-10/10. Not documented as given. Acetaminophen 650 mg TID PRN pain 1-5 out of 10. Documented as given on the following dates: 02/01/25; 02/02/25; 02/09/25; 02/10/25; 02/12/25 to 02/17/25. Faces pain scale used to rate pain. Interview with the Director of Rehab (DOR) services on 02/21/25 at 12:00 PM. The surveyor verified that R52 should be wearing the brace, but with the pain, he doesn't want to wear it or can't tolerate it. The DOR added that his pain presence may be decreasing is ability to participate in his ROM and wearing the right knee brace. Review of the facility policy titled Pain Management Policy stated, . Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. 7. Resident should be evaluated for any needed pain medication prior to, during and after treatments, (i.e wounds), care and/or therapies.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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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 ensure assessment for the use of bed rails was completed and alternative interventions were attempted prior to their use for two of three residents (R)4 and R27 sampled for bed rails. This deficient practice puts R4, R27 and any resident who has bed or side rails installed at risk for harm such as entrapment. Findings Include: 1) On 02/19/25 at 01:39 PM observed R4 in his room in his bed which appeared to be like a crib, it was incased in bed rails. Review of R4's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, cerebral palsy, unspecified (Primary, Admission), tracheostomy status, unspecified intellectual disabilities, functional quadriplegia, and unspecified lack of coordination, abnormal posture. A consent was found in the EHR signed by R4's mother on 06/01/04 for the use of bedrails. Resident had a care plan for his special mattress and full side rails. With this record review no nursing assessment or rationale for bed rail use was found, and no alternative interventions were attempted prior to using bed rails. On 02/21/25 at 10:06 AM an interview was conducted with the Director of Nursing (DON). Inquired if R4 had an assessment completed for his bedrail use and the DON confirmed resident did not have quarterly assessments of his bed rail use. Cross reference to F656 Develop/ Implement Comprehensive Care Plan for R27. Despite identifying R27's need for bed rails the facility failed to develop and implement a care plan for R27's bed rails. 2) On 02/19/25 at 10:15 AM an interview was conducted with R27 in his room at the bedside. R27 was observed lying in his bed with upper half bed rails positioned up. Inquired of R27 if he is able to use the control to lower and lift his bed and the back of the bed. R27 confirmed he could. Inquired if he needs assistance getting in and out of his bed and R27 stated he is unable to get out of bed on his own. Record review of R27's EHR found R27 signed a consent form to use the half bedrails and risks and benefits were explained to resident. Review of this consent form found it was not completed by the nurse, it did not include Nursing Assessment/Rationale, Alternative Interventions Attempted But Unsuccessful, and Bed Rail Assessment on the consent form. During this record review, did not find a care plan for resident's bed rails and there are no assessments completed for bed rails for R27. On 02/21/25 at 09:51 AM interviewed DON who confirmed the consent form that R27 signed was not completely filled out and that it should have been. Confirmed nurses are trained on how to fill out the form upon hire and stated it is pretty self explanatory. Inquired about R27's care plan and DON confirmed R27 does not have a care plan for the use of side rails. DON confirmed this should have been included in R27's care plan.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation and interview the facility failed to assure the controlled drugs were accounted for each shift by having licensed staff document a count each shift. The deficient practice puts the facility at risk for diversion of narcotic medications which could make medications unavailable for residents who might need it. Findings Include: On 02/20/25 at 08:30 AM after observing medication pass with RN10, reviewed narcotics log and narcotic count. Review of the narcotic log form found missing nurses signatures. Review of the narcotic log dated 02/09/25-02/16/25 found four entries out of the 48 entries missing nurses' signatures. Inquired of RN10 if this should have been filled out and RN10 confirmed narcotic count sheet had some blanks and confirmed this is supposed to be signed at the time of the count by the nurses. On 02/20/25 at 09:08 AM interviewed Resident Care Manager (RCM)1. Inquired of RCM1 if nurses who do the narcotic count have to sign the narcotic log and RCM1 confirmed nurses are to sign when they do the narcotic count on the narcotic count sheet. Requested a copy of policy regarding narcotic count. Inquired if nurses are trained on this and RCM1 confirmed nurses are trained on this. Review of policy titled 4.2 Controlled Medication Storage dated 01/24 stated, . medications included in the Drug Enforcement Administration (DEA) or state classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. Procedures . 6. At each shift change or when keys are surrendered, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses or approved individuals per state regulation and is documented on the controlled substances count report.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to assure medication errors with residents receiving medications, during medication pass observation, were less than five percent (%). One of five residents (R)29 sampled for medication pass, received medication in an altered form that was not ordered by the physician. The deficient practice has the potential to put all residents who receive medications at risk for a medication error when given their medication. Findings Include: On 02/20/25 at 08:13 AM, observed Registered Nurse (RN)10 prepare medications for R29. RN10 crushed R29's acetaminophen 325 mg (milligrams) tablet two tablets which is given BID (twice a day) for pain and RN10 opened R29's omeprazole DR (delayed release) 20 mg capsule which is given by mouth twice a day. Inquired of RN10 if R29 has an order to crush medication and RN10 stated R29 is not able to swallow pills and the lady said it was ok. RN 10 placed each medication separately into a medication cup with pudding and fed this to R29 at her bedside. Review of R29's Electronic Health Record (EHR) did not find a physician order that R29's medication can be crushed and given with pudding and no physician order stating it was ok to open R29's omeprazole delayed release capsule and give with pudding. On 02/21/25 at 10:10 AM interviewed Director of Nursing (DON) and inquired if nurses need a physician order to crush medication or open an extended release capsule before giving to resident and DON confirmed nurses are to get the physicians orders before giving medications this way. Review of facility medication error for the survey was 7.14% with two medication errors out of 28 observed medications administered to residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide routine dental services for one of one resident (R)4 sampled for dental care. The deficient practice puts R4 at risk for developing cavities and other mouth infections. Findings Include: On 02/19/25 at 11:49 AM observed R4 in his bed. R4 had his mouth open and surveyor noted R4 had a thick orange-colored build up on his front teeth. Review of R4's Electronic Health Record (EHR) found he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, cerebral palsy (disorder that affects ability to move, balance and maintain posture), tracheostomy status, unspecified intellectual disabilities, functional quadriplegia, and unspecified lack of coordination, abnormal posture. Review of R4's Minimum Data Set (MDS) quarterly assessment dated [DATE] and and annual assessment dated [DATE] found he is dependent upon staff for all of his care. Review of R4's EHR did not find any consultation notes or progress notes regarding a dental visit from the past year. On 02/20/25 at 10:15 AM, interviewed Certified Nurse Aide (CNA)6 and inquired about R4's morning care and CNA6 was able to explain what she does for R4 during his morning care which includes oral care. CNA6 stated if R4 is drooling she will clean around his mouth with the wipes or pink swab. CNA6 explained R4 is NPO (nothing by mouth), and stated she uses the dry brush to wipe his teeth. CNA6 stated she was not sure if they can use toothpaste since R4 is NPO. During this interview, inquired with Registered Nurse (RN)10 if resident sees the dentist and she stated he has a standing order to see one if he needs to. RN10 stated she will check about the dentist appointment regarding his teeth with the plaque and tartar build up. On 02/20/25 at 12:06 PM, interviewed RN10 who stated she left a note for resident's doctor and asked about a dentist appointment and she discussed this with resident's mother. RN10 suggested a one time dose of Ativan if he goes to the dentist. Inquired with RN10 when she does mouth assessment and she stated quarterly and as needed. On 02/20/25 at 02:44 PM, interviewed the Director of Nursing (DON) regarding resident's mouth assessment and dental visits. DON confirmed oral assessment is done annually by the nurse. Reviewed R4's last dental assessment with DON that was filled out on 08/21/24 which the nurse noted plaque build up. Inquired about R4 going to the dentist and the DON stated it is hard for resident to fit into the dentist chair because of his size and diagnosis (Cerebral Palsy). DON confirmed R4 has not seen the dentist within the past year. DON will inquire with other dentist office to see if they can accommodate resident and his custom wheelchair.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) R65 was first admitted to the facility on [DATE] for long-term placement. Review of R65's EHR revealed that on 10/18/24, R65 was transferred to an acute care facility for a higher level of care. Documentation of facility sending a written notification of discharge to the LTCO was not found in the EHR. On 02/19/25 at 03:26 PM, requested a copy of written notifications of discharge for all four residents from the Director of Nursing (DON). Documents were submitted for review on 02/20/25. On 02/20/25 at 11:16 AM, review of the documents submitted revealed that the LTCO was not notified of the discharges until 02/19/25. On 02/20/25 at 02:20 PM, concurrent record review and interview was conducted with DON in her office. DON acknowledged that written notifications were not sent out to the LTCO until 02/19/25 for all four residents sampled. Facility policy titled Discharge-Transfer of the Guest/Resident was reviewed with DON and confirmed that notification of the LTCO was not included in the policy. Based on record reviews and interview, the facility failed to provide proper notification of transfer/discharge to four of four residents sampled for Hospitalization (Resident (R)26, R42, R62, and R65). The facility did not send written notification to the Office of the State LTC [long-term care] Ombudsman (LTCO) for four of the four residents that were transferred/discharged . This deficient practice has the potential to affect all residents at the facility who are discharged or transferred to the hospital. Findings Include: 1) R26 was first admitted to the facility on [DATE] for long-term placement. Review of R26's Electronic Health Record (EHR) revealed that on 09/05/24, R26 was transferred to an acute care facility for a higher level of care. Documentation of facility sending a written notification of discharge to the LTCO was not found in the EHR. 2) R42 was first admitted to the facility on [DATE] for long-term care placement. Review of R42's EHR revealed she was transferred to an acute care hospital on [DATE]. Documentation of facility sending a written notification of discharge to the LTCO was not found in the EHR. 3) R62 was admitted to the facility on [DATE] for long-term care placement. Review of R62's EHR revealed that on 04/12/24, R62 was transferred to an acute care hospital and returned to the facility on [DATE]. Documentation of facility sending written notification of the discharge to the LTCO was not found in the EHR.

Feb 2024 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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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 the resident assessment accurately reflected the resident's status for one of three (Resident (R)71) sampled for closed records. R71 was coded on the discharge Minimum Data Set (MDS) as discharged to a short-term general hospital. Staff confirmed R71 was discharged home on [DATE]. Findings include: On 02/21/23 at 03:10 PM, conducted a review of R71's Electronic Health Record (EHR). On 01/21/24 at 03:53 PM, Minimum Data Support Staff (MDSS)6 documented in a progress note, Resident remained on skilled services for rehab services until 1/17/24 and was discharge to home on 1/18/24. Review of R71's discharge MDS with an Assessment Reference Date (ARD) of 01/18/24 documented in Section A 2105. Discharge Status- 04. Short-Term General Hospital. On 02/22/24 at 03:28 PM, conducted a concurrent record review of R71's EHR and interview with MDSS6 and MDSS1. After reviewing R71's progress notes and discharge MDS (ARD 01/18/24), MDSS6 confirmed R71 was discharged home and the discharge MDS did not accurately reflect the resident's discharge status.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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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 there was an ongoing resident-centered activities program that met the resident's needs, for 1 of 3 residents (Resident 4) sampled for activities. Specifically, the facility failed to consistently act on the resident's need for social contact and sensory stimulation and failed to develop and/or implement a person-centered activities program that the resident found meaningful. As a result of this deficient practice, Resident (R)4 was placed at risk of experiencing a decline in his psychosocial well-being and comfort. This deficient practice has the potential to affect all residents at the facility. Findings include: R4 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care. His current diagnoses include, but are not limited to, cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), aphasia (loss of ability to understand or express speech), intellectual disabilities, and functional quadriplegia (complete immobility due to severe disability that is not caused by injury to the brain or spinal cord). In addition, R4 has a tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), and a gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food/nutrition). Multiple observations were made of R4, daily, throughout the survey period, as he lay in bed in his room with the room completely silent. No radio observed anywhere on his side of the room. R4's television (TV) was positioned on the wall opposite his bed and was always off. The TV was also positioned in a manner that the closing of his privacy curtain would obstruct its view, even if it had been on. There were minimal pictures/photos around the room. Although he does have family, there were no family photos at the bedside. Observed on the wall next to his bed were four photos of himself, one colored picture of a bird, a card with an elephant pictured, and another bird picture on his cabinet door. In addition, R4 was not observed out of his room at all throughout the survey period. On 02/20/24 at 10:38 AM, observations were made at his bedside. Although completely non-verbal in response to greetings, questions, and conversation, R4 was noted to track movement with his eyes as the Surveyor walked around his bed and smiled slightly when spoken to. A review of his comprehensive care plan for Activities noted the following primary problem: .[R4] is admitted for Long Term Care . with needs for social contact and sensory stimulation . The care plan included six interventions: 2 having to do with group activities, 1 having to do with family visits, in-person or by video, and the remaining 3 planned interventions addressing activities for when R4 is in his room. 1. Provide . [R4] with all types of sensory stimulation . 2. Provide . [R4] with weekly or more 1:1 [one-to-one] room visits for socialization, social stimulation. 3. Turn on . [R4's] TV to all types of TV shows when awake . On 02/22/24 at 04:04 PM, received the last 6 months of Activity Logs for R4 from the Activities Manager (AM). A review of the Activity Logs for group activities noted that R4 attended group activities once a month for the past 4 months, twice in October, and not at all in September. A review of the documentation of 1:1 room visits by activity staff noted no visits in September, December, and January; 1 visit each in October and February; and 2 visits in November; for a total of 4 visits in the last 6 months. On 02/23/24 at 09:46 AM, an interview was done with AM near the elevator of the second floor. AM acknowledged that after pulling the Activity Logs at the Surveyor's request the day before, it was noted the documentation made it appear that R4 was not receiving the social/sensory stimulation and 1:1 room visits reflected in his care plan. When asked, AM reported that there were radios available for residents, and agreed that R4 could benefit from consistent music therapy and/or visual stimulation that was closer to him and in his line-of-vision. AM also agreed that R4's TV is too far from his view and would like to move it closer to him, in addition to ensuring that it gets turned on. When asked, AM could not identify specific TV channels or shows that R4 enjoyed watching, nor the type of music he enjoyed.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of Facility Reported Incidents (ACTS #10723, 10743), review of Complaint (ACTS #10735), complainant interview, staff interview, and review of policy, the facility did not provide timely psychiatric assessment for one Resident (R)46, out of three residents sampled, to reduce the risk through multiple falls. R46 had an increasing number of falls with recent fracture needing surgery and hospitalization. Findings include: (Cross reference F689 Accidents) Review of Electronic Health Record (EHR) showed R46 was admitted to the facility on [DATE] with a diagnosis including the following: Stroke, Adjustment disorder, Atrial Fibrillation, Atherosclerotic heart disease, High blood pressure, Anxiety, Restlessness, Agitation, Frequent falls . Initial assessment for falls using the John Hopkins Fall Risk Assessment Tool found R46 as being high risk for falls. Further fall risk assessments showed R46 continued to be high risk for falls throughout the course of stay. Comprehensive Care Plan problem start dated 06/23/23 identified Falls and read R46 was at risk for falls due to left frontotemporal encephalomalacia, poor safety awareness, fall history, impulsiveness, wandering behaviors, unsteady gait, and use of psychotropic meds. Approach included the following: added 07/23/23 1:1 provided prn (as needed) if resident is restless to increase supervision and safety . 08/03/23 resident will reside in close room near nurse's station, have low bed in place, fall mat in place, soft touch call bell within reach at all times . 09/02/23 Sertraline increased . 12/07/23 psych telehealth . 01/10/24 follow up psych telehealth, next psych telehealth follow up scheduled for 02/09/24 . 02/23/24 follow up psych telehealth 02/23/24 . EHR review showed that R46 had the following falls: 08/03/23 Unwitnessed fall, found sitting on bedside floor mat, alone at time of fall. 08/16/23 Unwitnessed fall, found sitting on floor, alone at time of fall. 08/23/23 Unwitnessed fall, found on floor, alone at time of fall. 09/05/23 Lowered to floor, lost balance. 09/16/23 Unwitnessed fall, found sitting on floor, alone at time of fall. 09/19/23 Witnessed fall, alone at time of fall. 10/18/23 Unwitnessed fall, noted on floor, alone at time of fall. 10/31/23 Unwitnessed fall, alone at time of fall. 11/01/23 Unwitnessed fall, found on floor, alone at time of fall. 11/09/23 Unwitnessed fall, found on bathroom floor, alone at time of fall. 11/10/23 Unwitnessed fall, found on floor mat, alone at time of fall. 11/19/23 Unwitnessed fall, found on floor, alone at time of fall. 12/08/23 Witnessed fall, alone at time of fall. 12/15/23 Unwitnessed fall, found on ground, alone at time of fall. 12/19/23 Unwitnessed fall, found sitting on floor mat, alone at time of fall. 12/28/23 Witnessed fall, alone at time of fall. 01/01/24 Witnessed, slid to floor. 01/02/24 Witnessed by other resident, alone at time of fall. 01/07/24 Witnessed by other resident, alone at time of fall. 01/08/24 Unwitnessed, found on floor. 01/09/24 Unwitnessed, found on floor, sent to hospital. 01/17/24 Witnessed, fell upon standing. 02/06/24 Unwitnessed, found on floor, sent to ER. Review of Facility Reported Incidents ACTS 10723, 10743 included the following: Care plan included laser alarm applied . supervision 1:1 as needed when restless . sent out to ER and admitted for surgical procedure. During review of Complaint ACTS 10735 and Complainant (C) interview on 02/21/24 at 09:05AM, C said the facility did not have psychiatric services. Staff interview on 02/23/24 at 11:30AM, Director of Nursing (DON) said that there were no psychiatric services on the Kauai, but they found services on Oahu. DON emphasized the care coordination effort has been multi-disciplinary and efforts to include the family and/or family representative has been on-going. Review of facility policy on Fall Prevention and Management read the following: Key elements of the fall prevention and management program . Dynamic treatment plan, role of interdisciplinary team, use of non-pharmaceutical interventions, appropriate and necessary use of devices (enablers, restraints), re-assessments, implementation, and evaluation of treatment plan . Review record of diagnoses which may contribute to increased falls risk and make sure they are addressed as needed ., most common diagnoses that may contribute to an increase in falls, Cerebrovascular accident (CVA) . Pharmacological assessment and review, review the use of off label antipsychotics, attempt dose reductions as indicated, review the use of benzodiazepines, attempt dose reductions as indicated . Quality improvement, collect falls data (including near miss data), track and trend the falls for a defined period of time to ascertain patterns or probable factors that need to be addressed .

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of Facility Reported Incidents (ACTS #10723, 10743), review of Complaint (ACTS #10735), complainant interview, staff interview, and review of policy, the facility did not provide enough supervision for one Resident (R)46, out of three residents sampled, to reduce the risk through multiple falls. R46 had an increasing number of falls with recent fracture needing surgery and hospitalization. Cross reference F684 Quality of Care Findings include: Review of Electronic Health Record (EHR) showed R46 was admitted to the facility on [DATE] with a diagnosis including the following: Stroke, Adjustment disorder, Atrial Fibrillation, Atherosclerotic heart disease, High blood pressure, Anxiety, Restlessness, Agitation, Frequent falls . Initial assessment for falls using the John Hopkins Fall Risk Assessment Tool found R46 as being high risk for falls. Further fall risk assessments showed R46 continued to be high risk for falls throughout the course of stay. Comprehensive Care Plan problem start dated 06/23/23 identified Falls and read R46 was at risk for falls due to left frontotemporal encephalomalacia, poor safety awareness, fall history, impulsiveness, wandering behaviors, unsteady gait and use of psychotropic meds. Approach included the following: added 07/23/23 1:1 provided prn (as needed) if resident is restless to increase supervision and safety . 08/03/23 resident will reside in close room near nurse's station, have low bed in place, fall mat in place, soft touch call bell within reach at all times . 11/15/23 family to help support resident by visiting in the evenings due to resident wanting a companion . 01/09/24 sensor alarm in-house and installed at foot of bed . 01/17/24 wear posey hipster briefs (hip protectors) as tolerated . EHR review showed that R46 had the following falls: 08/03/23 Unwitnessed fall, found sitting on bedside floor mat, alone at time of fall. 08/16/23 Unwitnessed fall, found sitting on floor, alone at time of fall. 08/23/23 Unwitnessed fall, found on floor, alone at time of fall. 09/05/23 Lowered to floor, lost balance. 09/16/23 Unwitnessed fall, found sitting on floor, alone at time of fall. 09/19/23 Witnessed fall, alone at time of fall. 10/18/23 Unwitnessed fall, noted on floor, alone at time of fall. 10/31/23 Unwitnessed fall, alone at time of fall. 11/01/23 Unwitnessed fall, found on floor, alone at time of fall. 11/09/23 Unwitnessed fall, found on bathroom floor, alone at time of fall. 11/10/23 Unwitnessed fall, found on floor mat, alone at time of fall. 11/19/23 Unwitnessed fall, found on floor, alone at time of fall. 12/08/23 Witnessed fall, alone at time of fall. 12/15/23 Unwitnessed fall, found on ground, alone at time of fall. 12/19/23 Unwitnessed fall, found sitting on floor mat, alone at time of fall. 12/28/23 Witnessed fall, alone at time of fall. 01/01/24 Witnessed, slid to floor. 01/02/24 Witnessed by other resident, alone at time of fall. 01/07/24 Witnessed by other resident, alone at time of fall. 01/08/24 Unwitnessed, found on floor. 01/09/24 Unwitnessed, found on floor, sent to hospital. 01/17/24 Witnessed, fell upon standing. 02/06/24 Unwitnessed, found on floor, sent to ER. Review of Facility Reported Incidents ACTS 10723, 10743 included the following: Care plan included laser alarm applied . supervision 1:1 as needed when restless . sent out to ER and admitted for surgical procedure. During review of Complaint ACTS 10735 and Complainant (C) Interview on 02/21/24 at 09:05AM, C said the facility did not have enough staff to watch R46 and was told that C needed to help watch or hire somebody to be with the resident. C met with the facility and felt that communication has improved. Staff interview on 02/22/24 at 03:25PM, Resident Care Manager 4 said that R46 needed 1:1 supervision at times but would not need it throughout the shift. Staff interview on 02/23/24 at 08:50AM, Registered Nurse 51 said he/she felt that there was not enough staff overall and not enough staff to do 1:1 with the residents. Staff interview on 02/23/24 at 11:30AM, Director of Nursing (DON) said that R46 needed 1:1 supervision as needed but did not present to need supervision around the clock. DON emphasized the care coordination effort has been multi-disciplinary and efforts to include the family and/or family representative has been on-going. Review of facility policy on Fall Prevention and Management read the following: Key elements of the fall prevention and management program . Dynamic treatment plan, role of interdisciplinary team, use of non-pharmaceutical interventions, appropriate and necessary use of devices (enablers, restraints), re-assessments, implementation, and evaluation of treatment plan . Review record of diagnoses which may contribute to increased falls risk and make sure they are addressed as needed ., most common diagnoses that may contribute to an increase in falls, Cerebrovascular accident (CVA) . Pharmacological assessment and review, review the use of off label antipsychotics, attempt dose reductions as indicated, review the use of benzodiazepines, attempt dose reductions as indicated . Quality improvement, collect falls data (including near miss data), track and trend the falls for a defined period of time to ascertain patterns or probable factors that need to be addressed .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify triggers which may cause re-traumatization, and consistently use trauma-informed approaches when caring for, and planning the care for, 1 of 1 resident (Resident (R)274) sampled for Trauma-Informed Care. As a result of this deficient practice, R274 did not have his needs met, was placed at risk of re-traumatization, and was hindered from attaining his highest practicable mental and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility with a history of trauma, post-traumatic stress disorder, and/or psychosocial adjustment difficulties. Findings include: R274 is a [AGE] year-old male admitted to the facility on [DATE] for long-term care with diagnoses that include, but are not limited to, Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), chronic post-traumatic stress disorder (PTSD), depression, anxiety, dementia, and insomnia. A review of R274's admission Social Services assessment noted the following: Resident is on Prazosin for Dx [diagnosis]: Nightmares/insomnia. Resident with Chronic PTSD related to his war experience/combat nightmares. He is an Army Guard. He has hx [history] of sleeping with tent on his upper part of the body/covers his head as it helps him feel secure. A review of the comprehensive admission assessment and corresponding care plan found no information of potential triggers for R274's PTSD or anxiety, nor did it contain resident-specific information to help reduce re-traumatization. There was no documentation that a review of R274's pre-admission PTSD history had been done, or that the brief history documented regarding sleeping with his head covered was addressed or investigated. A review of the facility's Trauma Informed Care policy, last revised on 07/12/23, noted the following: Residents identified as history of Trauma . will have Trauma Informed Observation progress note completed . Trauma events and triggers identified through the screening will be used to develop a care plan. On 02/21/24 at 09:09 AM, an interview was done with R274 at his bedside. R274 confirmed that he has PTSD from Vietnam. R274 reported that he was being followed for his PTSD at the VA [Veterans Affairs] and would see someone at the Vet Center once a week for counseling for his PTSD and nightmares. When asked, R274 stated that he had not been to the Vet Center, or had counseling offered to him at the facility, since he had been admitted . R274 stated he would like to go out to the Vet Center to continue his PTSD counseling. On 02/22/24 at 07:57 AM, a review of R274's EHR revealed no documentation of a Trauma Informed Observation being completed. Documentation of the Trauma-informed assessment that was done was requested from the Administrator. At 03:24 PM, the Administrator provided a 4-question Trauma Informed Care assessment titled Screening questions for PTSD that the facility had conducted. The questions on this form were screening questions to be answered with a yes or no, asking if the resident . had any experience that was so frightening, horrible or upsetting that, in the past month, you . The Administrator confirmed that these forms/questions were not appropriate for this resident and was not in alignment with the facility policy on trauma-informed care. The Administrator provided the State Agency with a Trauma-Informed Care Observation assessment form and Progress Note conducted by Social Services with R274 on 02/22/24, after discovering they had not used the correct assessment. On 02/23/24 at 11:23 AM, Social Services Associate (SSA)4 provided the State Agency with a copy of R274's last Mental Health Progress Note from the Vet Center on 01/23/24, which included a detailed history of his condition. At 11:33 AM, an interview was done with SSA4 in her office. When asked, SSA4 confirmed that the progress note/history from the Vet Center had been obtained by her today, after the information had been requested by the State Agency. SSA4 agreed that R274's pre-admission history should have been looked for, obtained, and reviewed prior to conducting his trauma-informed care assessment. SSA4 stated she would review it and re-do R274's trauma-informed care assessment. SSA4 also agreed that as R274 is forgetful (with dementia) and not a reliable historian, his assessment should be conducted with his wife present.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain from an outside resource, routine dental services to meet the needs of 1 of 1 resident sampled for dental concerns. This deficient practice has the potential to affect all residents currently residing in the facility. Findings include: Resident (R)48 is an [AGE] year-old male with no natural teeth, admitted to the facility on [DATE]. On 02/21/24 at 08:46 AM, an interview was done with R48 at his bedside. R48 complained of sore gums, and not being provided a textured diet that he could eat comfortably. R48 shared an example of being given dry cereal for breakfast with no milk to pour over it. R48 stated eating the dry cereal feels like it cuts into his gums, but he has no choice because he is hungry. R48 also reported that while he did have dentures, they no longer fit properly. When asked when the last time was that a dentist evaluated the state of his gums, and the fitting of his dentures, R48 replied that he had not seen a dentist in the facility, or been sent out to see a dentist, since his admission. A review of R48's electronic health record (EHR) revealed no dental consultations, and an oral exam, last completed on 09/03/23, done by a licensed practical nurse (LPN) from the facility. A review of the facility's Dental Services policy, effective 05/01/21, noted the following: The facility must: 1. Provide or obtain from an outside resource routine and emergency dental services to meet the needs of each resident. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial or full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impressions for dentures and fitting dentures. It is noted from the facility's definition above of routine services, that these services are outside the scope of LPN practice.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on an interview and record review, the facility failed to maintain an accurate medical record for two residents (Resident (R)24 and R225). An interview with the Director of Nursing (DON) confirmed a document for R225 was uploaded in R24's Electronic Health Record (EHR) erroneously and should not have been. Findings include: On 02/21/24 at 10:15 AM, conducted a record review of R24's EHR. A form titled, MD (physician) Response (attached on 10/12/23) for R225 filed in R24's EHR. The MD Response for documented the physician response to nursing staff regarding questionable orders for Acetaminophen, which would exceed the recommended daily dose of the medication and could potentially negatively impact R225's health status. Review of R225's EHR, Medication Administration Record (MAR), documented identified the orders nursing staff questions were present, the resident was not administered a dose which exceeded the recommended daily dose of Acetaminophen and was not impacted. On 02/22/24 at 12:42 PM, conducted a concurrent interview and review of R24's EHR with the Director of Nursing (DON). DON reviewed R225's MD Response form located in R24's EHR and confirmed the document was misfiled in the wrong resident's EHR. DON confirmed the Health Information Coordinator (HIC)9 was not scheduled to work today and unavailable for interview, but an in-service would be conducted with HIC9 upon returning to work.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure that staff followed hand hygiene and contact precautions practices consistent with accepted standards of practice. Registered Nurses (RN)60 did not complete hand hygiene between glove changes during a dressing change for a Pressure Ulcer (PU) on R70's coccyx. Staff Member (SM)15 did not wear personal protective equipment while delivering lunch to R11's room, who was on contact precautions. This deficient practice places the residents in the facility at an increased risk for communicable disease. Findings include: During an observation on 02/22/24 at 2:00 PM in R70's room with RN60 and RN75 prepared to change R70's dressings. Dressing changes for R70 included the wound on his left lower leg; two PUs on the upper back, and one pressure ulcer on the coccyx. While changing the coccyx PU, RN60 removed the dressing, cleaned the site, and removed her dirty gloves. RN60 picked up the clean gloves and started to place her fingers in the glove. The surveyor prompted RN60 by pointing at the hand sanitizer that was on the over bed table to complete hand hygiene. After using the alcohol-based hand sanitizer RN60 proceeded to put the clean gloves on and completed the wound care. Conducted an interview with RN60 and RN75 on 02/22/24 at 3:45 PM at the nurse's station regarding observations made during the dressing change. Staff validated hand hygiene was not done after removing the dirty gloves and before putting clean gloves on. Review of Handwashing and Hand Hygiene policy (revised 05/23/2023) documented, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: t. Before donning and after doffing gloves and PPE [Personal Protective Equipment]). 2) During an observation of the lunch trays being delivered on the third-floor unit on 02/20/24 at 12:30 PM, observed SM15 enter room [ROOM NUMBER] without donning a gown or gloves. A purple stop sign posted on room [ROOM NUMBER]'s door read, stop check with nurse before entering. The surveyor asked SM15 if a resident in the room is on contact precautions. SM15 was not sure why the resident was on contact precaution but would find out and get back to the surveyor. Review of R11's EHR documented a 0.8 by 0.5 by 0.2 centimeter wound on her back and is currently receiving wound care. An order for contact precautions could not be found in the physician's orders or any other part of the resident's EHR. Interview with the Infection Preventionist (IP) and Director of Nursing (DON) on 02/23/24 at 09:40 AM on the third-floor nurse's station. The IP and DON confirmed R11 was on contact precautions for a wound on the back and an umbilical opening and all staff should be gowning and gloving before going into the room, including delivering meal trays to any resident on contact precautions. Review of the Infection Control policy (updated 10/01/22) documented, Contact Precautions - used to minimize the transmission of infectious organisms through contact with hands or objects, usually found in nares, wounds, urine, and stool. Apply PPE before entering a room or resident/guest. Only gloves needed if delivering meal tray .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 02/20/24 at 11:20 AM, conducted an interview with R67. Inquired if the resident waits long for staff to respond to call lights. R67 reported the facility staff try their best to answer the call lights, but there just is not enough staff, especially if it's around a mealtime and staff are on break. While walking down the second-floor hallway on 02/20/24 at 02:05 PM, observed the call light was activated for room [ROOM NUMBER]. Entered the room and R30 requested for this surveyor to assist the resident back into bed, stating I've been in my wheelchair long enough, I need to lay down and rest for a bit. R30 was unable to independently transfer from the wheelchair to the bed. Inquired with R30 as to how long the resident had been waiting for staff to respond to the call light. R30 and R67 (share a room) both confirmed they have been waiting for over an hour for staff to help them and staff has not come to the room to check on why the residents activated the call light. On 02/23/24 at 11:53 AM, conducted a record review of R30's and R67's EHR. Review of R30's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/24 Section C. Cognitive Function, Brief Interview for Mental Status score was 15, indicating the resident is cognitively intact. Review of R67's admission MDS with an ARD of 01/24/24, Section C. BIMS score was 14 indicating the resident's cognition is intact. Review of Section GG. Functional Abilities and Goals: R67 is dependent on staff for toileting, showers, and dressing. 2) During an observation of the second floor Activities room on 02/20/24 at 11:20AM, R35 was calling out for attention saying, excuse me, excuse me. There were two staff members close by that did not immediately respond to R35's call for attention. R35 kept saying excuse me, excuse me three more times until staff said ok, hold on. After fifteen minutes past and R35 saying excuse me, excuse me another time, staff finally attended to R35's needs. During staff interview on 02/22/24 at 11:30AM, Activities Manager acknowledged that the close by staff members should have responded right away to R35. Activities Manager said that they would address this with the staff. Review of policy on Dignity and Respect read - Policy, it is the policy of this facility that all residents/guests be treated with kindness, dignity and respect. Procedure, 1. The staff will display respect for residents/guests when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings . Based on observation, staff interview and policy review, the facility failed to ensure the resident's right to a dignified existence and treat each resident with respect and dignity for (4) residents. Resident (R)35, R67, R30, R60 residents sampled. Findings include: 1) R60 was admitted to the facility on [DATE] with diagnosis which includes cancer, aphasia (the loss of the ability to understand or express speech), seizure disorder, and malnutrition. Review of R60's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/24, Section C. Cognitive Patterns, R60's Brief Interview for Mental Status (BIMS) was 4, indicating R60's cognition is severely impaired. Section GG. Functional Abilities and Goals documented R60 has functional limitation in range of motion for the upper and lower extremities on one side, uses a wheelchair, and requires substantial assistance (helper does more than half the effort) for toileting hygiene. A significant change MDS with an ARD of 01/01/24 documented, Section C. Cognitive Patterns, R60's Brief Interview for Mental Status (BIMS) was 00, indicating the R60 was unable to complete the assessment. Section GG. Functional Abilities and Goals documented R60 was dependent (helper does all of the effort; resident does none of the effort to complete activity) for toileting. As a result of R60's significant change, the resident was placed on hospice. Multiple observations were made of R60's Family Member (FM)1 at the facility visiting with the resident for times greater than 1 hour on 02/20/24 at 10:42 AM, 02/21/24 at 10:10 AM, 02/22/24 at 12:13 PM, and 02/23/24 at 10:32 AM. Due to the extended amount of time FM1 spent in the facility with R60, was interviewed on 02/21/24 at 10:10 AM. FM1 reported having to go to the nursing station often to get more water and ice for the resident (due to staff not providing it regularly for the resident), but there is no staff at the nurse's station. FM1 stated, when I do find staff, they tell me to use the call light, but staff don't come to the room to answer the call light. On 02/23/24 at 10:32 AM, observed FM1 at the third-floor nurse's station, speaking loudly at staff, stating, No one changed my wife all morning, she can't wait till 01:00 PM. At 12:30 PM, conducted an interview with FM1 regarding the event observed at the third-floor nurse's station. FM1 reported being upset because no one cleaned R60 all morning, the resident's brief was soiled.

Jul 2023 1 deficiency

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure that necessary behavioral health services were provided to all three residents in the sample. The facility did not implement a supportive, person-centered environment for R1, R2, and R3, by not adequately monitoring their behavioral health needs, and identifying and/or implementing specialized interventions for them. This deficient practice does not provide a supportive physical, mental, and psychosocial environment for all residents with behavioral health needs. Findings include: 1) Record review of the facility's completed Event Report dated 05/07/23 to the Office of Health Care Assurance (OHCA) obtained from the Aspen Complaints/Incidents Tracking System (ACTS) 10268. The report described R1's elopement from the facility on 05/03/23 discovered at 4:25 PM by staff. At 4:45 PM, R1 was found by Social Services (SS) at Walmart standing in line at the bank wanting to withdraw money. SS reminded R1 that she was under the care of a Public Guardian (PG) and that her PG has control of her funds. R1 became upset and did not want to return to the facility. R1 eventually returned to the facility accompanied by staff. The facility's investigation revealed that a Certified Nursing Assistant (CNA) who checked R1's vital signs (temperature, respirations, blood pressure) stated that R1 wanted to go to Walmart.R1 wanted to leave the facility because she had been unable to use the phone for three days and wanted to go to Walmart to withdraw money and reinstate service to her cellphone. Record review of R1's electronic health record (EHR). R1's referral documentation from the local hospital where R1 was transferred from, and the facility's face sheet revealed that R1 is a [AGE] year old resident admitted to the facility on [DATE] for physical therapy. Diagnoses included vascular dementia (lack of blood flow to the brain causing problems with reasoning, planning, judgment, and memory) mixed with anxiety and Alzheimer's, homelessness, and alcohol abuse. R1 was determined not to be able to make medical decisions as deemed by a psychiatrist who saw her while hospitalized . A Preadmission Screening Resident Review (PAS/RR) Level 1 Screen documented on 03/15/23 showed that R1 .has symptom(s) and/or current diagnosis of a Major Mental disorder and/or Substance Related disorder, which seriously affects interpersonal functioning .and/or completing tasks .and/or adapting to change . Record review of Social Services Assessment recorded on 03/16/23 at 11:55 AM by Social Services Assistant (SSA)1. It documented that R1 used tobacco products and alcoholic beverages daily, suffered from anxiety, but was not taking any medications to treat her anxiety. Unresolved issues in R1's life included finding a place to live in the community and had no desire to live in the facility. An incomplete Dehydration Risk and Substance Use Review observation was documented by a nurse on 03/16/23 at 12:52 AM. Under Substance Use Review, it stated, If yes to any below refer to social services for care planning and further review. The question for alcohol use was marked as yes. A progress note written on 04/26/23 at 5:13 PM by a nurse revealed that R1 requested to be taken to Walmart and that the Resident Care Manager (RCM, nurse manager) was notified. Care plan with no Last Care Conference date revealed that the facility had not care planned R1's behavioral needs and substance abuse on admission and therefore did not anticipate providing her with any support or supervision to help keep her safe. Orders revealed a Consult and Treat - Psychology/Psychiatric directive inputted on 03/15/23. On 07/06/23 at 08:29 AM, interviewed R1. R1 sat upright in bed, smiling and conversive, R1 explained the situation of her elopement on 05/03/23. R1 stated that she wanted to go to Walmart because she wanted to buy minutes for her phone. She self-propelled to the elevator, and snuck out by blending in with people who were going to go down the elevator because she knew that she wasn't supposed to leave the facility without notifying anyone. On 07/06/23 at 10:26 AM, interviewed Social Services Assistant (SSA)1 and SS2 in their office. SSA1 stated that R1's Public Guardian (PG) did not want R1 to contact her significant other (SO) because her SO financially abused R1 while R1 was previously hospitalized . SSA1 stated that R1 was not consistent with her thought processes and was oftentimes forgetful. SSA1 further stated that R1 was not seeing a psychiatrist because R1 was not taking any psychotropic medications (used to treat mental health disorders), but would benefit from behavioral health services provided by the facility and/or a contracted provider. On 07/06/23 at 02:07 PM, interviewed Resident Care Manager (RCM)1 at the nursing station. RCM1 stated that they have not had a behavioral health specialist (psychiatrist or psychologist) cover the facility for nearly two years and agreed that R1 would benefit from behavioral health services either provided by the facility and/or a contracted provider. 2) On 07/06/23 at 08:30 AM, observed resident (R)2 in the open area in front of the nursing station. R2 was being assisted to walk. R2 loudly cried and whined, unable to be comforted by staff, until another staff member intervened and R2 stopped crying and whining. Record review of resident (R)2's EHR. The Resident Face Sheet revealed that R2 was admitted on [DATE]. The Preadmission Screening Resident Review (PASRR) Level I Screen, date 05/10/23 was read. The question in Part A: Serious Mental Illness (SMI) .Does the individual, currently meet the criteria for SMI? . was marked yes. Reviewed care plan with no date documenting the Last Care Conference. An intervention under Psychotropic Drug Use, with start date of 06/29/23 included, Direct care staff to monitor resident frequently and document mood/behaviors. Refer to Mar [Medication Administration Record] for behavior log. Another intervention stated, SS [Social Services]/Nsg. [Nursing] to offer psych evaluation PRN [as needed]. The MAR was reviewed for the period of 06/22/23 to 07/07/23. There was no behavior monitoring log found for Sertraline (medication to alleviate depression) that R2 was taking. Reviewed progress notes from date of admission, 06/22/23 through to 07/06/23. On 07/06//23 at 10:49 PM, progress note written by a nurse stated, Receiving rehab services this morning. Less crying and whining today . R2's behaviors were identified, but were generalized in description. R2's behavior trigger(s), the length of the behavior, and non-pharmacological interventions to re-direct R2's behavior were not clearly identified. Record review of policy, Behavioral Monitoring, with original effective date of 06/19/20. It stated, .Documentation should include clinical features, frequency, and duration of the targeted behavior, as well as consequences of behavior for other residents. The behavioral note that is entered in the resident's records should review medical, psychiatric, environmental, and cognitive antecedents for the behavior . A behavioral monitoring flowsheet can be used daily or as needed and will include these components: .1) time and frequency of the problem behavior occurrences, 2) use of and outcomes of specific non-pharmaceutical behavioral interventions, and 3) use of and outcomes of medications . It further stated, .Ongoing measurement of effectiveness for behavioral interventions require behavioral monitoring flow sheets and nursing notes, etc. On 07/06/23 at 02:07 PM, interviewed Resident Care Manager (RCM)1 at the unit's nursing station. RCM1 stated that they have not had a behavioral health specialist (psychiatrist or psychologist) cover the facility for nearly two years and agreed that behavioral health services should be provided by the facility. 3) Record review of resident (R)3's electronic health record (EHR). Preadmission Screening Resident Review (PAS/RR) Level 1 Screen documented on 06/21/23. Primary diagnoses was Alcohol withdrawal syndrome, with delirium. Documented under Part A: Serious Mental Illness (SMI), the Yes space was marked for 1. The individual has symptom(s) and/or current diagnosis of a Major Mental disorder and/or Substance Related disorder, which seriously affects interpersonal functioning .and/or completing tasks .and/or adapting to change. Yes was also marked for .3. Has psychoactive drug(s) been prescribed on a regular basis to treat behavioral mental health symptom(s) for the individual within the last two (2) years with or without current diagnosis of SMI? R3's admission Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 06/28/23 revealed under Section D Mood that R3 responded in the affirmative to the question, B1. Feeling down, depressed, or hopeless with the frequency of 7-11 days (half or more of the days). Dehydration Risk and Substance Use Review, recorded on 06/23/23 at 08:46 PM by a nurse, was read. Under Substance Use Review, it stated, If yes to any below refer to social services for care planning and further review. Alcohol Use? was marked yes and it stated under If yes, When last used: Alcohol abuse, with delirium and Comments: Alcohol withdrawal. Care Plan with no Last Care Conference date documented did not identify R3's alcohol use and withdrawal and under Category: Baseline Needs, the only intervention addressing R3's behavioral health needs stated, PASAAR [sic] Level II Recommendation: PASRR I with 120 day monitoring. No behavioral monitoring flowsheets were found and nursing and/or social services progress notes did not reveal consistent monitoring of R3's depression and symptoms of alcohol withdrawal. Resident/Guest Assessment (Care coordination w/PASRR level II) policy and procedure, with effective date 09/01/17 was read. It stated under Policy: It is the policy of this community to coordinate assessments with the pre-admission screening and resident/guest review (PASRR) program under Medicaid in compliance with §483.20 to the maximum extent practicable to avoid duplicative testing and effort and to ensure that individuals with mental illness .receive the care and services they need in the most appropriate setting.

Feb 2023 17 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

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Based on observation and interview, the facility failed to assure a dignified existence for one of three sampled residents (R)56. Findings include: During an interview and concurrent observation on 02/07/23 at 12:30 PM, R56 stated to this surveyor that I don't like that I had to do it in my pants. I don't do this at home. R56 had his call light on and upon entering the room, he stated he needed to go. R56 stated that rehab had told him that he needed to walk and go to the bathroom. R56's call light was on and nursing station over 100 feet away. At 12:35 PM, surveyor walked to nursing station and asked who answers call lights? Registered nurse (RN) stated we all do Nurse's aide stated I am. Meanwhile, nurse manager (NM) walked past the conversation and towards the room and nurse's aide followed. Upon reaching R56's room, R56 stated he went already. R56 asked staff to close the curtain or cover him up when they change him. On 02/07/23 at 01:30 PM, interview with R56 who stated, I'm embarrassed because I don't wet my pants at home.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review (RR), the facility failed to ensure an Advance Directive and/or discussions regarding Advance Directives was documented in one resident's (Resident 16) medical record. As a result of this deficient practice, Resident (R)16 was placed at risk of not having her wishes honored for future health care decisions, should she become incapacitated. This deficient practice has the potential to affect all residents who wish to have end of life plans at the facility. Findings include: On 02/08/23 at 10:51 AM, a review of Resident (R)16's electronic health record (EHR) noted no advance health care directive (AD) found, and no documentation that it had been discussed. AD documentation was requested from the Director of Nursing (DON). On 02/08/23 at 03:14 PM, a copy of R16's AD was provided by the facility. On 02/09/23 at 01:31 PM, during further review of R16's EHR, it was noted that the facility had discussed the AD with R16 and obtained a copy of it from the acute care hospital on [DATE], following the state agency's (SA) request for documentation. On 02/10/23 at 12:08 PM, during an interview with social services staff (SW)2 in the Social Services office, SW2 confirmed that the facility did not document an AD discussion, or obtain a copy of R16's AD until after the SA had identified the deficient practice.

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a process to address grievances for one resident (R) as evidenced by the facility failing to acknowledge, document, investigate, and resolve verbal complaints filed by a resident's family representative as grievances. This deficient practice has the potential to affect all residents/representatives verbalizing complaints. Findings include: On 12/05/22, a complaint was received by the State Agency (SA) from Resident (R)169's son regarding her care, with one of the allegations being an inappropriate discharge. R169 is a [AGE] year-old female admitted on [DATE] for short-term rehabilitation (rehab) following a stroke with diagnoses that include chronic kidney disease, high blood pressure, osteoarthritis, and osteoporosis. Per the complaint, R169 was discharged on 11/09/22 because showed no progress [in rehab], despite a request by R169's son that she remain a bit longer because her house is not ready to comply with her needs. On 02/09/23 at 01:42 PM, an interview was done with the Administrator in the [NAME] Room. When asked for information regarding a grievance investigation/response for R169, the Administrator stated the facility had no documentation of a grievance. The Administrator did produce a progress note (PN) by the discharge nurse documenting R169's son displaying signs of anger and distress at the time of discharge. On 02/10/23 at 12:08 PM, an interview was done with social services staff member (SS)2 in the Social Services office. SS2 stated that nursing and social services staff were well aware that R169's son did not want her to be discharged . When asked to describe how they knew, SS2 reported that R169's son stated he wanted her to stay, he was resistant to discharge teachings and trainings, and was heard stating that he thought it was silly to be shown the rehab teachings because he and their home were not equipped to provide the care and monitoring she needed. Despite staff being aware that R169's son was not in agreement with the facility's plan to discharge her home, SS2 confirmed that there was no documentation of a formal grievance being filed by him (or on his behalf), nor was there documentation that the grievance process was offered in response to his verbal complaints to staff.

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

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Based on record review and interview with staff members, the facility failed to report an allegation of physical abuse to Adult Protective Services. Findings include: Cross Reference to F610. The facility submitted a report of abuse to the State Agency. Resident (R)168 alleged. staff shoved dirty gloves in his mouth when he yells; they beat me when they change or turn me, or during shower; staff will push him hard to the wall and it hurts his hands and arms during change of incontinence brief. Interview with social services staff, inquired whether this allegation was reported to Adult Protective Services (APS). It was reported that a phone call was made to report the allegation. Requested documentation of the contact with APS. The facility did not provide documentation of a referral to APS.

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

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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 complete a thorough investigation and maintain documentation that an allegation of physical abuse was thoroughly investigated. There was no documentation of the resident interviews that were reportedly conducted. The facility did not thoroughly investigate the allegation, the facility failed to investigate the root cause of the bruises on the resident's arms (injuries of unknown origin) which was not documented in their report, the private caregiver was not interviewed, and the facility did not follow up on staff member's witness of certified nurse aides asking resident about the resident about the allegation. Findings include: On 06/02/22 at 05:21 PM the facility transmitted an initial report regarding an allegation of abuse related to Resident (R)168. R168 reportedly informed Physical Therapist (PT) of foot pain. The Charge Nurse (CN)12 was informed and followed up with resident. R168 informed CN12, They beat me when they change me or turn me. They beat me when they shower me, but I didn't shower today. CN12 completed a skin assessment and noted no significant injuries. The initial report did not identify the alleged perpetrator. On 06/02/22, Social Services Staff (SS)1 interviewed R168. R168 informed SS1 that staff shove dirty gloves in his mouth, especially when he yells. The resident stated it happens mostly during the day when they change his personal brief. R168 did not know the name of the staff member and provided a physical description of the staff member. R168 informed SS1 that it happened yesterday (06/01/22) after breakfast. He also informed SS1 that during change of personal briefs they push him hard to the wall and it hurts his hands and arms. SS2 was documented as interviewing all nursing staff assigned to R168 on 06/01/22. On 06/03/22, SS1 showed the resident pictures of direct care staff that worked on his unit between 05/27/22 to 06/02/22 (there was a total of 43 staff). R168 identified four different staff members, one of which matched R168's physical description of the alleged perpetrator. On 06/05/22, SS showed the resident the photos again and R168 identified two of four staff members that were previously identified on 06/03/22. The staff member that reportedly matched R168's description (Certified Nurse Aide 5) was noted to have been on leave from 05/21/22 and returned to work on 06/02/22. Report also documented another skin check was done on 06/06/22 with no significant injuries. On 02/08/23 at 02:42 PM a record review was done. R168 was admitted to the facility on [DATE] with diagnoses which include but not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, history of sepsis, chronic systolic (congestive) heart failure, and atherosclerotic heart disease of native coronary artery without angina. A review of the annual/comprehensive Minimum Data Set (MDS) with assessment reference date of 04/21/22 notes R168 yielded a score of 14 (cognitively intact) when the Brief Interview for Mental Status was administered. R168 was not coded for having mood symptoms or exhibited behaviors (e.g., hitting kicking, threatening others, screaming at others, hitting, or scratching self, pacing). Also, R168 was not coded for rejection of care or wandering. R168 required extensive assistance with two plus persons physical assist for bed mobility (how resident moves to and from lying position, turns side to side), transfer (how resident moves between surfaces, including to or from bed, wheelchair, standing), and toilet use (how resident uses the toilet room, commode, transfers on/off toilet, cleanses self after elimination). R168 was also noted to require extensive assistance with one person physical assist for dressing (how resident puts on, fastens, takes off all items of clothing), eating (how resident eats and drinks), and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, applying makeup, shaving). R168 has impairment to one side of the upper and lower extremities. R168 also noted as always incontinent of bowel and bladder. Subsequent quarterly evaluation with assessment reference date of 08/22/22 notes R168 continued to be cognitively intact. The resident now reports feeling down, depressed, or hoped once a day. R168 continued not to display behaviors, rejection or care, or wandering. A review of the physician order dated 06/02/22 documents an order to observe weekly, right upper arm bruise 1.0 x 1.0 centimeters (cm); right arm (near elbow area) bruise 1.0 x 0.7 cm, and right elbow area bruise 1.0 x 0.7cm. Also noted left forearm bruise (4.0 x 2.8 cm), left arm (near AC) bruise (1.3 x 1.5 cm), and left upper arm bruise (5.0 x 1.0 skin intact). On 06/28/22, physician makes note of existing bruise in right arm, inner aspect of elbow, worsening and now measuring at 7 cm x 6 cm, please continue to monitor once a day on Sun 1530-2330. Medication orders include: albuterol, atorvastatin, Boost Plus with meals, cilostazol (anti-platelet), ferrous sulfate, Lasix, omeprazole, Procrit (treat anemia/low red blood cell count), and tamsulosin. Review of progress note for 06/02/22 (05:21 PM) notes R168 with multiple bruises during skin check. Bruises include right upper arm bruise (1.0 x 1.0 cm); right arm, near elbow (1.0 x 0.7 cm); right elbow (1.0 x 0.7 cm); left forearm bruise (4.0 x 2.8 cm); left arm, near AC (1.3 x 1.5 cm); and left upper arm (5.0 x 1.0 cm). Review of progress notes prior to the identification of the multiple bruises on 06/02/22, found no documentation of bruises or skin impairment. A request was made to the Administrator for the documentation of the facility's investigation. On 02/08/23 at 01:38 PM, the facility provided copies of their investigation which included: completed Event Report to the State Agency, interview/statements by staff members, and staffing schedule. A review of the completed Event Report did not provide the name of an alleged perpetrator. Review documents at the time of the incident, R168 had a care plan in place for occasional behaviors of being resistive, combative to care if he doesn't get his way, which daughter acknowledged. Also noted R168 with occasional verbal aggression with daughter and yelling at staff. The facility reported interviewing other alert and oriented residents on R168's unit and they all stated, they feel safe, comfortable, and they have not witnessed any abuse. The facility revised R168's care plan to prevent a similar incident from happening, intervention was added to require two staff present during care. The facility surmised based on interviews, results of the skin checks, and inconsistencies with the story, abuse and neglect has been ruled out. The statement provided by the Physical Therapist (PT)1 documents on 06/02/22 around 09:30 AM, resident was asked about his progress with therapy and if there is pain. The resident replied he has pain to his feet, a rating of 7/10. PT1 reported this to the CN12. A review of a written witness statement by CN12 noted R168 stated They beat me when they change me. CN12 asked when this happened, the reply was When they shower me, but I didn't shower today. R168 did not explain anymore and stopped talking. CN12 notified social services. A written statement from Certified Nurse Aide (CNA)3 documented, she provided AM (morning) care for R168. R168 refused a shower and was okay with a bed bath. CNA3 noted bruises were already on his arm. CNA3 also completed a statement of facts on 06/02/22 at 12:40 PM. CNA3 reported while feeding the resident lunch, resident stated he would get hurt while going to the shower. SS1 documented, R168 was interviewed at 06/02/22 at 11:30 AM. R168 reported to SS1 that staff put/shove dirty gloves in his mouth specially when he yells, states it happens mostly all day when they change his personal brief. R168 did not know the name of the staff member and reported it only today, to the physical therapist. The resident also reported that during incontinence care, staff will push him hard to the wall and it hurts his hands and arms. R168 reported the last time it happened was yesterday (06/01/22) after breakfast. The resident provided a physical description of the alleged perpetrator. On 06/03/22, Staff Member (SM)1 reported on 06/01/22 assistance was provided to R168 during the day shift but did not witness or was made aware of the alleged abuse. Reviewed statement by CNA4 (dated 06/06/22) who provided care on 06/01/22. CNA4 documents there were no complaints or report from the resident on that day and during morning care. SM2 provided written statement (no date of report) documenting on 06/02/22, while working, overheard two certified nurse aides asking R168 if he had been hurt by anyone. R168 reportedly replied, yes. The CNAs were overhead asking when, R168 replied all the time and clarified it happened in the morning. SM2 identified CNA3 and CNA 4 as the staff overhead interviewing R168. The statements by CNA3 and CNA4 does not document they approached and interviewed R168. There was no documentation investigator(s) followed up with CNA3 and CNA4 of the conversation SM2 overheard to rule out possible intimidation/retaliation efforts by the CNAs. On 02/10/23 at 09:55 AM, conducted interview with SS1 and SS2. Inquired who did the resident identify as the alleged perpetrator, staff explained the alleged perpetrator was out of work from 05/21/22 and the first day back was 06/02/22. Inquired who provided the last shower? There was no response to this question. SS1 explained the photos that were shown, R168 pointed to CNA5. R168 consistently pointed to CNA5. Further queried why was the staff out, they did not know. SS2 reportedly conducted the interviews. Requested a copy of the interview that was conducted with CNA5. SS2 agreed to provide email regarding interview with CNA5. Also, requested to review documentation of the interviews that were done with the alert and oriented residents on R168's unit. Staff members confirmed there is no written documentation of resident interviews. Also inquired whether the facility interviewed the caregiver that takes R168 out on day pass. No confirmation this was done. On 02/10/23 at 12:41 PM, the facility provided a copy of an email from SS2 which documented CNA5 was interviewed and has not worked with [R168] in weeks and has not had any negative interactions with the resident. The facility did not have documentation of questions that were asked during interview of CNA5. Review of the schedule provided by the facility for 05/31/22 and 06/01/22 (CNA5's reported first day back to work) did not list CNA5 on the schedule. On 02/10/23 at 11:03 AM, the Administrator was asked why CNA5 did not work from 05/21/22 to return on 06/02/22. Administrator was agreeable to follow up. Further inquired whether he interviewed the alleged perpetrator (CNA5), he responded social services conducted the interviews. Inquired whether they have documentation of the interviews with the residents on the unit, the Administrator responded it should be in the folder. Requested to review CNA5's personnel file to determine if there are any concerns regarding performance. Administrator was agreeable to follow up. Administrator returned and stated CNA5 was out on leave, which was not related to any disciplinary action. There was no documentation of staff to resident interactions or other allegations of abuse/neglect. On 02/13/23 at 02:14 PM an interview was conducted with CNA5 via telephone. CNA5 reported upon return to work she did not provide care to R168, she was not assigned to his unit. CNA5 recalled providing care for R168 when he was on another unit. CNA5 reported R168 was difficult to transfer, when touched, resident would complain of pain so staff would have to turn resident slowly and instruct the resident what to do. CNA5 recalled it was difficult to turn resident on his left side. CNA5 also reported staff would communicate with R168 on white erase board. CNA5 shared R168 would often yell when touched. CNA5 reported being on leave, being out until 05/31/22. Upon return, CNA5 reported she was not assigned to R168's group.

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the requirements for a facility-initiated discharge for one resident (R) in the sample (R169) as evidenced by the lack of provider orders for discharge, a medical clearance for discharge, and/or a discharge summary completed by the provider documenting the reason(s) for discharge. As a result of this deficient practice, R169 was placed at an increased risk of injury and/or readmission to an acute care facility. This deficient practice has the potential to affect all facility-initiated discharges. Findings include: On 12/05/22, a complaint was received by the State Agency (SA) from Resident (R)169's son regarding her care, with one of the allegations being an inappropriate discharge. R169 is a [AGE] year-old female admitted on [DATE] for short-term rehabilitation (rehab) following a stroke, with diagnoses that include pancytopenia (a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood), chronic kidney disease, high blood pressure, osteoarthritis, and osteoporosis. Per the complaint, R169 was discharged on 11/09/22 because showed no progress [in rehab], despite a request by R169's son that she remain a bit longer because her house is not ready to comply with her needs. On 02/10/23 at 11:42 AM, an interview was done with Nurse Manager (NM)1 at the Nurses' Station (NS). During a concurrent review of R169's electronic health record (EHR), NM1 confirmed that R169 was discharged with critical laboratory values (related to her pancytopenia) on 11/01/22 and again on 11/02/22 that were not rechecked prior to her discharge. When asked for a copy of the provider orders for discharge, a medical clearance for discharge, or a discharge summary completed by the provider, NM1 stated she needed to review the EHR further. At 01:05 PM, NM1 reported to the SA that with regards to discharge orders, the facility had documentation of physical and occupational therapy discharge recommendations that were signed by the physician on the day of discharge after R169 had already left. With regards to a medical clearance for discharge, NM1 stated there was no documentation found. With regards to a discharge summary by the provider, NM1 stated that although the provider does usually complete one, she could not find one completed for R169.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record the discharge home status in the RAI, Minimum Data Set (MDS) for one Resident (R)66 of three residents sampled. As a result of this deficiency, the facility put R66 at risk for further RAI, MDS inaccuracy. Findings include: During review of R66's most recent MDS, Assessment Reference Date 01/13/23, Section A2100 was inaccurately marked as Acute Hospital which meant that R66 was discharged to acute hospital. Review of R66's progress notes showed that R66 was actually discharged home on [DATE]. During staff interview on 02/09/23 at 08:40 AM, MDS Coordinator (MDS Coord) acknowledged that R66 was inaccurately marked as being discharged to acute hospital. MDS Coord stated that they would do the necessary correction. Review of the Long-Term Care Facility RAI 3.0 User's Manual read the following: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations . As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview with staff member, the facility failed to develop a baseline care plan which included minimum information necessary to properly care for the immediate needs of a resident admitted with a Foley catheter. Findings include: On 02/07/23 at 11:20 AM observed Resident (R)118 lying in bed and there was a covered catheter bag hanging from the side of the bed. The catheter tubing was observed to be touching the floor. R118 was admitted to the facility on [DATE] from an acute facility with hospice services. R118 was admitted with hospice services. A review of R118's care plan found the facility did not develop a baseline care plan to include Foley catheter care. Also noted there were no physician orders for the use of a Foley catheter and care related to the catheter. On 02/09/23 at 11:07 AM an interview and concurrent record review was conducted with Nurse Manager (NM)1. NM1 reported the order for use of a Foley catheter was not in the facility's physician orders, it is probably in the hospice orders. NM1 further stated although there is no order or baseline care plan, the nurses are aware R118 has a Foley catheter. NM1 confirmed a baseline care plan was indicated to include approaches which would include but not limited to checking for urine output, changing of the catheter bag, specifying catheter tubing and size, and providing peri care/cleaning.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to facilitate the ongoing program of activities designed to meet the resident's psychosocial and physical needs. Activities were not carried out for one of four sampled residents (R)4. R4 was not observed out of room and up in wheelchair for stimulation to maintain R4's physical and psychosocial well-being and independence. Findings include: R4's admission date was 01/12/11 according to the assessment reference date (ARD) on the minimum data set (MDS). Diagnoses include but is not limited to cerebral palsy. Observation on 02/07/23 at 10:58 AM shows resident in room in bed. Observation on 02/07/23 at 02:00 PM shows resident in room in bed. Record review (RR) of care plan(CP) done on 02/08/23 at 0900 AM indicates to include R4 in small group activities to be with groups of people, include in all types of stimulating activities to observe. CP activity dated 06/03/21 indicates Turn on R4's TV to all types of TV shows when awake, he likes watching all kinds of TV show or children's shows per his mother. RR of interdisciplinary care plan dated 01/13/21 indicates that certified nurses aide will transfer patient to wheelchair 2-3x/wk for up to 3 hrs as tolerated. Pictures included. Observation on 02/08/23 of R4 at 09:03 AM was done in his room. Has soft wraps on both arms. TV on to aquarium channel. Observation on 02/08/23 of R4 at 01:48 PM was done in his room. R4 did not have his splints on. Splints are on table and dirty. Interview was done on 02/09/23 at 10:52 AM with physical therapy manager (PTM) was done. PTM stated that R4 received OT and the result of the OT eval was to try and maintain positioning and not trying to restore but maintain, with the contractures. OT Care plan is sent to nursing to carry out. Observation on 02/09/23 at 08:46 AM Bed bath being done by staff member 3. Aquarium channel is on. Observation done on 02/10/23 at 08:20 AM shows resident in room in bed.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to manage critical lab [laboratory] values for one Resident (R) in the sample (R169), and failed to identify, care plan, and manage constipation for another resident (R16) in the sample. As a result of this deficient practice, R169 was discharged with an increased risk of injury and/or readmission to an acute care facility, and R16 developed potentially avoidable hemorrhoids. This deficient practice has the potential to affect all the residents at the facility admitted from an acute care facility or at risk of constipation. Findings include: 1) On 12/05/22, a complaint was received by the State Agency (SA) from Resident (R)169's son regarding her care, with one of the allegations being an inappropriate discharge. R169 is a [AGE] year-old female admitted on [DATE] for short-term rehabilitation (rehab) following a stroke, with diagnoses that include pancytopenia (a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood), chronic kidney disease, high blood pressure, osteoarthritis, and osteoporosis. Per the complaint, R169 was discharged on 11/09/22 because showed no progress [in rehab], despite a request by R169's son that she remain a bit longer because her house is not ready to comply with her needs. On 02/10/23 at 11:42 AM, an interview was done with Nurse Manager (NM)1 at the Nurses' Station (NS). During a concurrent review of R169's electronic health record (EHR), NM1 confirmed that R169 was discharged with critical [laboratory] (lab) values (related to her pancytopenia) on 11/01/22 and 11/02/22 that were not rechecked prior to her discharge. NM1 stated that R169 was admitted with the pancytopenia diagnosis and that her lab values were trending downward at admission. A review of R169's discharge summary from the acute care facility confirmed that she had been discharged on 10/25/22 with a ferrous sulfate (iron) order for her pancytopenia. A review of R169's admission orders to the skilled nursing facility (SNF) noted no ferrous sulfate order carried over. A review of R169's medication administration record (MAR) noted that ferrous sulfate was only added to her medications as a result of the second critically low lab value obtained by the SNF on 11/02/22. NM1 confirmed that the ferrous sulfate should have been carried over and could not explain how it had been missed. When asked for a copy of the provider orders for discharge from the SNF, a medical clearance for discharge from the SNF, or an SNF discharge summary completed by the provider, NM1 stated she needed to review the EHR further. On 02/10/23 at 01:05 PM, NM1 reported to the SA that with regards to discharge orders, the facility had documentation of physical and occupational therapy discharge recommendations that were signed by the physician on the day of discharge after R169 had already left. With regards to a medical clearance for discharge, NM1 stated there was no documentation found. With regards to a discharge summary by the provider, NM1 stated that although the provider does usually complete one, she could not find one completed for R169. 2) On 02/07/23 at 11:13 AM, an interview was done with R16 at her bedside. R16 reported that she has a doodoo problem. R16 explained that when she was admitted on [DATE], she was constipated and the SNF gave her medications for it, but now they don't. Stated that for the past couple days her bowel movements have been hard, and she has had to push. R16 reported that she asked for a stool softener weeks ago, but apparently Doctor didn't OK it. As a result, R16 states she has bleeding hemorrhoids sometimes, for which the facility has been giving her hemorrhoidal cream. On 02/09/23 at 01:18 PM, a review of R16's EHR noted the following order for a stool softener: one capsule every day as needed for no daily bowel movement, ordered on 12/23/22. Also noted was an order beginning on 02/01/23 for hemorrhoidal cream: apply . to rectum 3x [three times] daily as needed for itch. A review of R16's comprehensive care plan noted no care plan developed to prevent or manage constipation and/or hemorrhoids. On 02/10/23 at 11:30 AM, an interview was done with NM2 at the NS. During a concurrent review of R16's MAR, NM2 confirmed that the stool softener had not been given once since admission, but the hemorrhoidal cream had been administered almost daily from 02/04/23 - 02/09/23. NM2 agreed that staff should have utilized the stool softener order in addition to the hemorrhoidal cream to prevent and treat R16's hemorrhoids.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on observation, interviews and record reviews, the facility failed to ensure for three of six sampled residents (R)4, R16 and R169 received range of motion (ROM) exercises to prevent decline and reduction in mobility. Findings include: Observation on 02/07/23 at 10:58 AM shows resident in room in bed. Splints were not applied to BUE. Observation on 02/08/23 of R4 at 09:03 AM was done in his room. Has soft wraps on both arms. Record review (RR) of interdisciplinary care plan (ICP) was done on 02/08/23 at 09:05 AM. ICP provided and dated 01/31/21 indicates certified nurse's aide (CNA) will perform passive range of motion to bilateral lower extremities and did not address BUE or splints. RR of orders on 02/08/23 indicates ROM and up in chair three times a day. Observation on 02/08/23 of R4 at 01:48 PM was done in his room. R4 did not have his splints on. Splints were noted on bedside table. Splints looked over-worn and looked soiled. Registered nurse (RN)1 agreed and stated we need to order new splints from physical therapy (PT) It's dirty. RN1 attempted to put splints on and was not able to and called the certified nurse's aide (CNA)6 to assist to put splints on. Interview was done with CNA6 on 02/09/23 at 10:22 AM. Queried with CNA6 regarding ROM for BUE and or contractures. CN6 stated I gave him a shower and the physical therapist usually does the ROM. They are good with him and what he needs. He is stiff. We try to do what we can with what we have. Interview was done on 02/09/23 at 10:52 AM with physical therapy manager (PTM). PTM stated that R4 received OT and the result of the OT eval was to try and maintain positioning and not trying to restore but maintain, with the contractures. OT Care plan is sent to nursing to carry out. I saw R4 this morning for screening process and if R4 should be picked up by Occupational therapy (OT) for his hands. The splints don't fit him well and I don't know if they have stretched out and gotten old. Orders came today from nursing. ROM depends on if we have a long-term person, and we pick them and if we feel ROM is appropriate. PT/OT will write a care plan out and nurse's aide is to carry out. In his closet he has the pictures on how to position him and that is from last time he did therapy.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview with staff member, the facility failed to assure drug records are in order and that an account of all controlled drugs are maintained to ensure no diversion. Findings include: On 02/09/23 at 08:20 AM observation of medication cart was done with Registered Nurse (RN)8. Inquired what is the facility's process for ensuring accurate counts of controlled medications are done. RN8 explained two nurses will sign to attest to an accurate count of controlled drugs at the change of shift (oncoming and leaving). The nurse leaving and the nurse coming onto the shift. Requested to review their record. A review of the form titled, Emergency/Controlled Substance Inventory & Kit Verification for 02/01/23 to 02/08/23 was done. Review found missing signatures for the following days/shifts: 02/02/23, day shift of the oncoming nurse; 02/02/23, evening shift of the off-duty nurse; 02/06/23, evening shift of the on duty nurse; and 02/06/23, night shift of the off duty nurse. RN8 confirmed the missing nurse signatures. The facility provided a copy of the policy, Medication Storage - Controlled Medication Storage on 02/09/23 at 03:33 PM. The procedure includes, 6. At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation and interview with staff member, the facility did not assure medications were stored under proper temperatures. Findings include: On 02/08/23 at 09:20 AM observation of the medication storage room was done with Nurse Manager (NM)1. The refrigerator contained medication for the residents and an opened box of flu vaccine vials. A review of the temperature log (Medication Refrigerator Temperature Record) for January 2023 found no documentation temperatures were checked on the 03:00 PM to 11:00 AM shift on 01/08/23, 01/28/23, and 01/29/23. NM1 confirmed there was missing documentation and reported medication refrigerator temperatures are to be taken twice a day. On 02/08/23 at 10:40 AM, the facility provided the temperature record for December 2022. Review noted no documentation for the 03:00 PM to 11:00 AM shift on 12/02/22, 12/03/22, 12/14/22, and 12/18/22. A review of the policy Medication Storage - Storage of Medication provided by the facility on 02/08/23 at 10:40 AM notes in the procedure for medications requiring refrigeration a temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. Also, the temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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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 appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections for three of six sampled residents (Resident (R)35, R45 and R33). This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE) and facility failing to follow their Mitigation Plan and isolating (R)45. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) On 02/07/23 the State Agency (SA) was notified at Entrance that the facility had a current COVID-19 (COVID) outbreak, and as a result all staff on the affected floor (second floor) were required to wear at a minimum, eye protection and an N-95 respirator (N95) when in patient care areas. On 02/08/23 at 08:33 AM, observed Certified Nurse Aide (CNA)1 and CNA2 in room [ROOM NUMBER] assisting Resident (R)35 with her morning hygiene. Both CNAs were wearing purple procedure masks and face shields as they helped R35 brush her teeth. On 02/08/23 at 08:47 AM, an interview was done with Charge Nurse (CN)4 outside room [ROOM NUMBER]. CN4 confirmed that the required personal protective equipment (PPE) for all staff on the second floor was an N95 and a face shield when in resident rooms, or working directly with a resident (if outside the room, for example). On 02/08/23 at 08:49 AM, an interview was done with Nurse Manager (NM)2 at the Nurses' Station (NS). NM2 validated that all staff on the second floor should be wearing N95s and face shields. When asked how staff are informed and updated on PPE requirements, NM2 reported that PPE requirements are covered with staff during huddles [informal staff meetings] every day at 10:15 AM. In addition, NM2 stated that the Infection Preventionist (IC) makes compliance rounds daily and informs/reminds staff then. NM2 reported that the current PPE requirements had been in place/practice for a while. 2) Review of the Electronic Health Record (EHR) showed R45 was admitted on [DATE] with diagnosis including Cerebral Infarction, Wernicke's Encephalopathy, Hypertension, Asthma, Cholelithiasis, Calculus of Bile Duct, Hemiplegia, Hemiparesis . On 01/25/23, R45 tested positive for COVID-19 and was immediately moved to a private room and isolated for 10 days following the facility Mitigation Plan. After the 10 days, on 02/05/23, R45 was cleared from isolation and moved back to the previous semi-private room next to roommate R33. R33 did not show any signs and/or symptoms for COVID-19 and was tested negative. During an observation on 02/06/23 at 10:00 AM, R33 and R45 was in the same semi-private room with no transmission-based precautions and no isolation. On 02/09/23 at 03:00 PM, review of EHR showed that R33 tested positive for COVID-19. Review of R45's EHR (the roommate) revealed that 3 days prior, on 02/06/23, R45 again tested positive for COVID-19 but was not moved to a private room, was not isolated for 10 days, and did not follow the facility Mitigation Plan. During an interview with the Director of Nursing (DON), Infection Control Coordinator (IC) and the Administrator (Admin) on 02/10/23 at 10:20 AM, DON and IC said they were following the Mitigation plan but was not sure about the repeat positive COVID-19 test. During an interview with the Medical Director (Med Dir) on 02/10/23 at 01:00 PM, Med Dir acknowledged that the repeat COVID-19 test could remain positive and the Mitigation plan may need to address that further. Review of the Mitigation Plan read the following: Control Strategies (to be done if Person Under Investigation [PUI] is identified); 1. Isolation, a. Identify a private room that can be available immediately in the event a resident/guest is suspected of having COVID-19 or is confirmed COVID-19+, b. Immediately isolate a person suspected of having COVID-19; i. Move potentially infectious person to a private room and close the door . ii. Post Special Droplet/Contact Precautions sign . c. A resident with confirmed COVID-19 must be placed in a private room (red zone) . 11. Transmission-based precautions/isolation for a PUI can be discontinued if the result from at least one molecular assay for SARS-COV-2 is negative .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observations, staff interview and review of policy, the facility failed to properly transport two oxygen cylinders (O2 tanks) in a safe manner. As a result of this deficient practice, the facility put the safety and well-being of the residents, staff, as well as the public at risk for accident hazards. Findings include: During an observation on 02/07/23 at 10:30 AM, Maintenance Staff (Maint1) transported two O2 tanks in an unsafe manner. The two O2 tanks were laying sideways on a hand-truck cart, rolling back and forth hitting one another. Also, the head valve of the O2 tanks were sticking out the side of the cart having the potential of being knocked off during transport. During staff interview on 02/07/23 at 10:40 AM, the Housekeeping Manager (Hskpg Mgr) acknowledged that the O2 tanks were being transported in an unsafe manner. Hskpg Mgr further stated that the facility was working on obtaining portable oxygen cylinder holders for safe transporting of the O2 tanks. Review of facility policy on Oxygen Cylinder Storage read the following: Procedure, All freestanding cylinders shall be stored in a rack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them.

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide proper notification of discharge for three of the sample residents (Resident (R)169, R12 and R66) who were discharged home. The facility failed to provide written notification of the discharge to the resident or her representative, and/or failed to send notification of the discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred. Findings include: Resident (R)169 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation, and was discharged fifteen (15) days later on 11/09/22. During a review of her electronic health record (EHR) on 02/08/23 at 03:30 PM, it was noted that there was no discharge notification or LTCO notification found for the discharge. Discharge notification was requested from the facility. On 02/09/23 at 01:42 PM, an interview was done with the Administrator in the [NAME] Room. When asked for written discharge notification, the Administrator provided the Notice of Medicare Non-Coverage (NOMNC) signed by R169's son on 11/04/22. The NOMNC documented that coverage would end on 11/08/22, but did not specifically address discharge. On 02/10/23 at 12:08 PM, an interview was done with social services staff member (SS)2 in the Social Services office. When asked about LTCO notification for R169's discharge, SS2 stated that the facility's current practice was to send LTCO notification only for emergency transfers/discharges to an acute care facility. (3) Review of R66's progress notes showed that R66 was discharged home on [DATE]. During staff interview on 02/10/23 at 08:35 AM, Social Worker (SW2) stated that the facility would only send a notification to the Ombudsman when a resident is sent to the hospital for an emergency. SW2 stated for R66, the facility did not send a discharge notification to the Ombudsman. 2) Resident (R)12 was admitted to the facility on [DATE] and discharged on 02/07/23. On 02/08/23 at 01:51 PM an interview was conducted with Social Services Staff (SS)2 regarding R12's discharge. SS2 reported R12 requested an appeal to the discharge. The appeal was submitted to the quality improvement organization (QIO). The facility provided a copy of the QIO's response to resident's request for an appeal. The QIO responded on 02/06/23 via letter, informing R12, she no longer met the Medicare coverage requirements for skilled nursing facility services. Requested a copy of notification to the LTCO. On 02/08/23 at 02:35 PM, the facility provided a copy of the Notice of Resident Discharge/Transfer on 02/06/23 to inform resident of effective discharge date home on [DATE]. The reason for discharge was marked checked as, The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility. R12 signed the document on 02/06/23 to acknowledge receipt of notification and understanding of rights. Also noted three check boxes at the bottom of the form, the box for Copy Provided/Mailed to Resident Representative on ______, had a handwritten note declined 02/06/23. The other check boxes were not completed, Copy Provided/Mailed to resident at listed address on ______ and Sent to Ombudsman on ______. Interview with Social Services Staff (SS)1 inquired and requested a copy of notification to the LTCO of R12's discharge. SS1 responded notification was not sent to LTCO. SS1 clarified notification is only provided to the LTCO when there is an emergency and residents are sent to the hospital. Requested a copy of the facility's discharge policy and procedures. On 02/08/23 at 03:47 PM, SS2 provided a copy of the facility's policy and procedure titled, Discharge/Transfer Notice Process. Review noted the following, ii. Community initiated discharges, 1. SS/designee will issue a discharge notice 30 days prior to determination or as soon as possible [Notification must be made simultaneously], a. Resident/guest issued in person, b. Resident/guest representative (if applicable) listed home/mailing address, and c. Ombudsman via fax. Also noted, 2. All correspondence will be tracked on the bottom of the discharge notice. On 02/08/23 at 03:47 PM, SS2 provided a copy of the fax notifying the LTCO of R12's discharge.

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

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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 store, label, monitor, and discard food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure all perishable or refrigerated food items were labeled, dated, and monitored. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. Findings include: On 02/07/23 at 10:14 AM, during a tour of the facility kitchen with the Food Service Manager (FSM), the following observations were done: An opened gallon of Caesar (cream-based) Dressing with no date opened indicated and/or facility label. An opened gallon of [NAME] Slaw (cream-based) Dressing with 1/23 written in sharpie on the lid and no facility label. An opened gallon of Ranch (cream-based) Dressing with 1/23 written in sharpie on the lid and no facility label. An opened gallon of Oriental (cream-based) Dressing with two dates written in sharpie on the lid, 4/12/22 and 10/12/22. When asked how long the dressings are good for, the FSM stated cream-based dressings should be good for three (3) months [after opening]. Neither date written on the lid made sense to the FSM as she stated that the facility uses Oriental Dressing daily. When asked about the facility policy on labeling perishable items, the FSM stated that each item should have a facility label indicating at a minimum, the name of the item, the date it was opened, and the date to discard. A review of the facility Labeling Guidelines, last updated on 04/30/21, noted the following: *Items with a use by date, defer to that date UNLESS opened, then use per policy below. 30 days** (or otherwise stated as per expiration on label)* . Salad dressings (unless otherwise stated on exp [expiration] date/label .

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.
• 27% annual turnover. Excellent stability, 21 points below Hawaii's 48% average. Staff who stay learn residents' needs.

Concerns

• 38 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 73/100. Visit in person and ask pointed questions.

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About This Facility

What is Garden Isle Healthcare And Rehabilitation Center's CMS Rating?

CMS assigns GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Hawaii, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Garden Isle Healthcare And Rehabilitation Center Staffed?

CMS rates GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 27%, compared to the Hawaii average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Garden Isle Healthcare And Rehabilitation Center?

State health inspectors documented 38 deficiencies at GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER during 2023 to 2025. These included: 38 with potential for harm.

Who Owns and Operates Garden Isle Healthcare And Rehabilitation Center?

GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by OHANA PACIFIC MANAGEMENT CO., a chain that manages multiple nursing homes. With 110 certified beds and approximately 71 residents (about 65% occupancy), it is a mid-sized facility located in LIHUE, Hawaii.

How Does Garden Isle Healthcare And Rehabilitation Center Compare to Other Hawaii Nursing Homes?

Compared to the 100 nursing homes in Hawaii, GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER's overall rating (4 stars) is above the state average of 3.4, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Garden Isle Healthcare And Rehabilitation Center?

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 Garden Isle Healthcare And Rehabilitation Center Safe?

Based on CMS inspection data, GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER 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 4-star overall rating and ranks #1 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 Garden Isle Healthcare And Rehabilitation Center Stick Around?

Staff at GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER tend to stick around. With a turnover rate of 27%, the facility is 18 percentage points below the Hawaii average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 29%, meaning experienced RNs are available to handle complex medical needs.

Was Garden Isle Healthcare And Rehabilitation Center Ever Fined?

GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER 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 Garden Isle Healthcare And Rehabilitation Center on Any Federal Watch List?

GARDEN ISLE HEALTHCARE AND REHABILITATION CENTER 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.

Facility Details

Beds: 110
Avg. Residents: 71
Occupancy: 64.5%
Ownership: For profit - Corporation
Chain: OHANA PACIFIC MANAGEMENT CO.
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
Low Turnover: +3
38 Deficiencies: -10
Final Score: 73/100

Nearby Alternatives

SAMUEL MAHELONA MEMORIAL HOSPI... 5-star Kauai Care Center 3-star HALE KUPUNA HERITAGE HOME, LLC 3-star

View all in LIHUE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 125004