Hale Anuenue Restorative Care

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there was sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, in addition to their physical, mental, and psychosocial well-being. As a result of this deficient practice, the residents experienced a decreased quality of life and were unable to attain their highest practicable well-being.

Inspectors wrote4) An interview was conducted with R50 on 01/30/24 at 2:13 PM. Observed R50 was sitting in front of his bathroom. He reported that he is lactose intolerant, stated he has been given milk five times in the past two weeks. R50 reported today he tried the milk in his cup that came on his lunch tray and said it was regular milk, not the almond milk that he requested. At this time R50 complained of having loose stool, stated he believes it is from the milk he was given. Based on observation, interview, and record review the facility failed to ensure residents dietary needs and preference were met. 1) Resident (R) 52 food preferences were not followed. 2) Staff members providing feeding assistance and/or passing meal trays to residents were not aware of residents' special dietary texture needs to ensure residents are receiving the proper diet texture on their meal trays. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to apply standard infection control precautions to ensure the health and safety of its residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and promote quality of life for 3 of 4 residents sampled for dignity (Residents 74, 41, and 12). Specifically, the facility failed to ensure that Resident (R)74's hair was combed prior to placing her in the common area used for dining, and failed to ensure staff did not stand over R41 and R12 while providing feeding assistance. This deficient practice has the potential to affect all residents in the facility requiring assistance with hygiene, grooming, and feeding.

Inspectors wroteBased on interview and record review, the facility failed to provide proper notification of transfer/discharge for 4 of 4 residents sampled for Hospitalization (Residents 15, 24, 12, and 9). Specifically, the facility failed to issue written notification of transfer/discharge to the residents or their representatives for 2 of the 4 residents, and failed to send notification of the transfer/discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO) for 2 of the 4 residents. This deficient practice has the potential to affect all residents at the facility who are discharged or transferred.

Inspectors wroteBased on interview and record review the facility failed to provide written notification of the facility's bed hold policy to the resident or resident representative for two of four sampled for Hospitalization (Residents (R) 24 and R12).

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit minimum data set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) System within 14 days of its completion following the discharge of Resident 70. Transmitting health data in a timely manner facilitates computer-aided data analysis which impacts payment and quality.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that comprehensive person-centered care plans were developed and/or implemented for 2 of 21 residents (Residents 17 and 132) in the active patient sample. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 1 resident (Resident 74) sampled for a urinary tract infection (UTI) received the appropriate treatment and services to manage her acute urinary retention, as evidenced by repeated and routine intermittent catheterizations over a period of 5 days, causing unnecessary trauma to her urethra and placing her at increased risk of bladder spasms and UTIs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R)17 received the appropriate treatment, equipment, and/or services to increase or prevent further decrease in range of motion (ROM) of her left knee and hand. As a result of this deficient practice, R17 was hindered from reaching her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident (R) 52 was offered sufficient fluid when requested to maintain proper hydration and health.

Inspectors wroteBased on observations, interviews, facility policy review, and document review, the facility failed to ensure potentially hazardous cold food items were held at a temperature of 41 degrees Fahrenheit (F) or lower during tray line service for 2 of 2 meals observed. Additionally, the facility failed to ensure surfaces and equipment were maintained in sanitary condition in 1 of 1 kitchen. The deficient practices had the potential to affect all 90 residents who received food and/or beverages from the kitchen.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a urinary catheter drainage bag was covered to prevent it from being seen by other residents or visitors, to maintain dignity for 1 (Resident #19) of 2 sampled residents reviewed for urinary catheters.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to report an injury of unknown origin to the state survey agency (SSA) within the required timeframe for 1 (Resident #28) of 2 sampled residents reviewed for injuries of unknown origin.

Inspectors wroteBased on interviews, record review, facility document review, and policy review, it was determined that the facility failed to thoroughly investigate injuries of unknown origin for 2 (Resident #24 and Resident #28) of 2 sampled residents reviewed for injuries of unknown origin.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure a resident's right to be free from neglect. The facility did not assure Resident (R)10 was provided the care to address positioning needs and as a result of this deficiency, R10 experienced psychosocial harm and an increased potential for physical harm. Findings Include: Cross Reference to F656 Development/Implement Comprehensive Person-Centered Care Plan and F725 Sufficient Nursing Staff R10 had a stroke and was admitted to the facility on [DATE]. R10's diagnoses including Epilepsy, Hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage affecting the left non-dominant side, abnormal posture, muscle weakness, hypertension, vascular dementia without behavioral disturbances, aphasia, dysphagia, and tachycardia. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to protect three residents, R103, R302 and R39, from falls while residing at the facility. R103 and R302 had sustained major injuries after their falls and R39 continues to suffer from falls. The deficient practice resulted in the decline and expiration of R103; R302 was transferred to acute care and R36 could potentially suffer from a major injury if he continues to have falls in the facility. Findings Include: 1) Surveyor reviewed the electronic medical record (EMR) on [DATE] at 03:14 PM. The event completed report dated [DATE] stated that R103 was found on the floor lying next to her bed. The nursing assessment noted that she had swelling to her right shoulder. R103 was sent to an acute care Emergency Department (ED) at 07:25 AM. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure it adequately assigned staff to meet the needs of its residents. The deficient practice has the potential to impact the health and safety of all the residents. R103 and R302 had unattended falls with injuries. R36 is dependent on staff, on Hospice care, and his safety was not ensured. Staff did not respond to R10 crying or other sounds for staff assistance. R10 is dependent on staff for positioning needs and all care needs and is able to alert staff through various sound for assistance. R10 is unable to appropriate use the call light system. Findings Include: 1) R103 had an unattended fall on [DATE] at the facility and sustained a fracture of the upper arm. [...]

Inspectors wroteBased on observation, staff interview and review of policy, the facility failed to label two containers stored in the walk-in refrigerator. Findings Include: During an observation of the kitchen walk-in refrigerator on 07/13/21 at 10:30 AM, a container of Thousand Island Dressing and a container of Barbeque Sauce was not labeled with the dates that they were opened. There were more than half the contents remaining for the Thousand Island Dressing, and around half the contents remaining for the Barbeque Sauce. On 07/13/21 at 10:35 AM, the Food Service Director (FSD) was queried about the two containers not being labeled. FSD acknowledged that the two containers were not labeled and should have been labeled with the dates that they were opened. FSD proceeded and removed the two containers from the shelf. A review of the facility policy on Food Safety stated: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to apply standard infection control precautions to ensure the health and safety of its residents and staff working in the facility. The facility failed to appropriately isolate its residents who were newly admitted and not vaccinated for the COVID-19 when staff who was not wearing personal protective equipment (PPE) entered one resident ' s room. The facility also did not ensure that common equipment used between residents were disinfected appropriately. The deficient practices placed the residents and staff in the facility at an increased risk for disease transmission. Findings Include: 1) Surveyor made observations on 07/13/21 at 10:35 AM on the W Unit. Surveyor noted a yellow line was taped to the floor that indicated the rooms past that line were for residents on contact/ droplet precautions. [...]

Inspectors wroteBased on observation, staff interview, review of equipment service manual, and review of policy, the facility failed to: ensure routine maintenance, cleaning of the air particle filter, based on the manufacturer's recommendation, for one of four oxygen concentrators reviewed. This deficient practice put Resident (R) 98 at risk for the development and transmission of communicable diseases and infections, and 2. Ensure routine maintenance, cleaning of the air conditioner vents located in the kitchen. Findings Include: 1) During an observation, on 07/15/21 at 09:30 AM, of R98's room, a NewLife Elite Oxygen Concentrator was noted at bedside providing oxygen to R98. The air particle filter located on the back of that oxygen concentrator appeared dirty with dust on it. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the failed to ensure a comprehensive person-centered care plan was developed and/or implemented with measurable objectives and individualized interventions for 2 residents (Resident (R)10 and R36) in the sample. Interventions related to R10's positioning and communication needs were not implemented according to the resident's comprehensive care plan. R36's care plan was not followed for fall prevention when staff did not ensure that R36's call light was within his reach. As a result of this deficient practice, residents are at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being and potential of a negative impact on the resident's quality of life, as well as quality of care and services received. Findings Include: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the completion of neurological (neuro) monitoring assessments for R302 after her fall. Neuro checks provide close monitoring of possible brain injury sustained after a fall and a small change from baseline could indicate the start of brain swelling. Neuro checks were not completed as indicated in the early evening after R302's fall. She was later transferred to an acute care facility in the early morning of the next day and was found to have bleeding in her brain. Finding Includes: On 07/13/21 at 1:45 PM, surveyor reviewed the facility's Office of Health Care Assurance (OHCA) completed Event Report for a facility reported incident (FRI) about R302's fall on 08/03/20 at 2:45 PM. Details included that the certified nursing assistant (CNA) checked R302's blood pressure (BP) at 1420 or 2:20 PM that day. She had low BP. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure R36's safety by not placing his call light within his reach to help him alert staff for help. R36 could have potentially suffered further injury due to his history of falls and after receiving strong pain medication. Finding Includes: An observation of R36 was made on 07/15/21 at 09:32 AM. R36 was sitting up in bed with his eyes closed and he was slow to respond when his name was called several times in a loud tone. His breakfast tray was hardly touched and sat on the rolling bedside table in front of him. A vital signs (VS) monitor (equipment to check BP and heart rate) on a rolling apparatus was placed next to his bed. He had difficulty opening his eyes and groggily stated that he needed help with his eggs. Surveyor noted that R36's call light was up high on the right side of his pillow. [...]