Hale Makua - Kahului

Inspectors wroteBased on resident interview and review of policy, the facility failed to treat residents with dignity and respect for one of three residents (Resident (R) 150) reviewed for dignity. As a result of this deficiency, R150 was not promoted the right to the maintenance or enhancement of her quality of life. Findings Include: During resident interview on 01/07/26 at 10:11 AM, R150 relayed the following concerns: Staff took a long time to answer the call light (up to 30 minutes), would say they would be back and never return or would say just go in your pad; referring to urinating in incontinence underwear. R150 felt ignored and not treated with dignity because of this. Review of facility policy on call light use read: Purpose, to respond promptly to resident's call for assistance. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a comprehensive care plan addressing the presence of a pacemaker for one of one resident (Resident (R) 10) reviewed with a pacemaker. This puts R10 at risk of cardiac complications due to lack of individualize care planning related to the pacemaker. Findings Include:On 01/07/26 at 09:10 AM, an interview with Family Member (FM) 2 and FM3 was conducted. FM2 reported R10 underwent surgery in December for pacemaker generator replacement. Review of R10's Electronic Health Record (EHR) revealed that R10 was admitted to the facility on [DATE] with a cardiac pacemaker in place. Documented diagnoses included, but not limited to, Parkinson's disease without dyskinesia and atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the heart's arteries without chest pain). [...]

Inspectors wroteBased on interviews and record review, the facility failed to revise the comprehensive care plan for one of four residents (Resident (R) 10) reviewed for range of motion (ROM). R10's restorative nursing program (RNP) care plan was not revised following a pacemaker surgery that resulted in suspension of restorative services. This failure placed R10 at risk for not achieving preventative goals including maintaining strength, balance, and transfer ability, and for experiencing complication related to immobility. Findings Include:Cross Reference to F684, Quality of Care. The facility failed to communicate R10's post-operation status within departments to ensure R10 received continuous treatment and care, as soon as practicable. R10's RNP was not followed up on after the facility received documentation from the cardiologist indicating that R10 could resume normal arm movement. [...]

Inspectors wroteBased on interviews and record review, the facility failed to communicate a resident's post-operation status within departments to ensure resident received continuous treatment and care, as soon as practicable, for one of four residents (Resident (R) 10) reviewed for range of motion (ROM). Specifically, R10's restorative nursing program (RNP) was not followed up on after the facility received documentation from the cardiologist indicating that R10 could resume normal arm movement. This failure placed R10 at risk for not achieving preventative goals including maintaining strength, balance, and transfer ability, and for experiencing complication related to immobility. Findings Include:On 01/07/26 at 09:10 AM, an interview with Family Member (FM) 2 and FM3 was conducted. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide treatment/services to maintain and/or prevent a decline in range of motion (ROM) for one of three residents (Resident (R) 160) sampled for limited ROM. This deficient practice puts the resident at risk for decline in ROM and further contractures. Findings Include:On 01/06/26 at 11:13 AM, observed R160 lying in bed, supine with head slightly elevated and both arms against his chest area. Both hands were also bent on the wrists and angled down towards his feet. No splints or braces were observed to both upper extremities. On 01/07/26 at 11:00 AM and 02:30 PM, R160 was observed lying in bed without any splints, braces or pads to his upper extremities. R160 was a [AGE] year-old resident admitted for long-term placement on 09/02/25. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure adequate supervision and/or measures were in place to prevent accidents for one of one resident (Resident (R) 172) reviewed for elopement risk. As a result of this failure, R172 was able to elope from the facility without staff knowledge and arrived at a family member's home with assistance from another resident's visitor. Findings Include:R172 was admitted to the facility on [DATE] with diagnoses including, but not limited to, dementia, osteoarthritis of the right and left shoulders, spinal stenosis in lumbar region without neurogenic claudication, pain in the right and left feet, unsteadiness on feet, and a history of falls. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and services to prevent dehydration for one of three residents (Resident (R) 5) sampled for hydration, despite identifying the resident as at risk for compromised nutrition and hydration. This deficient practice puts R5 at risk of complications due to dehydration. Findings Include:On 01/06/26 at 10:14 AM, concurrent observation and interview with R5 at bedside. Resident was seen sitting in his wheelchair at bedside. No water container observed on the bedside table. When R5 was asked if he feels thirsty or mouth feels dry, he replied Yes. On 01/07/26 and 01/08/26 observation was done with R5 at bedside. No water container observed at bedside. On 01/08/26 at 02:51 PM, an interview was conducted with Nurse Supervisor NS (266). When asked if R5 was on any fluid restriction, she replied No he is not. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure pain management was provided to one of three residents in the sample. The facility failed to monitor and assess pain level with (Resident (R) 56) every shift. This deficient practice may put R56 at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. Findings Include:R56 was re-admitted to the facility on [DATE], with an initial admission date on 05/25/21. R56 diagnoses included, but not limited to, Parkinson's disease with dyskinesia, with fluctuations; Vitamin D deficiency; hyperlipidemia, unspecified, hypocalcemia; unspecified right bundle branch block; essential tremor; gout, unspecified; bilateral primary osteoarthritis of hip; bilateral osteoarthritis of knee; abnormal posture; and pain, unspecified. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to discard expired medications and intravenous solution stored in three of five medication rooms observed. Proper storage of medications is necessary to promote safe administration practices and decrease the risk for medication errors. This deficient practice has the potential to affect all residents in the facility who take medications and receive intravenous solutions. Findings Include:1) On 01/08/26 at 07:15 AM, the Ilima unit medication room was inspected. In the medication refrigerator, a clear plastic storage bag containing medication vials for Resident (R) 89 was checked. The medication label on the storage bag documented four vials of Lorazepam 2 milligram/milliliter (mg/ml) received on 06/10/25. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure appropriate protective and preventive measure for infections as evidenced by the failure to label and store nebulizer equipment for one of two residents (Resident (R) 78) reviewed for infection prevention related to respiratory. As a result of this deficient practice, the facility put the resident at increased risk for infections. Findings Include:On 01/06/26 at 11:04 AM, observed R78's undated and uncovered nebulizer mask with medication chamber and tubing connected to the nebulizer machine placed on R78's nightstand. On 01/07/26 at 07:52 AM, observed R78's uncovered mask with medication chamber and tubing connected to the nebulizer machine and wedged between the nebulizer machine and box of personal belongings on R78's nightstand. [...]

Inspectors wroteBased on observations, interviews and review of policy, the facility failed to treat one Anonymous Resident (ARes1) and Resident (R)499 of six residents sampled, with respect and dignity. As a result of this deficiency ARes1 was not promoted the right to the maintenance of enhancement of their quality of life. The facility also left R499 in her soiled diaper for more than 40 minutes, putting R499 at risk for urinary tract infection (UTI) and perineum skin breakdown.

Inspectors wroteBased on observations, record review, and interview with staff members, the facility failed to implemented residents' care plans to eliminate risk of an accident related to wandering and elopement and monitor the effectiveness of interventions as necessary for 3 of 4 (Residents 1, 2, and 3) residents sampled. 1) Resident (R)1 had an actual elopement, the facility failed to revise the resident's care plan to develop person centered interventions, direct care staff were unaware of approaches/interventions to employ for R1's wandering behavior and the wandering and exit seeking behaviors were not accurately monitored resulting in no baseline data to determine the efficacy of the interventions. 2) The facility failed to develop a care plan to prevent elopement for R2 with wandering behaviors prior to the start of the survey. [...]

Inspectors wroteBased on observation and interview with staff members, the facility did not execute a resident's right to reside in a clean home environment.

Inspectors wroteBased on observations, record review, and interview with staff members, the facility failed to develop a person-centered comprehensive care plan for 1 (Resident 2) of 4 residents reviewed for wandering/elopement behavior. This deficient practice has the potential to place resident at risk for accidents (i.e., falls, resident to resident altercations) and affect the resident's ability to achieve and maintain her highest medical, mental, and psychosocial needs and to cause adverse effects related to falls and resident to resident altercations.

Inspectors wroteBased on observations, record review, and interviews with staff members, the facility did not ensure a person-centered comprehensive care plan was reviewed and revised following an actual incident of elopement for 1 (Resident 1) of 4 residents in the sample.

Inspectors wroteBased on interviews and record review, failed to ensure one resident's right to be free from abuse. R106 hit R141 in her legs with his wheelchair, then left laughing. R141 sustained a 10 cm x 10 cm blue/purple discoloration on the left medial knee and 0.5cm x 0.5 cm light red mark on the left leg just below knee and reported to staff that she was going to her room because she was feeling unsafe because R106 hit her. As a result of this deficient practice, residents in the presence of R106 have the potential for abuse and more than minimal harm.

Inspectors wroteBased on observations, interview, Electronic Health Record (EHR) review and policy review the facility failed to assess pain prior to and manage one Resident (R) of the sampled, R252's pain during a dressing change for his stage 4 pressure ulcer (PU) on his right buttock. The deficient practice prevented R252 from attaining and maintaining his highest level of wellbeing. Findings Include: On 10/17/24 at 01:40 PM spoke with Registered Nurse (RN) 26 and inquired if she had done the dressing change for R99. She confirmed she had already done the dressing change to R99's feet/legs. Inquired if she was going to do a dressing change soon and RN26 stated she was going to do a dressing change for R252. On 10/17/24 at 01:50 PM observed dressing change for R252's stage 4 PU to his right buttock. [...]

Inspectors wroteBased on observations, interview, record review, narcotic count sheet review and policy review the facility failed to: 1) Label open on dates for five of six blood glucose test strips stored in two medication carts, have a nurse sign the narcotic count sheet when the count was done, store unopened insulin in a refrigerator per manufacture instructions and discard expired medication by the discard by date, 2) Ensure all medications used in the facility were stored in accordance with manufacturer recommendations in 3 of 16 medication carts and 3) Discard an expired medication stored on the storage cart. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident's right to be informed in advance, of the risk and benefits of the use of a psychotropic medication, and consent to treatment for two of five (Resident (R)134 and R141) sampled. R134's Resident Representative (RR)4 was not aware that the resident was receiving duplicate antidepressant therapy. RR4 confirmed the risk/benefits, education was not provided to RR4 regarding duplicate antidepressant therapy and did not sign a consent form. Requested a consent form from the facility and the facility confirmed a consent form was not obtained from RR4. As a result of this deficient practice, residents are at risk for more than minimal harm.

Inspectors wrote2) R67 is an [AGE] year-old female admitted to the facility on [DATE]. R67 has a medical history that includes, but not limited to, chronic obstructive pulmonary disease, dependence on supplemental oxygen, acquired absence of eye, and anxiety disorder. R67 had an annual assessment on 08/14/2024. During the assessment R67 had a Brief Interview for Mental Status (BIMS) score of 15, which means R67 is cognitively intact. Concurrent observation and interview were conducted on 10/15/24 at 10:27 AM in R67's room. R67 was laying in bed. R67's call light was laying on a chair that was against a wall. R67 was not able to reach her call button. R67 asked State Agency (SA) if he/she can hand her the call light. R67 stated that she can call for help, but frequently the call light is not nearby for her to use. Observation was conducted on 10/17/24 at 09:08 AM in R67's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered Comprehensive Care Plan (CP) for one resident in the sample (Resident 98). Despite identifying Resident (R)98 as an accident/safety hazards risk due to his smoking and behaviors, and after multiple documented incidents related to his smoking and behaviors surrounding his smoking, R98's smoking CP was not implemented consistently. As a result of this deficient practice, R98 was placed at risk for additional altercations related to his behaviors surrounding smoking.

Inspectors wroteBased on observation and record review, the facility failed to revise the care plan for one Resident (R)32 to provide the support needed when he leaned over in his wheelchair.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident with support of the head and neck while sitting in his wheelchair. The resident sleeping in his wheelchair slumped over to the right side throughout the day. The deficient practice affected one resident in the sample's quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment to prevent urinary tract infections. R180's catheter tubing was observed to have sediment and blackish growth on the sediment throughout the entire length of the tubing. Review of R180's Electronic Health Record (EHR) did not contain an order for treatment of sediment and blackish growth in the catheter tubing. As a result of this deficient practice, residents with catheters are at risk for more than minimal harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a thorough process to assure accurate reconciliation and accounting for all controlled medications, for 1 of 16 medication carts, in order to promptly identify loss or potential diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage and monitor the medication regimen for one Resident of five in the sample by implementing a gradual dose reduction (GDR) for use of an antipsychotic or provide the clinical rationale from the physician that it was not recommended. The deficient practice failed to promote the residents highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation and interview the facility failed to store cutting boards and resident plate lids on racks that did not have rust colored debris. This deficient practice could affect all residents who are provided meals from the kitchen, putting them at risk for foodborne illness. Findings Include: On 10/15/24 at 10:04 AM during initial tour of kitchen, a concurrent interview and observation was done. Observation of one rack that had cutting boards stored also had rust colored debris. The Acting Nutritious Services Director stated she would move the (cutting boards) to a different area. On 10/17/24 at 10:50 AM while in the kitchen, to observe the tray line, noticed a rack with rust colored debris that stored the lids for the residents plates. Acting Nutritious Services Director confirmed the rust colored debris and stated she is in the process of replacing both racks.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure proper cleaning procedures for shared equipment were followed by a staff member. This deficient practice promotes the development and transmission of communicable diseases and infections and has the potential to affect the residents in one of the facility units.

Inspectors wroteBased on observation and staff interview, the facility failed to secure a storage room containing Germicidal Bleach Wipes, Surface Disinfectant Wipes and Hand Sanitizing Wipes. As a result of this deficiency, the facility put the safety and well-being of the residents at risk for accident hazards.

Inspectors wroteBased on interviews, document and record review, the facility failed to provide the appropriate supervision and put interventions in place to prevent one Resident (R)1 with moderate cognitive impairment from elopement, resulting in harm. Although R1 exhibited exit seeking behavior on [DATE], he was able to leave the premises in his truck on [DATE]. R1 got lost and was returned to the facility approximately five and a half hours later by the local police department. As a result of the elopement, R1 suffered psychological and physical harm. R1 was afraid when police found him. When returned to the facility, he was cold, and both feet were swollen. In addition, the facility did not follow their own elopement risk program which endangered R1's health and/or safety as well as putting the public at serious risk when R1 drove a vehicle.

Inspectors wroteBased on interview and record review, the facility failed to honor the right of Resident (R)3 to receive visitors of her choosing at the time of her choosing, for both visits and telephone calls. As a result of this deficient practice, R3 was denied the opportunity to speak with her son when he called on the phone and denied the choice of receiving visits from her husband. This placed R3 at risk for a decline in her quality of life and prevented her from attaining her highest practicable well-being. The facility corrected the deficient practice prior to the abbreviated survey to investigate a complaint filed on her behalf.

Inspectors wroteBased on interviews, document and record review (RR), the facility failed to ensure that two Resident's (R)1 and R2 of a sample of four had their comprehensive care plans (CP) reviewed and revised in a timely manner to include high risk behaviors that needed to be closely monitored. R1 had exit seeking behavior, which was not added to the CP in a timely manner, and R2 was not swallowing his medications at the time of administration, which was not added to the CP. As a result of this deficient practice, there was increased risk the behavior would reoccur and may result in a negative outcome. This deficient practice has a potential to affect all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the activities of daily living, including personal hygiene for one of three residents sampled. As a result of this deficient practice, Resident (R)3 was hindered from attaining her highest practicable well-being. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate diabetic foot care for Resident (R)3. As a result of this deficient practice, the facility placed R3 at risk for avoidable injuries. This deficient practice has the potential to affect all residents in need of diabetic foot care.

Inspectors wroteBased on observations, record review (RR) and interviews, the facility failed to provide incontinence care, in accordance with professional standards of practice and individual care plans (CP) for two resident's (R)1 and R2, of a sample size of seven. As a result of this deficient practice, the residents were at increased risk of adverse outcomes related to incontinence that included comfort, skin breakdown and infection. This could affect their ability to meet their highest potential of physical and mental well-being. The deficient practice had been corrected prior to the survey, and met the criteria for past noncompliance.

Inspectors wroteBased on observations, interview, and record review (RR), the facility failed to follow the proper washing and sanitizing practices for the dishes and silverware to prevent the outbreak of foodborne illnesses as evidenced by wash and final rinse temperatures of the water in the High Temperature Dishwasher (using heat sanitization) that were well below the temperatures recommended for safety by the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code (https://www.fda.gov/media/110822/download), in addition to not monitoring that the proper temperatures were being maintained as evidenced by no retrievable documentation of temperatures since 10/01/23. As a result of this deficient practice, patient safety was compromised, and an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 8 residents (R) in the sample were free from accident hazards. R149 was not kept safe from being grabbed by another resident with a known history of this behavior. As a result of this deficient practice, R149 suffered a potentially avoidable accident with injury. Despite having been identified as a high falls risk upon admission in 2021, R133 did not have a Falls Care Plan added to his Comprehensive Care Plan until after he suffered an unwitnessed fall with multiple major injuries in June 2023. R110 was found to have a cigarette lighter on his bedside table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services (reassessing the residents' dietary/nutritional needs, consistently implementing related care-planned interventions, monitoring for effectiveness, and ensuring coordination of care among the interdisciplinary team) to prevent significant weight loss for 2 of 6 residents (Residents 153 and 147) in the sample, despite having identified them as at risk for compromised nutrition. As a result of this deficient practice, the facility placed these residents at risk for avoidable declines and injuries. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on resident interview, the facility failed to ensure residents were furnished with the information for contacting the State Survey Agency to file a complaint. This deficient practice has the potential to impede a resident(s) ability to exercise their right to file a complaint.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to uphold a resident's right to privacy of one resident (R), R367, out of two residents in the sample. A certified nursing assistant (CNA) did not provide the necessary privacy of R367 during his shower. This deficient practice violates the resident's right to privacy and could potentially cause psychosocial harm to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable, homelike environment for residents at the facility, as evidenced by hot, uncomfortable temperatures in the resident rooms, especially when the room door was closed for personal care, poor pest control, dusty electric fans that were widely used throughout the facility, and walls in resident room(s) in need of repair. As a result of this deficient practice, the residents unnecessarily experienced an uncomfortable environment that was not homelike, with the potential to cause psychosocial harm. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wrote2) During an interview with Resident (R)154 on October 10, 2023, they expressed an increase in their anxiety recently, due to the recent Lahaina Fire. The spouse escaped the Lahaina fire with car, family dog and themselves only. The home and all its contents was lost in the fire. Although R154 was not physically present when this occurred, she was traumatized by the news of how her immediate family had escaped, and the loss of the family home and belongings including important documents. Record review of R154's Electronic Heath Record (EHR), and interview with Neighborhood Supervisor (NS)3 and Social Services Assistant (SSA)3 confirmed there was no psychosocial assessment or comprehensive care plan completed for R154 after this traumatic event for trauma informed care. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to review and revise the Resident's Comprehensive Care Plan (CP) for 3 of 36 residents (R) in the sample (Residents 149, 75, and 147), to effectively address their status, condition, and needs. As a result of this deficient practice, staff did not have the information necessary to adequately care for these residents so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to: 1) Implement 2 (Residents 147 and 263) of 3 residents' bowel protocol. The facility failed to accurately document 147's bowel activity resulting in unnecessary invasive treatment (suppository and two enemas). This deficient practice has the potential to result in residents experiencing discomfort, fecal impaction, or receiving unnecessary treatment. 2) Assure a root cause analysis for 1 (Resident 75) of 5 residents investigated for skin conditions was done. The facility did not identify contributing factors of skin breakdown. This deficient practice has the potential to result in further skin breakdowns, lack of healing of existing wounds, and/or further wound infections. 3) Inform Resident (R)463 of a schedule change for an appointment with the cardiologist. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement the facility's infection prevention and control measures. Facility did not ensure that staff were wearing applicable personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP) and while handling potentially contaminated items, performed hand hygiene after removing gloves, and maintained shower chairs in sanitary and good repair. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases.

Inspectors wroteBased on interviews, the facility failed to assure residents of the facility were treated with respect and dignity and provided care in an environment that enhances their quality of life. This deficient practice has the potential to result in residents not attaining or maintaining their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to accommodate the needs of 1 of 2 residents (R) sampled by not ensuring that her call light was always placed within her reach, or positioned so that she could activate it. As a result of this deficient practice, R65 was placed at risk of not having her emergent needs met in a timely manner and was prevented from achieving independent functioning with regards to calling for help. This deficient practice has the potential to affect all the residents at the facility who can activate a call light.

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and ensure the resident's right to make choices about aspects of his life that are significant to him was supported for 1 of 6 residents (Resident (R) 110) in the sample. The facility did not identify and accommodate R110's choice to smoke more than twice daily. As a result of this deficient practice, the resident was at risk of potential negative psychosocial outcomes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one of the 36 residents (Resident (R) 8) in the sample was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. R8 had her bed positioned against the wall and a pillow was placed under the fitted bed sheet. As a result of this deficient practice, R8 was not able to get out of bed on her own.

Inspectors wroteBased on interviews and record review, the facility failed to provide written notice of transfer or discharge for one of three residents (Resident (R) 14) sampled for hospitalization, and failed to send a notice of discharge to the Office of the State Long-Term Care Ombudsman (LTCO).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Resident 2 and Resident 165) sampled received the appropriate treatment, equipment, and services to increase or prevent further decrease in range of motion (ROM). As a result of this deficient practice, both residents have been placed at risk of worsening contractures and hindered from reaching their highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility with ROM deficits.

Inspectors wrote2) R134 had an indwelling urinary catheter. It was observed by this writer that on October 10, 11, 12, 17 and 18, 2023, the catheter bag had a privacy cover over it, and was attached to the side of the bed. However, on each observed occasion, the bag with the privacy cover was sitting on the floor, allowing easy access for any bugs or insects crawling on the floor to enter into the privacy cover, providing a risk of contamination that may lead to a urinary track infection for R134. The facility failed to ensure safe and adequate catheter care was being conducted. Based on observations and interviews, the facility failed to ensure that 2 of 2 residents (Resident (R) 179 and R134) sampled for indwelling urinary catheters received the appropriate treatment and services to prevent urinary tract infections. [...]

Inspectors wroteBased on observation and interview with staff members, the facility failed to assure resident's enteral formula was labeled with resident's name, date and time of preparation, rate of feeding and the resident's room number on the label for 1 (Resident 75) of 1 resident sampled. This deficient practice has the potential to result in administration to the wrong resident, over/underfeeding, or using expired formula.

Inspectors wroteBased on observation, and interview, the facility failed to ensure 2 of 6 residents (R) sampled for respiratory services (Residents 2 and 165) received care consistent with professional standards of practice or facility protocol. As a result of this deficient practice, the residents' safety was compromised, and they were placed at an increased risk of avoidable injuries and/or adverse outcomes in the event of a respiratory emergency. This deficient practice has the potential to affect all residents at the facility with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs).

Inspectors wroteBased on resident interview, record review and staff interviews, the facility failed to identify a recent trauma and any triggers that may further traumatize the resident for one of the residents in the sample.

Inspectors wroteBased on observation, record review, and interview with staff member, the facility failed to competently provide nursing services for administration of medication as evidenced by the nursing staff not following standard procedure and best practice for administering medications. In addition, the nurse administered the medications approximately 2 hours after the scheduled time, as per the provider orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were labeled in accordance with professional standards, including accurate expiration dates. Proper labeling of medications is necessary to promote safe administration practices and decrease the risk for medication errors. In addition, the facility failed to clearly label a multidose vial (MDV, medication vial that is accessed multiple times to deliver doses to different residents) in one medication room out of three rooms sampled. The opening date of a multidose vial (MDV) of tuberculin (TB) purified protein derivative (PPD) was not clearly written on the vial. This medication is injected under the skin of residents to check for the presence of tuberculosis (disease where a specified type of bacteria infects the lungs and/or other organs). [...]

Inspectors wroteBased on record review the facility failed to maintain medical records on one resident (Resident 186) that were accurately documented, in accordance with accepted professional standards and practices. This deficient practice has the potential to affect all the residents at the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure pneumococcal vaccination was offered to one of the five residents (Resident (R) 179) in the sample. This deficient practice placed the resident at risk for acquiring, transmitting, and developing possible complications from pneumococcal disease.